Understanding the Forces Influencing the Move to Integrated Care

The historical separation of physical and mental health is slowly being taken apart, brick by brick, as a new foundation for integrated, whole-person care gains traction and scale in the United States healthcare delivery system. The 20th-century history regarding the emergence of psychiatry, its funding and acceptance as a discipline of medicine provide important context for understanding the movement to integrate these disciplines in practice.

The way in which provider groups undertake integration at a practical and tactical level will vary by organization; however, best practices for change management and program governance offer a blueprint for this important work.

The Origins and Growth of a Profession

The psychosomatic movement of the 20th century provided the context in which the discipline of psychiatry grew in practice, training, and research. It was the onset of World War II that brought about an enhanced public image for the field of psychiatry.

While the First World War saw the introduction of psychological testing for the assignment of military personnel and the creation of a Division of Neurology and Psychiatry to screen recruits and treat all mentally disturbed servicemen, the war did not leave a lasting mark on military psychiatry.

In the Second World War, more than one million men were rejected from military service because of mental and neurological disorders. Another 850,000 soldiers were hospitalized as psychoneurotic cases during the war. Psychiatrists and others later presented both these statistics as measures of America’s great unmet need for psychiatric services. The arrival of European refugee psychiatrists also contributed to the growth of a more influential psychiatric profession. As late as 1930, nearly 75 percent of the members of the American Psychiatric Association worked in state mental hospitals, and private psychiatric practice remained rare.1 

National attention was focused on conditions in state mental hospitals at the end of the war as a national scandal erupted in the press. Historian and author Albert Deutsch reported scenes of half-starved mental patients herded into filthy wards, stripped of any vestige of human decency. 2

Informed by the war experience and the state hospital situation, Congress passed the National Mental Health Act in 1946, providing funds for medical research and training programs and giving states aid for mental health clinics and other priorities. As a result, between 1948 and 1962, the National Institutes of Mental Health research grants rose from $347,000 to $42.6 million and training grants grew from $1.1 million or $38.6 million.

This prioritization of funding and training under the broad umbrella of mental health expanded the agency’s research into diverse problems such as child development, juvenile delinquency, suicide prevention, alcoholism, and television violence. The training programs developed sought to attract physicians by providing more generous stipends to residents in psychiatry than were available in other specialties.3

In the period of the Civil Rights Movement, deinstitutionalization became a broad policy goal for states when many groups were being incorporated into mainstream society. Daniel Yohanna, MD, describes three forces which drove the movement of people with severe mental illness from hospitals into the community:

1. the belief that mental hospitals were cruel and inhumane;
2. the hope that new antipsychotic medications offered a cure; and
3. the desire to save money. 

The Community Mental Health Construction Act of 1963 made federal grants available to states for establishing local community mental health centers and was intended to provide treatment in the community in anticipation of the release of patients from state hospitals.

In the nearly five decades since this Act, several factors have exacerbated the need for mental health services and complicated the effort to integrate mental and physical health in community treatment.

A brief history of the war on drugs notes that “in the 1960s, as drugs became symbols of youthful rebellion, social upheaval, and political dissent, the government halted scientific research to evaluate their medical safety and efficacy. In June 1971, President Nixon declared a ‘war on drugs.’ He dramatically increased the size and presence of federal drug control agencies and pushed through measures such as mandatory sentencing and no-knock warrants.”

The authors note it was the presidency of Ronald Reagan and the highly publicized anti-drug campaign of his wife Nancy Reagan, initiated the start of a long period of unprecedented incarceration, with the number of people jailed for nonviolent drug offenses increasing from 50,000 in 1980 to over 400,000 by 1997. This criminalization of minor drug offenses caused thousands with a substance use disorder to have their addiction and behavioral health needs directed to the criminal justice system, further fragmenting a whole-person care approach instead of enabling medical treatment in the community.

Practical Considerations for Integration Today

The journey to integrate behavioral and physical care has many paths, and the starting point will be informed by the present situation of the practice or organization undertaking the effort.

Organizations offering integrated care need to be sure that behavioral health is fully embedded into the practice, including a mission statement and work plan that addresses these services.

Many provider groups establish a core team with executive sponsorship and key clinical champions to drive the integration work into focus and to interface with the organization’s clinical services and infrastructure departments as a method to prioritize the effort and keep the change process front of mind. Developing the care model and workforce in parallel ensures that as processes are designed for universal and routine screening for mental illness and substance use within the primary care environment, the key work steps, roles and responsibilities of each team member involved are defined, documented, communicated and understood by all those involved in patient care.

Care coordination processes are central to a patient-centered approach and require a coordinated plan of services and care overseen by a designated member of the healthcare team. An integrated care plan should reflect the inventory of information needed by all members of the care team and remove duplicative or redundant data. It should clearly document the plan that puts the patient’s goals and priorities in a central location where their caregivers can see them and detail the actions each team member, including the patient, is responsible for carrying out.

In clinical operations, pathways for chronic disease management will need a review to incorporate the behavioral health needs of those in care. A population health focus with the capacity and systems in place to track all patients, not just those with an acute problem, allows for the proactive management of patients. Capabilities include clinical registries, the ability to assign patients with similar needs or conditions to cohorts, the development of shared care plans and integrated electronic medical records across the organization’s areas of clinical practice. 

Measuring the quality and outcomes of care are central components to all integration initiatives. Most healthcare providers have a performance improvement system in place that tracks the outcomes of core health indicators. Clinical measures significantly impact continuous quality improvement efforts; thus, mechanisms to collect and aggregate information on variation from integrated care outcome measures are needed. Identifying and acting on this variation brings consistency to operations, helps identify training needs, and supports the demonstration of quality and efficiency to government payors and health plans. Efforts to keep the whole team informed may include regular team huddles and improving learning through case conferences.

Successful integration of physical, behavioral, and mental healthcare is forefront in the minds of federally qualified health center leaders, state Medicaid programs, and increasingly with commercial health plans as well. While significant barriers remain due to lack of access, provider capacity, and the lack of payment parity for behavioral health services in relation to other medical care, the rationale for realizing whole-person integrated care has never been clearer to see nor as close within our grasp.

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Authored by Graham Brown, MPH, CRC

References:

1. Starr, Paul. The Social Transformation of American Medicine (New York: Basic Books, 1982), 73; 344-346.
2. Deutsh, Albert Deutsch. The Shame of the States: 1948, (New York: Harcourt, Brace and Company, 1948), 138-139.
3. Brand, Jeanne. “The National Mental Health Act of 1946: A Retrospect,” Bulletin of the History of Medicine 39, 3 (June 1965): 231–234.

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