BY CARRIE MARION, RN, BSN, CCM
For the past twenty years or so, the healthcare industry has been talking about holistic medical care, now termed whole person care. Of adults with behavioral health disorders, 67 percent do not receive adequate treatment. We know that one-fifth of patients who have heart attacks have depression. We also know that the chance for another heart attack in these patients is tripled if the depression is not treated. Cardiovascular disease is one of the leading causes of death in patients with serious mental illness (SMI). Contributing factors include obesity, smoking, diabetes, hypertension and dyslipidemia, which can contribute to cerebrovascular incidents as well. Patients who are taking antipsychotic drugs have an increased risk of cardiovascular disease, coronary artery disease and cerebrovascular disease. People with schizophrenia are three times more likely to experience sudden cardiac death. Substance abuse and mental health issues are co-occurring frequently, which also contributes to physical health issues, and as we know, physical health issues can contribute to mental health issues and lead to much higher and earlier mortality.
Several other factors also play a part, including social determinants of health issues that are experienced by persons suffering from mental illness and substance abuse. Some of the disease burden of physical and mental illnesses are contributed to by socioeconomic disadvantage, substance abuse comorbidity, medication side effects, unhealthy behavior and neglect of self-care. Added to issues of access to housing, appropriate nutrition, safety and no access to health insurance, it is not surprising that these individuals have difficulties obtaining general care.
As a healthcare system, we have been able to integrate many previously siloed functions into integrated delivery systems. However, integrating behavioral with physical health has remained fairly elusive. Our health system has long been fragmented and lacked collaboration and coordination. We have had some success in data delivery but still continue to be plagued by EMR inadequacies and limited ability to share data across systems, companies and practice settings. Because of the wide separation between general and mental healthcare, coordination between behavioral and physical health has not been very successful.
Having worked in a variety of different practice settings and across many different payer perspectives, in care management as well as quality, it seems to me that there has been a wide cultural separation between behavioral and physical health historically. In my opinion, the place where transformation has to occur is with the primary care provider community working together with behavioral health professionals on the grass roots level with patients. Many patients with BH conditions are being seen at the primary care provider offices, presenting the opportunity to replace separate systems of care that do not adequately meet the needs of patients with integrated, “whole-person” care. Historically there have been separations in training, payment and delivery systems in these areas of health that has prohibited integration.
Today, we are starting to see the emergence of different payment structures and delivery models that will support this integration and facilitate the pursuit of better patient experience, lower costs and improved population health, the Triple Aim in healthcare. In reviewing various programs, there are some central themes that continue to pop up.
The Patient Centered Medical Home accreditation initiative has gained wide acceptance. That seems to be the perfect vehicle for operationalizing more coordination between behavioral health and physical health for the patients. Data collection, management and reporting is central to this process, so the EHR used needs to include several operational components, including the ability to be provided to all participants, including physicians, care managers and consumers. Information both from and to the consumer is essential with clinical reminders, self-scheduling, secure email with providers, prescription refills and educational content. All medical providers need access to real-time information regarding patients as well as detailed data collection and reporting on defined, priority outcomes to measure progress and drive improvement. Defining outcome goals helps to drive accountability and to demonstrate the value of integrated care across the system. On the quality side, choosing relevant measures and establishing processes to obtain and analyze data will inform your basic premise of change or lead to further analysis of what steps will lead to the outcomes you are looking for. Sharing all data helps drive the motivation to change within the organization, and creating the feedback loops will continue to inform what is working and what is not working for continuous quality improvement.
Relationship development and identification is key, as well as the realization that there will be changes as time goes by. The ability to implement change management requires steady and adaptive leadership and will require continuous evaluation and course correction as needed. All of the key stakeholders need to understand the need for shifting the way care is delivered and accept the fact that there will be stumbling blocks along the way. The organizations need to do a very focused evaluation of the ability for change to occur in the organization and put people (change agents) into specific positions that will support this type of change.
Health plans and provider organizations have been rolling out value-based contracts for some time now. These contracts need to emphasize and reward quality and efficiency leading to improved patient outcomes and lowered costs while achieving the quality results desired. Our early value-based contracts do not always hit this mark. Reimbursement for telehealth and bringing healthcare to those disadvantaged areas where care is not easily accessed can help to improve the quality of care rendered to patients in these underserved areas.
Case and care management systems have long been focused on a collaborative model of care, both for catastrophic-type patients as well as chronically ill patients. Case managers are essential to this process from the standpoint of patient navigation through the system, to developing appropriate plans of care, and managing the execution of those plans as well as monitoring the patient through the entire continuum of care. Care managers are experienced and can be champions of the integrated model of care and can focus on bringing all the entities together in a collaborative approach. Care managers are experts in transitions of care, so they can and should assist with all transitions to make the healthcare journey safer and more reliable for each patient. Utilizing care managers in this way is not the usual approach; however, in an integrated, whole-person environment, it will be essential to a consistent and successful program.
There is still a long way to go. Starting with the primary care provider makes sense to me, and then evolving to incorporate more collaboration with specialists, facilities, all through the continuum of care to insure a safer, more coordinated journey through healthcare for the patient with much more proven positive outcomes, along with cost and resource management. ■
Carrie Marion, RN, BSN, CCM, is director of quality and community outreach, Prestige Health Choice. She has extensive experience in the care management industry including case, disease and utilization management, as well as behavioral health and quality. She has worked in all payer systems, including commercial, self-funded, Medicare, Medicaid, and Department of Defense, and has led accreditation efforts with all major accreditation organizations. Carrie has wide-ranging in the professional development of case management including as a founding member of CMSA, assisting in the development and leadership of the CCM certification process, and advising on case management standards of practice as well as standards for accreditation.
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BY CARRIE MARION, RN, BSN, CCM