1. Public Health Social Work: Advancing Integrated Health Care
Sandy (Cohen) Colts, MSW, MPH

2. Presentation Outline Social Work Mission & Health Impact Model
Shifting American Concepts of ‘Health’
Evolution of US Health Service Delivery
Health Care’s “Quality Chasm”
Vision for Care Integration
Emerging Trends in US Health Care Delivery
Public Health Social Work: Key Roles to Play in Care Integration

3. Social Work: Enhancing Human Well-Being
“The primary mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty. A historic and defining feature of social work is the profession’s focus on individual well-being in a social context and the well-being of society. Fundamental to social work is attention to the environmental forces that create, contribute to, and address problems in living.”
- NASW Code of Ethics

4. Social Work is a Health Profession!
Where social workers currently practice:
As of 2016, estimated there are about 682,000 social workers in the US
At least 300,000 are employed in health care delivery; many others work on issues related to social determinants of health (education, housing, child welfare)
Increased number of social workers in health: 50% but expected to increase to 70% in a decade
Social Work Health Impact Model helps us conceptualize our current and potential roles in health (Ruth, Wachman & Schultz, 2014)
Labor statistics on Social Workers in the US
social-workers.htm
Educating for Health Impact
Health social work, which employs half of all current social workers, is a growth area of the profession. Although public health social work is a longstanding practice within the profession--and a growing area of interest--education for health social work is still primarily focused on clinical care in health settings. The Health in all Social Work Programs Study, conducted by Ruth, Wachman, et al., indicates that the vast majority social work courses and specializations at the baccalaureate, masters, and continuing education levels focus on clinical practice. Yet, for the profession to effectively address health inequities, social work education must expand to robustly include practice at all levels of the Social Work Health Impact Model. While clinical approaches are valuable at the individual, family and group levels, clinical interventions have minimal population impact and must be paired with public health approaches if the profession is to successfully address the social determinants of health that produce health inequities. The failure to teach a broader set of skills limits graduates’ abilities to work, collaborate and lead on these issues in the larger health system.

5. Social Work Health Impact Model (Ruth, Wachman & Schultz, 2014)
Educating for Health Impact
Health social work, which employs half of all current social workers, is a growth area of the profession. Although public health social work is a longstanding practice within the profession--and a growing area of interest--education for health social work is still primarily focused on clinical care in health settings. The Health in all Social Work Programs Study, conducted by Ruth, Wachman, et al., indicates that the vast majority social work courses and specializations at the baccalaureate, masters, and continuing education levels focus on clinical practice. Yet, for the profession to effectively address health inequities, social work education must expand to robustly include practice at all levels of the Social Work Health Impact Model. While clinical approaches are valuable at the individual, family and group levels, clinical interventions have minimal population impact and must be paired with public health approaches if the profession is to successfully address the social determinants of health that produce health inequities. The failure to teach a broader set of skills limits graduates’ abilities to work, collaborate and lead on these issues in the larger health system.
Clinical approaches without intentional connection to the prevention, systems, and social determinants of health, remain limited in population impact regardless of their individual value. Thus, public health social work of any type may include clinical interventions but must be connected to prevention, systems transformation, and specific wide-lens efforts to address macro and social determinants.

6. Shifting Concepts of “Health” Through History
Before we can identify new roles for social work in the emerging health landscape, it’s important to cover some historical ground and review concepts of health, health care, and health reform

7. 17th Century Separation of Mind and Body: Still With Us!
Cartesian Dualism – Humans are comprised of two unlike substances which could not exist in unity:
Mind was unextended, an immaterial but thinking substance;
Body was an extended, material but unthinking substance. The body was subject to mechanical laws; but mind was not
Acceptance of Dualism shaped human concepts of health, resulting in focus on mechanics of ‘material body’ as primary object of medical science; this is the origin of the “medical model”
Named “Cartesian Dualism” in honor of Rene Descartes leadership on development of this theory
With medicine still very nascent and health being poorly understood at that time, Dualism was a disruptive new concept that enabled humans to conceive of vast new theories about health and illness. By separating mind and body, the concept of Dualism arguably marked a turning point that catalyzed the ensuing isolated development of new sciences and entire professions dealing with the mind or body, respectively. In retrospect, this paradigm appears to have established a mindset that health professions needed to choose whether to focus on mind or body – effectively eliminating the mere idea that an individual or group could be concerned with both body and mind. While Descartes is by no means entirely to blame for the fragmented health care system we have in the US today, it’s easy to imagine how setting all health sciences concerned with the mind or body on separate paths nearly 400 years ago has impacted not only our scientific advances, the development of entire health professions, and what health services we offer, but where, why, and how health care is provided, by whom, and the ways we conceive of health to this day (e.g. stigma and misunderstanding of mental health and substance use disorders).
References
Mehta N. Mind-body Dualism: A critique from a Health Perspective. Mens Sana Monographs. 2011;9(1): doi: /
EXERCISE: What continued impacts of mind/body dualism have you experienced or observed in your social work practice/training?

8. Late-18th to Mid-19th Centuries: Preventive Public Health & Sanitation
1790s: First large urban public health departments (or “boards”) established in Baltimore, Philadelphia, and Boston
Industrialization and Urbanization leads to filthy conditions and corresponding spike in disease
Greater understanding of air, water, waste, and proximity as factors effecting transmission of disease
The birth of Public Health as a profession

9. Late-19th to Mid-20th Centuries: Germ Theory & Vaccination
1877: ‘Germ Theory’ of disease proposed by Louis Pasteur
: Building on smallpox vaccine breakthroughs, rapid increase in discovery and development of vaccines
s: Widespread adoption of verified immunizations and intensive development and testing of new vaccines
References
Institute of Medicine (US) Committee for the Study of the Future of Public Health. Washington (DC): National Academies Press (US); 1988
1982. Starr, P. The Social Transformation of American Medicine. Basic Books, Inc., New York.
Life expectancy stats: Arias E. United States life tables, National vital statistics reports; vol 54 no 14. Hyattsville, MD: National Center for Health Statistics Available at: Accessed August 12, 2018.
Our World in Data: Life Expectancy. Available at: Accessed August 22, 2018.
Data chart included above – though I leave it to editorial discretion of ALPS team whether it’s helpful to include, maybe as an additional slide

10. US life expectancy increased from 49. 3 in 1901 to 68
US life expectancy increased from 49.3 in 1901 to in 1950 – largely due to greater immunization reducing rates of infectious disease
References
Our World in Data: Life Expectancy. Available at: Accessed August 22, 2018.
I decided to go ahead and insert this chart as it’s own slide – helping to break up dense text with some actual data – though I leave it to the editorial discretion of ALPS team whether it’s helpful to underscore the point.

