CIHS Updates Integrated Care Framework

Integration of primary care and behavioral health care is essential for improving health and lowering costs. Provisions in the Affordable Care Act are adding momentum to integration initiatives that have been implemented in recent years. However, the term “integration” is used inconsistently and applied to a wide variety of care models. Without an agreed-upon framework to classify integrated care settings more precisely, meaningful discussion and informed comparisons cannot move forward. The Center for Integrated Health Solutions (CIHS) has recently proposed a standard framework for classifying care settings according to their level of integration.

Integration occurs along a continuum of collaboration and integration. The basic framework for current taxonomies of integrated care settings was proposed in 1996. It set forth five levels of collaboration, from minimal collaboration through onsite collaboration (colocation) to full integration. The new CIHS framework updates the older one by outlining six levels on a similar continuum. It is designed to help organizations evaluate their degree of integration and determine which next steps to take toward an enhanced level. The framework also gives researchers and others a common set of terms for describing what is occurring in a given setting and for comparing models of care.

Unlike the older framework, the CIHS framework uses the terms “collaboration” and “integration” in particular ways. Collaboration describes how resources—namely, health care professionals—are brought together, and integration describes how services are delivered and practices are organized and managed. Like its predecessor, the overarching CIHS framework has three main categories—coordinated care, colocated care, and integrated care. However, each category now has two levels of degree along the continuum. Designers of the framework describe each main category in terms of a key element, which differentiates between the two levels in the category. For example, for the initial category of coordinated care, the two levels are “minimal collaboration” and “basic collaboration at a distance,” and the key element that differentiates between the two levels is communication—the frequency and type of communication.

A useful feature of the CIHS framework is how it restructures the characteristics that define and differentiate the six levels. Each level is now described from four distinct perspectives: clinical delivery, the patient's experience, practice and organization, and business model. For example, from the perspective of the patient, both collaboration and integration decrease in degree and complexity as care moves from level 4 of colocation to level 5—the first level of full integration—as patients experience a true “one-stop shop,” whereas for providers the degree and complexity increase.

The new framework is presented in a 13-page CIHS report. The report's authors emphasize that “no site can be fully integrated without changing how both behavioral health and primary care are practiced. The requisite practice change features a blending or blurring of cultures, where no one discipline predominates. . . . [A]lmost every practitioner wants integrated care, and believes it is the direction for healthcare to move towards, until they realize it requires they change how they practice. It is at that point they often try to change the concepts of their integration efforts to preserve how they currently practice.”

Practice change is built into the framework; it is the key element that defines levels 5 and 6, the final two levels in the continuum. According to the new framework, for clinical delivery, practice change means one treatment plan for all patients; for patients, it means a seamless response to their needs; for practice and organization, it means a transformation in care delivery; and for the business model, it means integrated funding based on multiple revenue sources and a single billing structure maximized for full integration.

The report is available on the Web site of CIHS, which is funded jointly by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration (www.integration.samhsa.gov/integrated-care-models/A_Standard_Framework_for_Levels_of_Integrated_Healthcare.pdf).