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Behind the Buzzword: What is “Integrated Care”?

Sharon Post and Renae Alvarez
June 13, 2017
Health & Medicine is hosting a forum on Wednesday, June 21 to share lessons from members of our Behavioral Health-Primary Care Integration Learning Collaborative. “Integrated care” has become a buzzword in health policy and we’d like to define what we mean by integration in the Learning Collaborative. We’d also like to describe Health & Medicine’s goals for the forum, which are to engage audiences around the lessons learned in two years of the Collaborative, to advance the discourse around state-wide mental health and Medicaid reforms, and to magnify the voice of people with mental illness and substance use conditions in these discussions.

What do we mean by integration?
When we first convened the Learning Collaborative, we knew we needed to build a sense of common purpose. We started by working together on a consensus definition of behavioral health-primary care integration. After some lively conversation and one working webinar, we arrived at a revised version of the National Integration Academy Council’s definition:
“Care that results from a practice team of primary care and behavioral health clinicians—who partner with community-based and wraparound service providers—which may include co-location and electronic health records (EHRs) sharing data, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address physical health, mental health, and substance use disorder conditions, health behaviors (including their contribution to chronic medical illness), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.”
Having agreed on a definition, we then had two other big questions: What ‘direction’ of integration was the Learning Collaborative working on—integrating behavioral health into primary care, or primary care into behavioral health settings—and what defines success with that mode of integration?

Directions of Integration
Behavioral health integration commonly refers to models that provide behavioral health services in primary care settings. We chose to focus on the “reverse” direction—integrating primary care into behavioral health settings. In making that decision, we were influenced by the work of Martha Gerrity, who points out that the evidence base for integrating behavioral health into primary care, especially for people with depression and anxiety, is far more advanced than for the other direction, integrating primary care into behavioral health settings. Research on integrating primary care into behavioral health—which shifts the focus of integration to individuals with severe mental illness (SMI) and substance used disorders (SUD) who are more likely to present at behavioral health providers than at primary care offices—is more sparse. Gerrity notes that existing research on behavioral health integration for people with SMI or SUD “do[es] not describe the models or target populations in enough detail to assist policymakers with implementing the models.”

Because a major goal of the Learning Collaborative is to assist both providers and policymakers to implement integration strategies (in partnerships with payers and consumers), we felt called to address this gap in research and practice. With our charge to generate learning among our members to further the integration of primary care into behavioral health, our next move was to develop criteria for assessing progress toward integration.

The Six Criteria
We adopted Gerrity’s view of integration as a continuum in which a set of strategies are arrayed in different configurations depending on the needs and resources in different communities. As systems progress along this continuum, patients and providers experience all services as a single system that wraps around the “whole person.” There are many roads to this level of seamless integration, but what defines progress along the way?

We asked the Learning Collaborative members, “What characteristics must a model have in order to be integrated, according to our definition?” After much deliberation, and more working webinars, we arrived at our Six Criteria: An integrated practice must be person-centered, evidence-based, and financially sustainable and provide comprehensive core services with clear workforce and technology standards.

We use the Six Criteria to keep us honest as we continue our work. Any intervention that helps fulfill one criterion must not violate any of the other five. This is an important accountability measure. When, for example, we are imagining bold solutions to the technical barriers to information sharing between providers, we are compelled to ask if we are meeting the demands of our person-centered criterion.

Goals for the Forum
When policy makers, practitioners, and researchers talk about behavioral health integration, we are essentially talking about people with SMI, SUD, and complex health needs. At this forum we want to meaningfully include those voices in the conversation. Taking action to include the perspectives of people with disclosed mental illness and substance use issues will only progress and enrichen the discourse around recovery-oriented care. We also seek to demonstrate the feasibility and value of including people with lived experience in every level of practice change and policy making.