The Integrated Behavioral Health Continuum: Theory and Practice

It is paradoxical that with the great increase in our understanding of health and disease and progress in medical treatment there continues to be such great dissatisfaction with the way we provide health care. The high cost to the individual and to the nation, the maldistribution of resources, and the byzantine payment mechanisms are just some of the causes of major complaint. Another problem with the way we provide health care is the fragmentation of the health care system into a multitude of agencies and programs, preventing us from providing the smoothly coordinated health services that our patients and we crave. Falling through the cracks of the system is so common that it is tacitly accepted as normal. The causes of this fragmentation include the devaluation of primary care and family practice by American medicine, the difficulty of coordinating professionals from different disciplines, the abhorrence of “socialized medicine,” the public-private distinction, complex bureaucracies, the multitude of payment mechanisms, and the entrepreneurial proliferation of health care organizations. It seems self-evident that bringing about better integration of services is of the greatest importance and that it should be the aim of any health care organization. How to achieve it is the subject of this multiauthored book from the American Psychiatric Press.

In an introductory chapter, Laurel J. Kiser, one of the editors, provides a schema for the evolution of health care in three stages. The first is the individual program focus, where most of us find ourselves now. In this situation, most health care administration is focused on the program (e.g., an inpatient unit or a rehabilitation program)—providing the treatment, managing the budget, coping with regulations, and, increasingly, handling competition from other programs. In short, meeting program goals. The second stage is the episode of care focus, which some are moving toward, where services are planned for treating an illness, perhaps in a variety of settings, indefinitely or until it is cured. At this stage a number of programs work together in a coordinated fashion to provide the array of services needed by the patient. The third stage is described as the management of health focus. Here there is a holistic emphasis on prevention of disease and promotion of wellness, a mending of the split between the mind and the body, and a focus on the needs of the whole community—a wonderful, if idealistic, vision. No doubt, there are many obstacles to be overcome in reaching this goal, in terms of our knowledge base, our technologies, our devotion to traditional paradigms, and our political will, but the objective is a noble one.

Sadly, the nobility of this goal is somewhat at odds with the current way of thinking in the United States, which views health care as an “industry” operating in a competitive marketplace. According to the industrial paradigm, “doctors and other professionals are…providers,” and their services are bought and sold like other commodities. What we provide is a “product.” The purchasers (employers or government agencies) are always right in this marketplace, and the managed care organizations and institutional care programs scurry around to buy and sell health care services at the best price. The recipients of the services have virtually no say at all; they are also a commodity of sorts, referred to as “lives” in insurance-speak. Most of us take pride in being industrious but have difficulty thinking of ourselves as industrial workers. Industries deal with raw materials, assembly lines, production methods, competitiveness, sales, marketing, profits, mergers, acquisitions, fat cats, unions, strikes, and lockouts. That is not what we thought we were getting into when we joined the medical profession, and it certainly seems inimical to attaining the goal of holistic community-focused health for all.

It thus comes as something of a surprise to discover that the authors of this book not only do not question the contemporary business approach but embrace it, or at least assume that this is what we have to accept. They give us a lot of guidance on how to coordinate and integrate services but are curiously uncritical of the status quo in terms of the current medical business philosophy. They do not even allude to the multiplicity of insurance companies and funding agencies, with their different rules, as a barrier to smooth integration of health care services. The “behavioral health” in their title does not come from psychiatry or psychology or health services; it comes from the insurance industry. It smacks too much of B.F. Skinner, and I am sure it does not reflect how the readers of the Journal think about the work they do.

Be that as it may, whether we adopt an industrial model, a socialized model, or some other, the issue of fragmentation remains, and ways of promoting integration need to be found. Nobody feels the impact of our fragmented system more keenly than the person with a complicated illness who has to cope with a variety of doctors, laboratories, clinics, hospitals, care managers, home care agencies, imaging companies, and, of course, insurances. As psychiatrists we see people with chronic mental illnesses move through an array of emergency departments, inpatient units, outpatient clinics, pharmacies, partial hospitalization programs, clubhouses, vocational programs, residential facilities, health maintenance organizations, Medicaid, Medicare, social services, etc. What is needed, clearly, is a way to deal with this chaos, introduce some coherence and continuity, and move ahead toward a system that truly promotes health and provides effective and efficient treatment for disease.

Chapter 1 in this book is followed by three chapters dealing with the theory of services system integration. Some of this material would have benefited from constructive editing to make it more readable (e.g., “Competitive programs within an organization are primarily operative in systems brought together under some form of horizontal collaborative structure”). The persistent reader can get an understanding of what integration involves, how to measure it, and what are the factors that militate against it. Some readers will find the following 17 chapters more useful. In these chapters, 23 authors deal with such practical aspects of mental health service administration as issues of access, documentation, fee scales, and staffing. Several of the chapters function as a primer, providing excellent overviews of basic aspects of health care administration, introducing the reader to concepts such as level of care, risk corridor, and centralized access models and covering aspects of administration such as staffing and reimbursement.

Two chapters are a little different. Chapter 16, “A Consumer View of an Episode of Care and How Self-Help Helps,” is well written, provocative, informative, and useful. However, it bears no relation to the rest of the book and says nothing about the integration of behavioral health care.

Chapter 14, “Current Research on Mental Health Systems Integration,” provides an excellent overview of recent mental health services research in this area but comes to disappointing conclusions. The volume of good research is small and shows it is possible to bring about greater integration of mental health services but that it is not clear from the research that a higher level of integration produces better patient outcomes in terms of symptoms, functioning, or quality of life. However, it is early days in this research field, and time may help build a stronger body of informative data.

It is in reading the research chapter that one comes to a somewhat disturbing realization about this book: that it is the researchers, conventionally stereotyped as remote from real life, disinterested, focused on their data sets, who are asking the questions about how the patients fare. The mental health professionals who represent most of the chapter authors discuss organizations and systems as if they were ends in themselves, geared to meet organizational objectives such as integration, profitability, and efficiency. There is no real discussion of how the methods and strategies they propose will affect the quality of the experience or the outcomes for the people who are supposed to benefit. A good example is the chapter on documentation. To judge from that chapter, one could easily conclude that the purposes of documentation are entirely administrative and legal—nothing to do with the quality of the interaction between the treatment team and the person receiving the care. One is again impressed with how the industrialization of health care and the commodification of psychiatry lead toward the devaluation of the patient. Thank God for the mental health service researchers!