Integrated care has become a hot topic among healthcare professionals, and behavioral health providers play a vital role in this growing movement. The roll out of the Affordable Care Act (ACA) and Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) means that 60+ million Americans now have greater access to mental health and substance use care and treatment. With less than half of the 50 million Americans with mental illnesses receiving care, integrating behavioral healthcare with primary medical care can jumpstart the growth in Americans getting the behavioral healthcare they need. Before that can happen, both primary and behavioral healthcare providers need the technology, frameworks, government support, and funding to make integrated care a reality.
Integrated care is the collaborative effort by healthcare professionals to provide clients with a comprehensive treatment plan. It involves shared communication and authority about treatment decisions, and it aims to address the whole person. The goal of integrated care is to provide holistic prevention and treatment that addresses a client’s biological, psychological, and social needs. According to the American Psychological Association, the “triple aim” of integrated care is improving patient access, quality of care, and cost effectiveness.
One approach to this model is to physically integrate behavioral health and primary care. This approach can be found in primary care settings, specialty settings ( such as pediatrics and neurology), and other settings, such as long-term care facilities, community-based health centers, and social services sites. Behavioral healthcare teams often work onsite in these scenarios. There are advantages to housing behavioral health and medical services in the same place. Doing so can increase the chances that clients follow through on a referral. It also gives health providers the opportunity to grow their skills and network in house.
However, physical integration doesn’t need to be the only approach to this model of care. Healthcare teams can meet the definition of integrated care as long as they share care plans and workflows. Health Information Exchanges enable patients and professionals to securely access medical information electronically. Behavioral health providers and primary care providers can take advantage of interoperability to securely share data with other healthcare professionals in an individual’s circle of care.
The Cherokee Health Systems is one example of a successful integrated care model. The CHS is a federally qualified health center and community mental health center where clients’ needs are evaluated across the board, and all issues are addressed in one place. They focus on low-income and underserved populations, and as of 2018, were providing care to 78,600 individuals. The system has grown to 48 clinical locations across Tennessee. Their model is characterized by shared delivery of medical and behavioral care, the assurance of behavioral healthcare at any visit, expanded health management, and support for patient engagement.
According to the Agency for Healthcare Research & Quality, research increasingly shows that integrating behavioral health improves diagnosis time, cost-effectiveness of treatment, and—most importantly—client outcomes. Integrated care has the potential to bridge gaps in diagnosis, and it increases the chance of treating comorbid mental health issues. Plus, it’s often more convenient for clients.
Separate systems of care can result in misdiagnosis, late diagnosis, or uncoordinated treatment plans. Integrated care can improve the accuracy and timeliness of diagnosis and treatment. Clients participating in integrated care are also able to decrease their overall healthcare costs by addressing behavioral health issues at the same time as any medical issues.
In addition to improved outcomes and decreased costs, clients are more likely to follow through with treatment for comorbid health issues when they have access to a “one-stop shop” for healthcare. Clients who would be hesitant to seek out behavioral health treatment alone are able to receive care in a familiar setting.
Finally, integrating behavioral care and primary care creates a deeper pool of expertise. Primary care providers have access to behavioral health professionals who can fill in the gaps where they lack time or training. Having a diverse set of professional skills in one setting can lead to better treatment plans.
In the past, behavioral health systems, funding, and laws have been structured apart from the medical health field. In order to integrate, a lot needs to change, including funding and policy changes that help providers accurately bill for their services. The industry is moving towards value-based care and alternative payment models, which should help incentivize providers to coordinate care in the most efficient way possible.
SAMHSA has launched the Strategic Initiative on Health Care and Systems Integration (SIHCSI) to improve the integration of behavioral health and physical health services. This initiative aims to increase access to services, improve the coordination of care across fields of heath, and improve health outcomes without driving up costs. SAMHSA even hopes that integration will eventually address social determinants of health, like safe housing, equal access to healthcare, transportation, and employment.
Interoperability and client access to health information are keys to providing successful integrated care. Providers need to have the ability to share information with Health Information Exchanges, with other providers, and with government entities. Improving protocols for sharing information and refining the rules against information blocking will help enable this kind of data sharing. Lastly, individuals need to be invested and empowered in their own care by having access to their health information and records.
Coordinated Behavioral Care (CBC) consists of a Health Home that provides care coordination to tens of thousands of New Yorkers, as well as an Independent Practice Association (IPA) that represents a partnership of over 50 health and human services organizations throughout NYC.
