The focus in integrated care model development and real-world clinical implementation of integrated care delivery is on those categories of quality measures shown to demonstrate effective integrated care:

Structural Measures – where clinical organizations demonstrate capacity to provide efficient care. Often framed as an accreditation/recognition program, they are based on a practice’s:

*policies                                        *staffing mix/care team
*expertise and training              *HIT functionality/clinical information systems
*co-location                                  *patient-centered care plan
*financing mechanisms             *decision-support protocols

Process-of-Care Measures – these address the extent to which providers effectively implement
clinical practices, or treatments, shown to result in high-quality or efficient care, e.g.

*access to care                                    *case management
*systematic patient identification    *use of evidence-based treatment
*info tracking and exchange             *team-based care/collaborative practices
*measurement-based stepped care  * linkages with community/social services
*self-management support               *systematic quality improvement

Outcomes Measures – these track the results of care interventions:

*symptom measures (PH9s)             *patient’s experience of care
*quality of life                                      *functional quality of life
*patient-centeredness                       *patient activation
*progress towards life goals             *medication adherence and side effects

In addition, there are also:

Contextual Factors such as

• • • • leadership                                    *organizational culture

Frameworks Offering Practical Guidance:  Recent research and implementation work has revealed that integrated care delivery progresses along parallel pathways comprised of structural, process and contextual components (see above).

A continuum-based framework can offer practical guidance to practitioners in both medical and behavioral health settings, PCPs integrating BH into primary care, and BH professionals in specialty BH setting integrating medical/physical care.  A Behavioral Health Integration (BHI) and the General Medical Integration (GMI) frameworks organize the essential component elements, divides them into 8 key domains, and details the specific steps needed from the historical level (non-integration), preliminary level of progress, intermediate and advanced.  (See link to Frameworks).

This framework tool is flexible in allowing practices to decide which domains of change to focus on, while at the same time laying out the entire journey to be attempted.

The frameworks are the result of real-world State Medicaid demonstration projects in the State of New York involving small-to-medium primary care practices, already having attained a Patient Centered Medical Home III level, to attempt integration and the real-world lessons learned therefrom.

While offering an integrated care roadmap, the frameworks also build on work on evolving models of integrated care.  Established models are now being tailored to target specific patient populations and policy initiatives developed to incentivize adoption in particular settings, e.g., obstetrics.

Current Hurdles:

There are few valid and feasible process and outcomes measures existing now to support integrated care and value-based (VB) payment approaches for patients with BH and co-existing general medical conditions.

The outcomes measures that do exist focus on a single-disease or population, rather than on the reality of multimorbidity in the patient population.

Finally, there are research gaps in how the efficiency of integrated care is conceptualized and measured.

Where We Go From Here:  Currently 3 key bottlenecks to integrated care implementation exist:

• need for payment policies that provide flexible support for process and structural elements of IC, and, at the same time, maintains accountability for the quality and efficiency of care
• which requires agreed quality measures.
  Once consensus QMs are in place, this will determine where practices focus their integration efforts.
• current demands on the primary care system in meeting the complex needs of patients with chronic BH and medical conditions:
  • • • lack of time
      • minimal training in mental health/addiction care
      • lack of care coordination between healthcare and social services

References:

Chung BHI Framework and GMI Framework
Ramanuj, Pincus et al, Current Psychiatry Reports (2019) 21:4
Chapman, Chung, Pincus, Psychiatry Services 2017: 68:756-758
McGinty et al, Psychiatry Online, June 2020