The i2i Center is delving into the concept of integrated care through a series of Policy Exchanges. This is the first edition of this series, and it focuses on core principles of integrated care from the very top of the hierarchy—the consumer and family member. We have asked individuals to be our Subject Matter Experts in this first edition to help us better define what integrated care really is and the core principles that serve as a framework.
See the i2i website for more information on integrated care at https://i2icenter.org/topic/integrated
The topic of integrated care comes up in just about any conversation that is around the future of healthcare. It’s clear that there are potentially great benefits to pretty much all stakeholders in the healthcare system. It is logical that coordinating the medical information and care decision making will reduce costs because more opportunities are created to identify issues earlier and to increase administrative efficiencies. More importantly, integrated care should lead to better quality and outcomes for the consumer and a part of what a consumer can expect in his/her own healthcare. That can mean a lot of things.
Each of you has your own personal experience as well as many years of tireless work and advocacy on the MH/I-DD/SUD system structure and policies. What do you think are the core values and principles that would make integrated care work for consumers?
North Carolina has recently determined that our public system of health care should integrate physical and behavioral health. People who use mental health services and their families have long desired that our health care be integrated. Successfully integrated care, however, demands that key values and principles are honored by all stakeholders, including health care recipients and families, health care practitioners, and provider and system administrators. High-value health care, then, is demonstrated when improved health and improved quality of life are the products of that care!
Desiring that our health care yields better outcomes, consumers and family members have long awaited the shift to the following transformational values: 1) that the mind and body cannot be separated and treated effectively or efficiently, 2) that the potential for optimal health is only as strong as the investment by patients and clients in their own health and in the systems intended to serve them, and 3) integrated care ensures that mental health care outcomes can be objectified and accounted for just as with primary care, and that as mental health improves, so will physical health status. Weaving these principles into implementation of system changes will guarantee better results in individuals and their communities.
For people with substance use disorder (SUD), the points that Laurie set out apply as well. When I explain why we need integrated care, I talk about management of diabetes, which is prevalent in NC. According to Diabetes North Carolina, 10% of adults here have diabetes and about 2.5 million people have prediabetes. Up to 30% of those with prediabetes are expected to develop type 2 diabetes within five years. That chronic condition requires lifestyle changes such as limiting alcohol, improving daily diet, and regular exercise. Untreated and without recovery supports, SUD or mental illness make it very challenging to start and maintain that healthy lifestyle. On the flip-side, for a person suffering the effects of untreated diabetes, it can be hard to maintain mental health and SUD recovery. With integrated care, the individual and respective professionals collaborate to align their efforts. The result is a much greater chance of successful outcomes for each condition.
But to get integrated alignment working effectively, full engagement is essential. We need to make integration the easy path for individuals and health care professionals. Two key engagement factors are social determinants of health (SDOH) and information flow. We need an effective interface for determining, communicating, and addressing the SDOH necessary for effective treatment and maintaining treatment outcomes. Information needs to flow in a timely, clear, efficient, and substantive way. For professionals, that includes getting the electronic health records and Health Information Exchange functioning reliably and with meaningful information outputs. For individuals, it includes careful crafting and delivery of information about plans, physicians, and options. Not all health practices and individuals will have the required resources for a seamless transition into integrated care and Medicaid reform. Part of the planning must be supportive contingency planning for during and after the transition period.
I’d like to capitalize on Karen’s statement that “full engagement is essential.” In fact, many consumer and family advocates welcome a reform that puts the patient/client or in limited cases a family member actually in the driver’s seat of his or her care! This would be true engagement, whereby the system is so attuned to the voice of the individual, who is the true expert on his own experiences and to a large extent, his needs, as a key driver in care and integration. North Carolina has a history of inadequate inclusion of the individual or his family members in the honest development of its people-serving systems. We have especially suffered from the minimization or exclusion of our voices throughout the Mental Health, Developmental Disabilities and Substance Use Services System. Recently, one well-known advocate stated to officials from the Substance Abuse and Mental Health Services Administration who were here to assess North Carolina’s Mental Health Block Grant implementation processes that “We have moved backward! My voice meant more fifteen years ago in this system than it does now.”
This de-facto exclusion extends to the point of the individual’s care. Consumers are not usually consulted but are dictated to, even if in a friendly manner. They feel un-empowered and at times hopeless. In fact, consumers and family members are so frustrated, especially as our system becomes more industrialized, that on May 22nd there will be a Legislative Action day planned by members of the state level Consumer and Family Advisory Committee where advocates and self-advocates, including local and state CFAC members, will be addressing their concerns to their elected officials. Advocates like me have addressed the Subcommittee on Mental Health at the legislature warning that our exclusion as system users and caring consumer or family advocates results in expensive, inefficient, and deficient system outcomes. We are asking for accountable government by ensuring we have more engaged, inclusive processes for developing systems, including the Medicaid State Plan implementation. Our hope is to ensure accountable results from dollars spent and demonstrating these outcomes in terms of real progress in people’s health and lives.
So, to sum up the principles you have noted that lead to integrated care:
There must be: