There is no question that there is an enormous push now for
what is being called Value Based Purchasing of health care services. In a sentence, payers would like to pay
providers for achieving certain outcomes related to reducing the overall cost
of care, while keeping people healthy by improving their care. It is a worthy goal.
As primary care physicians have struggled to move in this
direction they have encountered two major obstacles. The first is that many patients with the
poorest health and the highest health care costs have behavioral health and/or
substance abuse problems. The second is
that social factors, long considered out of the purview of medical or mental
health care, have emerged as major risk factors for ill health and extraordinarily
high health care costs.
So to prepare for the future, where payment will be based on
cost and quality (together referred to as “value”), health systems must figure
out a way to integrate care for behavioral health, social and substance use
issues into their delivery models – either through providing those services on
site, or through referral arrangements.
Many people now talk about integrating care and there are
many organizations and providers trying to achieve this. We often see this as the introduction of
psychiatrists or other behavioral health providers into a primary care practice
or the development of a referral relationship with good reporting back and
forth between primary care and mental health.
I have wondered what truly integrated care would look
like. You know, the kind where each
specialist focuses on their own area of expertise but every person seeing the
patient in the office is responsible for every aspect of their care and well
being. I believe an essential tool here
is a fully integrated electronic health record – one which organizes progress
notes chronologically irrespective of who the provider of care is that wrote
the note or whether they are a primary care provider, behavioral health
provider or a social worker trying to get housing for the patient. Just as importantly however, is the
requirement that every person touching the patient is working to help the whole
patient and shares a common interest in all parts of the patient’s well being.
Let me cite an example of how I will know when we have
achieved this level of integration.
A 53-year-old patient with hypertension, diabetes and
depression is seen bimonthly by her primary care physician and is being seen in
every month by the Institute’s psychiatrist.
The psychiatrist reads his own prior note to recall the patient’s last
visit to him and then proceeds to read the most recent primary care note as
well. He notes that the patient was
started on a new hypertensive medication on the last visit. He asks “I see Dr. Jones started you on a new
medication for your blood pressure last visit.
How is it going? Any problems
with it?”
The patient answers, “As a matter of fact, I had to stop it
after a few days because of a rash. I
guess I was allergic to it.”
“If you don’t mind, I’d like to check your blood pressure
while you are here since it was a bit high on the last visit to Dr. Jones,”
says the psychiatrist.
“Sure. That would be
great.”
As it turns out, the patient’s blood pressure is very high.
The psychiatrist then asks when the next appointment is
scheduled with Dr. Jones.
“Not for another 6 weeks,” the patient replies.
“After our counseling session, I’d like you to see someone
for your blood pressure before you leave.
Would that be OK?”
“I’d greatly appreciate that.”
At the end of her visit with Dr. Jones, he calls the nurse
on the primary care team, explains the situation and the patient is put in with
a physician on the team to adjust her medications.
Get it?
It’s not about people with different interests in the
patient each sticking to their own domain.
It is about each member of the patient’s care system being concerned about
the whole patient. That’s the Holy
Grail. Now we just need to figure out
how to get there.
