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Question: What would be your vision of the ideal integrated health care facility (mental and physical health) of the future?

This month's question is very timely. The integration of "mental" health and "physical" health has been written about and studied extensively. Recently, MichiganGovernor Snyder proposed directing funding for the public mental health system through the Medicaid Health Plans, arguing that this was the best way to integrate care.

This is an important topic because unfortunately, people with serious mental illness die, on average, 20-25 years earlier than the general population. There are many reasons for this, but the cause is usually untreated, preventable illness. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), barriers to primary care, coupled with challenges in navigating complex healthcare systems, have been a major obstacle to care. Yet, primary care is often the referral point to specialty behavioral health services.

So the solution is "integrated" care. Integrated means that both sides of the healthcare spectrum are well coordinated. One model of integration has primary care settings within behavioral health clinics. This model argues that all persons with behavioral health needs also need general medical care. This model is efficient and has been proven effective. However, it doesn't make behavioral health accessible to most people who are receive primary care services.

The flip-side of this model, where behavioral health specialists are put in primary care settings, has also been shown to be effective. The benefit of this model is that it accounts for stigma. Many people are reluctant to go to a mental health clinic because they don't want others to know they are suffering from a mental illness. So, if the specialist is available within their primary care clinic, they are more likely to follow up. The problem with this model is that traditionally this specialist is a social worker who, while very helpful, doesn't offer the full range of services that community mental health has available to it.

Since I'm being given the freedom to outline my ideal integration setting, I'm going to dream big here. What I would love to see is a movement toward community health and wellness centers. These centers would not revolve solely on a disease model, meaning that the focus is primarily on "fixing" illness. Instead there would be places that also focused on wellness and prevention. These centers would deliver quality care to the uninsured, those with Medicaid and Medicare, and those with private insurance. This way, no matter how one's circumstances changed over time, the care would still be in a familiar place with familiar people.

These centers would be located in the community, where people live so that transportation would not be an issue, rather than in big, complicated, hospital-based medical centers "downtown." People typically see hospitals as places for "sick" folks. Community centers are places for socialization, education and recreation.

In these community centers, all primary care needs could be met. For persons with severe and persistent mental illness, the current community mental health clinics are a primary care setting. Our settings are fairly holistic, offering assistance with obtaining benefits; food and housing; education and employment in addition to the clinical services. We also offer opportunities for socialization, and learning life skills to maximize independence. This is something missing from typical primary care settings that we have to offer.

Primary care settings are open to all, including those without current signs and symptoms of illness. There are recommendations for screening to identify risks, and make lifestyle changes before illness sets in. Often there are alternatives to medication, including physical activity, nutrition counseling, and "alternative" treatments that may be missing from typical mental health clinics.

The final benefit that I see to these sorts of community clinics is that the staff would interact and learn from each other. For example, symptoms that look like depression may be due to Lyme disease, vitamin D deficiency, or low thyroid hormone levels. Perhaps that person is going through a divorce, or has lost a job and can't afford their medications. Collaborations between the family medicine doctor, psychiatrist, nutritionist, case manager and therapist would help to address all of the person's needs.

I hope this ideal is not just a pipedream, but becomes a reality one day soon!