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Senior leaders of Trinity Regional Health System for the Quad Cities, a regional division of Des Moines, Iowa-based UnityPoint Health, were examining a proposed community survey to screen for heart disease when David Deopere noticed there was no consideration of depression as a risk factor.

"That should be in the survey," he remembers telling the executive team, explaining that research shows depression doesn't just make heart disease worse and harder to control, but it also plays a role in causing it. The president of Robert Young Center for Community Mental Health was there to add that perspective to a mainly medical conversation because the Moline, Ill.-based center has equal standing with the organization's four hospitals. Not just a service line, Robert Young is a separate nonprofit corporation and one of the few such centers to become part of a health system.

"Under one umbrella there is a full array of services for the severe and persistent mentally ill, the chronically mentally ill," Deopere says. "We have both inpatient and outpatient chemical dependency [treatment]; we run the psychiatric emergency service and the [mental health] access center. We don't contract with the hospital to do that; we, in fact, do it. We run inpatient psychiatry, child and adult; and we also have an entire array of outpatient child, adult and senior services at a number of locations." That depth of behavioral health capacity arms Deopere with the understanding to inject into executive issues.

Innovative Staffing

Whether it's a seat at the corporate head table or something short of that, health care organizations in the era of outcomes-oriented treatment and payment have to incorporate behavioral expertise to understand how mental illness and substance abuse affect overall care delivery. Behavioral health hospitals or community mental health centers can be woven into the continuum of care or a dedicated department within the health system can serve the purpose.

In Louisville, Ky., Our Lady of Peace has operated since 1951 as an inpatient mental health facility and, over the years, has expanded into a full range of outpatient and community-based services. It was part of a Louisville system that included Jewish Hospital and St. Mary's Healthcare, which then became part of KentuckyOne Health, a nonprofit system that also serves Lexington and rural eastern areas of the state. The expertise and resources of that health system allowed OLOP to look at innovative approaches to behavioral health integration sooner rather than later, says President and CEO Jennifer Nolan.

For example, the Louisville division of KentuckyOne developed a program to send patient navigators into homes of people at high risk of readmission to help them understand their respective physical conditions better and comply with discharge instructions. During the first year, navigators realized that these people had behavioral health problems that weren't being addressed. Input from experts led to the addition of a peer support specialist, a trained and certified lay person who has experienced the same behavioral issues as patients and who relate to patients and gain their trust, Nolan says.

"This isn't a professional coming in with a suit and saying, ‘Hey, I'm a therapist. What can I do to help you?' This is someone who has lived what they're living now," she says. The support specialists identify barriers to ongoing treatment, explain why specific care is helpful, "and really give them that hope and the little bit of energy that they need to reach out and get connected with a community resource."

Montefiore Medical Center's successful shift to care coordination, including its behavioral aspects, stems from nearly 20 years of formal efforts to instill medical and mental health management practices in its teaching hospitals and faculty medical group. In the mid-1990s, the New York academic medical center formed a centralized care management program, now headed by Henry Chung, M.D., as well as Behavioral Health Associates, which initially focused on risk-based contracting with health plans and evolved into a vehicle to provide behavioral services in primary care.

In the mid-2000s, Montefiore received a grant from the Robert Wood Johnson Foundation to identify and screen people undergoing chronic-disease management for signs of depression, then alert physicians in the network about these patients and advise them on what to do, Chung says. Rather than assign behavioral pros to all the varied physician practices on four health care campuses and beyond, the model for a "synergy team" called for a central office of behavioral and medical care managers to provide services as needed at practice sites. Licensed clinical social workers stationed at practices, for example, are supervised by psychiatrists operating from the care management center.

The form of integration at any particular practice was based on financial, practical and cultural factors, says Chung. Some practices are quite large with significant teaching functions, where it makes sense to embed as many clinical resources as possible. Others are smaller, where the culture would make it difficult to absorb behavioral professionals — or where space may be at a premium. Chung says evidence is emerging that a hybrid approach might be more cost-effective than locating a full array of medical and behavioral options in every practice site.

Tangible, Intangible Benefits

Health care organizations that don't have the benefit of in-house behavioral experience can start their own approach to integration, including tapping whatever expertise is in the area. In Salt Lake City, Brenda Reiss-Brennan had a private outpatient family-therapy clinic that had figured out a way to address behavioral needs. Word got around to Intermountain Healthcare physicians at one practice, and they referred families they could not manage effectively.

Intermountain engaged her as a consultant, along with its own experts, on clinical integration to build a pilot project to integrate mental health as a part of the treatment for all patients with diabetes, asthma and other difficult chronic diseases. Reiss-Brennan joined full time in 2001 as the mental health integration director. That first integration attempt expanded to seven practices as a result of a Robert Wood Johnson Foundation grant enabling the development of clearly defined treatment protocols, registries for both diabetes and depression, and the ability to merge them to see who had both.

"At that time we had high physician satisfaction, high patient satisfaction and neutral cost to the [Intermountain-owned SelectHealth] health plan — it wasn't costing any more money," Reiss-Brennan says. "And patients were getting better based on the depression outcomes that we were measuring." It was enough for the health system's leadership to further expand the mind-body integration initiative to 25 additional clinics and organize the approach so it could spread organically, she says. Additional operational support has been added across the system "so they could really make this regular life in all the clinics."

The care-integration incentives provided by health reform are an opportunity to organize for "incredibly rewarding work," Chung says. "We've largely ignored a lot of these patients from a systems perspective, because of the separate funding streams traditionally in the fee-for-service world" and exacerbated by the behavioral health carve-out movement of the 1990s. "And so this is the right time to bring it all back together. There's tremendously high patient satisfaction in doing this, but there's also high physician satisfaction. Providers feel they really are beginning to address the whole person when these resources are made available to them."

For more on integrating behavioral and medical care, read the October cover story, "The Evolution of Mental Health Care."

John Morrissey is a writer in Mount Prospect, Ill.