Lesson 10: Integrated /mental health/healthcare and future of mental health services in public sector Readings: Schuffman, D., Druss, B.G., & Parks, J.J. (2009). Mending Missouri’s safety net: Transforming systems of care by integrating primary and behavioral health care. Psychiatric Services, 60(5), 585-588. Hogan MF, Sederer LI, Smith TE, & Nossel IR. (2010). Making room for mental health in the medical home. Prev. Chronic Dis. 7(6):A132 [Erratum appears in Prev Chronic Dis 2010;8(1). http://www.cdc.gov/pcd/issues/2011/jan/10_0249.htm.] Mechanic, D. (2012). Seizing opportunities under the Affordable Care Act for transforming the mental and behavioral health system. Health Affairs, 31(2), 376-382. http://content.healthaffairs.org/content/31/2/376.short View the short video on the Health Resources and Services Administration (HRSA) website about a primary care program in Tennessee. Available at: http://www.hrsa.gov/publichealth/clinical/BehavioralHealth/ Introduction Goal 1 of the President’s New Freedom Commission Report states that: “Americans understand that mental health is essential to overall health.” This seems like a simple enough goal. It is, however, not as easy to achieve as it appears. The link between mental and physical health has long been a subject of interest to theorists and practitioners and has been studied in the general population. For example, in a general population study, Sederer et al. (2006) found that those New Yorkers who reported nonspecific psychological distress suffered more physical health problems, were more likely to smoke, be inactive and have a poor diet than those who didn’t report distress. They noted that these individuals were much more likely to have hypertension, hyperlipidemia, obesity, asthma, and diabetes. The link with physical health is especially important for those suffering from serious mental illness. We learned in a previous lesson that persons with serious mental illness were likely to die 25 years earlier than adults in the general population (Colton & Manderscheid, 2006). Of those who die, 87% do so because of medical illnesses (Parks, Radke, & Mazade, 2008). These studies, results from Sederer et al. in a general population, and others show that physical and psychological problems not only co-exist, but also have a relationship. Treating one without addressing the other will result in inadequate care for the individual who suffers from both. Not much in terms of practice, however, has been done to address this issue until fairly recently. Why Integrate Care? Addressing the physical health needs of persons with mental illness has become increasingly important as more evidence becomes available of the link between them. An account of a recently held forum at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care noted: “For years, the prevailing notion in medicine held that the body is treated in a physician's office and the mind in a ...

1. Lesson 10: Integrated /mental health/healthcare and future of
mental health services in public sector
Readings:
Schuffman, D., Druss, B.G., & Parks, J.J. (2009). Mending
Missouri’s safety net: Transforming systems of care by
integrating primary and behavioral health care. Psychiatric
Services, 60(5), 585-588.
Hogan MF, Sederer LI, Smith TE, & Nossel IR. (2010). Making
room for mental health in the medical home. Prev. Chronic Dis.
7(6):A132 [Erratum appears in Prev Chronic Dis 2010;8(1).
http://www.cdc.gov/pcd/issues/2011/jan/10_0249.htm.]
Mechanic, D. (2012). Seizing opportunities under the
Affordable Care Act for transforming the mental and behavioral
health system. Health Affairs, 31(2), 376-382.
http://content.healthaffairs.org/content/31/2/376.short
View the short video on the Health Resources and Services
Administration (HRSA) website about a primary care program
in Tennessee. Available at:
http://www.hrsa.gov/publichealth/clinical/BehavioralHealth/
Introduction
Goal 1 of the President’s New Freedom Commission Report
states that: “Americans understand that mental health is
essential to overall health.” This seems like a simple enough
goal. It is, however, not as easy to achieve as it appears.
The link between mental and physical health has long been a
subject of interest to theorists and practitioners and has been
studied in the general population. For example, in a general
population study, Sederer et al. (2006) found that those New
Yorkers who reported nonspecific psychological distress
suffered more physical health problems, were more likely to
smoke, be inactive and have a poor diet than those who didn’t
report distress. They noted that these individuals were much

