More than sixty years ago, the World Health Organization defined health as not just the absence of disease or infirmity but "a state of complete physical, mental, and social well-being." This description of wellness as a mind and body connection may not be a new concept, but integrating physical and behavioral health care is a relatively new model of care that is gaining national traction as a preferred approach to providing effective and efficient care in the very places where patients are most likely to ask for it—the primary care doctor's office.
The model holds particular promise for racial and ethnic minorities who have historically carried the greatest burden of disease in a number of health categories, including mental health, but who have limited access to needed behavioral health services. It is also the reason why the U.S. Department of Health and Human Services Office of Minority Health (OMH), through a cooperative agreement with the Hogg Foundation for Mental Health, set out to investigate the role and impact of integrated care to identify culturally and linguistically competent elements, strategies and practices that could form a basis for a new standard of care.
"This project that focuses on disparity populations is innovative," says Dr. Teresa Chapa, Senior Policy Advisory on Mental Health and federal project lead for OMH which has been at the forefront of investigating integrated care as an optimal care model for minority populations since 2004. "Our populations and communities typically go to primary care for all of their health care," Chapa says. "That is the most common ‘portal to both physical and behavioral health care.' So our efforts have been directed towards tailoring that portal to meet the needs for those entering with behavioral health issues."
Following a literature review and consensus meetings, the culmination of the project is the working document, "Enhancing the Delivery of Health Care: Eliminating Health Disparities through a Culturally & Linguistically Centered Integrated Care Approach" [PDF | 317KB] to be released later this month and which offers recommendations and examples of best practices for providers who may want to apply the ideas in minority communities where they work.
As a concept, integrated care addresses a key problem in healthcare that was outlined in the President's New Freedom Commission on Mental Health 2003 report. That document pointed to a fragmented and uncoordinated healthcare system that left too many people without the behavioral health treatments they needed.
This lack of coordination in care continues to be a significant issue for minorities and those with limited English proficiency (LEP), many of whom are over-represented among the nation's most vulnerable populations. A lack of health insurance, transportation and language concordance, along with long waiting lists result in barriers to accessing and receiving quality care. Other contributing factors include inadequate help seeking behaviors. Minorities may delay or avoid needed care because of stigma or shame. They may also lack an understanding about mental health treatments and recovery, or where to find services. These issues are further complicated when a service is not available in their primary language.
Fragmented care tends to be ineffective and costly by its very nature, argues Rick Ybarra, Program Officer at the Hogg Foundation who participated in the Cooperative Agreement with OMH. "We know that physical health impacts behavioral health and we know that behavioral health impacts physical health. Therefore, if you treat only one side of the equation, then you're not going to be able to achieve whole health as we think of it."
Ybarra points to the historical division between these two health services despite the fact that research shows that physical and behavioral health conditions often occur at the same time. Studies show that mental health problems increase the risk for physical health and substance abuse problems as well as for a number of chronic diseases, including diabetes and HIV/AIDS. People with chronic conditions have about a 30 percent psychiatric co-morbidity, yet few are evaluated for mental health conditions. Not providing behavioral health services comes with a social and economic cost, says Chapa. "But if you provide mental health services in a particularly packaged way, people are more likely to utilize those services."
The OMH and Hogg Foundation project provides guidance on ways providers could create robust versions for integrating care to meet the needs of minority communities. Since "providers are doing their work in silos," Ybarra says, the task is creating a new system of care that brings a multidisciplinary team together. The groups' June paper includes examples of culturally competent programs that have successfully incorporated integrated care designs and concepts into their practices serving different minority communities, such as the Charles B. Wang Community Health Center in the China Town neighborhood of New York City. By making no distinction between treatment rooms and by keeping mental health records confidential, the center has successfully reduced the issues of stigma and trust around behavioral health treatment and provided more people the possibility of accessing these services.
Integration as a practical approach is still evolving and financing remains one of the biggest challenges for its widespread implementation. But a number of federal government and state agencies, as well as foundations and other groups, are working together toward keeping the momentum moving forward. "The next steps are about training people how to do this," says OMH's Dr. Chapa. "People are interested in learning how to bring the disciplines together to more effectively serve the communities and include a new workforce of health navigators, and promotores de salud or community health workers. Our ultimate goal is to improve access and quality for health and behavioral health care."
Ybarra adds that in the last two years, the Affordable Care Act has become "a significant driver" behind integration, particularly since elements of the concept are already embedded in the landmark law. "I see it as almost a race," he says of the model's potential. "I see that everyone is going to be at different places - some states may have advanced this forward - but nonetheless you're seeing a lot of private payers, private insurance companies, a lot of organizations that are continuing to advance these efforts or are starting to ramp them up. Regardless of the Supreme Court ruling, they see that there is going to be a role for the integration of these services in care delivery systems. It is just a more efficient and more effective way of delivering care."
Hogg Foundation for Mental Health: http://www.hogg.utexas.edu/
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