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SAMHSA/HRSA integrated care core competencies manual needs stronger focus on primary care providers

June 10, 2014

Morning Zen Guest blogger ~ COL (Ret) George Patrin, M.D., CMHNetwork Advisory Council Member 

Subject: Review of SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) Core Competencies for Integrated Behavioral Health and Primary Care “promoting development of integrated primary and behavioral health services to better address the needs of individuals with mental health and substance use conditions, whether seen in specialty behavioral health or primary care provider settings,” purported to be “the first ‘national home’ for information, experts, and other resources dedicated to bidirectional integration of behavioral health and primary care.”

This CIHS Core Competencies manual is a “valiant effort to improve the effectiveness, efficiency, and sustainability of integrated services, which ultimately improves the health and wellness of individuals living with behavioral health disorders.” It is jointly funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) and provides training and technical assistance to community behavioral health organizations receiving SAMHSA Primary and Behavioral Health Care Integration grants, as well as to community health centers and other primary care and behavioral health organizations leading the field in providing better mental health care to their reliant population more efficiently. It is a very thorough and detailed manual laying out processes to truly incorporate mental and behavioral health into a primary care clinic settings, whether Pediatrics, Family Practice, or Internal Medicine. This represents a great effort to generate a national focus on integrated care with a single, widely recognized set of multidisciplinary competencies with a service approach for both behavioral health and primary care work forces. That said, all specialties should look to establishing integrated relationships with their Primary Care colleagues.

To truly support total health and wellness, “comprehensive first contact and continuing care for… any undiagnosed sign, symptom, or health concern,… health promotion, disease prevention, education, diagnosis and treatment…” competency processes must be centered on primary care rather than mental health care, both being vitally important, of course. To their credit, SAHMSA did ensure psychiatrists, psychologists, social workers, advanced practice psychiatric nurses, marriage and family therapists, addiction counselors, mental health counselors, psychiatric rehabilitation specialists, psychiatric aides and technicians, and peer support specialists and recovery coaches were all included in formulating these credentials. Unfortunately, this document risks acting as a ‘lobby’ for behavioral health professions in not detailing Primary Care professions as well up front. Additionally, Senior Content and Expert Key Informants are nationally recognized experts in National Mental Health and Family Health Medical Services, but the Primary Care voice didn’t come through as strong in achieving holistic recommendations. Certainly, if every office carried out every process outlined in this initial manual they would be more “integrated.” But for the average practice this manual may be too overwhelming for the sheer number of items it calls to address, producing more ‘box checking’ than actual integration if we are not careful.

Behavioral health is distinguished from “general health” in this manual, “recognizing imperfections in the distinction and language used to describe it.” But is “Behavioral health… distinct from healthy behavior?” I think not, as behavioral choices lead to healthy or unhealthy lifestyles, ultimately. Point is, people with undiagnosed or improperly treated mental illness, acute and chronic, are not in control of their behavior, or choices, until we assist them in understanding their condition(s).  Susan Blumenthal, M.D., Public Health Editor, The Huffington Post, and Former U.S. Assistant Surgeon General wrote “Mental health is fundamental to overall health. An important step forward is to recognize mental illnesses are like other diseases and must be diagnosed early and treated effectively. A critical component to reducing the toll of mental illness on individuals and communities is ensuring universal access to mental health care worldwide (A Mission to the Mind, June 5, 2014).” To seriously address the stigma of obtaining mental health care, integration of behavioral health processes into primary care services with comprehensive care plans is the best place to begin. The committee also notes: “the term ‘health conditions’ …is not specific to behavioral health.” They wisely call for the creation of “updated integrated care plans in consultation with healthcare consumers, family members, and other providers, including individuals identified by consumers as part of their healthcare team” within the care coordination core competency.  A wonderful competency premise raised by this committee is focusing recommendations on “consumers and family members as partners in the healthcare process whose strengths, goals and preferences should drive healthcare decisions.” We will get this right if we keep this premise the driving force. The first step in making this happen is to have our client, the consumer, sign an informed choice document on first visit listing the trusted individuals to call on should the patient be incapacitated from making healthy life-sustaining choices. This important detail is not addressed in the manual. We must not allow our interpretation of HIPAA directives to stop us from laying out crucial processes in this foundational credentials manual. 

It is gratifying the team came up with a single integrated set of competencies, realizing “most competencies required for integrated care were common to behavioral health and primary care providers…(and) separation would promote continued silos between disciplines and professions and foster an unnecessary interprofessional divide.” ALL Specialties and Consultants should heed this advice. The mandate to concentrate on “competencies generic to most basic forms of healthcare, such as those related to interpersonal communication” is crucial, and a great beginning, as “they are absolutely essential to the effective delivery of integrated care.” A major concern, however, is the authors have put their viewfinder on what the provider of integrated care can actually ‘do’ today, basing the competencies on ‘what is’ in practice currently, rather than what ‘must be.’ Implementing integration competencies training for our employees may not result in truly integrated processes if we avoid addressing integration of business processes frustrating our consumers and employees in delivering promises integrated care can deliver. “Levels 4, 5, and 6 integration, (involving) either close or full collaboration and one of three organizational models: some systems integration, integrated practice, or transformed/merged practice” must be addressed, or we risk perpetuating the current business model focusing on what we get paid for today, rather than what we should be doing. Unfortunately, our sick-care system concentrates on crisis intervention services today because that is where we are spending the most health care dollars. We need to reduce that expense by reducing need for these services with much less costly proactive preventive integrated services. Artillery units know we will not hit the target (outcome) we desire if we don’t aim with the proper trajectory. If we aim low in our expectations, we will not achieve desired outcomes! We have a long way to go in this regard, although transformational payer leaders are beginning to understand the difference between fee-for-service and bundled (capitated) prevention practices. Fact is, we need both types of incentives based on services provided by the type of practice – primary versus specialty care. To develop competencies with the end in mind, they must be written to the proper end state, accepted by all team member professions, and credentials should support this skill set with administrators as well as concentrating on clinical knowledge. “Knowledge and attitudes make the desired behavior possible, (and) demonstration of (an) essential skill(s) is the desired outcome” in our employees, but let’s set our teams up for success, and base those skills on a new paradigm of shared business resources and clinical skill-sets upon integration. For example, advisors suggest “competencies may not be applicable to care managers or navigators” indicating the recommendations are based on old disease and utilization management methods, rather than hands-on, consumer-centered clinical support and referral access processes at the ground level, in the clinic. Some call this “the medical home” model. This distinction is paramount to generating appropriate job descriptions and job roles to improve employee satisfaction, retention, and formal performance reviews, which ultimately drive consumer satisfaction.

