Integrating social and medical care may be best practice, but doing so is not without its challenges. Practices and their practitioners must work diligently to find solutions.
The concept of integrated care is not new. In fact, well-planned and executed collaboration and communication between health sectors, particularly behavioral health and primary care, is increasingly considered the gold standard of health care.
“Having interrelated services easily accessible in one location or being able to do warm handoffs to a care team member from the same agency allows the client to focus more on what they need—and on building a relationship with the provider—instead of focusing on finding the services they need, referral forms, eligibility, and scheduling,” says Shannon Ghramm-Smith, LCSW, senior vice president of the child welfare and behavioral health division and senior advisor at the Implementation Support Center at The New York Foundling.
Ghramm-Smith says integrated service delivery means ensuring the following:
• The client and their family/care partners receive prompts for preventive care to mitigate against any future acute medical or mental health care needs.
• When intervention is warranted, the client receives the right intervention at the right time.
When integrated services function together with a focus on prevention and well-being, patients may experience fewer health-related disruptions in their lives and enjoy overall better physical and mental health.
However, while the benefits of integrated care are well acknowledged, the practice of delivering such care is not simple. There are numerous challenges to implementation that require time, money, resources, and buy-in to overcome. For practices and providers throughout the country to achieve their version of the gold standard, they must be willing and able to work toward overcoming these obstacles.
Merging the Silos
Javier Favela, vice president of solutions, behavioral health, and integrated care at NextGen Healthcare, agrees. “The success or failure of a behavioral health and social care service provider adding primary care services often comes down to creating a happy arranged marriage between two areas of health care that have been kept separate for generations,” he says.
Combining the two sectors into an integrated or interrelated practice requires change at an organizational and individual level. Everyone—particularly leadership—must buy into the idea of an integrated practice. However, this can be difficult. Having been separate for so long, there are not only different models of care but also differing mindsets, cultures, and even hierarchies that must be merged.
“The medical model is still very much focused on quickly identifying medical issues and quickly coming up with a plan to address those issues,” Silverman explains, adding that this is a generalization that’s not true of everyone. “The behavioral health or social services model is much more focused on having the patient or the client lead the care and the session. It’s a longer visit frequently. It also is much more about uncovering what is going on from the patient’s perspective. There are operational challenges in bringing those two models together, and everyone has to get on board with how both approaches are helpful. How do we integrate them?”
Silverman believes that once physicians, nurse practitioners, and other providers see the benefits of integrated care and gain a better understanding of what is expected of them within an integrated system, they will be more on board and more willing to combine physical health with behavioral health and other aspects of social care. After all, they want their patients to have access to all of the necessary services. Physicians “want their patients to have housing,” Silverman says, “but they don’t really know—most of them—how to talk about that.”
“Reimbursement is pretty poor, especially in the Medicaid environment, for mental health providers, substance use providers,” Silverman says. “Often, I think it’s hard to make a business case for clinics and organizations about why they would even want to bring in mental health providers, as crazy as that sounds. The reimbursement for Medicaid behavioral health providers is notoriously poor, much worse than private, and even on private insurance, people are not particularly well reimbursed.”
Ghramm-Smith says that varying insurance payers within a state, as well as varying rules and structures, can make it challenging for providers to get reimbursed at all—poorly or otherwise. “It is oftentimes confusing for any provider—hospital system or small CBO (community-based organization)—to get fully paid for services they provide. Prioritizing advocacy for fair payment takes focus away from service delivery and staff training necessary to bring proven treatments to the communities that need them,” she says.
Additionally, some reimbursement rules, to put it simply, make smooth and timely integrated care nearly impossible. For example, a number of states have policies in place that prevent an individual using Medicaid from receiving multiple services in one day. Should a patient see both their primary care physician and their therapist on the same day, only one service would be reimbursed by Medicaid. While 32 states, as well as Washington, D.C., have made changes to allow for patients to receive more than one service, there are still 18 states that have not. This kind of forced delay makes integrated care more challenging and less effective.
“If you had a patient who said to you ‘I’m feeling really depressed’ and you even had mental health services or social services down the hall, you had to do this kind of horrible thing of ‘Can you come back tomorrow?’ or as a provider, [decide] is this serious enough that I need to send them to the hospital? It’s this terrible kind of puzzle,” Silverman says.
