- GESTIÓN Y HUMANIZACIÓN: Integrating Care for Persons, Not Only Diseases

Journal of Clinical Psychology in Medical Settings

© Springer Science+Business Media, LLC 2009

10.1007/s10880-009-9154-y

Integrating Care for Persons, Not Only Diseases

C. J. Peek1

(1) Department of Family Medicine and Community Health, University of Minnesota Medical School, MMC 381, 420 Delaware St. SE, Minneapolis, MN 55455-0392, USA

C. J. Peek

Email: cjpeek@umn.edu

Received: 4 February 2009 Accepted: 5 February 2009 Published online: 4 March 2009

Abstract Integrated care is geared toward enhancing usual care and decision-making for common combinations of medical and mental health conditions, including the behavioral health and behavioral change aspects. Yet even with comprehensive and well-integrated care for health conditions and well-coordinated teamwork in place, some patients do not engage or respond to care in the way clinicians would like or predict. This troubles patients and clinicians alike and may be chalked up informally to things like medical complexity (multiple co-existing conditions), mental health conditions (that complicate care), or simply the case being considered complex or difficult. It also raises the question of how to address person-specific factors that interfere with care of whatever conditions the patient may have, and invites behavioral health clinicians in medical settings to look beyond care of conditions to the care of persons, and to look beyond disease-specific care management protocols to master generic practices of care management across whatever conditions the person may have. This person-centered emphasis is intrinsic to the concept of the “patient-centered medical home” which has burst into animated discussion and demonstration among providers, health plans, government plans, employer purchasers, and professional associations across public and private entities. This represents an opportunity for collaborative care clinicians to help shape the national state of the art in medical home and includes a range of person-oriented (rather than disease-oriented) practices for care management, including working systematically with complex patients and difficult patient–clinician relationships.

Keywords Person-centered care - Health care home - Medical home - Collaborative care - Integrated care - Behavioral health integration

Integrated Care to Enhance Usual Care and Decision-making

Better integration of the biomedical and psychosocial aspects of care (and the work of different clinicians who provide it) is essential to quality, patient experience, and ultimately cost—as described elsewhere in this special issue. Behavioral health integration emphasizes identification of conditions (especially a mix of what are traditionally called medical and mental health conditions), implementing a more comprehensive and coordinated/team-based approach to usual care and decision-making for these conditions, and coordinating care in such a way that the patient understands how everything fits together and that “the right hand knows what the left hand is doing”.

Most integrated care is focused on establishing a better version of standard care and decision-making for conditions—and includes behavioral health, patient self-management and behavioral change aspects. An important traditional way of thinking about care is through disease categories, e.g., diabetes, depression, asthma, congestive heart failure and so on—and co-existing combinations of these conditions (Vogeli et al., 2007). Integrated care and other approaches such as the Chronic Care Model (Wagner, Austin, & Von Korff, 1996; Bodenheimer, Wagner, & Grumbach, 2002) are all geared to the proper care and prevention of all these exceedingly important conditions in the population—along with the important organizational supports needed to do it well. Establishing routine, reliable care (and teamwork) for any commonly occurring combination of biomedical and psychosocial conditions is indeed very important. As pointed out elsewhere in this issue, enhancing care in these ways can become quite challenging.

Unfortunately, even when a model of care that is enhanced by integrated care and well-coordinated teamwork is utilized, some patients still appear not to be getting what they need. This may be chalked up informally to things like medical complexity (multiple co-existing conditions), mental health conditions (that complicate the care), or simply the case being considered complex or difficult. It also raises the question of how to address person-specific factors that interact with usual care of whatever conditions the patient may have. This person-centered emphasis is intrinsic to the concept of the patient-centered medical home (Rosenthal, 2008; PCPCC, 2008) and has burst into animated discussion and demonstration among providers, health plans, government plans, employer purchasers, and professional associations across public and private entities.

