Value of Integrating Behavioral Health to Achieve Whole Person Care

In the face of overwhelming historical forces that resulted in the separation of behavioral health (BH) from physical health, evidence has been accumulating for decades demonstrating the interdependence of mind and body. In the field of psychoneuroimmunology, research has demonstrated the impact of adverse childhood experiences (ACEs) on future risk of both mental and physical disorders. Stress has been shown to directly impact the immune system, precipitating flares in chronic diseases such as eczema and psoriasis. 

There are still many unsolved mysteries in this realm. Recent studies in the US and Europe demonstrate a dramatically increased risk of Type 1 diabetes in people who are transgender. Another study published in June demonstrated an association of the infant gut microbiome with fear behaviors. Studies attempting to assess the impact of prayer on various health conditions have sometimes shown significantly improved outcomes. It seems the more we seek to understand human biology, the more apparent it becomes that the mind and body are inextricably intertwined.

If we move from the organ system approach to epidemiology, we see a similar story. In 2011, the Robert Wood Johnson Foundation published a report, Mental Disorders and Medical Comorbidity.  In this metanalysis, the authors discuss the increased risk of depression associated with chronic medical conditions. Starting with a prevalence of 5 percent in those with no chronic medical conditions, it rises steadily up to 12 percent in people with three or more medical conditions. Conversely, they found that people with schizophrenia or bipolar disorder were up to three times more likely to have three or more medical conditions than those with no mental illness.

The authors also reference the National Comorbidity Survey Replication 2001-2003, revealing that 29 percent of people with chronic medical conditions have a comorbid mental health condition, and 68 percent of those with a mental health condition carry at least one comorbid medical diagnosis.

The Pathway to Integrated Care

Even with a clear recognition that the distinction between mental and physical health is artificial, there remain significant challenges in building clinical pathways that provide “whole person” care.

In the past decade, most primary care practices have incorporated depression screening into their workflow, representing a small but meaningful step toward integration. Likewise, the recent development of federally sponsored certified community behavioral health centers (CCBHCs) includes a requirement that these behavioral health providers screen patients for their physical health needs. With 340 CCBHCs now spanning 40 states, we can see the beginnings of truly integrated care. 

The presence of screening sets a foundation for referrals to be made in both directions between behavioral health and medical providers. Building additional cross-training for initial evaluation and treatment will be a critical next step. Beyond that, fostering robust communication among the different providers and building reliable workflows for clinical handoffs will create opportunities to further integrate care. Ultimately, having teams of providers coordinate among themselves around the needs of each patient is required to advance the journey toward whole person care.

The Cambridge Health Alliance (CHA) represents an interesting case study. Located across the river from Boston where it has served as a laboratory for testing innovations in care, the CHA has evolved into a model that integrates the physical, mental, and social needs of its patients. Much of the work to date is described in their “GUIDE & TOOLKIT.”

The alliance has developed a carefully constructed team approach to care. Building on the concept of a core team that focuses on holistic engagement with each patient, the alliance has built robust capabilities in population health and care management, enabling the integration of behavioral health and social determinants of health into the care environment. In population health, the alliance incorporated a data and reporting structure that made it easy for care management staff to identify, prioritize and develop care plans for patients in need.

Charting a Path Forward

Federally qualified health clinics (FQHCs) can be considered another leader in revamping our clinical model toward whole person care. Most FQHCs offer a collocated combination of primary care, behavioral health, and dental services. For many of these clinics, the COVID-19 pandemic has highlighted and reinforced the value of this integration, motivating them to further invest in clinical software, staffing, and partnerships that advance their ability to meet the needs of their communities’ most vulnerable populations with an integrated, holistic set of services and technology solutions.

Tracking the progress of these and other provider groups working to build an integrated, patient-centered clinical model of care should help us all chart a path forward as we seek to close the clinical gap between mind and body. 

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Article Contributer: Dr. Martin Lustick, Senior Vice President, NextGen® Advisors 

NextGen Healthcare, Inc. (Nasdaq: NXGN) is a leading provider of ambulatory-focused technology solutions. We are empowering the transformation of ambulatory care—partnering with medical, behavioral and dental providers in their journey to value-based care to make healthcare better for everyone. We go beyond EHR and PM. Our integrated solutions help increase clinical productivity, enrich the patient experience, and ensure healthy financial outcomes. We believe in better.