11. Late 20th Century: Emergence of Population Health
Recognition of the limits of medical model and importance of public health and social factors which shape health
Development of population health, which focuses on health outcomes of a group of individuals, including the distribution of such outcomes within the group” (Kindig & Stoddart, 2003).
Exercise: Review the graph which addresses the social determinants of health. Consider all the factors that can help keep an individual and whole community healthy.
Origins of “Population Health”
David Kindig (U of Wisconsin-Madison School of Medicine) primarily attributed with defining the term “population health” and disseminating it
Kindig D. and Stoddart G. What Is Population Health? American Journal of Public Health. 2003;93(3): DOI: /AJPH
“What Are We Talking About When We Talk About Population Health?, " Health Affairs Blog, April 6, DOI: /hblog
Geographic v. Discrete “populations”
While the concept of “population health” initially referred more to geographically-defined populations (e.g. cities, communities, metro areas, states/nations), Kindig and Stoddard also acknowledge that the health of discrete populations with other mutual associations (e.g. employees of a large company, active patients of a clinic or health care system, or prisoners)
County Health Rankings model for determinants of population health (vhttp://
Health care services ~10% of population health outcomes
Environmental factors ~20% (e.g. air/water quality,
Socioeconomic status ~30% (e.g. employment, income, wealth)
Behavioral factors ~40% (e.g. tobacco/substance use, exercise, diet)
The development of this simple Framework/Model for Population Health is most important for highlighting the relatively limited role that health care interventions likely play in determining the overall health as a population. To quote experts who have done much more extensive research (Braveman & Gottlieb, 2014):
“The limits of medical care are illustrated by the work of the Scottish physician, Thomas McKeown, who studied death records for England and Wales from the mid-19th century through the early 1960s. He found that mortality from multiple causes had fallen precipitously and steadily decades before the availability of modern medical-care modalities such as antibiotics and intensive care units. McKeown attributed the dramatic increases in life expectancy since the 19th century primarily to improved living conditions, including nutrition, sanitation, and clean water (McKeown, Record, & Turner, 1975). While advances in medical care also may have contributed (McKeown, Record, & Turner, 1975; Mackenbach, Stronks, & Kunst, 1989; Mackenbach 1996), most authors believe that nonmedical factors, including conditions within the purview of traditional public health, were probably more important (Grundy, 2005).
McKeown, T., Record, R.G., Turner, R.D. (1975). An interpretation of the decline of mortality in England and Wales during the twentieth century. Popul Stud (Camb), 29(3),
Mackenbach JP, Stronks K, Kunst AE. The contribution of medical care to inequalities in health: differences between socio-economic groups in decline of mortality from conditions amenable to medical intervention. Soc Sci Med. 1989; 29(3):
Mackenbach JP. The contribution of medical care to mortality decline: McKeown revisited. J Clin Epidemiol. 1996;49:1207–13.
Grundy E. Commentary: the McKeown debate: time for burial. Int J Epidemiol. 2005;34:529–33.
Braveman, P., & Gottlieb, L. (2014). The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Reports, 129(Suppl 2), 19–31.

12. Evolution of US Health Service Delivery

13. Brief Evolution of US Health Care Services
Late 19th / Early 20th centuries: Hospitals as centers for indigent people
1930s – mid 1940s: Private v. Public Health Insurance
Late 1940s – mid 1960s: Insurance coverage grows; Scientific advances; Growing health inequities
Late 1960s: Passage of Medicare, Medicaid
1970s – 1980s: Rapid expansion of Health Maintenance Organizations (HMOs) and power of health insurers
If more detail on this topic is of interest, I could provide some more depth. If it helps to just have a reference, most of the extra information I would provider would just come from “The Social Transformation of American Medicine” by Paul Starr (1982). It’s a really fascinating historical review of how US health care evolved, but through a much more “social work-friendly” (sociological / anthropological) lens than simply health policy & politics alone.
Late 19th / Early 20th centuries: Hospitals as centers for indigent people
Before the late 19th century, hospitals were almost exclusively charitable, social welfare organizations, providing largely palliative care for poor, indigent people who could not afford medical professionals. “We now think of hospitals as the most visible embodiment of medical care in its technically most sophisticated form, but before the last hundred years, hospitals and medical practice had relatively little to do with each other,” (Starr, 1982, p. 145).
“In a matter of decades, roughly between 1870 and 1910, hospitals moved from the periphery to the center of medical education and medical practice…What drove the transformation was not simply the advance of science…but the demands and example of an industrializing capitalist society, which brought larger numbers of people into urban centers, detached them from traditions of self-sufficiency, and projected ideals of specialization and technical competence,” (Starr, p. 146).
“The sick began to enter hospitals, not for an entire siege of illness, but only during its acute phase to have some work performed upon them. The hospital took on a more activity posture; it was no longer a well of sorrow and charity but a workplace for the production of health.”
1930s – mid-1940s: Private v. Public Health Insurance
Establishment and growth of Blue Cross, Blue Shield, and other private medical insurance plans
Failure to include national health insurance as part of New Deal
Strength of the American Medical Association monopoly was the primary reason US could never muster political will to pass national health insurance. “In short, the AMA insisted that all health insurance plans accept the private physicians’ monopoly control of the medical market and complete authority over all aspects of medical institutions,” (Starr, 1982, p. 300).
RESOURCE: Altman S. & Shactman D. Power, Politics, and Universal Health Care: The Inside Story of a Century-Long Battle Prometheus Books: Amherst, NY.
mid-1940s – mid-1960s: Insurance coverage grows; Scientific advances; Growing health inequities
1946, Hill-Burton Act (Hospital Survey & Construction Act)
Rapid growth of employer-sponsored health insurance benefits – many consider to be an unintended consequence
“In 1943 the War Labor Board, which had one year earlier introduced wage and price controls, ruled that contributions to insurance and pension funds did not count as wages. In a war economy with labor shortages, employer contributions for employee health benefits became a means of maneuvering around wage controls. By the end of the war, health coverage had tripled (Weir et al., 1988)” – from Institute of Medicine (US) Committee on Employment-Based Health Benefits; Field MJ, Shapiro HT, editors. Employment and Health Benefits: A Connection at Risk. Washington (DC): National Academies Press (US); , Origins and Evolution of Employment-Based Health Benefits. Available from:
1965: Passage of Medicare, Medicaid
Enormous expansion of health insurance coverage for vulnerable populations – especially children, elderly, people in extreme poverty and those with qualifying disabilities
1970s – 1980s: Rapid expansion of Health Maintenance Organizations (HMOs) and power of health insurers
Rand Corporation, The RISE of HMOs:

