Journey to the Center of (Integrated) Healthcare
It was November of 2006. Southwest Colorado Mental Health Center (SWCMHC) had been serving the mental health needs of residents in southwest Colorado for almost 50 years. We were just completing a new facility that would combine our existing social detox with our emergency service staff and a newly conceptualized and designed Acute Treatment Unit (ATU) to provide crisis, inpatient/residential, psychiatric care (as the nearest inpatient psychiatric bed was an average of 7 hours away over mountain passes).
Due to the isolated rural and frontier character of the region, SWCMHC had a history and a culture of innovative solutions to problems … and we had our problems. The creation of this new facility allowed us to serve that population in need of acute treatment but in the process made it abundantly clear that our biggest problem was not resources but stigma. About half of the people we served through our emergency services were not our patients and the vast majority of these were without any mental health care. NIMH had released the National Comorbidity Survey Replication the year before (June 6, 2005 issue of Archives of General Psychiatry) which found among other things that the mean time between identification of a mental disorder and getting treatment was 9.7 years. This was followed in April of 2006 by a report in Preventing Chronic Disease documenting a 25 year shorter life expectancy among individuals with a serious mental illness. It was becoming clear to us that we needed a different way of thinking about providing care.
Concept of Care
That “new way” was introduced to us when a senior staff member came back from a conference presentation by Dennis Freeman, CEO of Cherokee Health Systems, on integration of care – the combining of behavioral health (mental health and substance use) with primary care. We adopted and modified the concept, making it our own which brings us back to November of 2006. I met with my Board of Directors individually and then collectively. At the Board meeting that month the Board resolved that it, “supports in principle the creation of an enhanced health system that integrates preventive, behavioral health, and primary care services.” This marked the official beginning of our commitment to transform to an integrated health system. Little did I anticipate the hurdles we were going to face.
Up to this time, the Four Quadrant Model (NCCBH, Behavioral Health/Primary Care Integration, prepared by Barbara J. Mauer, Revised February 2006) had provided the dominant conceptual framework for integration. This model provided a good starting point but it did not go far enough. It preserved the separation of physical and mental health, did not sufficiently accommodate the complexity of healthcare needs, supported a specialty behavioral health structure that we found was not helpful in the long run, and preserved a narrow encounter service structure.
Though we started thinking about behavioral health as specialty healthcare, because that is where we came from, we quickly discovered we had gone down the wrong fork of the road. Mental health and substance use needs to be fully integrated throughout the healthcare system and keeping it separate would undermine the very integration we were trying to achieve.
From there it became evident to us that we needed to transform both the behavioral and primary care systems if we were to achieve a truly integrated healthcare system. Our team struggled with this conceptual vision and began to think of integration on a continuum. We took a document entitled The Levels of Systematic Collaboration Model (William J. Doherty, Ph.D., Susan H. McDaniel, Ph.D., and Macaran A. Journey to the Center of (Integrated) Healthcare Bern Heath, Ph.D., CEO, Axis Health System, 2012 Baird, M.D.), integrated subsequent constructs, expanded and re-conceptualized integration, and included a sixth level entitled Full Collaboration in a Transformed Fully Integrated Healthcare System, thus making it clear that integration of services is more than consultation and more than co-location. This led to the publication of A Standard Framework for Levels of Integrated Healthcare through the SAMHSA-HRSA Center for Integrated Health Solutions in April of 2013. Authored by Drs. Heath and Wise Romero of Axis and Kathy Reynolds, ACSW of the National Council for Community Behavioral Healthcare, this Issue Brief establishes a national standard for the common understanding and evolution of integrated healthcare implementations.
In addition to the concept of a continuum, we adopted a care team structure. For us, care teams are different from the long-standing multidisciplinary team and more current physician led versions in that they are not led by a physician or any assigned discipline and is wholly patient centered. With the cultural “team” structure and institutional cross-training there is no place for providers to hide (making staff selection even more critical) and all participants are expected to contribute within and outside of their disciplines in the best interest of patient care.
As a small organization we were initially unprepared to create an entirely new service environment in a new facility. Consequently, we adopted an embedded strategy. We identified existing primary care environments and, using the principle of loss leadership, donated co-located behavioral health services to each of these environments. We did so recognizing that these sites would serve as a laboratory for us to learn how to most effectively integrate services (including training of our staff) and it would build service relationships that if successful would lead to sustained funding.
There is an important footnote to this early iteration of integration. We understood at the outset, from those that preceded us, that simply taking a community mental health service model and dropping it into a primary care environment would not work. Services in a primary care setting needed to be structured closer to the pace of the host service environment – a lesson also learned in school based health centers. Traditional therapy services and their delivery structure would not work in the new environment. With this in mind we trained staff from emergency services as our first integrated staff. These staff were much more flexible in their approach, fluid in their delivery, comfortable with a fast paced environment, and familiar with other community resources that could be brought to bear.
The loss leader strategy we employed was remarkably effective. It gave our organization the opportunity to develop and refine our service model in each of these settings while training existing staff and building cross-organizational relationships. In all settings our services and efforts to integrate were very successful. In all but two of these settings that success led to contracts for ongoing services.
