“The major problems in the world are the result of the difference between how nature works, and the way people think”

-Gregory Bateson

A short animation overview of what integrated care is and what it means to Path IHC.

Save the world? That feels a little dramatic. PATH Integrated Healthcare, along with thousands of other healthcare companies like it, focuses on delivering mental health and substance abuse services. Almost everyone would agree that these valuable resources are life changing. But would anyone think these services rise to the level of “world saving”? I believe they could be. Here’s why.

A 2015 study in the monthly journal published The American Medical Association (JAMA) sought to answer the question, “How many people die due to mental illness each year?”. This question proved difficult to answer because so many people with mental illness die from seemingly natural causes such as heart disease, infections, accidents, etc). However, the researchers recognized that the risk of people dying from both “natural” and “unnatural” causes was more than double when compared with people who had no history of mental illness. So, they asked a second question; “How many fewer deaths would occur each year if people with mental illness died at the same rate as people without a mental health condition?”. The answer to the second question is astounding. (1)

Who would like to save 8 million lives…every year?

8 million people die each year due to mental illness. Stated more precisely, 8 million deaths would not occur if people with mental illness and people from the general population died at the same rate (1). Add in over 800,000 death due to drug overdoses in the past 20 years (4) and you can see that what looks like a mental health issue is actually just a human health issue.

Despite efforts to increase awareness, individuals with mental health and substance use disorders are often under-diagnosed and under-treated in primary care settings. Similarly, those with mental illness and substance use disorders lack adequate general medical care (2). Some of the reasons for this include the lack of understanding of the relationship between mental and physical disorders and siloed behavioral and physical health care systems. If somebody is diagnosed with a chronic illness, they are 2x as likely to have a behavioral health illness. It’s also true the other way around; someone with a mental health diagnosis is more 3x more likely to have a chronic illness. 70% of behavioral health patients have a chronic medical co-morbidity (3).

Integration is the difference that makes a difference.

The complex relationship between mental health and mortality, not to mention mental health and quality of life, can make it difficult to see a direct path to recovery. If we can’t say for certain whether poor mental health directly led to a physical illness, or explain why some people respond well to medication while others struggle, or even decide which came first; substance abuse or mental illness, how can we possibly choose which type of service each person needs to recover?

Gregory Bateson was a pioneer in the field of systems theory, and he stated that, “It is impossible, in principle, to explain any pattern by invoking a single quantity” (6). Although he was discussing the relationship between numbers and quantities, the same is true when considering mental health, addiction, and potential solutions. It is impossible to say that 75% of someone’s problem is their drug use and 25% is their depression so let’s structure a treatment plan that is 75% NA groups and 25% anti-depressant medications. It’s a difficult to sentence to take seriously, imagine trying to live it.

Unfortunately, that is exactly what we do. When someone shows signs of needing help, we send them to a psychiatrist, or a therapist, or even their family doctor. If they have addiction issues, we arrest them, or send them to a self-help group like NA, or ship them off to rehab. While each of these services is important, offered alone, they are often insufficient. Not only does this disconnect fail to help a person who is suffering, it often harms them. Crossing the Quality Chasm notes that the resulting gaps in care, miscommunication, and redundancy are sources of significant patient suffering (5).

Integrated care is systems thinking brought to practice. Understanding that there are multiple factors that contributed to the development of a problems is acknowledging that individuals must be offered help geared towards all those areas if they are to successfully establish new patterns of behavior. More importantly, those sources of help must interconnect and work together to produce last change just as the systems of dysfunction worked together to produce ongoing pain. It is the relationships that harm and it must be the relationships that heal.

So, what is Integrated Care?

Integrated Care just means that a client can have all their health needs met in one setting by a team of professionals who collaborate to ensure that each service works in conjunction with all of the other services. This coordination of care is key to ensuring that clients get the highest level of care possible and have the best chance at achieving sustainable, positive change.

It can be delivered in multiple ways depending on who is providing the care, what type of care is being provided, where the care is taking place, and how services are being coordinated. Integration can take place in behavioral health, primary care, specialty clinics, and home health settings. For PATH Integrated Healthcare, it means that Psychiatric, Nursing, Therapy, and Case Management services are offered to all clients who are coping with a mental health and/or substance abuse issue. Services and their frequencies are then tailored to each client’s specific needs.

There are different levels of services integration. 1. Coordinated Care: concentrates on communication. 2. Co-located Care: which focuses on physical proximity. 3. Integrated Care: which combines collaborative communication and close physical proximity to emphasize coordination at every level within an organization.

Within each level, there are varying degrees of collaboration between care providers. These levels range from minimal to full integration. Minimal integration is when medical and mental health care providers work in separate facilities, have separate systems, and rarely communicate. Full integration involves a single health system’s medical, substance abuse, and mental health care providers working simultaneously to treat a patient’s individual behavioral, substance abuse, and medical needs utilizing open coordination of care.

Best of all, Integrated Care works!

A meta-analysis of 167 studies revealed that integrated care models were effective in improving outcomes in the following factors (7):

Client perception of quality of care

Evidence of increased patient satisfaction

Evidence of improved access to care

Reduced wait times for care

Increased client engagement scores

Number of caregiver contacts via reduced no show rates

Length of stay as clients achieved autonomy sooner

Quality of care /Adherence to established standards

Reduced readmissions

Reduced Emergency room and Hospital stays

Staff work experience

A 10-year study of 113,452 patients, conducted by Intermountain Healthcare shows the benefits of integrating care. Results showed that patients who received integrated care were screened at a much higher rate for depression than those in traditional practices. In team-based practices, 46.1 percent of patients were diagnosed with depression, compared to only 24.1 percent in traditional care settings. This allowed for earlier targeted interventions

Integrated care patients also showed higher rates of engagement and meaningful participation in care than those in traditional practices. According to the study, 24.6 percent of patients receiving integrated care followed protocols, compared to only 19.5 percent of traditional care patients. In integrated care settings a self-care plan was implemented 48.4 percent of the time, compared to just 8.6 in traditional settings. The rate of emergency room visits by patients was lower in integrated settings compared to traditional settings and hospital readmission rates were also 10% lower for patients in integrated care settings. This, despite patients actually seeing fewer total providers at a significantly reduced cost of care.

There are many studies that demonstrate the power of integrated care. Maybe even more impressive are some of the agencies who have come forward to promote and endorse integrated

Sources

1- Walker ER, McGee RE, Druss BG. Mortality in Mental Disorders and Global Disease Burden Implications: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2015 Feb 11

2- https://www.milbank.org/wp-content/uploads/2016/05/Evolving-Models-of-BHI-Exec-Sum.pdf

3- https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

4- https://www.cdc.gov/drugoverdose/index.html

5- Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

6- https://dailyimprovisation.blogspot.com/2016/01/bateson-on-numbers-quantity-and-pattern.html

7- Baxter, S., Johnson, M., Chambers, D., Sutton, A., Goyder, E., & Booth, A. (2018). The effects of integrated care: a systematic review of UK and international evidence. Bmc Health Services Research, 18, 1

8- https://www.integration.samhsa.gov/about-us/what-is-integrated-care

9- https://www.nimh.nih.gov/health/topics/integrated-care/index.shtml

10- https://www.nytimes.com/packages/pdf/politics/factsheet_healthcare.pdf