In the course of just a few decades, routine medical care has gone from being delivered primarily through community-based practices to being situated most often in large, corporately organized entities — as within those large provider systems, many more areas of care have become specialized. Another significant evolution has occurred over this period as well: Treatment for substance use disorders (SUDs) is now broadly accepted as one of those medical specialty areas, rather than being regarded as a marginal social support service. This is a positive shift, propelled by neurobiological and social science research firmly establishing SUDs as treatable health conditions.
Yet despite improvements in understanding and treatment expertise, patients with substance use disorders too often experience fragmented care that fails to fully address their overall health needs.
“Care integration” has become a catch-all term for a wide spectrum of responses to the growing recognition that people with SUDs often suffer from co-occurring health conditions, and that treating all of such patients’ conditions together is much more likely to be effective than treating just one. Integrated care is still far from standardized, and different models abound — but all are directed at addressing both substance use disorders and other health conditions to help each individual patient make progress toward recovery, improved general health, and overall well-being.
To get a sense of what care integration means to those who are making it a reality, we conducted an in-depth review of providers using four very different models. Boston Medical Center and the BayCare Medical Group are hospital-based health systems that incorporated SUD treatment services into their systems; Finger Lakes Community Health is a Federally Qualified Health Center (FQHC) that incorporated behavioral health into its service array; and Chestnut Health Systems is a behavioral health center that incorporated an FQHC. Each obtained the requisite state licenses that would allow them to deliver both SUD and general medical care.
First Steps toward Care Integration
Patients presenting with both chronic medical and addiction-related conditions were what initially motivated all four organizations to integrate SUD and basic medical care. Research shows that patients with multiple diagnoses who are treated for only one of them fare worse than those who are simultaneously treated for all of their presenting diagnoses; all four organizations recognized untended health conditions presented by their behavioral health patients.
Beyond the recognition of unmet need, two other factors emerged as important motivators: In all four cases one or more champions had the vision and leadership to change the practice of a clinic. And potential financial opportunity helped move BayCare and Chestnut Health Systems toward care integration, as they embraced new ways of working with payers to cover the costs of integrated care. The recent trend toward bundled, pre-paid, and capitated payment systems supports such innovations by giving providers an incentive to intervene early and with intensity, in the hope of deterring the more expensive episodic care associated with untreated acuity later on.
Once the providers were motivated, integration began one step at a time. In three of the reviewed organizations, patients were first provided access to SUD treatment through their contact with the general medical system, while the reverse is true of the fourth, where patients were provided access to medical care through the SUD system. Importantly, as each system evolved over time, patient access to integrated care became bi-directional, accessible through any point of entry.
At both BayCare and Finger Lakes Community Health, integration began with placing SUD-certified clinical staff in primary care clinics to provide clinical services and referral to specialty care. Chestnut Health Systems hired Advanced Practice Registered Nurses in its behavioral health clinics first, and then expanded that function — initially to primary care clinics, and later to a designated FQHC. The origins of integration at Boston Medical Center extend back to staffing “Room 5,” adjacent to the emergency department in the 1970s, where nursing and recovery aides monitored patients’ alcohol withdrawal symptoms. Room 5 no longer exists, having been replaced by a comprehensive assessment, triage, and follow-up service connected to the integrated clinics and specialty SUD services of the Grayken Center for Addiction Treatment.
Reviewing the processes that advanced integrated care in these organizations, we observed common threads in three areas: culture change, data sharing, and payment models.
The organizations have found that when licensed and professional staff move into health care settings that are new for them, they need an organizational culture that encourages a more flexible orientation, broader knowledge, and an expanded skill base. Doctors and other physical health care staff are exposed to clearer protocols for screening individuals with SUDs, and learn to determine which patients could be served by in-house clinicians rather than referred to more intensive treatment and recovery services. Meanwhile, SUD clinicians embedded in primary care gain a much better understanding of co-occurring physical health conditions. In-house training opportunities were noted by all of the provider groups as an important resource to facilitate care integration.
The Challenge of Data-Sharing
In fully integrated systems of care, providers of any service have access to the full medical records of each patient. But electronic medical records (EMRs) that are equally appropriate for both general medical and behavioral health use are challenging to develop for several reasons, from market forces to federal confidentiality regulations. Meanwhile, the development of workarounds for these challenges consumes financial and staff resources. Among the providers we reviewed, only Boston Medical Center has a single system that covers all services and patients. Chestnut Health tried a unified EMR system, but costs were prohibitive, so the facility came up with a partial solution by granting login privileges to a high proportion of its staff in both systems. BayCare is working toward introducing a fully integrated EMR system, while Finger Lakes is implementing a single health center EMR system.
Paying for Integrated Care
The reviewed organizations pay for the initial costs of integrating care in three ways: grants, third-party reimbursement, and self-funded operating sources. Many barriers present challenges to supporting integrated care with only third-party reimbursement, including regulations that limit billing for multiple services on the same visit; low reimbursement rates for behavioral health; a preponderance of uninsured patients; and conflicting licensing requirements.
Finger Lakes used operating funds provided by the Health Resources and Services Administration (HRSA) to purchase bilingual services, and receives support from third-party billing (Medicaid) and HRSA. At Boston Medical Center, the funding for screening, clinics, and some medication-based treatment comes from National Institute on Drug Abuse research grants. Boston Medical Center pays for clinic services through third-party billing, and subsidizes some overhead and administrative costs through its general operating budget. Research grants and third-party reimbursement are primary sources of financing at Chestnut Health Systems. Chestnut Health is notable for its explicit choice of optimal reimbursement sources for diagnosis, intervention, and licensure (SUD or FQHC). BayCare currently receives reimbursement from private payers and Medicare for its integrated strategies, though the current reimbursement structure makes it challenging for BayCare to offer Medicaid beneficiaries both SUD and primary care services.
All incremental processes depend on refinements and continuous improvement. As these four organizations moved toward greater degrees of care integration, they met the challenges of hesitant physicians, complex regulations, and budgetary requirements not designed to cope with “crossover” services. None of these issues were insurmountable, but each was nevertheless problematic until resolved.
Together, our four examples offer some key takeaways to providers and health systems considering their own next steps toward deeper integration of primary care and SUD care:
- Patient need is the prime reason to integrate SUD and general medical care.
- Organizational leaders must recognize that patients have multiple needs; their vision and drive to address those needs comprehensively is an essential ingredient of integration initiatives.
- Integration initiatives can prove financially solvent by efficiently caring for complex cases that would otherwise be high-cost, but such financial success depends directly on adequate reimbursement rates.
- Unified patient records, especially in the form of EMRs, are not yet fully enough developed to reliably support integration.
- Financial support for integration requires that providers be adept at blending and braiding research/grant monies, third-party reimbursement, and general operating revenues.
To learn more, read our full report, Integrating Substance Use Disorder Treatment and Mainstream Medical Care: Four Ground-Level Experiences.