State Seeks to Fix Critical Issues that Have Hindered Integrated Care

Lilo H. Stainton | March 28, 2019 | Health Care
Eventually could lead to ‘major shift’ in delivery of healthcare, with behavioral and physical medical care addressed by interconnected team

Doctors & Exec
Efforts to better integrate behavioral and physical medical care have already led to some major systemic reforms in New Jersey, with the state twice reshuffling how it oversees these elements of care in recent years. Behavioral and medical providers also are forming unique partnerships to better coordinate service.

State officials are now working to fill in key regulatory gaps, addressing small but critical issues that have long been blamed for blocking efforts to collaborate on care. Research has shown that patients who are only treated separately for physical or emotional ailments fare poorly over time and cost the system more money.

Earlier this month, the Department of Health announced several changes designed to make it easier for licensed healthcare facilities to offer treatments for both mental health and substance use disorder. Other changes proposed would make it easier for patients to get addiction treatment from their primary-care providers.

“By reducing bureaucratic hurdles for provider agencies, patients can get more of the care they need in one setting. This will be especially helpful in combating the opioid epidemic,” said health commissioner Dr. Shereef Elnahal.

However, the state is still working to create a single licensing process that would cover multiple aspects of care, something experts said is critical in creating a unified system.

Learning to cooperate

Others in the Garden State are examining the role providers play and how they can learn to work together more effectively to better serve patients. Behavioral health experts at Rutgers University are using funding from The Nicholson Foundation, which has prioritized integration efforts to help vulnerable populations, to build a future workforce more attuned to this type of collaboration.

Dr. Frank A. Ghinassi, president and CEO of Rutgers Health University Behavioral Health Care
Led by Rutgers Health University Behavioral Health Care, the initiative seeks to create a new education model and curriculum to guide the next generation of providers in how to care for the patient as a whole. The project — which involves eight schools for health professionals — is likely the only one of its kind of this scale, nationwide.

UBHC president and CEO Frank A. Ghinassi, who is spearheading the project, said it would lead to a “major shift” in the way care is delivered in New Jersey and beyond. As it is, he said providers receive little formal training on how to work as integrated teams, addressing both physical and mental needs, and patients suffer as a result.

“If we’re taught early on that our job is not only the knee, but also the mood and life circumstance of the person that owns that knee, the likelihood of success is much higher,” Ghinassi said. “It helps all professionals in healthcare to think about the entire individual and also to understand it’s not a matter of, ‘I write a prescription and you do what I told you,’” he said.

New Jersey has been wrestling in recent years with how to foster more integrated care, given the potential benefits to patients and public finances. To improve coordination, former Gov. Chris Christie shifted the massive Division of Mental Health and Addiction Services — with a $1.16 billion budget and 4,300 employees — from the Department of Human Services to the Department of Health. However, on advice from policy experts, Gov. Phil Murphy moved it back to DHS just eight months later.

First partnership of its kind in NJ

Early this year, Hackensack Meridian Health — a network of 16 hospitals, hundreds of outpatient offices and a medical school — joined forces with the Carrier Clinic, a well-known addiction provider established 100 years ago, in hopes of building a better integrated system of care. The first partnership of its kind in New Jersey, the merger echoes alliances formed in several large cities across the country.

In New Jersey’s current healthcare landscape, individuals — even those who regularly attend a primary-care doctor — often have limited access to mental health care; for example, research shows one in five youngsters is struggling with an emotional issue, but only one in ten gets proper treatment. And adults with serious mental illness may not be getting the medical care they need, even if they do have contact with behavioral health providers. Nationwide, these adults have been shown to die an average of 25 years earlier than normal for their age, largely a result of untreated medical conditions.

New Jersey has sought to connect pediatricians with behavioral health providers who can advise them on diagnoses and treatment, through a collaborative effort that has grown since 2015 to include nine regional hospital-based programs. With funding from the U.S. Department of Health and Human Services and The Nicholson Foundation, the state plans to invest another $2.3 million over five years to build on this work.

Much of this work has been informed by a report released in 2016 by Seton Hall professor John Jacobi and his colleagues that detailed some of the bureaucratic and regulatory hurdles New Jersey faces when it comes to integrating services. (The Nicholson Foundation also contributed to the report.) One of the key concerns Jacobi identified was confusion over regulations — designed to protect patient privacy — that some have interpreted as prohibiting mental health and addiction providers from sharing space, or from being located within facilities that offer primary care.

The DOH said it has released regulatory guidance designed to address this issue and make clear these providers can operate from a single location, if they comply with state and federal laws regarding client confidentiality. The state also issued a waiver designed to make it easier for mental health providers to offer addiction treatment in the same office.

Time to meet all of a patient’s needs

“Enabling integrated primary care is vital for New Jersey,” Jacobi said. The move by the DOH should also give caregivers confidence in the state’s process to develop a single license, to qualify facilities that could provide both behavioral and physical medical care, he said.

“With these waivers and clarified guidance, we are holding true to the goal that care for physical conditions, mental health, and substance use disorders should be integrated and coordinated,” Elnahal said. “Patients often have problems in all three categories, and it is past due for the health care system to design itself to meet all of a patient’s needs.”

To build a future workforce that is comfortable collaborating, The Nicholson Foundation has provided $1.5 million over two years to enable UBHC’s Ghinassi to research curriculum models, gather input from stakeholders, and craft a new education plan. The work will involve the Robert Wood Johnson Medical School, Rutgers New Jersey Medical School, as well as its nursing school, graduate psychology program, and the schools of pharmacy, dental medicine, social work and health professions — a wide and diverse buy-in Ghinassi said is unique and encouraging.

Barbara Kang, a senior program officer for The Nicholson Foundation
“In order for this to be sustained and for this to really work in New Jersey, we have to figure out a way to train for the future,” explained Barbara Kang, a senior program officer with Nicholson who is overseeing the project. “We need to build a pipeline of people who can work in this way.”

The initiative also reflects lessons learned from the Cherokee Health Systems, a Tennessee model that has succeeded in integrating behavioral health with primary care, Kang and Ghinassi said. Among other things, providers must adopt new terminology — referring to patients as “ours,” not “mine” or yours” — and learn to respect each other in new ways, so that physicians, nurses, psychologists and others all have an equal voice in crafting a patient’s treatment.

Other reforms involve changes in how physical space is used, they said. Instead of moving a patient from room to room, or office to office, the Cherokee model calls for the patient to stay in one place and have the healthcare professionals come to them. Bigger shifts call for cross-training, like educating doctors in motivational therapy, or encouraging psychiatrists to understand the emotional impact of chronic diseases.

“Ultimately, we want to make integrated care ‘the new normal’ throughout the state of New Jersey,” said Dr. Arturo Brito, a trained pediatrician who is now Nicholson’s executive director. “We want the next generation of health providers to start their careers knowing how to function effectively in inter-professional teams that provide high-quality, patient-centered, fully-integrated behavioral and physical healthcare.”