The Patient-Centered Medical Home

The Joint Principles of Patient-Centered Medical Home adopted by the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA) brought these disciplines together on medical home goals and principles (Joint Principles of the Patient-Centered Medical Home, 2007; Rosenthal, 2008). These principles form a common backbone for the medical home literature and demonstration projects and are regarded as a core feature of the national state of the art in health care home (Peek & ICSI, 2008). The term “Patient-Centered Medical Home” has come to signify not so much a set of brand new insights, values or principles (they are not), but an organized and shared concept that ties them all together in one coherent package rather than as separate and unrelated threads.

The Joint Principles appear in abbreviated form in that report (Peek & ICSI, 2008) and are shown here:

1. Personal physician … ongoing relationship … first contact, continuous and comprehensive;

2. Physician directed medical practice … leads team who collectively take responsibility for ongoing care …;

3. Whole person orientation … providing for all the patient’s health care needs … appropriately arranging care with other professionals … care for all stages of life … acute, chronic, preventive, end of life …;

4. Care coordinated/integrated across all elements of the complex care system … subspecialty, hospitals, home health, nursing homes, community … facilitated by registries, information technology … to get patients care when and where they need and want it in culturally and linguistically appropriate manner …;

5. Quality and safety … support optimal, patient-centered outcomes … defined by care planning … driven by partnership between physicians, patients, family … evidence-based medicine and decision-support tools … continuous quality improvement … patients actively participate in decision-making … and quality improvement at practice … information technology to support care, performance measurement, patient education, and communication … voluntary practice recognition … to demonstrate capabilities to provide services consistent with medical home model …;

6. Enhanced access to care … through systems such as open scheduling, expanded hours and new options for communication between patients, personal physician, practice staff;

7. Payment appropriately recognizes added value … care management outside the face-to-face visit … separate fee for service for face-to-face … coordination of care within a practice and between consultants, ancillary providers, and community resources … adoption and use of health information technology … enhanced communication such as secure e-mail and telephone … remote monitoring of clinical data … recognize case mix differences … allow physicians to share in savings from care management in office … payments for measurable and continuous quality improvements.

Medical home (or health care home) has gone beyond mere theory, with at least thirty-six demonstration projects in progress across the country (PCPCC, 2008), at least a dozen works in progress in Minnesota alone sponsored by provider groups, health plans, or state agencies (Peek & ICSI, 2008). The federal Center for Medicare and Medicaid Services is preparing to sponsor demonstration projects for Medicare beneficiaries with chronic conditions (CMS, 2008). All of these projects, whether well developed or just starting up, are designed to respond to those Joint Principles, including an enhanced payment model. To help systematize and share standards and criteria for practices to qualify as medical homes, several medical home criteria sets or certifications are also in play (NCQA, 2008; CMS, 2008; AAFP/TransforMED, 2008) along with state criteria such as are being developed in Minnesota by the Department of Human Services (Peek & ICSI, 2008).

Note that the Joint Principles for Patient-Centered Medical Home feature person-centered outcomes and structures, not primarily disease-centered outcomes and structures. Of course, well-integrated standard care and decision-making for diseases and conditions is essential, but the medical home literature and movement is focused on health outcomes across conditions, patient experience, and cost or affordability of care—commonly referred to in shorthand form as The Triple Aim (IHI, 2007).

The Triple Aim and the Joint Principles invite behavioral health clinicians in medical settings to look beyond care of conditions (including mental health conditions) to the care of persons, and to look beyond disease-specific care management protocols to master generic practices of care management or coordination across whatever conditions the person may have. Of course this is not a new insight to behavioral health clinicians and their primary care clinician partners in medical settings. But creating a shared view and vocabulary for just what these generic care management or coordination tasks are in the context of health care home represents an opportunity for behavioral health clinicians to add visible value to these emerging medical home demonstration projects.