15. Factors Related to a Silo’d Medical Model Driven Care System
Evolution of separate medical, mental health, oral health & social service/welfare systems
Repeated political failure to establish a universal, government- led system for comprehensive health care services: forces arrayed against “socialized medicine”
Result: Complex, patchwork system reinforced by:
Evolution of distinct professions
Stigma
Insurance/Payment models driven by cost containment
Health Policy
Behavioral and oral health carve-outs
EXERCISE: In your experience, what systemic factors have you encountered that make it difficult for health care providers to work as a united, integrated team?

16. Current State of US Health Services
Continuum of Health Services
Health Education
Screening & Prevention
Primary Care & Disease Management
Mental/Behavioral Health Services
Medical Specialties
Acute/Emergency Care
Inpatient Psychiatry
Inpatient Medical/Surgical
Post-Acute Care
Long-term Rehabilitation & Recovery Supports
EXERCISE: Social work alone provides many services: try listing as many service categories (e.g. case mgmnt, policy development, talk therapy, community org, clinical modalities) as you can.
The universe of professional health care services available today in any Western OECD country is vast – as science advances. In the US, this range of services is especially vast because of our greater specialization (and even sub-specialization) of health care providers.

17. Current State of US Health Services Continued
Health Services take place across a wide range of sites, which are generally not integrated….
Public Health
Primary Care Providers (pediatrics & adult)
Community Mental Health Centers
Independent Clinical Practices (mostly specialties)
Private Specialty Care Programs (incl. Mental Health & Substance Use Disorders)
Hospital-based Emergency & Inpatient Care
Post-acute Care Providers
Niche Programs for Discrete Populations
EXERCISE: Make a second list of all the places one might receive social work services. Comparing these lists, how would you describe the SW profession’s level of “integration”?

18. Lack of Integration Leads to “Quality Chasm” in US Health Care
Numerous Efforts to Address Lack of Quality by Institutes of Medicine Reports:
1999, To Err is Human
Between 44,000-98,000 preventable deaths in US hospitals every year
2001, Crossing the ‘Quality Chasm’
High-quality health care should be: 1) Safe, 2) Effective, 3) Patient-Centered, 4) Timely, 5) Efficient, 6) Equitable
2006, Improving the Quality of Mental Health Care
Meanwhile, US life expectancy is declining and infant mortality rates are higher than other OECD countries (CIA Factbook, 2018)
Last decline over two consecutive years:
The results we get from
Institutes of Medicine Reports:
1999, To Err is Human
2001, Crossing the “Quality Chasm”
Safe, Effective, Patient-Centered, Timely, Efficient, Equitable
2006, Improving Quality of Mental Health Care
Six Domains of Health Care Quality (from IOM, “Crossing the Quality Chasm” 2001)
Safe
Effective
Patient-Centered
Timely
Efficient
Equitable
US Life Expectancy decline
First time US has seen two consecutive years of decline since , when influenza caused an inordinate number of deaths. The only other decline in life expectancy in the last half-century occurred in 1993, there was a one-year drop during the worst of the AIDS epidemic.

19. Health Inequity in Mental Health—Another Outcome
Health Inequities in Mental Illness
Inequity “Drivers”
US continues to see persistent inequities in quality and length of life correlating to race, education, income/wealth, neighborhood, mental illness, and many more indicators of disempowerment – some gaps closing, but many widening
Greater mortality risk and disease prevalence
~20-25 year mortality gap among people living with serious mental illness.
Lack of timely access to high quality care Lack of coordinated care Fragmented planning and delivery of care Disproportionate disease burden and exposure to key risk factors Insufficient supply, cost, and availability of behavioral health clinicians Lack of meaningful or effective care Stressful society disproportionately affects poor, working class, people of color and other disadvantaged people
Mortality Gap
Olfson M, Gerhard T, Huang C, Crystal S, Stroup TS. Premature mortality among adults with schizophrenia in the United States. JAMA psychiatry. 2015:1-10.
Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care. 2011;49(6):

20. Why the Poor Behavioral Health Outcomes?
More specialists, fewer primary care doctors Not enough mental health specialists Lack of information exchange, care coordination High uninsured rate Prohibitive costs to access care Poor management practices (unreliable systems) Insufficient supply of adequately-trained behavioral health clinicians Providing unnecessary or ineffective care Less government spending on social services, public health Fragmentation and misalignment of health services
The disintegration of health care services is of course not solely responsible for the country’s sub-par quality of care and surprisingly poor health outcomes – thus no one should infer that care integration is a panacea for the many shortcomings of American health care. Still, much of the background presented earlier underscores how we arrived at today’s fragmented, frustrating system because of historical precedents, such as Cartesian Dualism and early US health policy being characterized by willful efforts to separate different health professions.
Less government spending on social services, public health
Book – The American Health Care Paradox
Bradley, Elizabeth H., and Lauren A. Taylor. The American Health Care Paradox: Why Spending More Is Getting Us Less. New York, NY: PublicAffairs, 2013.