While this directive did consider the “issue of culture… in all efforts to understand health, illness, treatment, resilience and recovery,” it appears to have concentrated on the culture of the consumers only. Ultimately, we must turn the magnifying glass on ourselves to identify core cultural and business changes required to truly provide patient (consumer)-centered wellness services, an approach leadership has missed to date. Writers state “effective delivery of integrated care requires system modifications to support changed practice,” but then go on to say “system design was outside of the scope of this project.” I submit this is the most important aspect of developing “core competencies” to lead integration. “Financing and organization of care delivery” are the major barrier to “ultimate competence of providers (and their teams) working (our) delivery systems.” Under the mantle of transformation, aside from locating a behavioral health specialist within the walls of a primary care clinic, processes still serve to separate specialties under separate funding streams and supervisory responsibilities. Integration refers to collaboration between primary care providers and all specialists and subspecialists on behalf of our client, the patient, not just behavioral health. To truly remove barriers in accessing the most urgent area, mental health, we must ‘reassign’ current assets, to include employees, from current Behavioral Health Clinics and services to Primary Care settings, whether on site or virtually connected to provide same day services. Additionally, funds for training need to be shared as well. This will be the biggest hurdle to drive true integration and elimination of redundancy and waste in the provision of services centered on patient needs and family concerns rather than the business bottom line.

Tearing down silos, then, is our biggest challenge to achieving a one team effort, eliminating referral and treatment patterns requiring patients to wait for access and once in, hand-carrying information from one office to another, one provider to another. Ultimately, the primary care provider is the most trusted health contact, the hub of information, and the constant adviser to ensure all processes are in the best interests of the whole patient without overlap or adverse side effects. All specialists, from behavioral health to pharmacy and all sub-specialties, should propagate a flow of information in and out of the Primary Care Team hub to and for the patient, who is, after-all, everyone’s client. Credentials competencies should address “Who works for who,” meaning, how is information  shared. Working off a comprehensive care plan, then, in a shared electronic health record (EHR) is paramount to building the ultimate integration model.  This should have been listed as a key competency in administration. Unfortunately, presence of an integrated EHR doesn’t guarantee all team members are accessing it or sharing their work within it, often because misconstrued HIPAA rules dissuade us, or lack of time due to work productivity demands prevents us from accessing past history and plan(s) in it. And let’s be honest, obtaining an EHR does not mean vital information in historical paper records is being transferred to it. This is a procedural competency not addressed in this initial effort.  

An ongoing concern of integration efforts is emphasis and management by behavioral health (BH), in this case the Annapolis Coalition on the Behavioral Health Workforce, a non-profit organization dedicated to “improving recruitment, retention, training and performance of the prevention and treatment workforce in the mental health and addictions sectors of the behavioral health field,” not primary care as a whole. It seems the recommendations, then, are meant to “shape curricula and training programs on integrated care,” but for behavioral health trainees primarily. An important detail not clearly outlined is a call for all sub-specialists to be cognizant of the need to keep primary care colleagues trained to the top of their license in each specialty area. We must all “educate others within (our professional circles).” BH specialists must understand they are to train PC colleagues to the top of their skill set in evaluating and treating MH conditions so the specialist can truly, then, operate at the top of their license, eliminating redundancy and cost. The integrated specialist should be carving out perhaps 20% of their time to train and provide acute consultation during the course of a work day. Fact is, after appropriate transformation to preventive efficient care medicine, centered on the consumer, we may need fewer specialists and certainly less hospitals to admit them to. Jobs will change and need for many specialists, yes, even psychiatrists, may decrease. We all need to get ready for this cultural awakening of the future and avoid letting ‘job protection’ guide our efforts. The way forward is in “preparing and further developing a workforce to deliver integrated care” as a multidisciplinary team unencumbered by silos of funding and political isolation to protect income streams.

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patrinCOL (Ret) George Patrin, M.D., spent over 23 years as an Army Pediatrician and Healthcare Administrator concentrating on Family Advocacy and Healthcare Process Improvement. His final assignment was as Northern Regional Command Special Projects Officer for Patient-Family Centered Healthcare assisting in writing DoD Patient Centered Medical Home (PCMH) Guidelines and Training. He has been a staunch advocate for both soldier and family member readiness throughout is military career. He is a sought after speaker on parenting education, child abuse prevention, school learning and behavior problems, and healthcare administration optimization. Dr. Patrin is a member of the Children’s Mental Health Network Advisory Council. He can be contacted at patrin.george@gmail.com.

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