Generic Challenges for the Care of Persons in the Health Care Home Model

Behavioral health clinicians in medical settings, especially in primary care, are asked to help a wide variety of patients with a variety of diseases or conditions, not only mental health conditions. Moreover, clinicians are faced with person or community-specific factors and context that can facilitate or interfere with usual care and decision-making for those conditions—and that are not primarily issues of diagnosis or disease protocols. Generic clinician skills and responsibilities are needed in the overall process of taking care of patients—whatever their diseases or conditions (Patterson, Peek, Bischoff, Heinrich, & Scherger, 2002). This is a major opportunity for behavioral health clinicians who become part of health care homes and are pledged to achieve the Triple Aim according to those Joint Principles. A similar way to organize emerging opportunities for behavioral health clinicians to help out with themes that cross diseases and conditions appears here.

Care Coordination

Care coordination is core to medical home Joint Principles, appearing in some form in every paper and demonstration project (Peek & ICSI, 2008). While many of the demonstrations feature separate care manager roles which are usually not behavioral health clinicians, behavioral health clinicians tend to be systems thinkers which is quite useful in their own clinical work with patients and a perspective useful to physicians, care managers, and other primary care providers when it comes to helping care coordination take place effectively at the level of the whole practice. Here are several avenues for bringing this perspective to bear:

Identifying the Key Factors and People to Coordinate in Each Person’s Case

Many patients bring multiple complaints, conditions, clinicians, treatments, and inextricable psychosocial and biomedical factors to their physicians, along with involvement in social agencies and personal or family circumstances that may affect choice of care plan. While clinicians can do only so much and need to focus their work rather than “take on the whole world”, it is important to make sure that enough of the big picture is being taken into account when it comes to care coordination. A care plan can fail from being too small or limited as well as from being too large and expansive. Identifying the key or minimum necessary set of factors and people for care coordination needed to get results is a task of the physician-led medical home team. Behavioral health clinicians are probably among those staff well suited for facilitating this task, by virtue of their perspective and skills.

Setting the Right Level of Collaboration or Teamwork

Many patients bring multiple interacting factors or providers that should be coordinated, but most clinical or social situations are not nearly that complicated or multifaceted. For each person, a judgment is made (either consciously or by default) on what level of collaboration or integration is required between providers, agencies, family members, or services provided. For some, a high degree of teamwork across multiple providers or services may be needed, and for others teamwork may not be needed beyond the primary physician and immediate daily team such as receptionist, nurse, or medical assistant. The medical home aim for quality requires enough teamwork, and the aim for affordability requires no wasted effort building teams or coordination where not needed. The aim of patient experience requires both enough and not excessive teamwork and coordination. Table 1 shows a five-level template for thinking about necessary level of collaboration between behavioral health and medical clinicians that can help structure this task (Doherty, McDaniel, & Baird, 1996; Doherty, 1995).

Table 1 Levels of collaboration (Doherty et al., 1996; Doherty, 1995)

1. Minimal collaboration

2. Basic collaboration from a distance

3. Basic collaboration on-site

4. Close collaboration in a partly integrated system

5. Close collaboration in a fully integrated system

Description

• Separate systems

• Separate facilities

• Communication is rare

• Little appreciation of each other’s culture; little influence sharing

• Separate systems

• Separate facilities

• Periodic focused communication mostly by letter, occasionally by phone

• View each other as outside resources

• Little understanding of each others culture or sharing of influence

• Separate systems

• Same facilities

• Regular communication, occasionally face-to-face

• Some appreciation of each others roles and general sense of larger picture, but not in depth

• Medical side usually has more influence

• Some shared systems

• Same facilities

• Face-to-face consultation, coordinated treatment plans

• Basic appreciation of each other’s role and culture; share biopsychosocial model

• Collaborative routines are difficult—time and operations barriers

• Influence sharing—with some tensions

• Shared systems and facilities in seamless biopsychosocial web

• Patients and providers have same expectation of a team

• Everyone committed to biopsychosocial model; in-depth appreciation of roles and culture

• Collaborative routines are regular and smooth

• Conscious influence sharing based on situation and expertise

Handles adequately

Routine care with little biopsychosocial interplay or management challenges

Moderate biopsychosocial interplay, e.g., diabetes and depression with management of each going reasonably well