2. more likely to have hypertension, hyperlipidemia, obesity,
asthma, and diabetes.
The link with physical health is especially important for those
suffering from serious mental illness. We learned in a previous
lesson that persons with serious mental illness were likely to die
25 years earlier than adults in the general population (Colton &
Manderscheid, 2006). Of those who die, 87% do so because of
medical illnesses (Parks, Radke, & Mazade, 2008). These
studies, results from Sederer et al. in a general population, and
others show that physical and psychological problems not only
co-exist, but also have a relationship. Treating one without
addressing the other will result in inadequate care for the
individual who suffers from both. Not much in terms of
practice, however, has been done to address this issue until
fairly recently.
Why Integrate Care?
Addressing the physical health needs of persons with mental
illness has become increasingly important as more evidence
becomes available of the link between them. An account of a
recently held forum at the Robert Graham Center for Policy
Studies in Family Medicine and Primary Care noted:
“For years, the prevailing notion in medicine held that the body
is treated in a physician's office and the mind in a separate
mental health facility. That view is slowly changing, however,
as a growing number of medical professionals and others
contend that such separation leads to ineffective treatment that
does not answer patients' needs.” (Michael Laff, October 20,
2014)
In order to address the complex health needs of individuals, the
concept of integrated care must be examined. First, what is
integrated care?
In their review of integration studies, Butler, Kane, McAlpin,
Kathol, Fu, Hagedorn & Wilt (2008) note two types of
integration. The first type is the integration of mental health
care into primary care and the second type is the integration of

3. physical health care into specialty mental health care.
Why is integration of mental health care into primary care
important? Butler et al. (2008) note five good reasons for this.
First, most people with mental health difficulties do not receive
treatment. Second, persons with mental health difficulties are
as likely to be seen in a primary care setting (23%) as in
specialty mental health (22%). Third, individuals with mental
health problems are more likely to see a primary care physician
each year, which puts primary health care in a better position to
recognize and provide treatment to people with problems.
Fourth, as noted in the Introduction, there is considerable
comorbidity between health and mental health and the untreated
interaction between the two results in high costs. By treating
these together, costs may be lowered. And finally, there is good
evidence that common mental health problems like depression
and anxiety can be effectively treated in the primary care
setting (ibid, pp. 9-10.).
The rationale for the second type of integration, providing
primary care in specialty mental health care is also explained.
In the past when patients were confined to a psychiatric
hospital, it was easier to treat both mental health and physical
health together. Once persons were integrated into the
community, their mental health needs may have been addressed
in mental health settings, but their physical health needs often
were not. Persons with serious mental illness who live in the
community are most often treated in specialty mental health
settings such as community mental health centers. While the
specialty mental health settings address psychiatric needs, they
are not often equipped to treat physical health problems. Their
services are designed to meet the specific needs of those with
mental health problems. Thus, even though persons with serious
mental illness may be at higher risk from certain diseases
because of high rates of smoking, sedentary lifestyle, poverty,
social isolation, no access to preventive healthcare and several
other such reasons, they may not receive the appropriate
treatment they need for their physical health problems (Parks,

4. Radke, Mazade, & Mauer, 2008). As if these social and
lifestyle reasons are not enough to create certain diseases,
another important factor may also predispose persons with
serious mental illness to physical health problems.
Antipsychotic medications, especially second generation drugs,
are having an impact on physical health. We are finding that
the very medications used to alleviate the symptoms of mental
disorders and assist these individuals to live a meaningful life
in the community are associated with the metabolic syndrome.
Metabolic syndrome includes such health problems as
cardiovascular disease, high blood pressure, diabetes, high
cholesterol, and obesity. Therefore, a constellation of factors
are involved that may result in poor physical health problems
for persons with serious mental illness and these problems may
not be addressed in services they receive through specialty
mental health care.
How does integrated care work for persons with serious mental
illness?
Basically integrated care is a way to coordinate care across
systems. A conceptual model associated with population-based
and system integration is the chronic care model (Parks,
Pollack, Bartels, & Mauer, 2005). It is an example of a way to
improve community based healthcare for persons with chronic
health conditions, including mental disorders. Although it can
be applied in a primary care setting, it also is relevant for
specialty mental health. The model relies on providing
continuous, planned care and uses information systems to
follow the patients’ health status, measurement of performance
indicators, and monitoring of evidence-based care protocols
(Parks, Radke, & Mazade, 2008, p. 6). A diagram of the model
is below:
Retrieved from:
http://www.improvingchroniccare.org/index.php?p=The_Chroni
c_Care_Model&s=2
An important part of the model is the concept of the healthcare