21. Emerging Trends in US Health Care Policy & Care Delivery

22. From Volume to “Value”
Since 2006, major shifts toward paying for health care services in ‘bundles’ or ‘budgets’ – not ‘fee-for-service’
Aim to change health care providers’ incentives from doing more to doing what’s best for people’s health
Referred to as ‘value-based’ or ‘accountable care’
Distinguished from ‘Managed Care’ by adding strong features for quality assurance and financial incentives
Integrating mental health and other non-medical providers became more feasible and valuable
Susan Baseman, Cristina Boccuti, Maralyn Moon, Shannon Griffin, Tania Dutta. Payment and Delivery System Reform in Medicare: A Primer on Medical Homes, Accountable Care Organizations, and Bundled Payments. Kaiser Family Foundation: CA. Nov Available at:

23. The Triple Aim
EXERCISE: Consider how co-locating and/or integrating health care services may achieve the ‘Triple Aim’
The Triple Aim Framework, first introduced in 2008 by the Institute for Healthcare Improvement (IHI), posited that some changes in health care would achieve all three aims:
Improve health of populations
Reduce per capita spending on health care
Improve patient experience of care
In decade since, Triple Aim has become a mainstream organizing principle for health care improvement, providing a helpful “business case” and validating theory for care integration
Institute for Healthcare Improvement (IHI) Triple Aim
Original publication (2008): Berwick DM, Nolan TW, Whittington J: The triple aim: care, health, and cost. Health Affairs 27:759–769, 2008.
Follow-up publication (2015): Whittington JW, Nolan K, Lewis N, Torres T. Pursuing the Triple Aim: The First 7 Years. Milbank Q Jun;93(2): doi: /
EXERCISE
The integration of health care services can advance the Triple Aim in several ways:
Population Health: 1) By integrating providers and creating multi-disciplinary teams, providers begin to learn from each other and encourage better health practices (e.g. BH specialists gain appreciation for cardiovascular health; 2) Having non-billing providers as part of a ‘medical home’ practice means that a team member is able to perform proactive outreach, engagement, and intervention out in the community that can prevent or more quickly address health needs;
Patient Experience: 1) Convenience of co-located service; 2) health care providers working as a team on your behalf; 3) more shared understanding and communication between one’s medical and mental health providers
Health Care Spending: Care integration may reduce total cost of care by: 1) preventing people/patients from having to make multiple visits to separate clinics/facilities for services they could otherwise receive at a single integrated visit; 2) accessible valuable, needed medical and mental health care when it’s needed may help prevent unnecessary exacerbation of health problems, thereby reducing acute/inpatient care use.

24. Patient-Centered Medical Homes
Joint Principles (first released 2007)
Team-based care & Practice organization
Knowing and Managing Your Patients
Patient Centered Access and Continuity
Care Management and Support
Care Coordination and Care Transitions
Performance Measurement and Quality Improvement
Agency for Healthcare Research & Quality:
PCMH Evidence & Evaluation:

25. Accountable Care Organizations (ACOs)
Implications of ACOs
ACOs have more fiscal freedom, but also risk for not over-spending and meeting quality standards.
Can use funds more creatively to offer patients what they need to be healthy, not only what’s billable.
Greater recognition of mental and behavioral health as critical drivers of population health and total.
ACOs have reduced hospital and ED use, improved preventive care and chronic disease management.
ACOs
A network of hospitals, clinics, physician practices and other providers who work together to provide coordinated, integrated care for an assigned population who receive financial compensation for meeting patient outcomes.
Term originated around 2006
Since 2010, > 900 ACOs have formed payment contracts with public and private insurers.
The term ‘Accountable Care Organization’ is typically attributed to Elliott Fischer & colleagues at Dartmouth-Hitchcock
References
Collins S. (2011). Accountable Care Organizations (ACOs): Opportunities for the Social Work Profession. NASW Brief. Available at: Accessed August 26, 2018.
Bachman SS. Accountable care organizations: opportunities for social workers. Health Soc Work. 2011; 36(4):245–247.
Centers for Medicare and Medicaid Services: Center for Medicare and Medicaid Innovation, “Accountable Care Organizations (ACOs): General Information,” cited November 23, 2015, available at
Kaufman BG, Spivack BS, Stearns SC, Song PH, O'Brien EC. Impact of Accountable Care Organizations on Utilization, Care, and Outcomes: A Systematic Review. Med Care Res Rev Dec 1: doi: /
“Since 2010, more than 900 accountable care organizations (ACOs) have formed payment contracts with public and private insurers in the United States; however, there has not been a systematic evaluation of the evidence studying impacts of ACOs on care and outcomes across payer types. This review evaluates the quality of evidence regarding the association of public and private ACOs with health service use, processes, and outcomes of care. The 42 articles identified studied ACO contracts with Medicare ( N = 24 articles), Medicaid ( N = 5), commercial ( N = 11), and all payers ( N = 2). The most consistent associations between ACO implementation and outcomes across payer types were reduced inpatient use, reduced emergency department visits, and improved measures of preventive care and chronic disease management. The seven studies evaluating patient experience or clinical outcomes of care showed no evidence that ACOs worsen outcomes of care; however, the impact on patient care and outcomes should continue to be monitored

26. Social Determinants of Health
EXERCISE: Imagine your state (MA in this case) decided to remove 5% of its Medicaid budget ($800 million) and reallocate it to social services. What could your state do with that money to improve population health?
Mainstream focus on vital social, psychological, economic, & environmental drivers of health
Catalyzed by ‘Population Health’ framework (Kindig et al.)
Maslow’s Hierarchy of Needs
Further emphasizes the need for care integration
The American ‘Health Care Paradox’
US spends more than all other countries on health and has some of the worst outcomes for a high income country
One reason: Low ratio of social service to health care spending
Health care = largest line item in gov’t budgets
Massachusetts, now following the lead of few other states in pursuing the ACO model for financing/delivering Medicaid services, include robust requirements that health care systems must screen patients for social determinants of health and provide some follow-up to assist them in accessing relevant services. Additional “flexible spending” budgets will be available so ACOs can invest creatively to help address their patients’ housing and food insecurity. These types of initiatives in health care are still groundbreaking, and represent a different form of systems integration – health care accepting more social service responsibilities– in addition to care integration in clinical practice.
Paz HL. NEJM Catalyst Blog.