Moderate biopsychosocial interplay requiring some face-to-face interaction and coordination of treatment plans

Cases with significant biopsychosocial interplay and management complications

Most difficult and complex biopsychosocial cases with challenging management problems

Handles inadequately

Cases refractory to treatment or with significant biopsychosocial interplay

Significant biopsychosocial interplay, especially when management is not satisfactory to either mental health or medical providers

Significant biopsychosocial interplay, especially those with ongoing and challenging management problems

Complex with multiple providers and systems; especially with tension, competing agendas or triangulation

Team resources insufficient or breakdowns occur in the collaboration with larger service systems

Identifying the Need to Change the Care Plan or Teamwork

Once the key elements for coordination and right level of teamwork are established, they will likely change as progress is made, setbacks occur, and other factors emerge. Furthermore, medical home principles call for care coordination for the clinic’s panel of patients, not just a subset of individuals who happen to command provider attention at any given time. Medical home principles emphasize registries and automated information tools that make it possible for a care manager or other figure in the practice to regularly scan for when something in the care of a patient needs to change. This function is amply demonstrated in the IMPACT literature on stepped care for depression, which includes regular care manager review of the panel and ability to change care depending on progress, lack of it, or relapse (Unutzer et al., 2002). The IMPACT model has also explored how mental health nurses, psychiatrists and other behavioral health professionals can be involved with panel management of depression in the practice (Saur et al., 2002; Hegel et al., 2002). While IMPACT was developed for depression, it also represents a promising template for the systematic care of other mental health or chronic conditions in primary care (Mauer, 2008).

Referral—A Human, Not Only Administrative Process

At times the usual health care home team may need to be enlarged to include medical, mental health or other kinds of specialists, community resources or special team members. This not only introduces complexity to the organization of care and enlarges the scope of who and what has to be coordinated, it can introduce confusion to the patient and family. Referral is indeed a provider-driven administrative process involving questions, data, letters, tasks, and insurance issues. But in the patient-centered medical home referral is also a human process. The aim of patient experience requires that patients know why they are going to any given provider, what to expect, and how it fits their overall plan—and be confident that “the left hand knows what the right hand is doing”. This involves well-timed and patient-friendly introduction of reasons for referral, developing a shared sense of its importance, and engendering trust in the person or service to which the person is being referred. Some referrals are more sensitive than others and cannot be rushed, e.g., those for mental health conditions, domestic violence, chemical dependency, or medical diagnoses such as dementia or diabetes that the patient may not yet be able to accept. Behavioral health clinicians may be important resources within a practice that recognizes the potentially challenging human dimension of enlarging the health care team and making referrals.

Reinforcing a Continuous Relationship With the Primary Care Physician and Team

Medical home principles emphasize continuous healing relationships with a primary physician and physician-led health care team. This means that the behavioral health clinician isn’t to be regarded as someone who simply takes over the care of patients with mental health conditions, or only does clinical work that is separate and parallel to the primary physician. The following are tasks or perspectives that a behavioral health clinician can take to reinforce this relationship while remaining meaningfully in the picture.

Working Within the Patient’s Conception of the Problem

Behavioral health clinicians often treat patients whose emotional, behavioral, social or psychological picture is intertwined with physical complaints and symptoms but who insist on a physiological explanation and cure—the medical problem for which they are consulting their physician. Many patients do not at first make the connections between physical symptoms, emotional states, stress, or personal realities, and these connections and insights cannot effectively be pushed onto patients. In the patient-centered medical home, the primary relationship with the personal physician is maintained, while a behavioral health clinician may be employed on the team to help the patient understand behavioral, psychological, or stress contributions to their presenting problems. The behavioral health clinician does not try to make the patient accept a behavioral or emotional explanation for physical symptoms or substitute for the ongoing relationship with the personal physician. In this way, the medical home team—led by the personal physician, but often involving a behavioral health clinician—can gracefully accommodate any combination of biomedical and psychosocial factors or conditions within an ongoing patient–physician relationship.

