Position Statement 13: Integration of Mental and General Health Care
Mental Health America is committed to the principle that mental health is an essential part of every person's health and well-being and that every child, adult, and family should receive mental health and substance use prevention, early identification, treatment, and long-term support regardless of how they enter the healthcare system.
Mental Health America believes that treating the whole person through the integration of mental and general health care will save lives, reduce negative health outcomes, facilitate quality care, and result in long-term cost savings.
Mental Health America believes that for people who live with chronic mental illnesses, general health is especially important, as a healthy body contributes to mental health recovery. Mental Health America believes that integrated healthcare systems enhance the essential role that social support services play in the recovery process.
Mental Health America believes that integration must involve the entire medical community and include the full continuum of mental health care services. Providers on both sides of the mental and general health care interface should receive full and timely information and should follow evidence-based protocols in order to identify and treat the whole person.
The Institute of Medicine (IOM) defines mental health integration (MHI) as a comprehensive approach to promoting the health of individuals, families and communities based on communication and coordination of evidence-based primary care and mental health services. It emphasizes integration as an example of quality health care delivery design that facilitates communication and coordination based on consumer and family preferences and sound economics.
The Institute of Medicine's report on Improving the Quality of Healthcare for Mental and Substance-Use Conditions1 characterizes integration or collaborative care as:
- Communication exists when each clinician caring for the patient (consumer) shares needed clinical information about the patient (consumer) to other clinicians also treating the patient (consumer)
- Collaboration is multidimensional, requiring: a shared understanding of goals and roles, effective communication, and shared decision-making.
- Care Coordination is the outcome of effective collaboration and corresponds to clinical integration.
- Clinical integration is the extent to which patient (consumer) care services are coordinated across people, functions, activities, and sites over time so as to maximize the value of services delivered to patients (consumers).
The interface of mental and general healthcare is well documented. There is a growing awareness of the influence of mental health and substance use conditions and the burden they place on individuals, overall health, and to society. Mental health and substance use conditions are widespread among persons with other health conditions including cancer, heart disease, diabetes, chronic obstructive pulmonary disorders, and other illnesses. Depression can adversely affect the management of chronic illnesses such as cardiovascular disease and diabetes2 . The Centers for Disease Control and Prevention (CDC) have pointed to the influence of mental health conditions on the onset, progression, and outcome of other illnesses3 . The CDC also points to the correlation between mental health conditions and health risk behaviors such as physical activity and tobacco use. There is also a growing body of research demonstrating the alarmingly high rates of overall health problems and premature death among individuals with serious mental illnesses4 . In fact, people with mental health conditions currently die 25 years earlier than other Americans5 .
Integration has proven to demonstrate improved health status in consumers and improved ability of physicians to manage mental health conditions6 . According to Mental Health, United States, 2004, a growing number of studies demonstrate that programs such as the chronic care model are effective and cost-efficient for improving the treatment of depression in primary care and that there are promising signs that the model is applicable to other mental health conditions. "Collaborative care has been shown to be predictably efficacious and effective if the type of relationship between mental health and medical providers, the population served and the type of service provided are adequately specified7 ."
The current health care system is unable to adequately address both sides of the primary care/behavioral health interface. Although primary care provides the majority of mental health care, barriers such as lack of financial compensation and available time with consumers make it difficult for health care systems to implement effective treatment strategies. Unfortunately, primary care providers commonly fail to recognize or treat some disorders including substance use disorders or depression. Physicians may lack the knowledge or the time to adequately diagnose and treat mental health conditions. Mental health providers suffer some of the same problems with a lack of knowledge of or time to diagnose physical health conditions.
The primary responsibility for providing mental health care continues to fall on primary care. In fact, 54% of individuals with a mental health condition are served in primary care settings. According to the American Academy of Family Physicians, 42% of patients with clinical depression and 47% with generalized anxiety disorder (GA) were first diagnosed by a primary care physician 8 . It is also important to note that most individuals prefer to receive their mental health care within primary care since it is perceived as less stigmatizing than the traditional mental health system 9 . The role of primary care identification and treatment of mental health conditions is important for special populations including older adults and low-income minority populations that are likely to go undiagnosed due to a lack of access to primary care. In addressing how to integrate mental health and general health, the Surgeon General's 2000 Report: Integration of Mental Health Services and Primary Health Care provides a set of twelve core principles to facilitate the development and implementation of national and local programs. They include an emphasis on consumers and their families, promotion of health and overcoming disparities, basic characteristics, financial incentives for team approaches, reimbursement to support evidence-based care, collaboration/collocation, chronic illness and continuity of care, standardized quality and outcome measures, building on existing models, research and demonstrations, investment in training, and information technology 10 .
