Beyond the ACA, Part One: Make Mental Health Part of Overall Health

Ron Manderscheid, Ph.D.
Executive Director, National Association of County Behavioral Health and Developmental Disabilities Directors

Without access to care, sustained recovery is not possible.Ron Manderscheid

That’s why each opportunity to break through barriers to access is critically important. When access to care becomes universal, millions of people with mental conditions who don’t get care today will get care. That care will be grounded in evidence-based practices and focused on the whole person, not a diagnosis.

Problems will be caught early; symptoms will be mitigated early in their course. And, ultimately, we can help make recovery not a potential outcome, but rather the expectation.

But change doesn’t happen overnight. Overcoming barriers to behavioral health care access requires persistent action and effort to target and sustain new ways of framing, delivering, and sustaining services and supports.

Behavioral health is part of overall health.

Slowly but surely, policy makers and researchers are reuniting brain and body in their thinking. That reunion has begun to help break down barriers to access, reduce the stigma that still surrounds mental health problems, and promote prevention and early opportunities for intervention. And it’s about time!

But to create an environment in which access is open to all, that policy and research reunion needs to be matched by a comparable reunion in program and practice. A number of structural changes—each an opportunity for our action and advocacy—can become the building blocks for full access to behavioral health care as part of overall health care.

Three Ways to Change the Structure of Community-Based Care

  1. Ending silos of care. In many places, state and county mental health and substance use service authorities are entirely separate from the state or county health care agencies. So too are their funding streams and the service programs those funds support. In some locations, behavioral health agencies are, themselves, split.

    When resources become limited, as they are today, program silos for behavioral and physical health—and between mental health and substance use services—often breed competition and adversarial relations, not collaboration and coordinated care. If we want to adopt a whole-person approach to health, organizational silos are not the ideal. Thus, we must advocate for breaking through a history of segregation.

  2. Providing integrated careIntegrated care recognizes the interplay of health and illness between body and brain. In practice, it may involve a health care team working under the same roof to prevent, assess, and treat an individual’s entire range of physical and behavioral conditions. Alternatively, integrated care may be achieved through collaboration across service sites.

    Integrated care makes every door to health care the right door to comprehensive, collaborative assessment and care for both physical and mental health. It patches gaps in the system so no individual falls through by emphasizing the whole person, not an individual disorder or illness. Is integrated care, however it is provided, practiced in our communities? If not, we should advocate for it.

  3. Establishing wrap-around service availability. We also need to provide supplementary supportive services to promote sustained recovery. Housing, job supports and placement, habilitation and rehabilitation, and transportation all play a role to a greater or lesser extent in a person-centered approach to community-based care and recovery.

A particularly promising model that can help achieve these structural aims comes in the form of a “health home.” It’s not a place. It’s a concept based on the premise that an individual’s health needs are served best in an environment in which there is a single door to all behavioral and physical health care needs across the continuum of care from health promotion through recovery.

With a health home, service silos become a thing of the past; supportive services are ways to build a person’s recovery and future. And early and integrated care becomes a standard for care, whether created by moving behavioral health into primary care settings or primary care into behavioral health settings.

Federal agencies are proposing adoption of the health home model through grant programs to communities across the country.

What’s happening where you live? Are these structural changes occurring in your community? 

9 comments
MotherofMims
MotherofMims

What's happening where I live? Discrimination against people with Severe Mental Illness. No expansion of Medicaid in my state. Oh no, my Governor won't take any Federal dollars, for ANYTHING! Homelessness and jail for the SMI, and our Baker Act facility isn't fit for a rabid dog! Baker Act works once properly medicated, but those are the lucky ones who can be admitted to a private mental hospital and pay out of pocket. The state doesn't care, they get you stabilized and throw you back out on the street in a couple of days. They don't follow through with keeping the patient's health maintained. We're screwed. No one cares. Laws need to be changed. Or SOCIALIZED MEDICINE like any other 21st century country. And no, I'm not leaving, I'd rather fight for people to being medically treated humanely. My family didn't leave the "Old Country" just for each and every generation to fight America's wars, and then die penniless or in the streets because they have an illness.

Celeste T
Celeste T

I used a poor description  "Shoved into Health Homes"  I forget so many do not understand a Health Home is not a place it is an approach to medical care. Folks are being put into this form of health care approach going in uninformed.

Celeste T
Celeste T

The concepts are good ones I support 100%, treat the whole person, but if folks are just shoved into Health Homes without being informed on what it is all about they will not be near as effective as they can be.  

In our area no one is taking any time to educate or share information with the users of the Health Home face to face on what is going on. For us peers here we are working hard trying to find out all we can on our own and some of us have been following the process for over 2 years when they first were being formed in our area the summer of 2011 when we first heard about them. We are sharing between ourselves what little we know in any manner we can. Watching as many webinars we can find which 99% are forcused for the providers hoping to gain more understanding then via Word of mouth, Peer driven support websites, social media, Google + Hangouts, peer driven newsletters we are trying to share the information that applies to how we will be living them the best that we can tell. We know how effective treating the whole can and is. We believe in Recovery.  We want wellness.

