National Council Framework Aims to Boost Adoption of Integrated Care

The Comprehensive Healthcare Integration (CHI) Framework, developed by the National Council on Mental Wellbeing (NCMW) and published in June, is a guide for physicians, payers, and policymakers to measure progress in organizing the delivery of integrated medical and behavioral health care services.

The framework was developed in consultation with a multidisciplinary group of experts in integrated care including representatives from APA.

During a symposium at APA’s Annual Meeting in New Orleans, NCMW Director Joseph Parks, M.D., and psychiatrist Ken Minkoff, M.D., senior systems consultant at ZiaPartners, introduced the CHI Framework as an instrument designed to boost adoption of integrated care.

“The field has been working on integration for 20 years,” Parks said. “Today there is a lot of evidence that integration really does improve outcomes and, in some cases, reduces cost. However, the overall uptake of integrated care has been spotty. It is not the standard across the whole health care system. A lot of integration initiatives were started but haven’t been sustained. We have evidence it works, but we don’t do it everywhere, and when we start doing integration, we don’t keep it up. That’s why we thought we needed to step back and look at where we are and where we are going.”

Parks said one important reason integrated care hasn’t been more widely adopted is that some models, such as the Collaborative Care Model—which has the most evidence for effectiveness—have very specific roles and protocols. “We thought an approach was needed in which any organization can become more integrated and make progress,” he said.

Toward that end, the CHI Framework describes eight “domains” of integrated care. These include screening, referral, and follow-up; prevention and treatment of common conditions; continuing care management; self-management support; multidisciplinary teamwork; systematic measurement and quality improvement; linkage with community/social services to address patients’ negative social determinants of mental health; and financial sustainability. Each of these refers to care processes that are related specifically to addressing physical health and behavioral health issues in an integrated manner.

The framework also outlines three “constructs,” or organized approaches, to integrating care.

• Screening and enhanced referral: This approach optimizes screening and “enhanced” referral processes—these are any processes that help link patients to the care they need, rather than simply giving them the name of a provider. It does not require significant investment and may be best for smaller practices and programs with fewer resources.

• Care management and consultation: This approach is a more robust commitment to a set of screening and tracking processes with associated on-site care coordination and care management.

• Comprehensive treatment and population management: This is the most robust model requiring comprehensive medical and behavioral health staffing in a single organization; for example, hospital, independent clinical practice, and Federally Qualified Health Center (FQHC). This model also measures and reports health outcomes along all of the eight domains.

A second reason the adoption of integrated care has been slow is that there has been no way to measure how well integrated a system or clinic is and what impact that has on outcomes—what the CHI Framework refers to as “integratedness.”

“If integration isn’t measurable, then it’s hard to attribute how much value or improvement in outcome has occurred as a result of integration,” Parks explained. “That makes it hard to get better reimbursement rates and the resources we need to sustain integration. Payers tell us they like the idea of integrated care, but they don’t know how to determine what is integrated care and what isn’t.”

The CHI Framework includes specific metrics that health care organizations can use to measure their progress in integrating care and examples of how to finance integration.

Finally, the CHI Framework offers recommendations for psychiatrists and mental health professionals, the organizations and health care systems for which they work, payers, policymakers, and regulators. As a practicing psychiatrist working within a FQHC, Parks said that he can use the eight domains and the three constructs to assess how well the FQHC is providing integrated care and to establish achievable goals for improving integration.

“We believe there are things in this report that anyone involved in integrated care can use to move integration forward,” Parks said. “If nothing else, you can find a more effective way to talk about integration with your colleagues and peers.”

The 35-member expert panel that helped to develop the CHI Framework includes, among others, Henry Chung, M.D., a member of APA’s Committee on Integrated Care; Lori Raney, M.D., former chair of the committee; and past APA President Anita Everett, M.D. ■