Merging Physical and Behavioral Health

It’s no secret that the future of health care delivery is somewhat uncertain. While few will disagree that reform is needed, how that will happen is still being debated. Regardless of what reforms are implemented, one thing is certain—case managers will continue to work with patients to improve outcomes.

Before health care became such a huge industry and, now, a burden to the nation’s economic well-being, physicians provided care to patients to improve and maintain overall health. The advent of managed care significantly altered how a physician provided care, resulting in a segregation of care and services that was meant to reduce costs and improve efficiencies. While efficiencies and costs have been better managed, the health and well-being of individuals, especially those who are considered complex, has not fared as well. A complex patient is someone with both physical and psychological issues, and in today’s health care environment the state of physical well-being tends to be addressed more adequately than the psychological state. This segregation has resulted in less than desirable outcomes, increased costs (typically seen in medical utilization), and inadequate utilization of psychological services.

The impact of medical illness on pre-existing psychiatric conditions and, reciprocally, the effect of psychiatric illness on existing medical conditions can be staggering. An individual with schizophrenia who is newly diagnosed with insulin-dependent diabetes, for example, may have a difficult time adhering to diet and medication regimens. An individual with uncontrolled diabetes who is seeing multiple providers may be dealing with undiagnosed depression, which may be the cause of poor control. Our current health care system prevents early identification of concurrent medical and behavioral conditions and the coordination of psychiatric and nonpsychiatric services, according to the analysis of Dr. Roger Kathol, the co-author of Healing Body and Mind: A Critical Issue of Health Care Reform.

The numbers adumbrating the segregation of care are overwhelming. While 10 percent of the population is chronically ill, approximately 2 percent of this group is complex. Yet complex patients account for nearly 50 percent of health care expenditures. Working with medically complex patients requires a willingness to address both biological and psychological problems, along with the ability to help the individual understand his illness, recognize and overcome barriers to access psychological care, follow the provider’s recommended treatments, and be able to navigate the health system. When this is accomplished, the individual will experience improved health status, and the burden of cost will fall. Such integration can result in decreased emergency room visits, hospital admissions, lengths of stay and pharmaceutical needs.

Defusing a Complex Situation

To more specifically define health complexity, we can say that interferences with health occur in four domains: biological, psychological, social and health system, each of which must be assessed for chronicity, current status and potential complications, or life threat. Most complex patients will have areas of concern in multiple domains simultaneously.

For the last 20 years, nine European countries have been studying complexity assessment to better address the needs of the complex patient by designing interventions based on the assessment. This research resulted in the development of an assessment tool, the INTERMED, which addresses an individual’s interaction within the domains. The tool is an online, interactive assessment that prioritizes which areas require immediate attention and allows for an action plan. The INTERMED was developed with the assumption that the four domains all interact and interfere with an individual’s ability to get better. The presence of one or more factors in the four domains can make an easily treatable condition complex. Kathol, the president of Cartesian Solutions, has worked closely with the Foundation and has adapted the tool for use in the United States. The American version of the tool is known as the IM-CAG, or INTERMED-Complexity Assessment Grid.

Case managers are skilled in assessment, planning and coordination of care, but expanded skills are required for the complex patient. The most important factor when attempting to integrate care is the development of a caring relationship with the patient. In all likelihood, the patient will not have experienced the level of caring and empathy the case manager can offer. A case manager’s willingness to acquire the necessary skills for integration is only the beginning. Organizations must be willing to change the current culture. Acculturation requires commitment from executives down to support staff to support the needs of the complex patient by creating interdisciplinary teams, demystifying mental health care and services, and supporting the incorporation of a mind-body connection in order to improve overall outcomes. Health care professionals must be willing to work with the whole patient, learn and apply new skills, and refrain from “handing off” the patient; in this model, one case manager works with a patient to address his or her biological and psychosocial needs and access to care.

The Case Management Society of America offers an integrated health management product that includes organizational consulting for integration and extensive training for case managers. While many organizations claim to be integrated, if patients see multiple providers, experience frequent ER visits or inpatient admissions, or take multiple medications, it is likely that no true integration exists.

Consider the patients in your care: the patient who has diabetes and suffers from obesity and is now taking an antidepressant; the young trauma patient with a history of DUI whose car accident occurred as a result of intoxication; or the 35-year-old woman with chronic abdominal pain who is on narcotics and frequently visits the ER. If any of these scenarios sound familiar, perhaps an assessment of the biological, psychological, social and health system domains will shed some light on where barriers to improvement lie. These are but examples of the complex patient. When care is effectively integrated, the barriers and contributors to complexity are discovered. Better care and attention to addressing the whole patient will result in a healthier patient and a reduction in resource utilization.

Rebecca Perez, RN, CCM, CPUM, is the president and owner of Carative Health Solutions and co-author of the Integrated Case Management Manual to be released in 2010.