The failure of the two settings made clear the limitations of the model we had hoped would lead to more fully integrated and financially sustainable operations. It was not that embedding behavioral health services was not effective. Quite the contrary. While the services were incredibly valuable to the providers in the clinics and the patients as well, the culture of the primary care settings were dictated by the owner’s system needs – which is perfectly understandable. This is an important reality and resulted in an essential lesson for us. Our embedded model improved care up to a point, but it did not significantly change the culture of services in the host organization, nor lead the practice to evolve to higher levels of integration.
We came to the realization that while improving co-located integration efforts with more integrated mechanisms resulted in a substantive improvement in care and outcomes it was still less than it could be. In short, to achieve its potential the clinic setting needed to have a service and cultural commitment at all levels to a shared vision of integration.
That led us to decide to build a new facility operated entirely by us and specifically designed to be fully integrated. With this decision, the organization committed itself to the strategic vision of transforming its entire operation.
Transformation raised a further problem as each of our communities was in a different place regarding access to primary care, willingness to collaborate, concerns around competition, and comfort with the integrated vision. The value and process of integration are, from a community perspective, subtle and not easily understood. At the same time community engagement is critical for the funding and political support necessary for such a sweeping transformation. Thus we came to understand that there are many paths to integration and not all implementations will result in the movement to higher levels of integration.
To further the organization’s transformation, the Board and staff recognized that we needed to change the name under which the transformed organization would do business. In September 2009 the Board adopted the new name of Axis Health System (as services would rotate around the axis of individual and family healthcare needs). The changing of our name had a surprisingly powerful impact on our transformation. It made it more understandable to both the community and to our own staff – even though we were not yet directly providing primary care services.
As we proceeded down the path of transformation the fiscal, operational and conceptual complexity of integration was increasingly felt. In January of 2010 we purchased the property for the new facility which made the transformation more real for both the Board and staff. That month we also received an endorsement to pursue Federally Qualified Health Center status (which was ultimately unsuccessful) from a local group that had earlier opposed it. Lastly, in January we received a request by a school district for Axis Health System to serve as Medical Sponsor for their school based health initiatives district-wide. These events made it clear that it is important to have a sound and inspired vision. It is important to be creative in weaving that vision into the unique needs of the communities being served. Yet perhaps most important in bringing a vision from concept to reality is patience and perseverance allowing the concept to mature in various settings which in turn generates opportunities for progress over time.
Over the next two years (in the very teeth of the recession) we raised funds to build the facility, overcame local political and zoning hurdles, began construction and in January of 2012 we opened Cortez Integrated Healthcare – the flagship and the first stage of our transformation to an integrated health system.
Challenges Today and Tomorrow
Though largely anecdotal, to date the results of our integrated model have been breathtaking. Yet, challenges remain. Increasingly greater levels of integration require the merging of and access to health information. None of the major, enterprise-wide, electronic health records for behavioral health or for primary care are built to talk to, or communicate with, the other. With the Regional Health Information Exchanges in their infancy, this promising resource has not yet matured to a level that will solve this problem. In consequence, we have needed to create our own Health Tracker TM. It pulls select data from the behavioral health and physical health records, as well as our population based screening tools to generate a profile that is readily accessible to all practitioners and meaningful to the patient as well.
Fragmented and siloed health records are not the only thing getting in the way of integrating healthcare. So, too, are funding structures. Traditional fee-for-service (FFS) billing does not support truely integrated care. FFS structures stumble over same day billing restrictions and do not reimburse for consultations without the patient present, electronic contacts or a large volume of care management all of which are essential for improved health outcomes in an integrated healthcare system. FFS structures inadvertently provide incentives for ineffective, fragmented and churned visits rather than active management of care focused on health outcomes. Global payment structures are needed that hold providers accountable for outcomes but do not limit or compromise the structure of service delivery which can be designed locally for maximum impact.
Combined with global payment, integrated healthcare is our best vehicle for bending the cost curve. It does so by materially reducing costs through more effective primary care and consequently better health outcomes. Exercise programs reduce weight, risk for Type 2 diabetes, depression, hypertension and associated coronary disease, among other conditions. Cost savings inure not directly to the primary care sites, but to insurance companies who save by reduced hospital care and reduced needs for specialty care. Creating cost savings for insurance companies provides integrated settings the opportunity for funding through a risk sharing/gain sharing compensation structure that returns a share of those savings to primary care which can then invest them in services, supporting a continued evolution of effective care.
If we move from FFS to a global payment structure it shifts compliance/accountability and productivity to population based (by site, payor source or both) outcomes. In short, we need to stop measuring units of service (volume) and instead measure the impact of our services (outcome). This better aligns our work to its goal (improved health) and provides a foundation for establishing cost savings – essential to making the case for healthcare reform and state innovation.
Our concept of integrated, whole person, healthcare is population based, patient-centered, outcome driven and technology enabled. We have come a very long way in the six years since we began this journey and we see every day, in the patients we serve, that this is the direction healthcare should and must move. Yet we are still swimming against the current of traditional healthcare’s workforce training, service funding, politics and accountability structures. One of my colleagues in this venture, Pam Wise Romero, Ph.D. said to me, “Everyone wants to do integrated care until they realize that they have to change how they practice.”