Remarks by
A. Kathryn Power, M.Ed.
Director
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
Integrated Care: Transformation through Collaboration
April 15, 2009
Augusta, ME
PowerPoint Version (1.71MB)
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
[Slide 1—Title slide]
Thank you, Wendy [Wolf, President and CEO of MeHAF] for your kind introduction and for the invitation to join you at this important gathering. This conference couldn’t be timelier. The integration of mental health and general health care is more than just the latest fad and it’s not the wave of the future. It’s here today, and Maine has been a leader in thinking about, planning for, and implementing services that address the totality of an individual’s health care needs.
Do you remember when Wilfred Brimley advised us to eat our Quaker oats because it was “the right thing to do?” Providing whole health, person-centered, evidence-based mental health and general health care is the right thing to do for the health of individuals of all ages…for the health of our communities…and for the health of our Nation.
We may think that reforming the delivery of health care services is a luxury during difficult times but, in fact, it’s an absolute necessity. According to the American Psychological Association’s recent Stress in America survey, almost half of Americans say they are increasingly stressed about their ability to provide for their family’s basic needs.
Indeed, we know that the National Suicide Prevention Lifeline has experienced a 30 percent increase in calls over the last year, with crisis centers reporting a significant increase in the number of people who are calling because they have lost their job or their home or are afraid they will.
And sadly, the economic downturn is believed to be a factor in a spate of recent mass killings. The Washington Post reports that 57 people have died in a string of eight such incidents in the past month alone. Jiverly Voong, the gunman who killed 13 people in Binghamton, NY, before turning the gun on himself, was depressed after losing his job, but kept all of this “pressure” inside, his sister told reporters.
We must, therefore, redouble our efforts not so much to reform health care—with an emphasis on access and costs—but to reform the very way we think about health itself.
[Slide 2—Global burden of disease]
Integrated care and the premise on which it rests—that mental health is essential for overall health—represent a sea change in our thinking. In fact, I believe we have reached the “tipping point” where it is no longer appropriate to consider the mind and the body separately. Research, practice, and the wisdom of health care consumers themselves tell us otherwise.
We are here today to rejoin the head and the body by “creating the neck,” as Center for Mental Health Services Medical Director Dr. Ken Thompson is fond of saying.
That we must do so is an unquestioned imperative. We know that the top three leading causes of disability worldwide are behavioral health disorders, as reported in the World Health Report of 2001.
Closer to home, a study of Medicaid recipients in Maine found that individuals with serious mental illnesses have a significantly higher prevalence of major medical conditions than do individuals without serious mental illnesses. These include conditions that are in large part preventable.
Based on this study and research in more than 16 other States, CMHS and the National Association of State Mental Health Program Directors concluded that people with serious mental illnesses die, on average, 25 years earlier than the general population. This is a public health crisis that must be addressed.
I’d like to offer my thoughts in three key areas to help frame your discussions. They include:
- First, a historical perspective on efforts to provide integrated care. As we work together to transform the delivery of health care in this country, we need to understand where we have been.
- Second, a look at integrated care in the context of a public health approach to health care. This is where we must be heading.
- And finally, major Federal efforts that support the important work you are doing here in Maine.
[Slide 3—IOM 6 aims]
Integrated Care: The Early Days
The concept of an integrated approach to health care is not new. Hippocrates, widely credited as being the father of medicine, believed in a delicate interrelationship between the mind and the body. He maintained that an individual’s physical symptoms were affected by his or her psychological state, spiritual leanings, and social connections.
This integrated view of mind and body began to shift during the early part of the 17th when some prominent European philosophers began to develop the worldview that underlies today’s Western medicine. France’s Rene Descartes, in particular, viewed the “mind” as completely separate from the “body.” This partitioning ushered in a separation between so-called “mental” and “physical” health that persists to this day, despite scientific evidence to the contrary.
Thankfully, in recent years, the pendulum has swung again. In 2001, the Institute of Medicine gave us a framework for this new vision of health care. In its Quality Chasm report, the IOM called for health care in this country to be safe, effective, patient-centered, timely, efficient, and equitable.
These concepts underlie the principles of the Patient-Centered Medical Home, as proposed by four groups—the American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians, and American Osteopathic Association. The Patient-Centered Medical Home includes such components as a whole person orientation, care coordination, quality and safety, and enhanced access. It mirrors the IOM’s emphasis on a person-centered approach to managing multiple health conditions.
What does a person-centered approach mean in practice for people with mental and substance use conditions?
