Integrated services: a multi-disciplinary approach to healthcare

Since 2001, cooperation and collaboration among Rhode Island’s insurers, physicians and behavioral health specialists has spawned practices that marry medical and psychological services. The coming year holds significant promise for more co-located and fully integrated practices.

Nine years ago, Providence-based Psychological Centers, Inc. began co-locating psychologists and other behavioral specialists at select primary care practices across the state. Currently, 15 sites feature both primary care physicians and behavioral specialists.

Jeffrey Migneault, Ph.D., director of the Center for Integrated Care (CIC) at Psychological Centers, reports that Paul Block, Ph.D., co-director of Psychological Centers and two physicians have been collaborating for the last two years on a design for a new model, Lifelong Personal Health Care (LPHC).

This concept grew out of the limitations in the current co-located model, according to Migneault. While the existing system has yielded benefits, it is not fully integrated, he says. “It depends on medical doctors’ referring and recognizing issues psychologists could help with.”

Migneault explains that the LPHC represents a co-equal model comprising a team of primary care physicians (PCP), behavioral care providers (BCP) and a care coordinator. “The patient will be introduced to the PCP and the BCP at the same time as leaders of the team,” he says. “The treatment plan would be developed from the medical doctor and the behaviorist.” The care coordinator would oversee the medical aspects of the integrated plan, he adds.

Patients with chronic health conditions stand to benefit most from this new model. “The outcome for chronic conditions is better if the behavioral component is part of the treatment plan. Long-term outcomes depend on what the patient does,” says Migneault.

Initially LPHC will operate on a part-time basis, according to Migneault. “The practice won’t go to five days at the beginning. We’ll start slowly and optimize the model,” he says.

Payment issues are also being worked out. “We are talking with the insurance companies. United and Blue Cross/Blue Shield are progressive and willing to fund reimbursement,” Migneault says.

While psychologists will play an integral role, Migneault asserts that this model holds much promise for the physician. “It’s more rewarding work to have a team to address complicated issues so physicians can focus on what they do best,” he says, noting that medical doctors at co-located sites offer praise for their behavioral colleagues. “I’m amazed by PCPs and what they are trying to do, often in 15 minutes. They have case-loads of thousands. To [expect them to] understand, track and prioritize psychosocial issues is unreasonable.”

LPHC received $65,000 in seed funding in October 2009 from the Rhode Island Foundation. Owen Heleen, vice president for grant programs at the Foundation, says, “We see tremendous benefits to models that fully integrate skills.” While he admits there is no “silver bullet approach” to healthcare, he points out that having different models can lead to the optimal system. “We are happy to support these really good ideas.” He credits Psychological Centers with the work it is doing to develop a successful, cost-effective model of integrated care. “Psychological Centers has the expertise to put together the technical and actuarial work. They know how to become sustainable for others to look at and then sustain their own models,” he says.

Another major supporter of co-integrated medicine, Blue Cross/Blue Shield of Rhode Island has provided significant financial backing for integrating medical and behavioral health offices and is taking its commitment to healthcare one step further.

“We’re committed to the concept of the medical home and are in the process of establishing patient centered medical homes around the state,” says William Hancur, Ph.D., associate medical director of behavioral health at Blue Cross/Blue Shield of Rhode Island. Based on National Committee for Quality Assurance (NCQA) models, these practices emphasize a coordinated care management process that fosters long-term partnerships between patients and physicians.

Hancur cites “one big wrinkle” in Blue Cross/Blue Shield’s concept though. “We are requiring a behavioral health component from the beginning,” he says. “This flows from our commitment as a company to pay attention to all aspects of health.”

According to Hancur, Blue Cross/Blue Shield is providing grant funding to offset rent, infrastructure and other costs associated with the implementation of the medical home.

Additionally, Hancur notes that financial incentives will be offered to behavioral providers to entice them to leave their current practices and join the integrated models. “We will pay more for behavioral and assessment codes. We are looking at providing a mechanism to pay the provider for services,” he says.

Behavioral care practitioners will be required to spend a minimum of 20 hours or half the hours the practice is open on-site. “The expectation is that [the position] will likely become full time as the availability of behavioral care practitioner services becomes indispensable to the primary care physician,” says Hancur and emphasizes the lasting effect a behavioral specialist can have on chronic medical conditions. “When patients get only medications, it’s not the best way to treat. You need to influence behavioral changes to improve the condition,” he says.

The integrated concept requires 30 behavioral care providers for the first phase, says Hancur. “We will provide a week of training to teach them how to practice in a medical setting. It’s different than how they are used to practicing.” He adds that while interest is certainly necessary, experience, ability and the right personality is critical to success.

Hancur hopes to see 10 co-located medical homes launch sometime in 2010. “Eventually every practice of sufficient size should be a medical home. An office with one or two practitioners is too small to be a medical home, as it is currently defined,” he says, adding that small practices could combine forces to provide some of the same services as a medical home.

Hancur says, “The future of healthcare must be in this direction. We’re rolling big dice. We have to build a research and outcome component to show true medical cost offsets. It is absolutely critical to demonstrate significant cost savings. We have to make changes in the existing system or we will be crushed under our own weight.”