It wasn’t that long ago that we thought drug treatment was a separate issue from alcohol treatment. We didn’t think about providing housing for people with addiction or that many of the addicts we saw also had a mental illness. It was not unusual to ask our new clients about their substance issues, but we didn’t venture over the border to the mental health questions or the primary care issues they may face. We didn’t think about it. Mental health counseling was not what we signed up for, was outside our scope of practice and funding streams do not pay for it.
Consumer-centered approaches by individuals and organizations have caused the face of health care to change. For the better part of three decades, providers of substance treatment have struggled with the extent of mental illness presented by consumers and how that affected consumer outcomes. The incidence of substance addiction in mental health centers has grown to over 50 percent of those coming in the doors. Primary care physicians and emergency department personnel speak with frustration at the lack of available resources for patients with serious primary care issues who also have co-occurring substance addiction and/or mental illness.
Consumer-centered services challenge the provider to meet a broad array of consumer needs. The last three decades have witnessed providers across the country expanding and integrating services so the consumer receives mental illness and addiction treatment at the same time. It has given rise to substance treatment programs and mental health centers combining under one roof, while providing housing and other supportive services. More recently, primary medical care has come to the behavioral health facility and counselors are available in private primary care practices. What once was the community mental health center, the community substance treatment program or the community medical clinic is now the Community Health Center. The treatment response is designed and delivered in the same complicated, integrated manner in which the issues present themselves. This does not guarantee a perfect result, but when a consumer has this level of comprehensive delivery of services, the likelihood is much higher that a successful outcome will occur.
If a quality improvement process tells us that our consumers need psychiatric treatment while they receive substance treatment, then it is the provider’s responsibility to figure out how to provide it in an effective, high-quality manner. When a service provider hangs a shingle for a particular service, there is an implied ethical duty to access other necessary services either by expanding the provider’s expertise and knowledge base or by collaborating with another provider that can cover the needs presented by the consumer. Health problems don’t live in our bodies in an isolated manner, nor can they be treated as such. Ignoring a co-morbid disease process because it does not fit the model, the provider, the money or the politics just wastes the time and money of everyone, as the untreated disease will undermine the all the work done in treatment. Behavioral health and primary care providers are looking to each other for integrated solutions to the issues presented by consumers. It becomes a complicated relationship because of the new integration of years of culture, payment systems and procedures that must now work together. But there are a growing number of examples around the United States that have forged these new relationships and are offering consumers the comprehensive health care—mental health, substance, primary care—they need to live healthier, more productive lives.
While the many systems in our body live together and influence one another in sickness and in health, the bureaucratic and political systems that regulate and control the purse strings for most of the money spent on behavioral health care are not quite so practiced at working together. It was only within the last six years that funds were established in Nebraska that addressed co-occurring mental illness and addiction when the majority of people in the public system have some degree of these two disorders and the services have been provided since the 1980s. Who pays for the mental health services in the substance treatment program? The system is highly regulated by the federal and state governments and unable to adapt very quickly to newly identified needs. It is also influenced by politics in the legislative and executive branch, which often focus on spending, lower budgets and no new taxes, rather than the successful outcomes from the new ideas in delivering health care. When the focus is on the institution or entity, rather than the consumer, it will be the consumer that loses.
The irony is that spending the right amount of money for the right treatment at the right time will save our insurance companies and governments lots of money through savings in hospital, criminal justice, corrections and numerous other costs. One California study done in the mid-1990s and replicated in 2005 found that for every one dollar spent on treatment, seven dollars were saved in health care spending. Getting paid for the actual cost of services has often been a challenge, but these new relationships present even greater challenges for payor systems and providers that are working out new paradigms in service-delivery and payment models.
The solution starts with leadership. From the many corners that influence our system, we must have broad-minded leadership that can pierce through the challenges of the current system to provide a quality, comprehensive, accessible, integrated, holistic and consumer-focused system of care that will help consumers get better with every step. That leadership will come from the politicians who exhibit the kind of courage to implement a system of care that is effective, responsive and fiscally responsible. That means spending adequate funds on the illnesses that are costing other systems—jails, police, hospitals—untold dollars because the consumer has not received the care they needed. It will take leadership at the provider level to assess the needs presented by consumers then respond with commensurate services. Providers must also gather the data that documents the need and shows the outcome of their treatment strategy. It asks all who are involved in behavioral health care to adopt a quality improvement- and information-driven approach to understand their successes and failures and to adjust toward success. It will require leadership from consumers and family members to augment the work of established providers with services and support mechanisms to help individuals who need to begin services or to help those completing services. It takes the warm heart and thinking mind of the volunteers from the community, whether it is faith-based, an interested family member or friend to provide the support so critical to sustaining a program of recovery.
The new face of behavioral health is Community Health. It does not lose the specialty of substance treatment, mental health therapy or the practice of primary care medicine, it just combines them in a highly effective manner. If we spend our time and money helping those that are the most ill in our community, the entire community will be better. We will be more efficient in our service delivery and spending, more effective in our outcomes, have more satisfied consumers, and the entire community will benefit. A healthy community needs a quality, integrated health care system.