- It means that everyone in this country who needs treatment for a mental health condition has access to care when and where they need it.
- It means the care they receive is the highest quality care available, based on current evidence and practiced with fidelity to accepted models.
- It means that the services we provide are not only effective but also efficient, provided in the right amount, at the right time, and for the right reasons.
- It means that we empower individuals to take charge of their recovery and their lives, and we empower communities to provide the full range of services and supports that individuals need to live meaningful and productive lives.
- It means that we design services to reflect individuals’ values and needs.
- And it means that we address the root causes of illness morbidity and mortality, including poverty, inadequate access to medical care, and racial and ethnic disparities.
The best way to accomplish these aims is to meet people where they are, and for many individuals who have mental health conditions that means primary care. Indeed, half of all care for mental disorders is delivered in general medical settings. This is particularly true for certain groups, including older adults and racial and ethnic minorities, who may be uncomfortable seeking care in specialty mental health settings. Unfortunately, primary care physicians vary in their ability to recognize, diagnose, and treat mental disorders, leading to lack of treatment or inappropriate care.
[Slide 4—IMPACT]
Over the last 10 years, a number of studies have tested various models of an approach called “collaborative care.” Several focused specifically on the treatment of late-life depression in primary care. These include The Primary Care Research Study in Substance Abuse and Mental Health Services for the Elderly or PRISMe, funded by SAMHSA and several Federal partners, and Improving Mood–Promoting Access to Collaborative Treatment or IMPACT, funded by several foundations.
Regardless of the specific program, these models share two common elements. The first is systematic care management by a nurse, social worker, psychologist, or other trained clinician. Care managers coordinate the treatment plan, educate patients, provide follow-up, and monitor progress. The second key element is consultation among the care manager, primary care practitioner, and a consulting psychiatrist or other mental health specialist.
Extensive research has shown that these collaborative care models can achieve significant reduction in depression, promote better coordination of mental health and general health problems, and are cost-effective. They also help reduce ethnic disparities in quality of care. This is mental health transformation in action!
[Slide 5—Mental health continuum]
Integrated Care: The Public Health Approach
Clearly, there is a role for behavioral health care within the primary care setting. To recognize the importance of mental health to overall health, the National Council for Community Behavioral Healthcare (NCCBH) this week released a report that recommends we rename the patient-centered medical home to be the person-centered health care home.
I believe this name change is more than semantic. Individuals of all ages in this country need and deserve a health care team that is focused on promoting health and preventing illness, which is the very essence of a public health approach to health care. This is where we must be headed if we want to support healthy citizens, healthy communities, and a healthy Nation.
The Centers for Disease Control and Prevention, a sister agency in the U.S. Department of Health and Human Services (HHS), has embarked on a “Healthiest Nation” initiative. The key values that guide their work include the following public health concepts:
- First, health is valued as a person, community, national, and international asset.
- Second, health protection is understood as a strategic economic imperative by nations and businesses.
- Third, people have the information they need to make decisions when, where, and how they need it.
- And fourth, people are confident that the health system will protect them and provide effective and affordable care when they need it.
Public health is a community approach to preventing and treating illnesses. Its premise is that caring for the health of the individual protects the community, while—in turn—caring for the health of a community protects the individual. As such, health promotion is a primary focus of a public health approach.
Think about Type 2 diabetes. We now know that diet, physical activity, and even modest weight loss can forestall or prevent the onset of Type 2 diabetes in at-risk individuals.
In the same vein, we are learning that if we intervene early, we may be able to prevent the onset of some mental disorders, lessen their impact, or preclude co-morbid conditions and long-term disability.
Last month, the Institute of Medicine and the National Research Council released the much anticipated report, Preventing Mental, Emotional, and Behavioral Disorders among Young People: Progress and Possibilities. CMHS was pleased to support this update to the seminal 1994 report, Reducing Risks for Mental Disorders. That report provided the basis for understanding the science of prevention, examined early research in the field, and proposed areas for further study.
This new report focuses on our Nation’s young people. We know that half of all diagnosable lifetime cases of mental illness begin by age 14, and three-fourths of all lifetime cases start by age 24. We also know that first symptoms occur 2 to 4 years prior to the development of a diagnosable disorder, which means we have an important window of opportunity in which to respond. Unfortunately, data show a significant lack of access to services for both mental health and substance use problems for our Nation’s youth.