5. home (or patient-centered medical home). The patient-centered
medical home change concepts include: engaged leadership,
quality improvement strategy, empanelment, patient-centered
interactions, organized, evidence-based care, care coordination,
enhanced access, and continuous, team-based healing
relationships
(http://www.improvingchroniccare.org/index.php?p=PCMH_Cha
nge_Concepts&s=261).
The medical home brings together all the elements of care
including primary care, behavioral health services,
bio/psychosocial/spiritual model of care, and disease
management strategies into a collaboration that coordinates
services and identifies who is responsible for managing the
activities related to a patient’s care.
Considerable research is being conducted on patient centered
health care homes to determine whether and how they impact
patient outcomes. A Commonwealth Fund survey conducted in
2006 (Beal, Doty, Hernandez, Shea, & Davis, 2007) found that
adults with medical homes had improved access to care overall,
improved rates of preventive screenings, and were better able to
manage chronic conditions. Hardy (2009) describes a study
conducted by the Group Health Cooperative in Seattle,
Washington in which outcomes from 9,200 patients from that
agency’s medical home are compared to a control group without
a medical home. During that study emergency room visits
decreased by 29%, the rate of hospitalizations fell by 11%, and
there were 6% fewer in-person visits. Hardy notes that at the
time of his writing (September 2009), there were approximately
25 active medical home projects in 17 states throughout the
nation.
An example of integration can be seen in a relatively recent
federal initiative. For persons in the general population, the

6. Health Resources and Services Administration (HRSA) has a
Primary Care Integration Initiative that is being implemented in
Federally Qualified Health Centers (FQHCs) through the nation.
The initiative permits already existing sites to apply to expand
their services, through grant funding, so that services for
behavioral health including mental health, substance abuse, and
dental services are addressed.
The Schuffman, Druss, & Parks (2009) article describes a
Missouri pilot project on integration of mental health and
physical health at selected FQHCs and community mental health
centers throughout the State. The work continues on this
important project and it is being expanded to other centers.
Beginning in January 2011, Section 2703 of the PPACA allows
states ”to obtain, if approved by CMS, 90 percent federal
Medicaid matching funds for eight consecutive quarters to
reimburse the health home services . . . “ (Silow-Carroll &
Rodin, 2010-11). Persons who can receive services under
Section 2703 must be Medicaid eligible and have: (1) two or
more chronic conditions; (2) one chronic condition and are at
risk for another; or (3) a serious and persistent mental health
condition. Chronic conditions are defined as a mental health
disorder, substance use disorder, asthma, diabetes, heart disease
and being overweight (a body mass index over 25). States may
apply to have their Medicaid state plan amended to include
health homes, either in primary care, mental specialty care or
both and can choose which of the defined chronic conditions are
covered.
Missouri was the first state to implement health homes for
persons with mental illness. The Missouri Department of
Mental Health has been instrumental in developing and
implementing health care homes for participants who are
Medicaid eligible and have chronic illness. The Missouri
project is a collaboration among Missouri HealthNet, the
Missouri Foundation for Health, the Missouri Primary Care
Association, the Missouri Coalition of Community Mental
Health Centers and other stakeholders. For more on Missouri’s

7. pioneering in this area see the articles that appeared as the
initiative began implementation:
http://www.stlbeacon.org/health-science/health/113764-
missouri-is-first-to-implement-health-homes-for-patients-with-
chronic-illnesses; and
http://www.commonwealthfund.org/Newsletters/States-in-
Action/2011/Jan/December-2010-January-
2011/Snapshots/Missouri.aspx.
The Missouri health homes project began on January 1, 2012
and was expected to “reduce inpatient hospitalization and
emergency room visits, enhance the amount of primary care
nurse liaison staffing available at community mental health
centers, add primary care physician consultation, and enhance
the State’s ability to provide transitional care between
institutions in the community.” (See:
http://dmh.mo.gov/about/chiefclinicalofficer/healthcarehome.ht
m) Preliminary results over 18 months of the program are
encouraging and show that both health status is improved and
there is a reduction in costs of care. An account of the project
and preliminary report can be found at:
http://dmh.mo.gov/mentalillness/mohealthhomes.html and
http://www.naspo.org/dnn/default.aspx (The Promise of
Convergence: Transforming Health Care Delivery in Missouri).
The effort to address the first goal of the President’s New
Freedom Commission is still in its infancy. It will be
interesting to watch the implementation of this program and to
see whether it achieves the kind of outcomes, long term, that
have been shown on a smaller scale.
NOTE:
You can find more on Health Homes in Missouri at:
http://www.nashp.org/med-home-states/missouri and
http://aspe.hhs.gov/daltcp/reports/2012/HHOption-MO.pdf
More on states health homes proposal status and the key