As a Health Home, CBC provides comprehensive care management for children and adults in New York. The Health Home program provides integrated care and care coordination services to individuals who receive Medicaid and also have a serious mental illness, HIV/AIDS, or 2 or more chronic medical conditions. CBC’s care managers work with a full range of providers within their members’ communities: including hospitals, community medical and mental health clinics, substance use treatment programs, and housing services. By factoring in social determinants such as food scarcity and lack of social support, CBC’s care managers support individuals in managing their behavioral health and/or chronic conditions.
One of the reasons that CBC’s integrated care models have been so successful is the recognition that there can be multiple types of integrated care. Traditionally, integrated healthcare has brought social workers and mental health clinicians into the primary care setting. But, for individuals with severe behavioral health conditions, CBC has recognized that the first contact point with the healthcare system for these individuals is often a behavioral health provider, not primary care. Recognizing that behavioral health can be an individual’s entry point into the healthcare system, CBC realized that “reverse integration,” where doctors are brought into behavioral health settings, can be even more effective in some cases.
CBC has also leveraged technology and their care management platform to better understand the needs of its members. By producing geomaps of all the services under their Independent Practice Association (IPA), which includes food pantries, shelters, and Article 31 clinics, they can understand whether there are gaps in their network. They also conduct surveys of their community to ensure that they have available care managers that speak the languages of their culturally and linguistically diverse member population.
Above all else, CBC focuses on member engagement. If a member is struggling to make their mental healthcare appointments, care managers will look at all the potential reasons for this — whether it’s lack of transportation, lack of childcare, or a healthcare condition. CBC understands that successful integrated care is not simply a merger of behavioral health and primary care. It’s the ability for all providers to account for a person’s unique life circumstances in order to help them better manage their conditions.
The shift toward integrated care has already begun, and there are many tools for providers who want to take the first step:
Interoperability and client access to health information are keys to providing successful integrated care. Providers need to have the ability to share information with Health Information Exchanges, with other providers, and with government entities. Improving protocols for sharing information and refining the rules against information blocking will help enable this kind of data sharing. Lastly, individuals need to be invested and empowered in their own care by having access to their health information and records.
Article
Written by: Dom DiFurio
Americans’ health care experiences are as varied as their backgrounds. For some, their income, housing, transportation, and other factors that shape their everyday lives can be obstacles to accessing much-needed health care.
However, recent changes to federal health care policies could eliminate some of these barriers. The federal agency over Medicaid provides health care to more than 76 million adults and children, some of whom may benefit from new programs being enacted in several states to meet their unique socioeconomic needs.
Foothold Technology analyzed resources from the Centers for Medicare & Medicaid Services, or CMS, and KFF, as well as plans from state health departments, to illustrate how states are implementing new guidance on addressing social conditions inextricably tied to health, known as health-related social needs, within their communities.
HRSNs are the supports needed to overcome what are known as social determinants of health, or the nonmedical factors that impact health outcomes and care. The World Health Organization defines SDH as “the conditions in which people are born, grow, live, work and age.” SDH came to light most recently when the COVID-19 pandemic arrived in the U.S., highlighting how income, working conditions, and access to nutritious foods—or lack thereof—can affect public health in a time of crisis.
Black, Hispanic, and Indigenous communities were disproportionately impacted by the pandemic for various reasons that didn’t stem from the virus itself. Decades of being underserved by health care systems, food insecurity, overrepresentation in customer-facing service jobs, as well as the chronic stress of racism and earning lower wages on average than their white counterparts, made many people of color more vulnerable to the virus.
Socioeconomic factors can influence as much as a 50% variation in health outcomes for Americans, meaning improving underlying issues like housing instability could be half the battle in helping someone living with diabetes live a longer, healthier life, for example. In recent years, the federal government has started to adopt wide-ranging responses to address those issues, including through new guidance from the CMS, with the potential to impact more than tens of millions of people.
Expanding its focus beyond illness and disease alone, the U.S. health care system is lurching toward diagnosing and addressing social risk factors among Medicaid beneficiaries. Increasingly, programs are building out services to address underlying risks like financial strain, housing instability, food insecurity, limited English proficiency, and a lack of transportation, all of which can contribute to poor physical, mental, and behavioral health outcomes.
The Department of Health & Human Services issued its most recent call to action for health care professionals nationwide last year, encouraging them to partner with community organizations to address those HRSNs. This comes with a raft of new policies and guidance for CMS and health care organizations following decades of research into the impact of socioeconomic conditions on health.
Research on the effects of socioeconomic factors on health outcomes began in the 1960s. Still, it was not until 2010 that the WHO released a framework to help further health equity for people from all backgrounds through government policy.
In 2021, the CMS sent letters to state health agencies informing them of ways they could potentially use Medicaid and Children’s Health Insurance Program funding to address certain social determinants of health. By November 2023, the agency had approved plans from several states to begin providing services to meet HRSNs. Many of them include providing housing support, nutrition, and transportation services.