I’m pleased to be able to share with you two key findings from the new report. First, the 2009 update reveals concrete evidence that an increasing number of mental, emotional, and behavioral disorders are, in fact, preventable. Second, and equally important, this groundbreaking report goes beyond the 1994 report by recommending the inclusion of mental health promotion in the full spectrum of mental health interventions.
The authors conclude, “The nation is now well positioned to equip young people with the skills, interests, assets, and health habits needed to live healthy, happy, and productive lives in caring relationships that strengthen the social fabric.” This should be the vision for health care reform.
Just as a person-centered health care home supports prevention, it also recognizes the importance of the personal, social, economic, and environmental determinants of health. Indeed, The World Health Organization defines health as “a complete state of physical, mental, and social wellbeing and not merely the absence of disease or infirmity.”
Unfortunately, for too long, we have excluded people with mental health conditions from the social fabric of our lives. We know that social exclusion increases the likelihood of significant psychological distress and psychiatric illness, including substance abuse.
On the other hand, social inclusion means that we adopt policies and activities that are not necessarily planned as mental health interventions, but—because they improve access to a wide variety of resources—have important mental health effects.
This means that we must confront the poverty that cripples opportunities and worsens health outcomes for many individuals with mental health conditions. As the authors of the new IOM report point out, “the future mental health of the Nation depends crucially on how…the costly legacy of poverty is dealt with.”
We must promote employment, volunteerism, social connection and other meaningful activities for individuals with mental illnesses, who have the highest unemployment rates in the Nation.
We must address the inequitable distribution of health care resources.
And, most important, we must work to eliminate the discrimination, fear, and bias that keep individuals with mental health conditions at the margins of society.
Ultimately, without access to housing, health care, meaningful activities, and social support, individuals of all ages are excluded from all that it means to be healthy in today’s society.
[Slide 6—NCCBH quadrants]
Finally, the concept of a health care home underscores the fact that not only do we need to integrate mental health into primary care; we also need to integrate primary care into mental health. The early mortality statistics I cited make clear that many individuals with the most serious mental illnesses do not have adequate access to health care resources.
Indeed, studies reveal that individuals with mental disorders receive low rates of preventive medical services, even when they are actively treated by primary care providers. Discrimination, lack of coverage, and difficulty fitting into the fast paced model of primary care are among the many reasons this disparity exists.
The newly enacted Mental Health Parity and Addiction Equity Act requires insurance coverage for mental and substance use disorders to be equivalent to that offered for other medical conditions. This hard-won legislation is testament to the growing recognition of the need to integrate care for mental health and general health problems.
But parity alone is not the answer, particularly for people with the most serious illnesses who are served in the public sector. We must be diligent in promoting a whole health approach in both the specialty mental health and primary care sectors. Earlier this month, SAMSHA released a grant announcement seeking to fund the inclusion of primary care into mental health, which I’ll discuss in a moment.
Ultimately, person-centered care requires that each individual is treated in the health care sector that is most equipped to serve them, by the practitioner who is best prepared to address their full range of needs. In a 2003 paper on behavioral health/primary care integration, NCCBH proposed a four quadrant clinical integration model to reflect this fact.
In the report it released this week, the Council updated this approach to incorporate the principles of a person-centered health care home. The model is not prescriptive about how care is organized, nor does it preclude individuals from receiving care in multiple settings. But it does provide an important framework in which to consider the practice elements and clinical roles required to provide whole health, person-centered health care for a range of mental health and general health conditions.
[Slide 7—Federal Partners]
The Federal Response
The work you are doing here in Maine, and in States and communities around the country, is the center of gravity for health care transformation. At the Federal level, we can stimulate and support and compel such innovation, and I’d like to share several recent and ongoing efforts with you.
For three years, ending in 2005, SAMHSA and the Health Resources and Services Administration—a sister agency at HHS—funded the Collaboration to Link Health Care for the Homeless Programs and Community Mental Health Agencies. People who are homeless are especially burdened by the need to find care for multiple, overlapping conditions. The collaboration was designed to build capacity for mental health screening and assessment in homeless health care programs and to promote outreach and engagement in community mental health agencies.
Across the 12 sites, the most common service integration strategies were co-location of services, joint staffing, cross referral, and clinical case management. As a result of these interventions, individuals spent fewer days homeless, were less likely to be hospitalized, and reported increased satisfaction with life. This is transformation in action!
Because we know financing barriers can stymie even the most dedicated efforts at integration, SAMHSA, HRSA, and the Centers for Medicare and Medicaid Services identified barriers and developed solutions to permit mental health services to be reimbursed within primary care. Our report, Reimbursement of Mental Health Services in Primary Care Settings, is available on the SAMHSA Web site at www.samhsa.gov.
