A previous article outlined a new clinical model called consolidated behavioral health (CBH). As noted in that article, this model integrates three currently separate dimensions of health status into one. Those dimensions are emotional health, substance use and health-promoting behaviors. It was also noted that this cohesive, multi-dimensional construct can be put into practice to drive fundamental changes in the behavioral healthcare delivery system. This article outlines those changes.
Every behavioral healthcare professional should have the expertise to help the paradigmatic depressed person who abuses alcohol and lacks motivation to eat well or exercise. Help does not mean treating one of these problems and referring the person for help with the two other issues. It means having a depth of understanding in each domain and understanding how one domain impacts the other.
Why does such a client today need to consult with a mental health clinician, a chemical dependency expert, and a wellness coach to get adequate care? Why do we not recognize that such care is actually inadequate? Each professional should understand in real time how their focus is impacted by the other domains. The wellness nurse providing education on nutrition and exercise is really in the dark.
Patients don’t know. Asking if they would like to access care for a specific behavioral health problem is like asking a medical patient if they would like to work in one clinic on their high blood sugar or another on their high blood pressure. The professional should know that the patient is overweight, at risk for both diabetes and hypertension, and so in need of treatment that addresses all three concerns.
Similarly, the behavioral healthcare clinician should know that their patient is at risk for both clinical depression and substance use disorder. A consolidated view of their behavioral health status is needed. Treatment must be attuned to how each problem potentiates the other. For example, weight gain is exacerbated by depression and alcohol use, and the best wellness plan will fail in isolation.
Three approaches we can no longer afford
Programs that are focused on diagnoses, especially mental health or substance use diagnoses, exist for historical and funding reasons. They are clinically misguided. We know that a large percentage of patients getting a diagnosis in the mental health or substance use disorder category have a co-occurring disorder in the other group. It is likely that those co-occurring conditions are often missed, under-treated, or referred out for services that either don’t get delivered or are addressed in relative isolation from the original condition.
There is another problem with this diagnostic approach, namely, the focus on meeting criteria for a diagnosis. We should understand that even sub-clinical levels of disorders can impair functioning. Mild symptoms have a meaningful impact, both on their own and in combination with other behavioral health disorders. Treatment plans should focus on how the presence of mild mood or substance use issues impact other problems.
It is time to recognize health-promoting behaviors as critical and very difficult to change. In fact, health behaviors are so difficult to change that we must end the legacy model of having nurses and coaches provide education with basic goals and plans. We are not rational actors in many ways, especially when it comes to eating, exercising and using nicotine. Behavioral clinicians need to dissect motivational issues and understand how mental health and substance use problems might interfere with health behaviors.
Mending the public-private split
Clinical discrepancies can develop when programs for the same disorders are developed in isolation from one another. This is our history in behavioral healthcare. The forces maintaining separation between public and private healthcare sectors are powerful, and so the recommendations here are limited to starting a long-term process of reconciling these distinct worlds at a clinical level.
The first track for reconciliation should be focused on identifying best practices for treating the most severe disorders within mental health and substance use domains. Patients with serious mental illness and chemical dependency should receive the best clinical interventions regardless of sector. For example, if peer support and supportive housing are empirically validated, then every payer should cover them. Comparative research is needed when a best practice is unclear.
A large percentage of a person’s health status can be attributed to their health behaviors, but this is especially critical for patients within the behavioral healthcare industry. Patients with serious mental illness are dying decades before their peers, and this is often because of a dearth of healthy behaviors. Also, people with mental health disorders smoke at two to four times the rate of the general population, and those with substance use disorders often struggle with nicotine addiction as well.
Health-promoting behaviors have been the focus of standalone and largely unsuccessful wellness products for decades. It is time to recognize the need for the behavioral healthcare industry to incorporate this dimension of behavioral health into its core competency. Much work needs to be done to determine effective interventions, but the work will benefit from being considered alongside mental health and SUD domains.
Integration or consolidation
The CBH model is agnostic on the value of integrating behavioral healthcare with primary care. There are potential benefits from such integration, but great limitations as well, especially if primary care integration is undertaken with our industry in its current fragmented state. We need to fix our own house before we embrace a major commitment to external, structural collaboration.
Calls for integrated care can be classified in two ways, as political statements and as clinical viewpoints. Politics is about the use of power. We should not be ceding our limited endowment of resources and influence to the current healthcare hierarchy based on some vague hope of it working out well. As a clinical position, I would suggest consolidation in place of integration.
The consolidation that I am recommending is far more immediate and organic than the integration demands we hear from all quarters. It is immediate in that these are internal changes that leverage existing assets. It is organic in that related services are being brought together to make a stronger entity, rather than distinct services being combined into still distinct services.
Integrated care may be a compelling union of separate entities, but consolidated behavioral health combines three health domains into a more coherent and effective whole. Consolidation is the process of making something stronger or more solid, and in this case, we create a potent new domain from three that have been historically separate. We also elevate and empower CBH professionals.
A move toward integrating healthcare services may ultimately be a productive step, but behavioral health consolidation is a more pressing need today. How should an integration of healthcare services proceed? The next article in this series will explore the limited potential of primary care integration.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.