Reprinted from the "System Navigation" issue of Visions Journal, 2014, 10 (1), pp. 31-33
Mental health and substance use problems are often intertwined with each other and with general health problems. Quality care in such circumstances requires mental health, substance use and general health care providers to collaborate or work together effectively. It may also involve professionals from education, child welfare and other human service systems.
Typically, however, all these care providers are trained to recognize and respond to only one part of a person’s needs. For example, the doctor who prescribes methadone for a patient may have very little awareness of the substance use or mental health counselling the client is accessing (or could be accessing) at separate programs in the community.
These different programs are usually found within parallel systems that each focus on a different area of need. These systems also compete with each other for funding and other resources. Not surprisingly, the result is fragmented services that do not promote the well-being of the people they serve.
This has led to numerous calls for integrated care, particularly for people with dual mental health and substance use problems. But what do we mean by integration?
Discussions of integration are often confused by a lack of clear language and concepts. The Substance Abuse and Mental Health Services Administration in the United States has identified three levels of integration: 1
Integrated treatment involves communication and interaction between service providers to ensure that the multiple strands of a person’s needs can be addressed. This may be as simple as enhanced referral that involves appropriate information sharing and follow-up.
Integrated programs involve the use of teams of different kinds of health professionals or effective links between programs to ensure a person’s diverse needs are addressed when the person accesses service for any particular need.
Integrated systems involve an organizational structure that supports an array of programs addressing different needs but linked through common system support functions (e.g., needs assessment, strategic planning, information management, funding and other management functions).1
Integration at any of these levels can exist to varying degrees and may involve various combinations of these levels. Integration at one level does not ensure integration at another level. A lack of integration at the systems level can slow or block integration at the program or treatment level.
So, what actions and supports would help reduce fragmentation and make the system easier to navigate for people seeking care? Unfortunately, there are no easy solutions. The evidence around system-level integration is limited2 and does not point to a specific approach for integrating systems to enhance collaboration. Nevertheless, there is general acknowledgement that systems do matter when implementing new approaches and innovations.3
Toward more integrated systems
Research suggests the following areas are important to focus on when seeking to increase system integration and support collaboration.
A comprehensive, person-centred approach
Basically, the goal of system integration is to ensure a person receives care that addresses multiple needs in a coordinated and efficient way.
A person-centred philosophy with a focus on needs, engagement and participation4 is a characteristic of effective system integration. Understanding the experiences of people who need to access services is central to creating system change.
Therefore, the involvement of consumers and their families in managing their health, and in the design and evaluation of programs and services, is critical. An example of consumer involvement is Patients as Partners (www.patientsaspartners.ca), a collaboration between the BC Ministry of Health, health care providers and consumers. This collaboration aims to include a “patient voice” in improving BC’s health care system.
While a person-centred approach is central to achieving integration, it doesn’t mean that actions should focus only on the individual. The unique circumstances of each individual are influenced by many factors related to physical, social and political environments. Recognizing that there are many contributing factors opens up a wealth of potential strategies for maximizing the health of individuals, communities and populations.
A key element of systems integration is providing comprehensive services.4 This means facilitating co-operation among health and social care organizations, having multiple points of access, and emphasizing wellness, health promotion and primary care.
So, an integrated system designed to promote the health and well-being of individuals will need to take a comprehensive approach. That is, it will be structured to support health care interventions at multiple levels (e.g., individual, institutional setting, community). For example, an intervention to reduce alcohol-related harms might involve providing self-management tools to help individuals explore making positive changes to their behaviour. They might also provide hospital-based screening and brief intervention for at-risk drinking, and a community-wide “responsible beverage service” strategy.
Integrated primary care
Strong and integrated primary care is a consistent feature of effective health care systems.5,6,7 In BC, the Primary Health Care Charter sets the direction of primary health care in the province. The charter describes primary care as providing “first contact access for each new need, long-term comprehensive care that is patient-centred, and coordination when care must be sought elsewhere.”8
A framework developed by the Quality Improvement and Innovation partnership in Ontario (now part of Health Quality Ontario; www.hqontario.ca) provides a way to picture primary care and guide change.5 The desired outcomes are healthier populations, an improved client and care team experience, and more efficient use of resources.
The framework puts those served by primary care (clients, their families and the communities in which they live) at the centre; they are the core focus. Surrounding these consumers of primary care are the key elements of effective primary care:
a focus on the population as a whole rather than just those who seek care
partnerships with other health and community services
commitment to quality improvement and innovation
performance measurement to assess whether changes and improvements achieve their goals
Together these elements contribute to the overall quality of care delivered.
Evolving an integrated system
Elements of a system can either promote or impair integration and collaboration. Characteristics of effective system integration include:4
Funding models that ensure equitable funding for different services or levels of service (e.g., acute care, mental health, home care, social care, etc.) and do not create barriers to collaborative practice
Means of promoting teamwork between professional groups to build collaborative relationships and inter-organizational understanding
A governing body with diverse representation from all stakeholder groups that understand how to deliver services along a continuum based on the health needs and goals of individuals and populations (e.g., the needs of a person with mild depression differ from those of a person living with severe depression and HIV)
Well-designed systems for the exchange of information among services and service providers
There isn’t a one-size-fits-all approach for system integration. The considerations listed above, however, show promise in helping us change the way we think about and deliver traditionally isolated mental health and substance use services and supports. These considerations provide guidance for all those involved in the planning and design of service delivery systems, whether they are planners, funders, administrators and front-line staff, as well as consumers and their families.
About the author
Dan is Assistant Director (Knowledge Exchange) with the Centre for Addictions Research of BC. He leads a team that communicates current evidence about substance use in a way that supports the evolution of effective policy and practice
Bette is a Research Associate with the Centre for Addictions Research of BC and a member of the knowledge exchange team
- Substance Abuse and Mental Health Services Administration. (2002). Report to Congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders. Washington, DC: Department of Health and Human Services. www.samhsa.gov/reports/congress2002.
- Butler, M., Kane, R.L., McAlpine, D. et al. (2008). Integration of mental health/substance abuse and primary care. Rockville, MD: Agency for Healthcare Research and Quality. www.ahrq.gov/clinic/tp/mhsapctp.htm.
- Schmidt, L.A., Rieckmann, T., Abraham, A. et al. (2012). Advancing Recovery: Implementing evidence-based treatment for substance use disorders at the systems level. Journal of Studies on Alcohol and Drugs, 73(3), 413-422.
- Suter, E., Oelke, N.D., Adair, C.E. et al. (2009). Ten key principles for successful health systems integration. Healthcare Quarterly, 13(Oct), 16-23.
- Kates, N., Hutchison, B., O’Brien, P. et al. (2012). Framework for advancing improvement in primary care. Healthcare Papers, 12(2), 8-21.
- DeGruy, F.V. & Etz, R.S. (2010). Attending to the whole person in the patient-centered medical home: The case for incorporating mental health care, substance abuse care, and health behavior change. Families, Systems & Health, 28(4), 298-307.
- Dickinson, W.P. & Miller, B.F. (2010). Comprehensiveness and continuity of care and the inseparability of mental and behavioral health from the patient-centered medical home. Families, Systems & Health, 28(4), 348-355.
- BC Ministry of Health. (2007). Primary Health Care Charter: A collaborative approach. (2007). www.health.gov.bc.ca/library/publications/year/2007/phc_charter.pdf.