Outside of the payers themselves, providers must find ways within their practices to bill for integrated services accurately and efficiently. That in and of itself is a challenge. Without the right tools, organizations may find themselves adding to the workload and complicating vital processes.
“Many times when we work with organizations, we find multiple EHRs [electronic health records] and technology solutions to support their complex programs and service needs. This creates operational, financial, and clinical inefficiencies,” Favela says. “For example, I worked with a large behavioral health organization that added primary care services [and was] working toward becoming a certified community behavioral health clinic and a federally qualified health center. This organization was using one system for behavioral health and their social service programs and another system for their primary care services. We found they had 14 administrative staff doing double entry into the two systems. There was a high risk of data entry error, and clinical and operational inefficiencies. After moving to one single EHR, the organization improved its revenue cycle management, eliminated unnecessary administrative staff doing dual entry, and improved outcomes for its clients.”
Training can and should happen within the care agencies, although it is often a piece that goes missing. “Training for staff is often kind of forgotten, or there’s no money for it,” Silverman says. “Training is so important to help staff have the language to feel confident in talking about these issues.”
When possible, training professionals before they become providers is ideal. Students who have the opportunity to learn about integrated care in school are better prepared to serve their patients in integrated settings. Although such training is not universal, it is increasing at schools throughout the country and in a variety of ways.
For example, Kognito, an experiential learning company, has developed a simulation that allows health professional students to train on the Screening, Brief Intervention, and Referral to Treatment approach. The simulation gives students the opportunity to not only use the screening tool but also practice the conversations they would have after receiving the results of the assessment.
Learning and practicing virtually, as opposed to live role play, allows the learner to learn more freely and independently, says Dawn Bornheimer, director of higher education and clinical health at Kognito. “We used to have this two-way mirror, and we had to conduct the role-plays where we were being observed by a professor and roleplaying with a peer,” she recalls. “In that instance, there’s a perceived judgment and to some extent anxiety experienced by the learner as they think, ‘There’s something I’m supposed to say. I have to role-play this scenario while making sure that I’m doing everything right.’ It’s a lot of pressure.
“When you’re using the Kognito conversation platform, you have the opportunity to practice in a safe, judgment-free environment. The feedback you receive is delivered to you through the platform in real time by a virtual coach.”
The simulation removes any element of bias that can be present among even the best educators and trainers, allowing students to continue to develop their skills.
Outside of tools such as simulations, schools are working to not only weave integrated care or interprofessional collaboration into curriculum but also create experiences for the students through practicums. For example, at the University of Vermont (UVM), the Vermont Trauma, Resiliency, and Equity Education initiative provides a stipend to second-year students in UVM’s master’s programs for social work or counseling. The funding pays for courses (three to six credits) that specialize in “trauma-informed, resilience, interprofessional, and culturally responsive practices” while requiring students to complete their second-year placement in an integrated care setting.
Additionally, systems-based practice is one of the UVM College of Medicine’s six primary competencies. “Within that competency is the specific programmatic objective to demonstrate understanding of the essentials for collaborative teamwork, including interprofessional team dynamics, communication skills, and conflict resolution within the context of a well-functioning team,” says Karen Lounsbury, PhD, a professor of pharmacology and director of foundations and preclinical assessment. “To achieve that objective, interprofessional education is longitudinally integrated into the curriculum with a goal to help medical students develop the communication and collaboration skills they need to function productively on health care teams.”
“It is important to have an IT [information technology] governance structure and a team that works to develop workflows in the electronic health record that support both primary care providers and behavioral health providers,” Favela says. “It is also imperative to train administrators and providers on how to leverage tools not only to document services but also to provide truly collaborative communication.”
However, he notes, health care innovators have also started thinking beyond EHRs to additional tools and resources that can aid in delivering integrated care. “As the industry shifts to value-based care and new payment models, we are seeing population health, care management, and patient engagement tools are becoming critical to meet the consumer where they are, achieving better outcomes and reducing cost. Providers need real-time, meaningful clinical insights at the point of care to close care gaps and better manage their patient population. Technology will need to evolve to meet consumer demand and continued risk of labor shortages,” Favela says.
But again, it’s not just technology and other resources that will help make integrated social and physical care work. It’s not just training and increased buy-in. For integrated care to function at its highest ability, there must be solutions at every level of providing care, from payers and documentation to the staff and patients.
In short, for integrated care to be properly implemented, the resources and solutions available must also be integrated.
— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.