27. Vision for Integrated Behavioral & Medical Health Care
A window of opportunity to address major flaws in the design of US health care delivery

28. Vision for Integrated Care
Team-based care, within and across organizations
Co-location of services for natural, real-time handoffs
Fully-integrated health care practice in the “clinical microsystem” – providers from all disciplines change how they operate to incorporate new perspectives
Person-centered care planning with all providers
Seamless, reliable information sharing
Applicable models for diverse care delivery settings

29. SAMHSA-HRSA Center for Integrated Health Solutions
EXERCISE: When might co-locating or fully integrating mental/behavioral health, medical, and other providers be helpful, or not? What barriers exist that could stymie integrated practice?
One locus of government agency leadership in care integration is the Center for Integrated Health Solutions ( – a training and technical assistance center jointly funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and Health Resources and Services Administration (HRSA). The SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) promotes the development of integrated primary and behavioral health services to better address the needs of individuals with mental health and substance use conditions, whether seen in specialty behavioral health or primary care provider settings
CIHS has developed a 6-level framework to reflect various characteristics and degrees of care integration. It describes 3 main stages of care integration: Coordinated Care, Co-Located Care, and (Fully) Integrated Care, in order from least to most integrated practice. They also suggest the ‘key elements’ of each stage are Communication (for coordinated care), Physical Proximity (for co-located), and Practice Change (for more advanced integration). While there may be a sense of bias toward believing more integration is always better, the reality is that fully-integrated care (Levels 5-6) may not be practical, feasible, or even necessary in all settings, or for certain patient populations. Just want to get the point across that a higher level of care integration (on this framework’s 1-6 scale) is not necessarily better/attainable, so the lower levels of care integration can still add great value.
EXERCISE: What are some circumstances in which co-locating or fully integrating mental/behavioral health, medical, and other providers may not be possible? What practical / structural barriers exist that could prevent integrated practice?
Reference for image: Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C.SAMHSA-HRSA Center for Integrated Health Solutions. March 2013.
Link to SAMHSA-HRSA webpage with resources:

30. Features of Care Integration
References
Singer SJ, Kerrissey M, Friedberg M, Phillips R. A Comprehensive Theory of Integration. Med Care Res Rev Mar 1. doi: /
Functional Integration: Formal, written policies and protocols for activities that support accountability & decision making among orgs and individuals. Strategic planning, financial management, information exchange, quality improvement
Structural Integration: Physical, operational, financial, or legal ties among organizations & teams. Focus on shared structures, not activities. Composition of teams, information systems, governance mechanisms, hiring certain provider types
Normative Integration: Sharing a common culture and exhibiting a culture that prioritizes care integration across units and organizations. Shared vision & mission, collective attitude, sense of urgency. What cultural elements are horizontally and vertically shared.
Interpersonal Integration: Collaboration or teamwork among health care professionals, nonprofessional caregivers, and patients. Requires clarity of roles and responsibilities, positive attitudes about teamwork, and identifying with the team.
Process Integration: Often referred to as “clinical integration,” organizational activities to integrate patient care services into a single coordinated process over time. May include use of shared care plans, multidisciplinary case reviews.
Distinction between Organizational & Social Features -- “The distinction between organizational and social features is critical,” (p.5)
Organizational --
Social –
P.5: “As early as the 1920s, organizational scholar Mary Parker Follett conceptualized integratoin as a social process of encountering, confronting, and unifying the desires of various parties in service of creating a collective mind, feeling, and will (Metcalf & Urwick 1942).”

31. “Four Quadrant” Model
Developed by the National Council for Community Behavioral Healthcare (Introduced 2006; Revised 2009)
Mauer, Barbara J. Behavioral Health/Primary Care Integration and the Person Centered Healthcare Home. April The National Council for Behavioral Health Care.
“Four Quadrant” model:
Mauer, Barbara J. Behavioral Health/Primary Care Integration and the Person Centered Healthcare Home. April The National Council for Behavioral Health Care.
The “Four Quadrant” model is a highly influential framework that proposes different forms of team-based, integrated care based on service users’ “physical health” and “behavioral health” needs. Unlike the CIHS six-level continuum of care integration, the Four Quadrant model offers guidance mostly on considering which sites of care (primary care vs. specialty BH clinic) may produce the best outcomes/experience for different patient populations, as well as what types of providers will likely be involved in the patients’ care.

32. Care Integration by Setting
Primary Care
Behavioral Health
Integration Approach
Co-location, coordination, or full integration of behavioral health services within a primary care practice.
“Reverse integration” of primary care (usually a nurse) and health promotion into specialty BH clinics.
Target Population
Larger, broader population with more prevalent BH conditions (e.g. depression, anxiety, PTSD)
More narrow cohorts with serious mental illness (e.g. bipolar, schizophrenia, personality disorders)
Evidence Base
Collaborative Care trials (see Cochrane Review)
IMPACT trials (AIMS Center, Univ of Washington)
Druss et al. pilots in VA
Evaluation of SAMHSA Primary & Behavioral Health Care Integration grant program,
Interest and research investment in this area lagged more than a decade behind integrated primary care (PBHCI),
Prelude: Due to the highly fragmented nature of services for medical conditions v. mental health conditions, naturally the models for care integration are also classified in two main camps: integration of BH services into PC practice, or the integration of PC/medical services into BH clinics.
General Care Integration Resources:
Great, free integrated care lit review resource: Evolving Models of BH Integration: Evidence Update, (May 2016, Martha Gerrity, Milbank Memorial Fund)
SAMHSA-HRSA Center for Integrated Care Solutions (CIHS):
AIMS (Advancing Integrated Mental Health Solutions) Center, University of Washington, Psychiatry & Behavioral Sciences Division of Population Health.
Background on ‘Health Home’ model(s) for people with more serious mental illness
Alakeson V, Frank RG, Katz RE. Specialty care medical homes for people with severe, persistent mental disorders. Health Affairs (Millwood). 2010;29(5):
Early demonstrations of promising “Behavioral Health Homes” programs (emerging evidence base):
Druss B.G., Rohrbaugh R.M., Levinson C.M., Rosenheck R.A. (2001). Integrated Medical Care for Patients with Serious Psychiatric Illness: A Randomized Trial. Archives of General Psychiatry. 58(9):861–868.
Rubin A.S., Littenberg B., Ross R., Wehry S., Jones M. (2005). Effects on Processes and Costs of Care Associated with the Addition of an Internist to an Inpatient Psychiatry Team. Psychiatric Services. 56(4):463–467
Kilbourne A., Post E., Nossek A., Drill L., Cooley S., Bauer M. (2008). Improving Medical and Psychiatric Outcomes among Individuals with Bipolar Disorder: A Randomized Controlled Trial. Psychiatric Services. 59(7):760–768
Druss BG, von Esenwein SA, Compton MT, Rask KJ, Zhao L, Parker RM. A Randomized Trial of Medical Care Management for Community Mental Health Settings: The Primary Care Access, Referral, and Evaluation (PCARE) Study. Am J Psychiatry. 2010;167(2):
Scharf D.M., Eberhart N.K., Schmidt N., et al. (2014). Evaluation of the SAMHSA Primary and Behavioral Health Care Integration (PBHCI) Grant Program: Final Report (Task 13). Santa Monica, CA: RAND Corporation. (Accessed August 13, 2018:
Gerrity M, Zoller E, Pinson N, Pettinari C, King V. Integrating primary care into behavioral health settings: What works for individuals with serious mental illness. New York, NY: Milbank Memorial Fund
Tepper M, Cohen A, Progovac A, Ault-Brutus A, Leff S, Mullin B et al. Mind The Gap: Developing an integrated behavioral health home to address health disparities in serious mental illness. Psychiatric Services, 2017;68(12);