Involving Patients in Their Own Care

Patient-centered medical home principles emphasize patient self-management and engagement in their own care—with sensitivity to preferences, cultural factors, shared decision-making and their readiness to set particular health or health behavior goals. Patients and families increasingly want to understand what best care is, and often but not always expect clinicians to negotiate care plans rather than merely give orders. Many patients are already educating themselves, having access to much of the scientific information that clinicians have via healthcare Internet sites, disease-specific education and support groups, social networking websites, and direct advertising, e.g. for pharmaceuticals or devices. Clinicians can harness this energy, especially for patient self-care of chronic conditions. In addition, new models are needed for helping patients become producers of their own health, not only consumers of healthcare services, as described by Doherty and Mendenhall (2006). Behavioral health clinicians who are seen as part of a medical home team may be able to use their skills to enhance and extend primary care provider efforts to engage patients, set goals and customize the approaches to each person and family in addition to treating mental health conditions as an on-site member of the clinical team.

Improving Healthcare Relationships

A commonplace observation is that when patient–clinician relationships are distant or distrustful, standard care may not “take” nearly as well as when patient–clinician relationships are closer and more trusting. All clinicians have had difficult patients or to put it more constructively, difficult patient–clinician relationships. Medical home goals for health outcomes and patient experience will require constructive patient–clinician relationships. The Joint Principles emphasize longitudinal healing relationships—and that makes it important to monitor the state of these relationships and improving them where they are not positive. Again, behavioral health clinicians who are familiar with working with individuals, families and groups with a systems orientation may be able to help a medical home team build and maintain good patient–clinician relationships even when multiple clinicians and family members are in the picture.

Addressing Patient Complexity and Social Context

Clinicians have all encountered complex patients and reacted with a diffuse gut feeling rather than exhibiting a patterned response for just how the patient is complex and what to do about it. This is unsatisfactory for both patients and providers and can leave clinicians with the feeling that patients are “not listening to me” or are noncompliant. Some of these patients may feel “no one can help me”. Yet the principles of the patient-centered medical home ask clinicians to understand and tailor care to the larger whole person context within which patients present themselves—including whatever non-medical factors may affect the success of medical care. One step is to develop a shared vocabulary and assessment system for patient complexity such as done in inpatient settings in the Netherlands (de Jonge, Huyse, & Stiefel, 2006; Stiefel et al., 2006). This approach is being adapted for use in fast-paced primary care clinics in Minnesota (Peek, Baird, & Coleman, 2008). Others have written about the challenge of developing shared concepts and tools for managing complexity in chronic care (Weiss, 2007; in a special issue of the Journal of General Internal Medicine entirely devoted to this topic).

According to the emerging literature on patient complexity, it is not uncommon for clinicians to find themselves serving patients whose social situations are as threatening to health or recovery than the medical aspects of the illness itself. For example, patients living in actively abusive situations or other dangerous social conditions are often swimming upstream when it comes to managing their symptoms and illnesses. Financial problems, social isolation, resignation, and high levels of distress and distraction can undermine usual care and decision-making for conditions, particularly when patients need to participate in their own care, e.g., taking medications, health behavior changes, and coming to appointments. Patient complexity can affect patient–clinician relationships as expressed by the motto “Most difficult patients started out merely as complex.” (Peek & Heinrich, 1995; Patterson et al., 2002). Behavioral health clinicians are likely to have contributions to make on medical home teams when it comes to assessing and proposing action for patient complexity and rebuilding patient–clinician relationships in the broad medical context.

