Truly Integrated Health Care
By Teresa Cutts
The explosive focus in medicine and healthcare on integrated health or medicine in the last 10 years usually refers narrowly to integrating some form of behavioral health care into primary care practices. While medical cost offset data in natural experiments like the Hawaii Medicaid pilots in the 1990s and work with Kaiser Permanente in primary care practices have shown these narrow efforts to be both financially viable and result in ultimate savings in cohorts and payor groups, we in Stakeholder Health are advocating for a bolder, broader focus on total, comprehensive integrated healthcare.
By total, comprehensive integrated healthcare we mean several things:
Bio-psycho-social-spiritual health is integrated health. Our broad focus on integrated health comes from our work with the World Council of Churches, Mental Health and Faith Communities Consultation, held at Christian Medical College, Vellore, India, 2007. During that consultation the WCC experts defined integrated health and healthcare to encompass “bio-psycho-social-spiritual” components, clearly adding a faith-based aspect to how we conceptualize whole person health and care.
- Building community capacity via behavioral health training. Capacity building and training community members in Mental Health First Aid, resiliency and the use of population health screening tools (e.g., the PHQ-9 for depression, the GAD-7 for anxiety, AUDIT or SBIRT for substance abuse, etc.) is key. These trainings allow community members to be part of the “first responder” integrated health workforce and safety net to help prevent mental disorders before they occur and avert some of the interpersonal (homicide) and intrapersonal (suicide) violence that is growing ever more common in the US and worldwide. For instance, in the World Health Organization’s World Health Report in 2002, 49 percent of all worldwide violence was accounted for by suicide alone. We can never prevent mass homicide/suicides, such as Newtown, BUT, we can help increase our workforce deep in community who can help us build a bigger safety net.
Further enhancing community capacity by combining self-management of chronic disease with depression, anxiety and other behavioral health training. Large cohorts of Medicaid population studies have consistently shown that coupling depression and anxiety treatment for chronic conditions (e.g., diabetes) increases compliance and improves overall medical outcomes. Plus, people with persistent mental health disorders die, on average, 25 years sooner than their counterparts without mental illness, usually of cardiovascular disease (Colton and Manscheid, 2006). As such, let’s always combine chronic condition self-management classes with Mental Health First Aid type offerings, as part of truly integrated healthcare. Additionally, let’s train community members in behavioral sleep hygiene rules/management, basics of good brain health throughout a lifetime (from brain development in the critical 0-3 years to ways we know to prevent Alzheimer’s Disease) as well as pain and stress management basics.
- Translating the science of the prevention of depression, substance abuse and childhood abuse into practice immediately! It is a sacrilege that we know that 22-38 percent of all initial depressive episodes could be prevented using models and practices we already have: strength-based and resiliency training, cognitive behavioral programs for depression, web-based programs, public health efforts, taking a developmental perspective, targeting high risk populations (post-partum, elderly, college students, etc.) and testing evidence-based interventions (Munoz et al., 2012) with the widest reach in community. Like programs and data exist for prevention of substance abuse and childhood trauma. These efforts can improve quality of life, decrease suffering, show huge cost savings, but, most importantly, save lives. We must start using these programs now, without waiting for grant funding to start a pilot.
Aligning, leveraging and integrating the assets of both healthcare systems and community (especially faith-based ones) in a true place-based population health management partnership, led by and driven by people, not hospitals or health systems. We advocate making the walls of the health systems invisible and having them handle disease management, while the congregations and community handle healthcare management. We know that only 10 percent of healthcare outcomes are predicted by access to clinics and hospitals. Let’s engage people in place-based efforts to improve health and drill down to the social determinants of health. For example, we know that being poor, with its accompanying unremitting stress or allostatic load, perception of being a “have not” in a “have” society, income disparity (Wilkinson and Pickett, 2009) and lack of trust, all set up our most under-served people to have higher prevalence of mental disorders, as well as overall poorer health status (Sapolsky, 2005).
How can we deploy community members to help here? Kimberlydawn Wisdom of Henry Ford Health System in Detroit and her coalition of four competing health systems have deployed community health workers who have managed to reduce infant mortality to zero in their current cohort of under-served women, and have added stress management for mothers as a key part of training.
Methodist Le Bonheur Healthcare’s Memphis Model of the Congregational Health Network (now 599 mostly African-American Churches strong) uses volunteer liaisons embedded in congregations (over 700 formally trained) to provide community caregiving, trained in chronic care management, Mental Health First Aid, Better Brains across the lifespan and ten more topics. The CHN liaisons’ work has been shown to significantly decrease readmissions and gross mortality rates, as well as to navigate peoples to more appropriate levels of care (e.g., hospice, home health).
Here in Winston-Salem, N.C., our Supporters of Health (community based triagers) have demonstrated a readmission rate for some very socially complex people that is one-third of that of all people being discharged from the hospital overall.
The community can and will make a difference, if we honor their intelligence and trusted relationships deep in even the toughest neighborhoods; what we call “boots and brains on the ground.” Working together as health system providers, peer mentors, trained lay peoples, community health workers, etc. , we can improve overall bio-psycho-social-spiritual health for all people, which is Truly Integrated Healthcare.
Teresa Cutts, Ph.D,. is Asst. Research Professor, Wake Forest School of Medicine, PHS, Dept. of Social Science and Health Policy and co-leader of the Stakeholder Health Secretariat.