Could integrated care deliver better health services as COVID-19 crisis starts to ebb?

Anxiety, stress, depression, substance use and more — is it time for New Jersey to renew its push for providers who can offer multiple services under one roof?
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Kids have struggled with remote learning and isolation. Parents have been forced to balance child care and work-from-home responsibilities. Most people delayed routine medical screenings at some point during the past 15 months — or were forced to put off serious treatments — and almost everyone is dealing with stress and anxiety from the pandemic.

The toll COVID-19 has taken on behavioral health in New Jersey and nationwide is well documented. Now, some in New Jersey say it’s time for a new model in health care, one with additional mental health and substance-use support, all integrated in a single location that also provides primary care or other medical services.

“Mounting evidence is demonstrating that there are significant mental health issues as a result of the pandemic. And they are likely to be long-lived, if unaddressed,” said Dr. Arturo Brito, a pediatrician who heads The Nicholson Foundation, a New Jersey-based philanthropic organization that has long advocated for a more integrated system of care.

“There’s no better time to revisit this than in the beginning of the recovery phase from this pandemic,” he said.

Integration advantages

Integrated care — in which mental health and substance-use therapies are coordinated with physical care and a full range of treatments are easily available at one facility — is not a new concept in New Jersey. The idea is if done right, it can result in better health outcomes and patient experience while also controlling costs.

State officials have been working for years to create a single license that permits more integrated services at a single location and have implemented several interim steps along the way. With the pandemic and the economic fallout that resulted, there is renewed interest in this effort and new legislative proposals that could jump-start the process.

Brito, who is no longer directly involved with the state’s work on this issue, said the recent growth in public behavioral health needs underscores the importance of an integrated system that people can easily navigate.

The public health impact of the pandemic alone is significant:  state data shows more than 1 million New Jerseyans have been diagnosed with COVID-19 since March 2020, including some 26,000 who have died as a result. Millions more are struggling with grief, wage cuts or unemployment and other stressors.

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Anxious about return to ‘normalcy’

New Jersey’s reopening, with crowd-limits ending and restaurants adding capacity, can add to the stress for some people, according to Assemblyman Louis Greenwald (D-Camden), a longtime mental health advocate. “You’re going to see a whole new wave of anxiety in people as we go back to work and get back to normalcy,” he said.

Greenwald — who recently introduced a package of legislation to strengthen the state’s behavioral health system — said we now have an opportunity to improve what has become an uncoordinated, disjointed patchwork of physical and behavioral-care providers. “This pandemic has really laid bare and exposed this true dilemma, not just in New Jersey but in states around the country,” he said.

A 2016 study by Seton Hall professor John Jacobi identified some of the biggest barriers to integrated care in New Jersey, including a regulatory system that largely treated behavioral-care providers and medical clinicians as separate entities. The report led the state to empanel experts, and the group worked with officials at the state Department of Health, which licenses health care providers, to develop a new framework to encourage more coordination and integration.

By the end of 2019, according to those involved, the DOH had prepared draft guidelines for a single, unified licensing system that would allow facilities to provide a greater range of behavioral and physical health services under the same roof. But when the pandemic swept the state a few months later, work on the reform effort appeared to stall.

Breaking down behavioral-health barriers

Greenwald’s legislation seeks to address several long-standing issues in the state’s behavioral health system. It includes a proposal for a pilot program that would allow 24-hour urgent-care centers to offer additional mental health services. Another bill would create a loan program to fund community-based integrated-care programs. A third measure would seek to better connect people who visited the emergency room in a psychiatric crisis with follow-up care.

A separate bill (A-5269), co-sponsored by Assemblywoman Valerie Vainieri Huttle (D-Bergen), would address a second concern flagged in the Jacobi report: the significant confusion providers have about what the current regulations do permit. This proposal would require the DOH and the Department of Human Services, which oversees community-based mental health and substance-use services, to publish an integrated-care licensing guide with clear language detailing what is allowed under the existing structure.

“Providers are clamoring” for understandable guidance on what is now possible under the existing regulatory system, Greenwald said. Behavioral and physical health providers are “already migrating towards each other,” he added.

Greenwald called the integrated licensing guide legislation — which has yet to be scheduled for a hearing or vote — a “critical first step,” and a bridge to a more permanent solution. “It’s really about creating a single license,” he said.

Easing toward integration

The DOH had taken several steps over the years to enhance regulatory integration, including issuing a “shared-spaces waiver” that eased some of the most onerous restrictions on medical providers seeking to expand behavioral health services. But confusion among providers continued.

The waiver didn’t address organizations that specialize in behavioral care, which still required separate licenses to build out primary care services. While a few behavioral health providers have been able to incorporate more medical services — to manage patients’ chronic conditions, like diabetes or high blood pressure, or treat urgent issues like wounds — advocates said most must refer people elsewhere for these options.

That’s been an ongoing concern for Carolyn Beauchamp, president and CEO of the Mental Health Association of New Jersey, which represents community providers. People with serious mental illness die on average several decades earlier than those without similar diagnoses, she said, in part because they are less likely to have access to regular medical care. Individuals in this situation may only be comfortable visiting a regular counselor or group leader and would benefit from being able to obtain other services on site, she explained.

“It’s been a long-standing problem getting physical care for people with serious mental illness,” Beauchamp said. “We are very eager to have the Department of Health promote a single license process as soon as possible.”

Christie’s approach

Former Gov. Chris Christie, who became a strong advocate for mental health and substance use treatment, embraced the Jacobi report and ordered multiple changes in pursuit of creating a more integrated system of care. Six months before he was to leave office, the second-term Republican governor surprised lawmakers and stakeholders with a call for the DOH to take from the DHS oversight responsibility for the state’s four psychiatric hospitals and community-based behavioral health providers.

Just eight months later, Gov. Phil Murphy, a Democrat who followed Christie and is now seeking a second term himself, reversed much of Christie’s directive. Murphy left the psychiatric hospitals under DOH but returned much of the community-based behavioral health governance to DHS. But the licensing process remained the purview of the health department — and advocates continued to push for reform.

Donna Leusner, communication director at the DOH, said work on the regulatory reform is ongoing, even under COVID-19. “The Department understands the significance of a single license regulatory framework for both providers and patients, the impact it can have on the delivery of care and continues this work despite the pandemic,” she said.

Leusner said the agency is also taking short-term action; regulatory changes can take up to a year with the requirements for public comment and formal publication. “To ensure providers are offered more immediate flexibility, the department has issued guidance and multiple waivers addressing the issue,” she said.

The DOH is also working with stakeholders to “identify and address remaining barriers” and will issue other orders as needed to “support the more immediate delivery of integrated care,” Leusner said. “The Department also continues to work with facilities on an individual basis to help with any licensure applications or barriers they may be experiencing.”

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