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‘Future State’ Offers Roadmap to Consolidation of Behavioral Healthcare

February 23, 2021

The behavioral healthcare industry has no guarantee of success in the coming years. A day of reckoning is coming for the U.S. healthcare system’s unbearable cost, and every field should anticipate disruptive changes. Our industry will be better positioned for that day through consolidation. We should consolidate subspecialty areas, practice locations and levels of care. These big changes are achievable.

Consolidation is more than a response to overall healthcare trends. Our field is fragmented. Mental health and SUD care remain compartmentalized without clinical justification. Consensus grows that behavioral health is fundamental to effective primary care, but we continue as an isolated specialty rather than as an integral part of that setting. Our outpatient and inpatient services are disconnected.

The strategic plan outlined here is comprehensive. While it springs from criticism of the status quo, it is profoundly pragmatic and optimistic. The all-inclusive nature of consolidation is the plan’s boldest feature. The goal is to strengthen and expand our field for the sake of all stakeholders. A corollary aim is the resuscitation of primary care. Earlier articles address key features of this Future State plan.

Subspecialty consolidation

Our field has historically compartmentalized care for mental health and SUDs. This contradicts patient experience. Patients cope daily with the interaction of these problems, and our care must match this reality. Next, we should designate health behavior change as one of our subspecialties. Unhealthy behavior drives chronic health conditions, and our field surpasses others in behavior change expertise.

The most novel aspect of this proposal relates to health behaviors. Existing programs in this area (e.g., weight reduction) are separate and manualized. Many patients need an individualized approach focused on the interaction of all their clinical issues. Health behavior change is a subspecialty ripe for clinical consolidation. Its inclusion is the first bold step in a larger transformation of our field.

Let us hasten the day when clinicians are comfortable addressing the connections between mental health, substance use, and health behaviors for every client. These domains differ greatly, but they all fall within the purview of a behavior change expert. We have deep knowledge in each domain today. Some clinicians may need additional training as we move to the day when this consolidation is standard.

Practice consolidation

Clinicians in our field practice in many settings, but most work as specialists in offices separate from the rest of healthcare. Integrating behavioral health clinicians into the primary care setting is not a new idea. Yet the proposal here is a radical consolidation. Behavioral healthcare should be a key dimension of primary care. Therapists should be as numerous as PCPs. The need for behavior change is great.

The case for this consolidation is best understood historically. The skills of psychotherapists likely would have been incorporated in the original design of the primary care setting if therapy had been as mature and well-researched as it is today. Our field might not be defined by the DSM to the extent it is today. We might instead be focused on consolidated behavioral health needs in primary care.

We have had many limited calls for integration. An example is the collaborative care model. Its focus on medication management obscures how therapists can help primary care patients broadly with major, minor, and subclinical disorders. All contribute to dysfunction, the complication of medical disorders, and treatment noncompliance. Our clinicians are needed on the frontlines, not as side advisors.

Consolidation of levels of care

Our levels of care need to be consolidated through linkages that strengthen programs at each level. Outpatient care is infrequently a conduit to higher levels of care. It is profoundly isolated from facility-based care, especially in the commercial healthcare world. Public sector systems have facilitated greater connections among levels of care and use crisis stabilization resources outside of hospitals.   

Intermediate levels of care are critical for people with severe behavioral health issues, and yet they have never thrived as institutions because they largely function as a step-down from inpatient care. They can only become vital options for stabilizing people in crisis if outpatient providers function more effectively as referral sources. This will not happen if our outpatient work continues as an isolated specialty.

The consolidation of levels of care rests on repositioning our clinicians into primary care. In that setting patients are more likely to be monitored over time, flagged when in crisis, and referred to the appropriate level of care for stabilization. Our services are as fundamental to primary care as any found there today. We will fully utilize all levels of care only when our home base is the primary care setting.

Tinkering Is not an option

The researcher in me ponders pilot testing these ideas. Yet we have no time to tinker, and it would accomplish little. Some elements have been tested and others are too broad to test. Let us restructure our field around basic principles. This Future State plan is not radical, but its impact would be. Healthcare is poised for change. Our future should not be left to fate. Let us consolidate.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.

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