Expanding access to behavioral health services, substance use disorder services, and vital human services such as those for people with intellectual and/or developmental disorders is vital to providing high-quality, whole-person care to everyone in need. As an initiative to expand access to and improve care, the Substance Abuse and Mental Health Services Administration (SAMHSA), a branch of the U.S. Department of Health and Human Services, is in the process of evaluating and awarding new grants to support existing and new Certified Community Behavioral Health Centers (CCBHCs) across the nation. These new funding grants can be used for building or upgrading a CCBHC’s health IT infrastructure to support coordinated whole-person care.
There are two models of care that a CCBHC can choose to integrate physical health services and behavioral health and human services:
- Partner with, for example, a Federally Qualified Health Center (FQHC) that provides comprehensive primary care services
- Develop primary care practice internally
Either model can be made to work. There are, of course, opportunities and risks associated with each model that must be considered to be successful.
Advantage of the partnership model
The main benefit of the partnership model is that a contractual partnership limits clinical and financial risk for the CCBHC in providing primary care services. CCBHCs refer to these partners as Designated Collaborative Organizations or DCOs. Because most behavioral health (BH) executives come from a purely BH background, including both their education and their executive experience, they often lack experience in physical health services or primary care practice administration. Therefore, the DCO model can be considered ideal as it comes with the people who have the experience, leadership, and acumen to operationalize and build primary care practices.
To be successful, each partner needs to have a vision and be committed to changing the way they practice to accomplish integrated, whole-person care. This would include behavioral health practitioners screening for physical ailments and sharing that assessment with the primary care provider and vice versa. These are minor changes, but easy to overlook.
Risk of the partnership model
The main con of the DCO model is that it often results in what continues to be a siloed delivery system, even when co-located. According to Dr. Martin Lustick, a principal with NextGen® Advisors, research shows that co-location in and of itself doesn’t provide tangible value. Dr. Lustick says in a recent podcast on this topic, that DCO contracting is “almost too easy for behavioral health organizations to contract with FQHCs” to each provide their own expertise “without being forced to change the way they think about” how they operate and do their own work.
This model typically comes to life as two separate organizations working together, but with very limited collaboration at the point of care. It also tends to involve two completely separate electronic health record (EHR) systems, because in many cases, the physical care providers must use the FQHC’s EHR to bill for services. As such, the two organizations aren’t able to effectively share clinical notes, treatment plans, or other data vital to truly integrated, whole-person care.
Advantage of developing primary care services internally
The major benefit of developing primary care internally is that it is much easier to fully integrate teams working for the same company, with the same internal processes and technology. This model of care makes it much easier to operationalize the integrated whole-person care vision that considers each person’s body and mind at the point of care. Teams using this model work side-by-side and essential information about the individual and their care is being combined in a single EHR—providing an integrated view of their care, including both psychotropic and physical health medications, as well as interactions and contraindications being easier to check. This model is shown to improve both the experience and the outcomes of the individual being treated.
Trade-off of the internally-developed integrated model
One of the trade-offs of this model is that the organization must make sure that they have the right expertise to operationalize primary care within their organization. This takes time and is an investment in hiring the right people for the right roles to support integrated care from a clinical quality and revenue cycle management perspective. Successful integration also requires leadership over a substantial change management process that considers differences in culture and former operating paradigms. It takes patience and dedication to bring together two formerly different approaches to care.
Recommended best practices for integration
There is a long-standing historic separation of behavioral health services and physical care services. It’s only in the past few decades that we’ve seen the shift to integrated, whole-person care. To bridge this divide with regard to delivery systems, the following are a few recommended best practices:
- As part of program development and operationalization, it is important to include primary care experts in the appropriate divisions in an organization. For example, the quality department must ensure that physical health compliance and quality measures are being captured.
- It is important to have an IT governance structure and a team that works to develop workflows in the EHR that support both your primary care providers and behavioral health providers, and train providers on how to leverage tools to not only document services but to provide truly collaborative communication. It is important to find a solution that supports encounter-based care in a robust manner, and episodic and program-based care delivery across the continuum of care, supporting both behavioral health and primary care regulations.
- Alignment of mission, culture, financial sustainability including funding and reimbursement, alignment of leadership, and data and reporting are critical for a successful journey toward whole-person care. This can be a challenging change management process and cultural shift.
Finally, organizations may want to engage a consultant or advisor with expertise in establishing integrated care models. There is no one right answer. Each CCBHC must find the path to integration that best suits them with a plan to take advantage of the opportunities and minimize the risks. Success requires shifts in every aspect of the organization: policies, procedures, physical location, organizational culture, technology, and shared services.
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