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Rural Health Information Hub

Nov 18, 2013

Models of Care Integration Continue to Evolve

by Candi Helseth

Although most existing health care systems that integrate primary care with behavioral health or oral care share similar terminology and structures, there is not one nationally recommended model for care integration.

Primary care, dental health, behavioral health puzzle piecesBut, according to Ana Bridges, a professor who specializes in integrated behavioral healthcare at the University of Arkansas, “While there are definitely different degrees of integration, ideally, integration has these components: providers work together in the same setting, share patient records, meet together to discuss a patient's needs and coordinate the patient's care throughout the spectrum. Basically, there are also a lot of informal activities that make care management an overall team approach. That results in improved patient access and reduced patient barriers.”

Integrated care models perhaps can be implemented even more successfully in rural settings due to commonalities found in rural practices, noted Rachel J Valleley, PhD, a licensed psychologist and professor at the University of Nebraska Medical Center. “In rural areas, integrated care magnifies the benefits for patients, physicians and behavioral health providers by improving access to care for patients, providing a referral source for busy rural practices and a consistent referral stream for behavioral health providers,” Valleley said.

Behavioral Health Integration Models Help Meet Community Needs

The SAMHSA-HRSA Center for Integrated Health Solutions strongly encourages healthcare integration, defining integration as “a systematic coordination of general and behavioral healthcare.” The Center notes that integrated behavioral care can occur within primary care settings, behavioral care settings or within health homes.

The Maine Health Access Foundation (MeHAF) encourages integration partners to develop collaborative models individualized to meet their community's needs. MeHAF Senior Program Officer Becky Boober said key elements that partners are asked to keep at the forefront are: patient choice in the care setting, patient and family participation in service development, collaboration between physical and behavioral health providers who share common patient medical records, and solution-focused, cost-effective treatment for physical and behavioral conditions. MeHAF grantees assess patient and community needs and develop their models accordingly.

“Seven out of 10 people in a doctor's office will have both physical and behavioral health issues,” Boober said. “While behavioral health encompasses mental illnesses such as bipolar disorder and schizophrenia, the field of treatment also includes more common ailments such as anxiety, depression, obesity and poor lifestyle choices.”

To continue integrated learning and implementation, MeHAF funds support services such as the Integrated Care Training Academy and the Learning Community. Patient-Family Advisory Councils meld providers with patients and family members to share ideas that improve care delivery and patient satisfaction. As providers see the positive results, Boober said initial hesitancy has diminished and partners are going beyond their internal organizations to consult with other entities committed to developing best practice integration models.

Valleley said that family practice and pediatric primary care physicians in rural areas are those primarily providing health care—and they often lack a mental health provider to refer people to for addressing mental health concerns. “So in rural areas, the primary care physician has to do it all,” she said. “Having a behavioral health provider be part of that team will allow rural patients to access services without having to travel long distances. In fact, in our experience in rural Nebraska, we have found that a major incentive for recently graduated physicians to join a practice was the presence of an on-site behavioral health provider.”

Most Oral Care Integration Still a Work in Progress

Oral care integration with primary care has not yet been as widely adopted as behavioral health integration, but is still evolving.

According to the report, Returning the Mouth to the Body, there are four general models for oral care integration—full integration, colocation, primary care provider service focus and collaboration—and that no one approach should be considered the “gold standard.” The Oral Health Toolkit on the Rural Health Information Hub website describes an Oral Health-Primary Care Integration Model and lists strategies that rural communities are using to integrate oral health and primary care, which include referral partnerships between dental clinics and primary care practitioners, and school-based models for dental assessment.

“Some Health Centers locate oral health team members, such as a dentist or dental hygienist, in the primary care setting,” said Irene Hilton, DDS, MPH, dental consultant for the National Network for Oral Health Access (NNOHA). “Depending on state practice regulations, these dental providers may conduct oral health screenings, exams, deliver preventive procedures and make referrals to the dental department. These efforts build positive, collaborative relationships between the medical and dental departments. The process is bi-directional with dental staff able to send patients with high blood pressure readings or potential uncontrolled diabetes directly to medical for same day assessment. In addition to screening for high blood pressure and diabetes, some Health Center dental programs conduct rapid HIV testing and follow-up during the dental appointment.” NNOHA advocates also for a Patient-Centered Health Home that offers integrated medical and dental services as one of the solutions to limited oral care access.

The Health Resources and Services Administration (HRSA) has been engaged in efforts to integrate oral health and primary care.  “About 75 percent of HRSA-supported health centers offer comprehensive primary dental services on-site or through contract services, along with primary care services,” said Marcia Brand, PhD, HRSA Deputy Administrator. “We've supported the development of curricula that teach non-dental providers about oral health, and supported a project that models the implementation of a core set of oral health clinical competencies for non-dental health care professions in community health settings.”

HRSA has supported the Association of American Medical Colleges developing a curriculum for medical students on oral health, as well as the American Academy of Pediatrics – Oral Health Quality Improvement Module.  HRSA currently is sponsoring a pilot project (IPOHCC) with NNOHA to implement the core set of oral health clinical competencies for non-dental health care professionals in the Community Health Center setting. In addition, HRSA's Oral Health IT Toolbox (no longer available online) promotes the integration of oral health primary care through health IT, which allows multiple providers to connect and share information that could be relevant and valuable to the provision of care, across multiple settings.

The Institute of Medicine* has called for integrating oral health care into overall health care, to be accomplished, in part, by non-dental health care professionals taking a role in oral health care, and for primary care providers to educate individuals about how to prevent oral diseases, to assess risk and screen for oral diseases, and to deliver preventive services. The Smiles for Life, a national web-based and interactive oral health curriculum, aims to enhance the role of primary care clinicians in the promotion of oral health for all age groups. Recently, the American Dental Association teamed up with the National Association of Community Health Centers to increase awareness and integration of oral and primary care.

Affordable Care Act Promotes Health Care Integration

Mental health and substance use disorder services are one of the 10 essential benefits that will be covered under the Affordable Care Act (ACA); dental care is also one of the essential benefits, but that benefit is restricted to children.

According to SAMHSA, primary and behavioral health care integration is an opportunity under the ACA to improve health care quality through the systematic coordination of primary and behavioral healthcare. Because provisions within ACA provide incentives for integrating behavioral health and primary care, providers are prioritizing behavioral health as a primary integration effort.

The ACA also provided for grants to school-based health centers and includes oral health services in qualified services to be provided at those centers.

“The new healthcare laws are written with the understanding of treating people more holistically and focusing on integrated care to accomplish that,” Bridges said.

*In March 2016, the Institute of Medicine changed its name to be the Health and Medicine Division (HMD), National Academies of Sciences, Engineering, and Medicine.

Back to: Fall 2013 Issue