Integrated Healthcare: Frustrations, Success Stories from Front Lines

Providers push to integrate physical and mental care for the poorest in New Jersey

Cindy Mann is a former deputy administrator at the Centers for Medicare and Medicaid Services.
For the healthcare providers treating some of New Jersey’s most impoverished patients, it has become clear that integrating physical treatments into a regimen of mental health and substance-abuse care makes lots of sense. A comprehensive approach is more likely to help a patient get or stay healthy and feel better about the experience itself, while it costs the system less in the long run.

Now, as the healthcare landscape continues to evolve in the wake of the 2010 Affordable Care Act, government regulators have also begun to encourage this integration.

“You can’t separate the behavioral health and the physical care. It’s all one individual. You can’t put this in silos,” stressed Dr. Lynda Bascelli, medical director at Project H.O.P.E., a Camden clinic that is part of the county’s Federally Qualified Health Clinic and offers a mix of physical, mental, and substance abuse care.

Bascelli joined more than a dozen colleagues Tuesday at the War Memorial in Trenton for the second annual Good Care Collaborative conference. The Collaborative was launched in 2014 by Dr. Jeffrey Brenner, a family physician who helped spark a healthcare revolution in South Jersey, and his colleagues in the Camden Coalition of Healthcare Partners. It seeks to bring together a broad section of healthcare providers, payers, policy experts, educators, and others across the state to reform and improve New Jersey’s Medicaid program, the federal insurance for poor and disabled patients, which funds much of the care these doctors provide.

The conference also built on a report released in late March by Professor John Jacobi and his colleagues at Seton Hall Center for Health and Pharmaceutical Law and Policy, which found that state bureaucracy often stood in the way of seamless, coordinated care. Despite the good intentions of state officials and their recent moves to ease the division, the Department of Health generally licenses physical care providers, and the Department of Human Services regulates behavioral healthcare. Observers said this has created a disconnect that’s been hard to overcome.

Even more changes will be needed for these doctors and nurses to reach all the patients in need and provide full and appropriate treatment, providers said. Regulatory barriers to integrated care remain high, funding is still too scarce, and critical patient needs, like employment and transportation, are outside the purview of the medical system.

However, Jacobi, who moderated the “On the Ground Perspectives” panel at Tuesday’s conference, urged providers to work with state regulators to move the process forward. “The departments are not the enemy here — they are on board and very committed to move forward with integration,” he said.

Valerie Harr, deputy commissioner for Human Services, which runs the $10 billion state and federally funded Medicaid program, echoed Jacobi’s sentiment. Gov. Chris Christie has also embraced the transition and has pledged to help the state provide more holistic care.

“We’re working to support a lot of these efforts,” Harr said. “We are taking Prof. Jacobi’s report under great advisement.”

Harr said the state’s initial effort to create a managed-care model for certain long-term Medicaid treatments has demonstrated the advantages of integrated care. By working closely with patients to assess their medical needs, even visiting them at home if required, providers have discovered many are also suffering mental health disorders and can arrange for the proper follow-up care, she said.

[related]“That wasn’t possible prior to managed care,” she said. “It’s allowed the state to learn and start planning toward our next effort in integrated care.”

New Jersey is certainly not alone in this quest. Oregon and Maine have had recent success linking behavioral and physical care and Rochester, NY, led the way with an integrated system decades ago, experts said.

“What’s going on around the country is a tremendous amount of transformation,” explained Cindy Mann, a lawyer who works with diverse stakeholders on Medicaid reforms. Mann is a former deputy administrator at the Centers for Medicare and Medicaid Services, which oversees both federal programs. “It’s not just states. It’s healthcare providers of all ilk. Integration of care is a big focus for everybody. “

Changes in the Medicaid program, the largest funder for healthcare nationwide, drive reforms in other areas, Mann noted. The Affordable Care Act called for a significant expansion of the program to cover far more low-income Americans, including almost 400,000 New Jersey residents, as well as other changes designed to improve the quality of care and the patient experience while reducing cost.

“Expanded coverage is the foundation for everything we do,” Mann said. The goal was not just to get people enrolled, but also to ensure they actually received appropriate, high-quality care. Knitting together comprehensive care that addresses behavioral and physical concerns is essential on many levels, she said, adding, “You cannot effectively make a dent in your healthcare cost until you think about integration.”

Coordinating psychological and physical care around a specific patient is critical, but it is also important to connect that individual’s needs to the region’s health network, experts agreed. Kimberly Briggs, a psychiatric nurse with Virtua Health, described how the Case Conferencing Project she leads has enabled five separate hospital systems to be on the same page when treating the area’s most challenging patients. By creating electronic medical records that can be accessed by any of the region’s hospitals, doctors can provide better care for the 800 patients who are part of the project.

“These (records) will now travel with the patient, so when they show up in any emergency room that information will be part of the record,” Briggs said. “The patient won’t have to retell the story over and over again. The archeology has already been done.”

But integration within the healthcare system is just the start, some participants noted. Brenner, with the Camden Coalition, has focused recently on the “housing first” model, which suggests that a safe, stable place to call home is a critical first step in any recovery, be it physical, mental or addiction-related. Some procedures, like organ transplants, aren’t even considered for a patient without a home.

“When you don’t have a place to live, you’re focused on your survival every day,” explained Harry Postel, a social worker and associate executive director of Catholic Charities. Homelessness leaves people open to numerous negative influences, he said, and makes it challenging to handle common healthcare tasks like taking regular medication or getting to follow-up appointments. There is also a need for financial and job counseling, even transportation, he said. “Without this support, it’s really hard to get the follow-through you need to get the outcomes everyone wants.”