SAMHSA and HRSA also co-lead the Federal Partners Workgroup on the Integration of Primary Care and Mental Health. The Federal Partners comprise a group of more than 20 Federal departments and agencies that meet together to plan collaborative activities on behalf of people with mental health conditions. Our efforts are not codified in law and they receive no special funding. We meet together as concerned citizens, mental health professionals, and stewards of public resources to transform the delivery of health care in this country.
I’m pleased to note several major accomplishments of the Primary Care/Mental Health Integration Workgroup. Recent activities include:
- First, development and updates to a compendium of integration activities across participating Federal agencies, which can be downloaded from our Web site.
- Second, development of a report on the Integration of Mental Health, Substance Abuse, and Primary Care, prepared by one of the Agency for Healthcare Research and Quality’s Evidence-based Practice Centers. This comprehensive report examines state-of-the-art research on behavioral health/primary care integration—including models for integrating mental health into primary care and vice versa. It examines barriers to implementation and sustainability and features program examples. You can download a copy of this report from the AHRQ Web site.
- And third, a listening and learning session called “Making It Real” that brought together a group of early innovators with those who want to adopt and adapt integrated behavioral health and primary care models. The meeting was held at the Morehouse School of Medicine in collaboration with the Carter Center. We hope to make a summary of this session available soon.
Finally, I want to highlight our newest grant program. SAMHSA is now accepting grant applications for the Primary and Behavioral Health Care Integration program. We hope to improve the physical health status of people with serious mental illnesses by supporting communities to coordinate and integrate primary care services into publicly funded community mental health agencies. We expect the services we fund will incorporate a prevention and wellness approach and show cooperation and collaboration across community mental health and primary care.
This grant announcement reflects our commitment to reduce early mortality among people with serious mental illnesses by 10 years over the next 10 years, which we call our “10 by 10” campaign. The 10 by 10 campaign is the outgrowth of a SAMHSA-sponsored summit that resulted in a National Wellness Action Plan for People with Mental Illnesses. The plan is built on the following vision:
We envision a future in which people with mental illnesses pursue optimal health, happiness, recovery, and a full and satisfying life in the community via access to a range of effective services, supports, and resources.
In Maine, you are helping some of our most vulnerable citizens access the full range of mental health services, general health care, and social supports they need to live full and satisfying lives. This is a beacon of hope for all of us doing this challenging and rewarding work.
[Slide 8—Suicide Lifeline]
Veterans Health Care
Before I leave you this afternoon, I want to touch on a topic that is near and dear to my heart. I am heartened to see that one of your statewide projects concerns the health care needs of our returning servicemen and women. As a retired Captain in the U.S. Naval Reserve and a mental health professional, I am deeply troubled by the significant number of suicides among both active duty personnel and returning veterans. There is no greater indication of a lack of comprehensive, coordinated health care. Yet we know that suicide is a preventable tragedy.
I recently had the privilege of testifying before the Senate Armed Services Committee with some of our foremost military leaders. It is clear they are committed to address the invisible wounds of war—including posttraumatic stress disorder, traumatic brain injury, and depression—before they lead to the ultimate act of desperation…the taking of one’s life.
This is one of the reasons that SAMHSA added a feature to the National Suicide Prevention Lifeline so callers can identify themselves as veterans and be connected to professionals from the Department of Veterans Affairs. As a result of this collaborative effort with VA, when individuals dial the Lifeline at 1-800-273-TALK, they hear: “If you are a U.S. military veteran or if you are calling about a veteran, please press ‘1’ now.”
In its first year of operation, more than 67,000 veterans called the Lifeline, leading to more than 6,000 referrals to VA Suicide Prevention Coordinators. Another 780 callers identified themselves as active duty military.
This type of collaboration—between a health services agency and a veterans’ service organization—exemplifies the level of cooperation, commitment, and resource sharing necessary to transform the delivery of health care in this country. I know we are all up to the task.
[Slide 9—RFK quote]
Wrap-up and Closing
I’d like to leave you this morning with these words from Robert F. Kennedy, who said:
Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope…and crossing each other from a million different centers of energy and daring those ripples build a current that can sweep down the mightiest walls of oppression and resistance.
Thank you for sending forth tiny ripples of hope—and for resisting the impulse to maintain the status quo—as you strive to ensure that each and every American has access to whole health, person-centered health care. They deserve nothing less.
Thank you. If we have time, I’m happy to take your questions.
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