Call to Action
Mental Health America is dedicated to supporting national, state, and local efforts to integrate mental and general health care and to continued efforts to improve the quality of mental health and substance use services available in general health care settings and the quality of primary health care services available in specialty mental health care settings. Our goal is to foster the broad implementation of available research and models in real-world health delivery systems, to ensure that services are appropriate to the population being served, and to eliminate the clinical, financial, policy and organizational barriers to the integration of mental and general health care.
- The integration of mental and general health care must occur at all system levels including the federal, state, and local levels. It also requires a clear effort to overcome the clinical, financial, policy and organizational barriers to fully integrating mental and general health care.
- Many effective mental health services, especially psycho-social, recovery-oriented and rehabilitation services have not been provided in traditional medical treatment settings. It is essential that such services be provided as components of integrated treatment of mental health conditions.
- The federal government should clarify the ability of primary care providers to bill for mental health services, including prevention, screening, and consultation. Medicaid should financially support care coordination and other integration models that have proven to be effective at addressing the needs of diverse populations.
- The federal government should build integration into grant programs, information technology, and policies. The private sector should share its experience with care coordination in order to help foster the growth of integration in all health systems.
- There should be a national action agenda established to foster relationships between consumers, providers, physicians, and payers to overcome the barriers that prevent broader utilization of integration models.
- States and local authorities should also develop initiatives to oversee the provision of health care and to develop community coalitions that can implement integration models that address their communities' unique needs.
- Information technology has the potential to improve the delivery of comprehensive services through improved communication and coordination. The coordination of information systems that bridge systems should promote the use of shared databases across all health service areas while maintaining patient/consumer rights and privacy. Integration also requires better coordination of quality outcome/performance measures. If the quality metrics used to measure healthcare are not aligned, efforts to establish best practices in integration will be pointless. Measurement standards should cross mental and general health and should be influenced by consumer preferences and input.
- As Health Information Exchanges are established, states should assure the maintenance of strong privacy and consent policies concerning mental health and substance abuse conditions along with those concerning the treatment of minors. Technological and policy solutions should be developed so that these important protections do not prevent or inhibit the exchange of electronic health records between general health and behavioral healthcare providers in order to integrate care and prevent medical errors.
- The federal government and states should expand incentives for behavioral health providers to reach Health Information Technology Meaningful Use standards so consumers/patients of these providers can receive integrated care. Organizational issues that need to be addressed include training on both sides of the integration interface: Healthcare workers need to be educated on the value of addressing all health needs in an integrated way, on the recognition of health conditions, and on how to treat mental conditions and when and how to refer to community services.
- It should be an overarching goal to reduce the stigma within both provider communities to eliminate the separation of mental and general health and to overcome stereotypes about individuals with mental health conditions.
- A first step should be better utilization of screening tools in primary care settings with tools that are culturally competent and appropriate for varying literacy levels.
- Evidence-based practices should be expected regardless of the care-setting. Providers should be held accountable for the off-label use of psychotropic medications with children and any overuse of these medications for behavioral management in institutional settings like nursing homes for the elderly.
- Research is needed on the use of integration models with various mental health conditions and for addressing the needs of disparate populations and co-morbidities.
This policy was approved by the Mental Health America Board of Directors on June 9, 2012. It is reviewed as required by the MHA Public Policy Committee. Expiration: December 31, 2017
- IOM, Improving the Quality of Health Care for Mental and Substance-Use Conditions, Quality Chasm Series. Washington: National Academies Press, 2005.http://www.iom.edu/?id=30858
- CDC, The Role of Public Health in Mental Health Promotion, September 2, 2005 / 54(34); 841-842.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a1.htm
- See MHA Policy Statement P16 - The Health and Wellness of Individuals with Serious Mental Illnesses http://www.nmha.org/go/position-statements/
- Morbidity and Mortality in People with Serious Mental Illness. NASMHPD. October 2006.http://www.nasmhpd.org/general_files/publications/med_directors_pubs/Technical%20Report%20on%20Morbidity%20and%20Mortaility%20-%20Final%2011-06.pdf
- Quality of Health Care Committee, 2004. Section III. Mental Health Care in Primary Care Settings
- Blount, Alexander. Integrated Primary Care: Organizing the Evidence Families. Systems & Health. 2003
- AAFP Mental Health Care Services by Family Physicians Position Paperhttp://www.aafp.org/online/en/home/policy/policies/m/mentalhealthcareservices.html
- Annexure et all., 1997, as reported in the Surgeon General's 2000 Report: Integration of Mental Health Services and Primary Health
- Core Principles from Surgeon General's 2000 Report: Integration of Mental Health Services and Primary Health Care.http://0-www.ncbi.nlm.nih.gov.catalog.llu.edu/books/bv.fcgi?rid=hstat5.section.2952