33. “Collaborative Care” Model
Collaborative Care is associated with significant improvement in depression and anxiety outcomes compared with usual care, and represents a useful addition to clinical pathways for adult patients with depression and anxiety.
It involves several health professionals working with a patient to help them overcome their problems. Collaborative care often involves a medical doctor, a case manager (with training in depression and anxiety), and a mental health specialist such as a psychiatrist. The case manager has regular contact with the person and organizes care, together with the medical doctor and specialist.
Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, Dickens C, Coventry P. Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD DOI: / CD pub2 Available at: Accessed August 23, 2018.
‘Collaborative care’ is an innovative way of treating depression and anxiety. It involves a number of health professionals working with a patient to help them overcome their problems. Collaborative care often involves a medical doctor, a case manager (with training in depression and anxiety), and a mental health specialist such as a psychiatrist. The case manager has regular contact with the person and organizes care, together with the medical doctor and specialist. The case manager may offer help with medication, or access to a ‘talking therapy’ to help the patient get better.

34. Early Pioneers
AIMS (Advancing Integrated Mental Health Solutions) Center, Univ. of Washington
Improving Mood -- Promoting Access To Collaborative Treatment (IMPACT) trial (Unutzer et al., 2002)
Southcentral Foundation (Alaska) – “Nuka”
Video: Interview with CEO Katherine Gottlieb
Intermountain Health Care (Utah)
Video: Demonstrating the value of team-based care
Cherokee Health Systems (Tennessee)
AIMS Center (aims.uw.edu); IMPACT trial (
IMPACT trial
Unützer J, Katon W, Callahan CM, Williams JW Jr, Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noël PH, Lin EH, Areán PA, Hegel MT, Tang L, Belin TR, Oishi S, Langston C; IMPACT Investigators. Improving Mood-Promoting Access to Collaborative Treatment.. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA Dec 11;288(22):
Southcentral Foundation (Alaska) --
“Nuka” is an Alaska Native term that means strong, giant structures and living things. It is also the name given to Southcentral Foundation’s whole health care system, which provides medical, dental, behavioral, traditional and health care support services to more than 65,000 Alaska Native people.
Gottlieb, K. (2013). The Nuka System of Care: improving health through ownership and relationships. International Journal of Circumpolar Health, 72, /ijch.v72i
Abstract: “Alaska Native people are in control as the "customer-owners" of this health care system. The vision and mission focus on physical, mental, emotional, and spiritual wellness and working together as a Native Community. Coupled with operational principles based on relationships, core concepts and key points, this framework has fostered an environment for creativity, innovation and continuous quality improvement. Alaska Native people have received national and international recognition for their work and have set high standards for performance excellence, community engagement, and overall impact on population health. In this article, the health care transformation led by Alaska Native people is described and the benefits and results of customer ownership and the relationship-based Nuka System of Care are discussed.”
Intermountain Healthcare is a not-for-profit health system based in Salt Lake City, Utah, with 22 hospitals, a broad range of clinics and services, about 1,400 employed primary care and secondary care physicians at more than 185 clinics in the Intermountain Medical Group, and health insurance plans from SelectHealth.
Started developing their mental health integration program in 2000 – which has since been spread to dozens of their primary care practices, including family & internal medicine, and pediatrics
How Intermountain Healthcare's mental health integration is improving care. Available at: Accessed August 26, 2018.
Reiss-Brennan B, Brunisholz KD, Dredge C, et al. Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost. JAMA. 2016;316(8):826–834. doi: /jama
Cherokee Health Systems is a Federally Qualified Health Center (FQHC) and a Community Mental Health Center, and is a national leader in integrating primary and behavioral/mental health care. It has a mature structure for an integrated practice team; is constantly striving to innovate to improve integrated service delivery; and, in response to demand from other systems, has developed training in primary care/behavioral health care integration.
New Models of Primary Care Workforce and Financing Case Example #7: Cherokee Health Systems. (Prepared by Abt Associates, in partnership with the MacColl Center for Health Care Innovation and Bailit Health Purchasing, Cambridge, MA, under Contract No I/ T.) AHRQ Publication No. 16(17) EF. Rockville, MD: Agency for Healthcare Research and Quality; October 2016.
Healthcare Transformation at Cherokee Health Systems: Blending Behavioral Health Providers into the Patient-Centered Medical Home. Presentation to National Council for Behavioral Health by Dennis S. Freeman, Available at: Accessed August 26, 2018.

