Public Health Social Work Advancing Integrated Health Care

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

Presentation Outline 1. Social Work Mission & Health Impact Model 2. Shifting American Concepts of ‘Health’ 3. Evolution of US Health Service Delivery 4. Health Care’s “Quality Chasm” 5. Vision for Care Integration 6. Emerging Trends in US Health Care Delivery 7. Public Health Social Work: Key Roles to Play in Care Integration

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

Social Work is a Health Profession! Where social workers currently practice: • As of 2016, estimated there 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)

Social Work Health Impact Model Wachman & Schultz, 2014) (Ruth,

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

17 th 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” EXERCISE: What continued impacts of mind/body dualism have you experienced or observed in your social work practice/training?

Late-18 th to Mid-19 th Centuries: Preventive Public Health & Sanitation • 1790 s: 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

Late-19 th to Mid-20 th Centuries: Germ Theory & Vaccination • 1877: ‘Germ Theory’ of disease proposed by Louis Pasteur • 1879 -1900: Building on smallpox vaccine breakthroughs, rapid increase in discovery and development of vaccines • 1900 -1950 s: Widespread adoption of verified immunizations and intensive development and testing of new vaccines

US life expectancy increased from 49. 3 in 1901 to 68. 21 in 1950 – largely due to greater immunization reducing rates of infectious disease

Late 20 th 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.

Evolution of US Health Service Delivery

Brief Evolution of US Health Care Services Late 19 th / Early 20 th centuries: Hospitals as centers for indigent people 1930 s – mid 1940 s: Private v. Public Health Insurance Late 1940 s – mid 1960 s: Insurance coverage grows; Scientific advances; Growing health inequities Late 1960 s: Passage of Medicare, Medicaid 1970 s – 1980 s: Rapid expansion of Health Maintenance Organizations (HMOs) and power of health insurers

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, governmentled 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?

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.

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”?

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: 1962 -63

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 Lack of timely access to high quality care Lack of coordinated care Fragmented planning and delivery of care Greater mortality risk and disease prevalence Disproportionate disease burden and exposure to key risk factors • ~20 -25 year mortality gap among people living with serious mental illness. 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

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

Emerging Trends in US Health Care Policy & Care Delivery

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

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: 1. Improve health of populations 2. Reduce per capita spending on health care 3. 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 EXERCISE: Consider how colocating and/or integrating health care services may achieve the ‘Triple Aim’

Patient-Centered Medical Homes Patient-Centered Medical Home: Joint Principles (first released 2007) 1. 2. 3. 4. 5. 6. 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

Accountable Care Organizations (ACOs) 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. Implications of 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.

Social Determinants of 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 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?

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

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

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?

Features of Care Integration

“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 2009. The National Council for Behavioral Health Care.

Care Integration by Setting Primary Care Integration Co-location, coordination, or full integration of behavioral health Approach services within a primary care practice. Target Population Behavioral Health “Reverse integration” of primary care (usually a nurse) and health promotion into specialty BH clinics. Larger, broader population with More narrow cohorts with more prevalent BH conditions (e. g. serious mental illness (e. g. depression, anxiety, PTSD) bipolar, schizophrenia, personality disorders) Interest and research investment in this area lagged more than a decade behind integrated Collaborative Care trials (see Druss et al. pilots in VA Evidence Cochrane Review) Evaluation of SAMHSA Primary & primary care Base IMPACT trials (AIMS Center, Univ Behavioral Health Care of Washington) Integration grant program, 2009(PBHCI), 2009 -2015 2013

“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.

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)

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

Need for Public Health Social Work 1. Changing health care system: ACA innovation, rollbacks, cost containment 2. Worsening national health statistics: decreases in life expectancy and increased infant mortality 3. Rampant health inequities driven by social determinants: racism, sexism, economic inequality, lack of access, unraveling of ACA, attacks on immigrants. 4. Increased number of social workers in health: 50% but expected to increase to 70% in a decade 5. Demographic challenges: globalization, urbanization, aging, immigration 6. Growing emphasis on collaborative approaches: strong emphasis on inter-professional and crosssectoral initiatives 7. Environmental issues: natural disasters, climate change, terror, and war 8. Diseases/disorders: pervasive chronic disease; emerging and persistent infectious diseases, mental disorders, trauma 9. New roles for social work: integration, care coordination, behavioral health, etc. 10. Social work broadly involved in health: but under increased pressure to demonstrate impact in competitive health system

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

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

Areas for PHSW Engagement 1) Direct Client Services 2) Clinical Practice & Program Management 3) Health Systems Improvement 4) Community Health Assessment 5) Research & Evaluation 6) Health Policy & Advocacy

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.

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

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

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

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

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 (35) and give everyone time to discuss: 1. What other ideas do you have that were not adequately covered to help foster health system integration? 2. What type of health work might appeal most to your personally? Why do you think that may be? 3. Are there other means of engagement in the health system that you would like to learn more about?

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.

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.

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 G 05 HP 31425. 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 bjruth@bu. edu • Madi Wachman, Co-Principal Investigator madi@bu. edu • Alexis Marbach Co-Principal Investigator alexis_marbach@abtassoc. com • Nandini Choudhury, Research Assistant nschoud@bu. edu • Jamie Wyatt Marshall, Principal Consultant jamiewyatt 1@gmail. com