8. features of their plans can be found at:
http://www.medicaid.gov/state-resource-center/medicaid-state-
technical-assistance/health-homes-technical-
assistance/approved-health-home-state-plan-amendments.html
For more on lesson learned on health homes, see:
http://healthaffairs.org/blog/2015/08/11/advancing-integrated-
behavioral-health-care-in-texas-and-maine-lessons-from-the-
field/
Assignment and Group Discussion
Your response to the question below and your participation in
the group discussion will be worth points
1. What do you think some of the challenges are in
implementing health care homes for persons with serious mental
illness? How might that differ from implementing health care
homes in a general or primary care clinic?
Again, please try to have your initial answers to the question on
the Discussion Board by Friday so that you can respond to
others in the class by Sunday night.
References
Beal, A.C., Doty, M.M., Hernandez, S.E., Shea, K.K., & Davis,
K. (June, 2007). Closing the divide: How medical homes
promote equity in health care. Commonwealth Fund, pub. no.
1035.
Butler M, Kane RL, McAlpine D, Kathol, RG, Fu SS, Hagedorn
H, Wilt TJ. (October 2008). Integration of Mental
Health/Substance Abuse and Primary Care No. 173: Executive
Summary (Prepared by the Minnesota Evidence-based Practice
Center under Contract No. 290-02-0009.) AHRQ Publication
No. 09-E003. Rockville, MD. Agency for Healthcare Research
and Quality, pp 1-6. Available at:
http://www.ahrq.gov/downloads/pub/evidence/pdf/mhsapc/mhsa
pc.pdf
Colton, C.W., & Manderscheid, R.W. (2006). Congruencies in
increased mortality rates, years of potential life lost, and causes
of death among public mental health clients in eight states.

9. Preventing Chronic Disease: Public Health Research, Practice,
& Policy, 3(2), 1-14.
Hardy, K. (September 1, 2009). Study: Medical home model
increases quality of care, reduces cost. Healthcare IT News.
Retrieved on 10/21/2011 from:
http://www.healthcareitnews.com/news/study-medical-home-
model-increases-quality-care-reduces-cost
Laff, M. (2014). Speakers emphasize the need to build bridges
between primary care, mental health, Robert Graham Center
Forum, AAFP. Retrieved on 10/23/2014 from:
http://www.aafp.org/news/practice-professional-
issues/20141020rgcforumprimmental.html
Parks, J., Pollack, D., Bartels, S., & Mauer, B. (2005).
Integrating behavioral health and primary care services:
Opportunities and challenges for state mental health authorities.
Medical Directors Council: National Association of State
Mental Health Program Directors.
Parks, J., Radke, A.Q., Mazade, N.A., & Mauer, B. (2008).
Measurement of health status for people with serious mental
illness. Medical Directors Council: National Association of
State Mental Health Program Directors.
Schuffman, D., Druss, B.G., & Parks, J.J. (2009). Mending
Missouri’s safety net: Transforming systems of care by
integrating primary and behavioral health care. Psychiatric
Services, 60(5), 585-588. Retrieved on 7/20/11 from:
http://www.ps.psychiatryonline.org/cgi/reprint/60/5/585
Sederer, L. I., Silver, L., McVeigh, K.H., & Levy, J. (April,
2006). Integrating care for medical and mental illnesses.
Preventing Chronic Disease: Public Health Research, Practice,
& Policy. Retrieved on 10/12/11 from:
http://www.cdc.gov/pcd/issues/2006/apr/05_0214.htm
Silow-Carroll, S. & Rodin, D. (December 2010/January 2011).
States in action archieve: Health Homes for the chronically ill:
An opportunity for states. Commonweath Fund. Retrieved on

10. 10/14/13 from:
http://www.commonwealthfund.org/Newsletters/States-in-
Action/2011/Jan/December-2010-January-
2011/Feature/Feature.aspx