35. Public Health Social Work: Current & Potential Roles In Advancing Care Integration
Why Public Health Social Workers are well-equipped to support care integration, what they are currently doing, and opportunities for future growth

36. Need for Public Health Social Work
Changing health care system: ACA innovation, rollbacks, cost containment
Worsening national health statistics: decreases in life expectancy and increased infant mortality
Rampant health inequities driven by social determinants: racism, sexism, economic inequality, lack of access, unraveling of ACA, attacks on immigrants.
Increased number of social workers in health: 50% but expected to increase to 70% in a decade
Demographic challenges: globalization, urbanization, aging, immigration
Growing emphasis on collaborative approaches: strong emphasis on inter-professional and cross- sectoral initiatives
Environmental issues: natural disasters, climate change, terror, and war
Diseases/disorders: pervasive chronic disease; emerging and persistent infectious diseases, mental disorders, trauma
New roles for social work: integration, care coordination, behavioral health, etc.
Social work broadly involved in health: but under increased pressure to demonstrate impact in competitive health system
From ‘Quick Overview of ALPS Grant and Public Health Social Work Model for Consultants’ background
Public Health Social Work (PHSW) History: One of the oldest forms of social work, it dates to the early 20th century when social workers and public health officers collaborated on infectious disease control, maternal and child health promotion, and the settlement house movement (Popple & Leighninger, 2011; Ruth, Sisco & Marshall, 2016). Moved by shared Progressive Era values of promoting human health and well-being, social work was viewed as a key component of public health, even at its inception. From its outset, public health-informed social work was distinguished from other forms of social work by its willingness to investigate social factors as causes of poor health. Early public health social workers combined epidemiologically-informed casework, community-level interventions, and vigorous policy advocacy to bring about the major societal level changes that improved overall health (Bracht, 1978; Rice, 1959; Ruth & Marshall, in press; Ruth, Sisco & Marshall, 2016). While social work’s role in public health has evolved over the course of a century, the fundamentals of public health social work remain.
Conceptualizing PHSW for a New Era: Key Characteristics and Features
Public health social work is characterized by the following features and elements:
A shared commitment to promoting individual and population health and well-being
Use of epidemiologically-informed approaches
Attention to the needs of vulnerable sub-populations and health injustice
A focus on addressing the social and macro determinants that shape health
An emphasis on prevention at all levels
Multi-level intervention—from individual to systems—to impact and improve people’s health
Reliance upon cross-sectoral, inter-professional, and transdisciplinary collaborations
Advocacy for systems, environmental, and structural change in the conditions that affect health

37. Relevant Assets of PHSW
Understand individual, family, and community health in micro and macro social contexts
Depth in both public health and social work
Expansive knowledge of social & health care services
Communication and facilitation skills
Interdisciplinary, collaborative practice
Attention to equity for vulnerable populations
Use of appreciative inquiry to bridge relational divides
Grasp of individual and organizational psychology
Recognize how social/power structures maintain status quo

38. Areas for PHSW Engagement
Roles for PHSW Activity
Direct interventions for individuals, groups, and families (e.g. behavioral health, case management, patient navigation, palliative/Hospice care)
Management of clinical practice(s) and/or program(s)
Health Education & Literacy
Deliver, design, manage earlier, preventive clinical interventions (e.g. Response to adverse childhood events; First Episode Psychosis)
Care Transformation Leadership
Program Evaluation
Community Asset Mapping & Health Needs Assessment
Shaping Social Work & Public Health Education
Health Services Research
Health Policy, Legislative Advocacy
Clinical Interventions
Direct interventions for individuals, groups, or families
Mental & behavioral health
Case management / Patient navigation to access vital health services
Darnell JS. Navigators and assisters: two case management roles for social workers in the affordable care act. Health Soc Work. 2013;38(2):123–126.
Palliative care / Hospice
Management of clinical practice(s) and/or program(s)
Prevention & Health Promotion
Influencing Systems within the Current Context
Addressing the Social Determinants of Health

39. Areas for PHSW Engagement
Direct Client Services
Clinical Practice & Program Management
Health Systems Improvement
Community Health Assessment
Research & Evaluation
Health Policy & Advocacy
Numbers 1-6 reflect gradual transition from higher to lower on the Social Work Health Impact Model pyramid

40. Direct Client Services
Integrated clinical practice in primary care, specialty mental health, hospitals, community-based teams:
Clinical social work (behavioral health)
Care coordination
Patient education & navigation
Supervise other providers practicing team-based care
Case Management
Assess, plan, implement, coordinate, and monitor options for services required to meet an individual’s health and human service needs.
Care Management
Particularly for “high-need, high-risk” individuals – the 5% of Americans who account for about 50% of all health care spending.
Resources/References
Erin P. Fraher, Erica Lynn Richman, Lisa de Saxe Zerden, Brianna Lombardi. (2018). Social Work Student and Practitioner Roles in Integrated Care Settings, American Journal of Preventive Medicine, 54(6, Supplement 3), S281-S289, ISSN ,
CASE Management: “A collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet the client’s health and human services needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes,” (Commission for Case Manager Certification, 2010).
CARE Management: Sometimes less appropriately called case management or utilization management. Helps achieve better health outcomes by anticipating and linking patients with the services they need more quickly. Care management also helps to avoid unnecessary testing and care by preventing medical problems from escalating. Case Management may be one tool in the toolbox of Care management, but there is also use of analytics tools for proactive earlier intervention, person- and family-centered care planning, coordination with informal caregivers and other professional service providers, and targeted support to facilitate care transitions.
High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? Commonwealth Fund: New York. Available at. Accessed August 26, 2018.
"Respondents all identified social workers as having a unique skill set that could be used in Medicaid reform, including expertise in the social determinants of health...trauma-informed care and caring for people with more complex care needs, with the potential to reduce Medicaid costs by preventing unnecessary emergency department visits or other health care encounters,” (Bachman et al., 2017, p.S251)

41. Practice and Program Management
Managing integrated care teams
Practice all clinical perspectives and blend with social work paradigms (person-centeredness, social contexts)
Implementing models of integrated care
Translation of evidence-based models into practice
Change Implementation & Management
Stakeholder/Faction Engagement
‘Psychology’ of Managing Human Systems (W.E. Deming)
Force Field Analysis
Psychology of Managing Human Systems, from W. Edward Deming’s “System of Profound Knowledge”:
System of Profound Knowledge intro:
Psychology of Human Systems intro:
Force Field Analysis (source A technique that helps to identify and assess significant factors that may promote or inhibit change in an organization or community. Five steps are involved in conducting a force field analysis:
Clearly specify the desired objective.
Identify the people that will determine if the objective will be achieved.
Assess the strengths of each driving and restraining force
Identify the actors that might attempt to influence the outcome.
Select a strategy for change.