For our state all that is of concern is the money aspect and it has nothing to do with Recovery or our wellness.  What is surprising (but is it really though) is our state Health Department and Medicaid by not giving the "financial support" needed for peer inclusion in the health home process the opportunity to reduce ED visits, Hospitalizations and rehospitalizations within 30 days is being greatly compromised.  From my perspective no one in leadership in these agencies has any common sense, they just don't get it.

I have concerns about the way electronic information is shared.  The consent forms used leave something to be desired.  Your information is automatically shared with the Health Home then you can "Opt Out" of being in one. You have lost all your right to privacy. After the fact, after the Health Home has access to ALL your medical information "behavioral health records" which they have the right to save in any format they choose, print, enter into their databases etc. then you are allowed to "Opt Out". So now your information is in their database so what happened to privacy of your behavioral health rmedical information? A person should be offered the opportunity to say no first before any information is shared with the Health Home not the other way around.

The plus side in our state, Medicaid Redesign and money is forcing something to occurr that is great and that is throwing out the Medical model and using a Recovery approach to wellness.  So us peers will benefit but the next hurtle....teaching the providers how to ustilize a Recovery approach to wellness.



CFYM_Host
CFYM_Host moderator

You are clearly ahead of the curve as most people have not yet heard of the term "integrated care," much less what the term means or what models of care are being discussed and pilotted across the states.  And I won't disagree with your assessment that most information currently out there has been designed for providers.  We hope you'll continue to follow this blog as we plan to feature more information and discussion about integrated care in the coming weeks. 

 In the interim, we'll be on the lookout for consumer focused resources on the topic.  For basic information, consider viewing SAMHSA's  tip sheet, "Understanding Health Reform: Integrated Care and Why You Should Care (www.samhsa.gov/healthReform/docs/ConsumerTipSheet_IntegrationImportance.pdf).  

Anyone else out there with some thoughts on resources for consumers on integrated care? 

Celeste T
Celeste T

@CFYM_HostCeleste T

24 minutes ago

@CFYM_Host Thank you for your reply.  There is a weakness in our system in regards to the Health Home process and believe it or not they forgot about us!  Strange as it sounds it is true.  No one has taken any time to talk with peers in our system about the new approach to healthcare using a Health Home. We are in the mist of using them already and are still waiting to here anyone explain what is going on. We are the ones doing the research to find out on our own.

What is a Health Home? Who is our Health Home?  What is the consent form? Why is it needed?  What does it do? Why do I have to sign it and who gets to see my mental health records? Who or what is a navigator? What is a care manager? Who is the care manager? 

 These terms most likely are unique to our system as I am sure the nomenclature across the country as Health Homes are looked at will most likely be identified in their own way but I hope you see what I am trying to convey.  We don't matter, it is the data and the records and the billing and all the other ingredients that are being attended to but no one remembers us, the person the whole blasted system is being put together for.  Go figure.

I believe 100 % we should be attending to our needs as a whole attending to our mental health issue and physical health needs simultaneously but the implementation leaves a lot to be desired from my point of view.

I support the use of the technologies to share medical information but in regards to mental health there is no reason my Cardiologist needs to see "ALL" my mental health records.  He needs to be aware of what medications I am on but why is "ALL" information sent to him and that is what our official state "consent form" says.  The word "ALL" is capitalized. "All" my behavioral health medical records will be sent out.  If the Federal system uses this same approach to loss of privacy then I am super concerned for all my friends across the county.

Both physical and mental health should be addressed as a whole which is what the Health Home concept is about but it is the implementation of one without including feedback from the user nor informing consumers of what this process is about that is the failure.

The purpose of a Health Home is to communicate between medical health providers. How about the communications link with the user.  Check the flow charts is there a link to the person or just the data collected.

Iris40
Iris40

As Celeste mentioned the concept of a Health Home is wonderful but not if people are just shoved into a practice.  Also, this is harder to implement than it appears.  On a somewhat humorous note, my Primary Care doctor as been in four different practices since I began seeing her seven years ago.  So what is a patient to do, stay with the doctor or the practice?  The last time EHR caused a twist. She gave the new practice automatic rights to her patients' records.  I did enroll as someone who would allow any doctor that needed to see my records could, but I didn't expect something like this to happen.  I thought they would be used only in emergency situations.

MotherofMims
MotherofMims

Thank you for links to additional information.

Celeste T
Celeste T

@Celeste T @CFYM_Host  The event was informative.  It is a start.  I am really pleased to see our agency take this first step which I hope will be followed by many more which at this point i think they will be in regards to sharing info between the providers and the recievers of services.  That's all for now folks.

Celeste T
Celeste T

@Celeste T @CFYM_Host   Update:  Our Public Mental Health Recovery services program has now planned a Q&A for folks to learn more about intetrated care the "Health Home" this week.  It is very encouraging to see this happening. 

Although I no longer receive public mental health services now using a private provider I have been welcomed to attend the event. I hope this will be a reoccuring event since the client base in our focused Recovery program is always changing.

This Q&A is not the time to address questions about controversial parts of the implementation of the approach.  Integrated care is here to stay. This Q&A is the time to address folks questions on how will it effect them.

This is a great step forward in our system and most appreciated by those of us concerned about this need for the sharing of information.