For most of the 20th Century there has been a conceptual as well as a practical division between those professionals that help people with physical/medical problems and those that help people with mental/behavioral problems. In this dualism, traceable philosophically to Descartes, individuals with clear physical problems like abrokenbone go to a medical doctor such as their family practitioner or orthopedic surgeon, and individuals with depression or marital problems go to a mental health professional such as a psychologist or social worker.
This would be a felicitous state of affairs if all medical problems were solely due to physical causes and all medical problems were solely treated by physical therapies. It would also be a happy state of affairs if all mental problems were caused by nonphysiological, psychosocial causes and entirely treated by nonphysiological `talk` psychotherapy. However, this is not the case. Broken bones are caused by behavioral problems (e.g., marital abuse, alcoholism, poor diet). Medical problems are treated by behavioral changes (diet, exercise, and other lifestyle changes). And most medical treatments require and can be defeated by behavioral compliance problems with the prescribed regimen (pill taking, showing up for the scheduled procedure, etc.). Moreover, mental health problems can be caused and treated byphysiological factors (neuron-chemical imbalances, endocrine problems, and psychotropic drugs). Thus, fragmenting the treatment of the mental and physical problems to two distinct realms makes little conceptual or practical sense.
This is further compounded by the fact that mental health has traditionally been surroundedbyproblems of stigma. Amental health diagnosis seems like the `booby prize` to many patients and thus is to be avoided. This attitude can cause avoidance and therefore poor penetration rates and continued health problems. A seamless integrated team dealing with the whole patient can avoid much of this stigma and therefore result in more appropriate and complete treatment.
The book describes the promise of integrating behavioral and medical care in the primary care setting-a move that recently has been gaining momentum. It also describes the many complexproblems associated with this movement. At times there is a focus on a particular problem; at other times these problems are only briefly mentioned. Below, we will describe some of these major problems as these set an important research and practical problem solving agenda. We do this very much in the spirit of Gertrude Stein's deathbed words. When she was asked what is the answer? she responded by saying, `Damn the answer; What is the question?`
Major Problems and Questions
What kind of skill sets in what kind of team produces what kinds of effects in what kinds of patients with what kinds of problems?
How does one define the target problems-by DSM diagnosis? By treatment focus (e.g., treatment adherence, stress management), by both etc.?
What interventions produce more appropriate future medical usage? Is this more appropriate medical usage less so that the increased costs of the behavioral interventions are offset and even leveraged?
How does one obtain `buy in` for integrated care from all the relevant stakeholders?
How should the professionals be trained to work together and to have the requisite clinical and managerial skills?
What sort of clinical and operational protocols should be developed and used? To what extent, for example, are practice guidelines useful?
How is care to be coordinated? What is the role of case management and how is this do be done well?
How are stepped care models developed and to what extent are these useful?
To what extent are interventions community based v. clinic based?
To what extent is a public health/population management perspective useful?
What is the government's role? To what extent should it provide regulation or payment?
What should the ideal health benefit look like?
What are the issues surrounding different kinds of delivery systems such as staff models, networks models, fee for service models v. capitated models?
What do mental health parity laws mean in an integrated care environment?
How does this system ideally inter face with an Employee Assistance Program?
What are the roles of processes such as utilization review, pre-certification, and credentialing?
What is the role of integrated care in specialty medical practice such as oncology?
What are the implications of integrated care for the carve in or carve out contract?
What sort of accountability and quality assurance process should occur?
What is the role of the various guild organizations such as the American Psychological Association or the American Medical Association?
What are the implications for solo practice and hospitals?
How does the issue of the art v. science of practice impact on this movement?
What sort of management information system is ideal?
What are the implications for long-term psychotherapy and proponents of the diverse `schools` of psychotherapy?
What sort of outcome research and program evaluation projects are priorities and how can these be done in relatively cost-effective and unobtrusive ways?
How does one develop and implement sound financial models for integrated care so that these systems are seen as good business practices?
How does one appropriately screen, assess, and triage in an integrated practice? What assessment devices need to be developed and what are the psychometric properties of existing strategies?
To what extent does an integrated care model improve penetration rates?
To what extent does it decrease stigma?
To what extent should treatment be individual therapy and to what extent should it be conducted in groups?
To what extent do these professionals need to have management, business, and entrepreneurial skills?
To what extent should tele-medicine and web-based technologies be involved?
What are the roles of different disciplines in this effort (e.g., thenutritionist)?
To what extent can the cost-savings of integrated care reverse the very controversial problems of the cost-containment strategies used by some existing managed care companies in denying services?
What is the appropriate relationship between psychotro-pic drugs vs. psychotherapy?
To what extent can integrated care help resolve the serious and perineal issue of treatment compliance?
How can psychotherapy be adapted to the 'world of primary care' in which interventions are generally much more brief, focused, and `on the fly`?
What will be the attitude of employers-one of the largest payers for medicalservices-regardingintegrated care? Can one show higher employee functioning and lower absenteeism, for example?
How should special populations defined in various ways (e.g., geriatrics or African-Americans) be addressed?
How can integrate care teams more effectively rule out psychological problems so that actual medical problems can be more effectively identified and treated?
What are the best marketing strategies for this type of delivery system?
How is this approach to resolve issues of research dissemination and knowledge utilization?
Is health care, including integrated care, a commodity or are there substantive and particularly quality distinctions?
What is the role of outside accrediting agencies such as NCQA?
What is the relevant actuarial knowledge that needs to be obtained, and how is this best gathered?
What is the role of bench marking and report cards?
How are `housekeeping tasks` such as claims processing best accomplished?
What are the best grievance procedures?
How does one decrease unwanted treatment variability?
How are providers justly compensated and how are they properly incentived? What are the advantages of equity models? How is the problem of decreased provider income to be addressed?
What is the role of the masters-level psychotherapist v. doctoral level professional?
What changes in the formal training of professionals are called for?
How does one monitor adherence and competence to protocols? What are the best supervision, case conferencing, and continuing education programs?
Should there be specialty certification or degrees relevant to integrated care?
What is the role of alternative medicine in integrated care?
What are the role of prevention and wellness programs and other programs targeting generally lifestyle issues?
How does one structure the physical setting so co-location is optimized?
How does one handle the handof f or the consult between a PCP and a behavioral health specialist?
How does one handle emergencies?
How is record keeping handled?
What is the role of natural helpers in the patient's environment such as ministers and friends?
How does one educate and manage office staff?
How does one enhance provider satisfaction?
How is the problem of relapse addressed?
How does one handle patient choice and patient rights?
What disease management programs are critical and what are the specifics of these?
These are some of the major conceptual and practical problems surrounding health care in general but also involved in integrated care. These are often both fascinating intellectually and nettlesome practically. However, these mustbe addressed in order to painfully produce more optimal healthcare. We think the chapters in this book represent steps in this direction.
Finally, we note that this structure of this book is a bit unusual. We have main chapters followed by commentaries. These commentaries are meant to address some of the most important issues in the chapters as well as to reflect on some of the more controversial issues contained in the chapters. We hope that this format allows the reader to see the important dialogue around all these important issues.