42. Health Systems Improvement
Partnership between Health Care & Social Services
Develop integrated networks of health & social services
Address social determinants of health
Care Transformation Leadership
Human Factors – Deming’s ‘Psychology’
Training & coaching teams on care integration
Strategic planning for population health

43. Research and Evaluation
Conduct the research that will prove social work’s value!
Participate in Translational Research and Implementation Science
Foster collaboration between integrated care programs & providers and Public Health Social Work researchers
Publish and present about experiences of health care integration and transformation from PHSW perspective
Translational Research
Implementation Science
Foster collaboration between integrated care programs & providers and Public Health Social Work researchers
Publish and present about experiences of health care integration and transformation from PHSW perspective

44. Health Policy and Advocacy
We need to change this: “Social workers have been relatively absent from guiding state and federal health policy,” (Bachman et al., 2017).
Use APHA and NASW National & State Organizations
Advocate for issues important to helping Social Workers practice in more integrated clinical and managerial models
Engage other health professionals to promote social work as vital contributor to improving US health care
Advocate (or work) to develop policies that will address communities’ social determinants of health
Social Determinants of Health: Social Workers have absolutely been speaking this language and leading great advocacy for decades to help us get to a point where SDOH is a mainstream term, and developing strategies for address them
"Although Medicaid policymakers can articulate the value of social work in addressing social determinants of health, there is little evidence of social work involvement in Medicaid system reform initiatives. As state reform efforts increasingly target payment and delivery system change across health and social services and Medicaid, there is a role for social workers to engage in these innovations. Social work’s understanding of social and welfare supports, social justice orientation, community organizing, and cultural responsiveness, among other things, can help Medicaid promote access, integration, high-quality affordable care, and prevention. Social workers are thus primed to take a leadership role in Medicaid reform” (Bachman et al., 2017, p.S254)
Social Work’s Role in Medicaid Reform: A Qualitative Study (2017, AJPH, Bachman et al.)

45. Exercises: Integrated Care Opportunities
Having reviewed these suggestions for various ways social workers can play important roles in transforming health care to become more integrated, let’s break into small groups (3- 5) and give everyone time to discuss:
What other ideas do you have that were not adequately covered to help foster health system integration?
What type of health work might appeal most to your personally? Why do you think that may be?
Are there other means of engagement in the health system that you would like to learn more about?
Social Determinants of Health: Social Workers have absolutely been speaking this language and leading great advocacy for decades to help us get to a point where SDOH is a mainstream term, and developing strategies for address them
"Although Medicaid policymakers can articulate the value of social work in addressing social determinants of health, there is little evidence of social work involvement in Medicaid system reform initiatives. As state reform efforts increasingly target payment and delivery system change across health and social services and Medicaid, there is a role for social workers to engage in these innovations. Social work’s understanding of social and welfare supports, social justice orientation, community organizing, and cultural responsiveness, among other things, can help Medicaid promote access, integration, high-quality affordable care, and prevention. Social workers are thus primed to take a leadership role in Medicaid reform” (Bachman et al., 2017, p.S254)
Social Work’s Role in Medicaid Reform: A Qualitative Study (2017, AJPH, Bachman et al.)

46. Summary and Conclusion
We are DIS-integrated! Professional health services in US evolved into a disintegrated system, driven largely by theory of mind-body separation and medicine’s consolidated power.
But, there are opportunities due to shifts: Shifts in contemporary concepts of human health (toward more holistic, integrative theories) and in US health policy have created great opportunities for SW and medical providers to work together in integrated care models.
Know important concepts: Concepts of population health, accountable care, value-based payment, and social determinants of health capture the essence of US health care reform today – opening new avenues for Public Health Social Work (PHSW) to play valuable roles.
Integrated Care: can refer to more than the literal integration of health care services – also accepting broader concepts of what drives health and working to address individuals’ needs beyond what any one person alone can accomplish. Think broadly!
PHSW is powerful approach: PHSW training is particularly valuable for providing, managing, evaluating, and improving the complex delivery of integrated care in various practice settings.
Social workers – whether PHSW or not – are vital to someday realizing a more effective, dynamic, financially solvent US health care system, and can play roles at any or all levels of the Social Work Health Impact Model.

47. About the Author
Sandy (Cohen) Colts, MSW, MPH, has worked in academic, non-profit, government, and health care settings, specializing in behavioral health care, health services research, quality improvement, program design, management, & evaluation, and health care transformation. After completing the MSW/MPH program in Social Work (clinical practice) and Public Health (health policy & management) at Boston University, Sandy spent several years working with the Institute for Healthcare Improvement (IHI), where he developed new program evaluation systems for organizational learning, and contributed to Commonwealth Fund research of high-performing health care systems across the US. Sandy is currently Program Manager for Behavioral Health Care Transformation at Cambridge Health Alliance, leading efforts to improve clinical practice and operations to achieve the Triple Aim and reduce health inequities among adults with serious mental illness.

48. Acknowledgements
The Advancing Leadership in Public Health Social Work Education project at Boston University School of Social Work (BUSSW-ALPS), was made possible by a cooperative agreement from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number G05HP We wish to acknowledge our project officer, Miryam Gerdine, MPH. Thanks also to Sara S. Bachman, BUSSW Center for Innovation in Social Work and Health, and the Group for Public Health Social Work Initiatives
The ALPS Team:
Betty J. Ruth, Principal Investigator
Madi Wachman, Co-Principal Investigator
Alexis Marbach Co-Principal Investigator
Nandini Choudhury, Research Assistant
Jamie Wyatt Marshall, Principal Consultant