A Historical Perspective on the Integrated Care Model

Truly comprehensive, patient-centered care must encompass both physical and behavioral health to support effective care that leads to improved outcomes. As it turns out, centuries-old notions about the separation of physical and behavioral health still stand in the way of true integration.

In medieval times, it was believed that for the soul to ascend to heaven, the human body had to be preserved intact. These beliefs greatly hindered the study of the human body since the study of anatomy required dissecting corpses which was a strictly forbidden, blasphemous practice. It was only in the 14th century that human dissection was permitted by the Catholic Church and used as a tool for teaching anatomy in Bologna, Italy, after a hiatus of over 1,700 years.

George Engel proposes that the church's permission to study the human body included a tacit prohibition against corresponding scientific investigation of the human mind and behavior since in the eyes of the church, these had more to do with religion and the soul and should therefore remain in the church’s domain.  

In the 17th century, Rene Descartes proposed the concepts of Cartesian dualism. This theory postulated that the mind and body were actually two very distinct entities and that events in the body are very separate from events that happen in the mind. The widespread adoption of this approach solidified the separation of mind and body in the evolving science of medicine. 

Research and study mainly focused on the anatomy, physiology, and chemistry of the body, thus establishing the supremacy of the biomedical model. This separation became entrenched for hundreds of years until the 20th century when the “psychosomatic movement” began to emerge in Europe and the United States.  

Psychosomatic theories were formulated to try and bridge the divide between mind and body by exploring the relationships among physical, psychological, and social factors in the causation, prognosis, and treatment of illness. Psychosomatic medicine was initially met with some criticism as there was an overemphasis on how mental disorders and distress could directly cause disease by suggesting a single cause of disease theory rather than a multifactorial approach to the origins of disease.

Many unexplained symptoms became the domain of psychosomatic medicine in ways that at times alienated physicians and patients alike. Angela Kennedy pointed out that diseases that could be explained by measurable biological and physiological changes were deemed more legitimate and worthy “value,” whereas diseases in which these changes could not be measured were delegitimized and stigmatized. This was unfortunate, as it clearly slowed the progress towards a holistic view of human illness integrating both mind and body.  

In 1977, George Engel proposed the biopsychosocial model which recognized the nuanced and multifactorial causality of disease, suggesting that in any and every disease state there is an interplay among biological, psychological, and social factors. This model and its acceptance and integration into medicine’s mainstream provide the theoretical underpinning of modern-day integrated care.  

A recent original research article and editorial in the Annals of Internal Medicine addresses the factors influencing physician practices adoption of behavioral health integration in the United States. The authors report the results of a qualitative study in which they interviewed the leaders and clinicians of 30 physician practices who had already integrated behavioral health.  

Models for Integrating Behavioral Health

There are several approaches to integrating behavioral health into a practice. One is a co-located model, in which the behavioral health practitioners and the practice providers share a common physical space, allowing patients to be treated by both disciplines seamlessly. This model also fosters collaboration, relationships, and interaction among the patient’s different providers as they share the same office space and interact with one another daily.  

Another model is the collaborative model, whereby offsite behavioral health clinicians collaborate with providers to create common care plans or joint interventions. In some cases, psychiatrists might be offsite but offer collaborative support to a team of behavioral health care managers onsite who are interacting directly with the patient. A recent study from the University of Michigan found that only 44 percent of primary care providers co-located with behavioral health clinicians. In rural practices, the number of co-located practices was even lower at only 26 percent.  

An Annals study in 2020 found that practices that had undertaken integration with behavioral health were motivated by a desire to improve access to behavioral health services for patients, as well as improve responsiveness to patient’s needs identified in the behavioral health screenings which all practices are now required to conduct. There was also a perception among practices that having this type of practice model enhanced the reputation of the practice.  

The Annals study identified several clear barriers to implementing this model, among them cultural differences between behavioral and non-behavioral health clinicians, impediments to information flow related to non-integrated disparate electronic platforms and onerous, overly restrictive privacy regulations. Billing challenges and payment model deficiencies and concerns regarding financial sustainability were also highlighted as challenges to successful integration.  

Recently, NextGen Healthcare partnered with Xtelligent Healthcare Media to conduct a national survey of provider organizations on the topic of Integration of behavioral health and primary care services. One of the promising findings of this survey was that for those on the integration path, 75 percent expect their organization will offer fully integrated services in the next two years.

Interestingly, the authors of the Annals study refer to the potential for telehealth and virtual care to resolve some of these challenges. The study was clearly conducted prior to the COVID-19 pandemic, which induced rapid, exponential growth of virtual care across both primary care and behavioral health. In fact, NextGen Healthcare has also seen a significant increase in usage of virtual visits — enabling over 1.5 million in just the past year. This trend might blur the differences between the co-located and collaborative models, as in the context of virtual care, the geographic proximity of the providers matters a lot less.

In the editorial devoted to this topic in the Annals, the author bemoans the fact that less than half of primary care practices have adopted this integrated care model, stating that medicine’s mind-body problem persists to this day. There is clear evidence that integrated care models improve patient outcomes. Virtualizing this care will likely further offer the ability to scale and implement this model across more practices in both urban and rural settings. Ironically, it might be integrated technology platforms providing automation, effortless interoperability, and analytics-driven medical and behavioral health workflows that will finally help bridge medicine’s mind-body divide.  

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Article Contributer: Dr. Betty Rabinowitz, Chief Medical Officer for NextGen Healthcare

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.