The growing gap between Primary Health Care and Specialised Mental Health Care is worrying not only for the government, but for the service user as well. The fragmentation of healthcare is a threat to the continuity and consistency of care provision. Additionally, the affordability of healthcare at the desired quality level is at stake. The Five Year Forward View for Mental Health report identified the development of ‘new models of care’ as a priority. Supported by an improved overall health infrastructure, new care models must enable more effective collaboration between all providers in the health and health-related sectors and provide better access to care for the service user.
Mental health and physical health cannot be considered in isolation. It is assumed that a well-functioning health service depends on an integrated approach towards physical health, mental health, social care and the third sector, ideally with a cost-reducing effect. Mental health is essential for improving overall physical health outcomes, just as physical health is essential for improving overall mental health outcomes. For a more complete picture, social functioning must also be considered as a prerequisite for achieving and maintaining good health.
The materialisation of a holistic biopsychosocial view of health and healthcare can improve health outcomes and health satisfaction at a lower cost point. That is why integrated care has caught the interest of funding bodies, healthcare providers, and service users alike.
Obstacles to new models of care
A lack of communication between the different healthcare departments has driven down care quality levels, while costs have gone up. Primary care is eminently holistic with its interconnected focus on physical, mental and social wellbeing, but in order to fulfill its function it depends on information sharing with other healthcare providers and health-related sectors.
Currently, primary care often loses visibility of the service user and the care process when service users are referred to specialised mental health care or social care. The lack of an overarching IT infrastructure for the accurate gathering, sharing and management of care data from all health and health-related sectors minimises their ability to make informed decisions about healthcare policy and appropriate step-down care. Since psychological and physical wellbeing are tightly interwoven, inferior information exchange not only affects mental health policy but physical health policy as well.
The healthcare system struggles to implement integrated care pathways in common practice, partly due to lacking standards for integrated healthcare. This stands in the way of the development of transparent and value-based goals and a clear operational model to achieve those goals. Consensus should lead to the development of clinical procedures with excellent operational productivity.
Another main obstacle is a lack of agreement on the rational division of professional responsibilities. Every profession has to adhere to different standards, with certain standards around big topics, such as case management and self-management, more challenging for some than for others. Especially those in medicine still hold a traditional view of healthcare and are reluctant to cross disciplinary boundaries. Considerable changes in healthcare culture are needed in order to establish effective interdisciplinary collaboration between providers of other healthcare and related sectors, and to establish better access to healthcare for the service user.
Changing healthcare practice
There is emerging evidence that an integrated approach to healthcare contributes to improved performances across the wider healthcare system. Integrated healthcare takes a holistic and pragmatic view to achieve the health and social gains that are needed. It should be a priority to develop integrated care pathways and make them available to all health professionals. But, as the adoption of any new model of care can be disruptive to daily practice, certainly during the rolling out period, health professionals must be informed about their overall benefits in the medium to long term.
It might be necessary to make external funding available to ensure that support staff have the necessary skills and time to implement the new, collaborative models of care. It allows GPs to concentrate on their core responsibilities towards healthcare. The appropriate use of time and expertise benefits overall operational efficiency, but also contributes to job satisfaction of GPs and other staff.
IT departments should also receive extra funding to simplify interdisciplinary communication between healthcare professionals, as well as communication between professionals and their service users with technical aids. An integrated electronic patient record to which access can be authorised according to the specific needs and goals of the service user can support collaborative care in the broadest sense of the word.
Funding new models of care
The costs associated with the adoption of new models of care are difficult to estimate, but they are a vital component in the decision-making process. It goes without saying that cost analyses must be made at all levels, not only at implementation level. Whether sustainable healthcare models will be adopted or not, depends largely on a positive balance between overall running costs and revenues.
At times it’s not easy to assess how other professionals deliver quality of care, which stands in the way of building trust during in-depth, interdisciplinary collaboration initiatives. It’s therefore important to develop standardised norms on healthcare delivery and quality to tackle this persistent problem to effective integration. Physical health, mental health and social care workers, service users and funding bodies must engage in an ongoing dialogue that focuses on the development, dissemination and adoption of integrated healthcare models.
Summarising the most important characteristics for a successful adoption, models should be:
- Substantively justifiable and attractive for providers within all sectors;
- Easy to implement in the daily routine;
- Evidence based;
- Customisable to the explicit needs of service users and their relatives;
- Destigmatising and at the service of social rehabilitation;
- Easily adaptable to a change in circumstances;
- Contributing to the functioning of society as a whole.
The expectation is that this will promote the dissemination and adoption of integrated care pathways in common practice, as well as encourage service users to adhere to care plans, while keeping associated healthcare costs under control.
The Collaborative Care Model
The Collaborative Care model, developed at the University of Washington by the team of Unützer, has emerged as the most effective model of integrating mental health care in primary care settings. The model offers opportunities to achieve the Triple Aim of health care reform: improving access to care; improving health outcomes; and making the most cost-effective use of the available healthcare workforce. Its success is to a great extent fuelled by holistic workflows in which members of a multidisciplinary team blend their knowledge and skills in one integrated healthcare process. Based on the principles of effective chronic illness care, the Collaborative Care model involves a shift in how traditional medicine is practiced.
In the Collaborative Care model psychologists are positioned next to primary care professionals to support the healthcare process with diagnostic assessments and brief counseling of service users. Where necessary, psychiatric consultants are called in to assist with complex differential diagnoses and complex pharmacological management that go beyond the competencies of GPs.
The following principles define the core of Collaborative Care:
(1) Patient-Centred Team Care
Disciplines collaborate effectively within a shared care plan that is focused on patient-centred goals. Collaboration results in a better healthcare experience for patients and increased patient engagement with oftentimes improved health outcomes.
(2) Population-Based Care
A defined group of patients is tracked in a registry. Focus is not only on the ‘numerator’, i.e. the patients who present for care, but also on the ‘denominator’, i.e. those patients who need care and who are not yet recognised and engaged in care, or those who have initiated care but are falling through the cracks because of inadequate follow-up. Mental health specialists provide caseload-focused consultation, not just ad-hoc advice.
(3) Measurement-Based Treatment to Target
Treatment plans clearly articulate personal goals and evidence-based tools routinely measure clinical outcomes. Treatment to target requires providers to systematically track patient improvement and to adjust treatments if patients are not improving as expected.
(4) Evidence-Based Care
Patients are offered treatments with credible research evidence to support their efficacy in treating the target condition. Collaborative Care is one of the few integrated care models that has a substantial evidence base for its effectiveness.
(5) Accountable Care
Providers are accountable and reimbursed for quality of care and clinical outcomes, not just the volume of care provided.
Research and Evaluation
There is great potential for research and evaluation in the area of the dissemination and adoption of new models of care. At present there still are few research data available to support the value of proposed solutions, as access to accurate data about the dissemination and adoption of new healthcare models is complicated by a communication gap between research and clinical practice. In order to settle this, an infrastructure is needed that not only allows for the gathering of healthcare outcomes at an individual level, but also for the gathering of information on how new models of care are adopted by providers.