Preventing Disability

Clinicians and their patients of course want to provide and receive good care for their conditions. But in the end patients want to feel better, function better, and continue with their lives. Disability is not a disease but can become a major care management challenge across a wide variety of diagnoses. Preventing disability has to do with helping patients resume life in the face of their medical conditions, rather than gradually becoming disabled, discouraged or withdrawn from life. Effective care of a disease or injury can still leave a patient with fear and needlessly diminished participation in meaningful relationships and activities. Helping a person re-engage in life realistically but confidently after illness or injury is within the scope of the Joint Principles of medical home. As expressed by another care management motto, “Sometimes managing the disability is a bigger challenge than managing the disease” (Patterson et al., 2002). Here again, behavioral health clinicians may have perspectives and skills helpful to medical home teams.

Integrated Care and Taking the Medical Home State of the Art to the Next Level

The national state of the art in “medical home” is indeed person-centered rather than disease centered, with a fairly consistent set of goals anchored in the Triple Aim of health outcomes, patient experience, and affordability. But considerable variation still exists in specific medical home goals as they relate to how behavioral health factors and expertise will be incorporated (Peek & ICSI, 2008). This variation presents opportunities for behavioral health and primary care clinicians who favor integrated care to participate in the ongoing national and state dialogue to help shape the state of the art in medical home. The following are opportunities that need to be weighed in on in a timely manner:

• To what extent are behavioral health, mental health, and substance abuse conditions and expertise in these areas to be a visible part of the purpose and goal of medical home and integrated with general medical care?

• How and to what extent should general medical care be integrated with specialty behavioral health care in a “health care home” for patients with serious mental illness—integrating care in the other direction (Mauer, 2008; Bartels, 2004)?

• To what extent should contemporary understanding of the inherent interactions between mind, brain, and body be featured in the basic philosophy, clinical and service orientation of medical home (Mauer, 2008)?

• To what extent should medical home employ evidence-based approaches to integration of primary care and behavioral health such as IMPACT (Unutzer et al., 2002; Mauer, 2008) and the DIAMOND Initiative (ICSI, 2009) for stepped care of depression in Minnesota, a project that also involves an altered payment model intended to cover care management costs?

The national state of the art in medical home has not yet coalesced around a consensus view of what kind of behavioral health, mental health, or chemical dependency capability is to be a normal part of medical home and what parts are linked, but outside as a specialty service or resources. This represents a twofold opportunity for integrated care clinicians to help shape the national state of the art:

1. The exploding interest in patient-centered medical home suddenly provides publicly meaningful context and significance for integrated care and its long history of literature and demonstration. For example, this author has seen a number of physicians and health system leaders suddenly become aware of the field of integrated care, thanks to its significance for medical home. Those working to develop integrated care can join the larger dialogue taking place in general medical care and medical home development to show that behavioral health integration is another important way to make good on the Triple Aim and the Joint Principles. The medical home state of the art will not advance in this respect if integrated care enthusiasts talk mostly among themselves or only about the care of mental health conditions rather than their potential contribution to these broader person-centered issues in health care.

2. Once in the larger conversation, integrated care clinicians can help shape the medical home state of the art by bringing their accumulated literature, experience, and practical wisdom to bear in an organized and disciplined way that establishes the credibility of their literature and lessons learned—by being centered on the pressing challenges of those working on medical home and looking at their own work through that lens. Even if integrated behavioral health becomes a standard principle in medical home, a roster of more specific behavioral health integration tests and experiments will need to be done within the many and growing medical home demonstration projects, and integrated care clinicians will need to help design them and affiliate with the larger goals and development teams for medical home.

By becoming knowledgeable and affiliating with the larger goals and principles of patient-centered medical home, behavioral health and primary care clinicians can give greater significance to their long history of work on integrated care and substantially enhance the current national state of the art in medical home. Integrated care, along with the relationships that come with it, are not only for medical or mental health conditions, but for the persons who may have those conditions—in their full social context that affects health, healthcare outcomes, patient experience, and affordability of care. Behavioral health clinicians in particular have an important window of opportunity to join the national dialogue on health care home with their current and potential colleagues from primary care, health plans, purchasers, and government plans who want to move the state of the art to the next level on behalf of patients, providers, payers, and all of us.