They’re focused on saving federal money and improving health overall by consistently ensuring vulnerable populations use Medicaid care to prevent more expensive acute care and emergency services down the road.
In its most recent plan to address HRSNs in Medicaid and Medicare services, California proposes providing assistance for people in nursing homes and those exiting the criminal justice system and reentering public life, among other things.
It also provides medically tailored meals for those transitioning from nursing homes into new settings and funds medicine refrigeration for folks transitioning from one type of housing to another so they don’t lapse in their treatment. The approved plan also proposes processes to enroll those released from the criminal justice system in Medicaid and Medicare.
Oregon’s latest approved plan for CMS funding aims to provide continuous coverage for young people and improve health equity for better health outcomes throughout the state.
It proposes focusing on underserved populations, including children aging out of foster care, people experiencing homelessness, and adolescents approaching adulthood with complex health care needs.
It also aims to tackle support for stronger, more stable housing for vulnerable populations. It will allow funding to cover up to six months of temporary housing for people transitioning out of institutional care, whether that’s an emergency shelter or a correctional facility. It also allows for one-time coverage of moving costs, deposits, and medically necessary air conditioners, heaters, humidifiers, and similar devices.
Like other states, Massachusetts aims to assist vulnerable populations by supporting housing, nutrition, and reduced health care costs in its approved proposal.
It also plans to spend on the infrastructure required to provide support like behavioral health counseling, including a proposal to allocate money for student loan repayment for people who become behavioral health specialists, family nurse practitioners, and primary care providers.
In Arizona, a new effort aims to keep people moving between housing situations enrolled in Medicaid so that they can receive stable care. Recently approved proposals to provide support for HRSNs also include an effort to expand the dental services provided to Indigenous communities. Approximately 1 in 20 Arizonans identify as Indigenous, and a large portion of the state is designated as federally recognized Native Nations.
Native American populations experience poverty at nearly twice the rate of Americans overall, according to Census Bureau data. Community advocates, including the Native American Connections, have called for increased federal funding for health care for Native Americans to help provide culturally appropriate treatment for conditions like substance use disorders and mental health.
Arkansas’ approved plan focuses on providing additional services to people with substance use disorders and serious mental illness living in rural parts of the state, as well as veterans at risk for homelessness and young adults who have been a part of the juvenile justice system and pregnant people with high-risk pregnancies. It’s doing so by setting up programs called Life360 HOMEs at existing, qualifying Medicaid hospitals.
Arkansas is among the states with the highest percentage of rural hospitals at financial risk, caring for populations with more expensive medical needs on limited resources.
Like Oregon, Arkansas provides tenants’ rights education and the potential to cover moving costs and deposits for a housing unit for at-risk patients.
New York’s expanded plan involves significant commitments aimed at improving the health and well-being of its residents. This includes initiatives to connect people with housing and nutrition services, marking a substantial state investment in addressing health-related social needs.
The expansion also allows New York to allocate substantial funds to other Medicaid initiatives. These efforts include establishing stable funding for hospitals that serve underserved communities, enhancing comprehensive care for people with substance use disorders, and making lasting investments in the health care workforce statewide.
The initiatives also promote closer collaboration among primary care providers, community organizations, and behavioral health experts. These improvements benefit the state’s adults, children, pregnant people, and individuals with disabilities who are living in low-income households and are largely covered by Medicaid—and are more likely to face barriers to continuing care.
Under New Jersey’s plan, the state will provide meal support in various ways to long-term care patients transitioning from institutional care back into communities and those with diabetes or at risk of diabetes, including the one-time cost of stocking their pantry. Specifically, the proposal will provide medically tailored meals for pregnant people with either preexisting diabetes or gestational diabetes, a form of the disease that can occur during pregnancy.
It will also seek to tackle housing instability for Medicaid recipients by contracting with local organizations to assist them in applying for housing aid or receiving legal assistance to prevent eviction.
The state of Washington’s plan similarly focuses on housing, nutrition, and case management. Case management refers to the services health department workers and contractors provide when connecting people with health care, referring them to specialized services, and assisting with nonmedical factors impacting care, like finances.
The plan establishes processes to work with people in the criminal justice system to screen for mental and behavioral health disorders and get enrolled in Medicaid 1.5 months before their expected release. It also establishes specialized centers directed at caregivers and those who have been found misusing substances like alcohol in public. These centers would allow caregivers to get a break from care. At the same time, workers continued providing the usual level of care to the patient, and so-called stabilization centers would provide those misusing substances with a 24-hour space to get sober in a supportive environment.
Story editing by Alizah Salario. Additional editing by Kelly Glass. Copy editing by Paris Close. Photo selection by Lacy Kerrick.
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