The adoption of whole person care approaches and the need for integrated care strategies continue to rise. According to recent data, primary care physicians prescribe 45% of all antipsychotic medications and 79% of all antidepressant medications. Medicaid behavioral health benefits are moving away from “carve out” models towards integrated care. Each year, more and more health plans include behavioral health in their primary care capitation models. And, at last count, 73% of primary care provider organizations and 51% of specialty provider organizations have adopted a strategy to integrate treatment.
Should innovation and growth plans for specialty provider organizations include primary care integration? The answer is likely to be yes. The key will be to find the right integrated care delivery model that fits your organization’s business needs. As my colleague, Senior Associate Christy Dye, said at a recent OPEN MINDS Executive Roundtable, “Each specialty and primary care provider organization should adapt their strategy to align with the evolving landscape of whole person care by integrating services, improving care coordination, embracing a team-based approach, and engaging with the community. The ultimate goal is to provide comprehensive, patient-centered care that addresses physical, mental, and social well-being.” A recent analysis found over 80 types of integrated care models on the market, ranging from patient-centered medical home/health home models to Certified Community Behavioral Health Clinics (CCBHCs). There are more than 10,000 health care practices with 50,000 clinicians certified by NCQA as patient-centered medical homes. Between 2015 and 2023, there was a 6% increase in the number of states with Medicaid health home benefits. CCBHCs are a more recent phenomenon—there are 431 CCBHCs operating across 41 states, many of which are grant-funded.
Integrated Care Service Line Models
At OPEN MINDS, we see the integrated care service line models as having five categories:
1. Specialty Care. In this category, specialty providers deliver services (virtually or in person) in a primary care setting, as part of a collaborative care model, or clinically integrated network. The co-location model in this category is often a starting point for integrated care models for specialty providers.
2. Primary Care. In this category, specialty providers pull in primary care partners (again, virtually or in person) to deliver primary care service on-site (co-location) or as part of a collaborative care model.
3. Care Coordination/Care Management. In this category, specialty providers play the care coordinator role for all health care services for select consumers. It may include case management, care navigation, and community outreach services.
4. Patient Center Medical Homes or Health Homes. These are both team-based, whole person care delivery models.
5. Combined Primary Care & Behavioral Health Services. This last category of integrated care is where specialty provider organizations deliver primary care services rather than contract or coordinate with primary care providers. Models here also include CCBHCs, FQHCs, and FQHC ‘lookalike’ organizations.
Challenges To Integrated Care Models
There are several challenges to making an integrated care strategy work ranging from tech issues, to workforce challenges, as well as working with health plans.
Challenge #1: Technology Infrastructure & Electronic Health Record Interoperability
Often, the biggest challenge to integrated care is sharing health record information. The easy fix for this challenge is to have all care providers on the same EHR platform so that staff can access the complete health record (behavioral health and primary care) and that a comprehensive, integrated care plan can be developed. However, most of the integrated care models being implemented involve multiple provider organizations and multiple electronic health record systems. In these instances, you need interoperability—the real-time, seamless exchange of the right health record information between provider EHRs—so that care can be planned and delivered.
Challenge #2: Going Beyond The EHR; The Need For Technology Platforms For Care Coordination & Consumer Engagement
The second major challenge to successful integrated care models is having the right technology platforms for care coordination and consumer engagement. For care coordination, providers may need additional software technologies beyond the current EHR functionality in place and may need to ‘coordinate’ care with organizations that do not have electronic health care records. Key care coordination functions include care planning and resource coordination, medication management, advocating for service recipients to obtain needed social determinants of health (SDoH) interventions, and assisting with hospital and emergency room diversion.
Consumer engagement increases the likelihood that consumers will participate in the management of their health and has been demonstrated to improve health outcomes and decrease costs. There is no fixed model for consumer engagement, with the approach dependent on the population. Some of the most common tools are patient portals, email and text communication programs, personal outreach with peers and health educators, and avatar peers for recovery support and treatment plan adherence.
Challenge #3: Staff & Talent Acquisition
The third challenge is the workforce challenge. In this case, I don’t mean just the ongoing problem of hiring and retaining skilled managers and direct care staff. This challenge here is also about talent—having competencies in whole person care. Many individual providers have not been trained in integrated care models or have experience in integrated care settings. The skills and operations for integrated care assessments, treatment planning, and service delivery are different from those used in settings that deliver behavioral health and primary care separately.
Challenge #4: Contract Competition
Competition for the emerging whole person care contracts is growing. A growing number of medical home/health home contracts are available with health plans. Many health plans are now paying for enhanced care management (ECM), community support, and in lieu of services (ILOS) programs. New provider organizations are building and pitching models that provide integrated services with a capitated primary care/behavioral health model.
Challenge #5: Patient Attribution Problems With Health Plans & Payers
For health plans, the issue is attribution—the assignment of consumers to specific provider organizations and the attribution of costs (and savings) to that provider organization. Overall, contracts in whole-person care? should foster a collaborative approach among providers, payers, and patients, with a primary focus on improving consumer health outcomes, reducing costs, and addressing the broader determinants of health. This is essential in moving to meaningful value-based reimbursement arrangements, which are often key to integrated care models.
Payers and health plans have been focused on integrated care coordination and service delivery, with the realization that 10% of consumers use 70% of health care resources. And that half of those high-cost consumers have behavioral health conditions. But because health plans have limited functionality in their data and claim payment systems, and many provider organizations don’t have a method of assessing the necessary ROI, integrated care remains the exception, not the rule.
I was speaking to my colleague, Senior Associate Deanne Cornette, about integrated care models for specialty providers, and she said, “Whole person care is an important piece to strategy, as is the commitment to treating individuals with compassion, empathy, and a holistic approach that acknowledges their physical, mental, and emotional well-being as inseparable elements of their overall health… No matter the model, whole-person care will require an upfront investment in staff, process re-engineering, and supporting technology—investments that will take serious planning to translate into a stable bottom line.” The strategic shift to integrated care is formidable for specialty providers, requiring organizations to embrace value-based care, leverage technology, promote collaboration, and focus on patient-centered care. The executive teams with the right planning, expertise, and data will be the ones best positioned to take advantage of the inevitable move to integration.