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January 26, 2015 - Kim Moore [see other posts]

Putting the Pieces Back Together

Putting the Mind Back Into the Body

A great article appeared in the Wall Street Journal ("Tot Therapy: Psychiatrists Join Up With Pediatricians," January 13, 2015, D. 1) reporting how a large pediatric practice in the Bronx had successfully integrated behavioral health into its practice. The benefits to consumers were many and the effectiveness of treatment was being demonstrated. The health problems are being addressed wholistically, recognizing that physical and behavioral health issues co-occur and influence each other.

It is a strange fact of our American health care system that some health conditions are segregated out for treatment. Almost always due to historical accident, we find some body parts not welcome for service in the traditional medical settings of physicians' offices and hospitals. For years I wrote articles with a similar theme under the name: "putting the mouth back into the body." Dentistry has grown up as a stand-apart model of care with separate education sites, professional organizations, insurance and operating businesses. Only very occasionally are dentists even credentialed members of hospital staffs, and serious dental problems appearing in emergency rooms are temporarily "bandaged" (pain pills and antibiotics) for possible treatment later at a different location with an appointment. The Health Ministry Fund for years invested in programs to bring dental preventive and basic treatment to where people are otherwise located: physicians' offices, schools, safety net clinics, etc. We continue that effort through support of the dental therapist occupation for Kansas. See more about the Kansas Dental Project at kansasdental.com/care.html.

With mental health, the division is only slightly less severe than dentistry. Physicians regularly provide mental health interventions for patients, and they are licensed to do so. There are, however, considerable limitations, generally self-imposed by physicians, on the scope of behavioral health services available. For example, surveys demonstrate that physicians are often reluctant to screen young children for behavioral health issues because they don't feel comfortable treating them and are unsure if there are places to accept their referrals if they screen into treatment needs. See KansasKidLink.org/resource-directories. It is relatively rare to find a mental health professional co-located with a physician practice. Likewise, only occasionally can one find a physician co-located inside a mental health center.

Change is coming, perhaps fairly quickly, due to transforming issues inside health care delivery. As new bundled fee structures make all health care providers more responsible for "total body" patient outcomes versus incremental service delivery, the need for effective behavioral interventions for patients assigned to medical practices is becoming more evident. Likewise, the poor physical health of many persons with chronic mental health issues is driving improved case management techniques inside mental health centers, which are again increasingly responsible for the entire care of their patient base. Kansas is implementing a new health home program for high user segments of the Medicaid population requiring development of integrated mental and physical health services to better serve consumers and also reduce costs.

A recent training provided by Cherokee Health Systems (Knoxville, TN) in Hutchinson (sponsored by Horizons Mental Health Center) provoked very interesting discussion among some of the community's health providers (Hutchinson Clinic, Hutchinson Regional Medical Center, Horizons, Reno County Health Department and PrairieStar Clinic). Cherokee operates a very successful national model of integrating medical and behavioral health care inside a federally-qualified health center with multiple locations. They have many great lessons to share and have educated many in Kansas with support from the Sunflower Foundation and the Kansas Association for the Medically Underserved (and others). Our local providers discussed multiple possibilities (some already implemented with Horizons and PrairieStar) at bringing behavioral and physical health services together. Crossing existing professional and operating boundaries and the turfs associated with those borders is not easy, but there appears to be an increasing desire to do so, driven by the financial realities of reformed payment systems as well as the demonstrated improved patient outcomes when real integration is present.

Philanthropy needs to continue to encourage this integration process, and we anticipate doing so through rural pilot projects bringing mental health centers and critical access hospitals/rural health clinics into greater cooperative structures. Likewise, there need to be more opportunities for diverse health providers to learn together and brainstorm new patterns for integrating care. There is a possibility that, in all the turmoil of change in health care, consumers and diverse providers might find opportunities to create places and systems which actually care about the whole person in cost-effective structures producing better results. Mind and body reconnected! What a concept!

Footnote: Please note that co-location may not be the right approach for good integration of care. It is frequently only a first level approach to more effective integration.