This article is part of State of Health, a series examining integrated care and its potential to improve Michiganders' health. It is made possible with funding from the Michigan Health Endowment Fund.

When Megan Sova was three years old, she began accompanying her father, Dr. David Sova, on his morning weekend rounds in Grand Rapids’ hospitals. Through the years, she developed a love for the practice of medicine — and a great dislike for blood. While studying for her masters’ degree at Western Michigan University, she wrote a paper on the benefits of integrating behavioral health into primary care practices.

And when she graduated three years ago, she opened up a counseling practice in offices adjoining her father’s primary care clinic.

Another counselor, Shawna Bennett, has since joined her. David Sova says the arrangement has "been very beneficial" for his medical patients, especially those with chronic pain.

David Sova.

“When I’m in talking to a patient and they spill their guts (and) tell me they’re going through a divorce (or) a death in the family or got fired, I can usually ask Megan or Shawna to talk with them for 10 or 15 minutes, a simple visit," he says. "Then they come back. They feel more relaxed. It’s nice that I have somebody here when I do have a crisis. For me to refer (patients) to someone outside my office could take weeks. Here, we can basically guarantee that they’re seen the same day, next day, or same week.”

Many Michigan providers are coming to the same conclusions as the Sovas. Primary and behavioral health often feel like different worlds, and it can be difficult for some patients to cross from one to the other. Accordingly, the idea of combining the two disciplines has become one of the most commonly discussed approaches to the increasingly popular concept of integrated care.

Why integration?

The Michigan Department of Health and Human Services’ (MDHHS) plans for integrating behavioral and physical health are already underway. Beginning in October 2019, pilot sites in Muskegon, Saginaw, Genesee, Lake, Mason, and Oceana counties will implement changes that include data-sharing, new care management workflows, and improved reporting so that medical providers within managed care plans are aware of their patients’ behavioral health issues.

“We realize that our system can and must do a better job of meeting our residents’ holistic needs, and that we must have a health care system that unifies the provision of behavioral and physical health care,” says Lynn Sutfin, public information officer for MDHHS. “We want to ensure that all parts of someone’s care team work together and communicate, that all of their health needs are being met, and that they have the supports they need to live in their communities.”

The state hopes that improving coordination of behavioral and physical health will make more care available for individuals with mental illness, intellectual or developmental disabilities, or substance use disorders while improving access to community-based services and supports. Other goals include better customer health and satisfaction, improved provider network stability, and financial efficiencies.

“Evidence supports that well-integrated care produces better outcomes and is more efficient,” Sutfin says.

Kevin Fischer, executive director of the National Alliance on Mental Illness – Michigan (NAMI), concurs.

Kevin Fischer."It would be a great benefit for people living with a mental health diagnosis if everyone treating them had a total picture," he says. "... I think if we integrate care properly, we can (also) go a long way to reducing the stigma associated with receiving mental health care."

Although the 2000 federal Mental Health Parity and Addiction Equity Act (MHPAEA) was supposed to prevent insurers from imposing less favorable benefit limitations on mental health coverage than on physical health coverage, Fischer says states are not enforcing it. Integrating behavioral health into primary care settings is an alternative for making that parity a reality — especially among Michigan’s African-American, Latinx, and Arab-American residents and other underserved populations.

“While stigma affects all, data supports that African-Americans in particular experience disparity with regard to properly diagnosing mental health issues and having care available to them,” Fischer says. “Stigma affects everybody, but it varies by culture."

When mental health is treated separately from physical health, providers miss the connections between mind and body and cannot prescribe a care plan that works best for the patient.

“Integrating services normalizes mental health services. One of the excuses men have for avoiding mental health services is, ‘I can’t be seen coming out of a psychiatrist’s office.’ Integrating services helps that,” Fischer says. “I don’t have to go through a special door to get that care if my primary care is provided under the same roof.”

Integration in practice

Michelle Duprey.Michelle Duprey is director of Integrated Health Care at Starfish Family Services, which offers behavioral health services in Livonia, Dearborn, and Westland, and in Inkster within Western Wayne Family Health Centers. Duprey’s role includes working with other area primary care, pediatric, and OB/GYN practices to integrate behavioral health into their existing services. She is the director of the University of Michigan's (U-M) Online Certificate in Integrated Behavioral Health and Primary Care.

“What’s the basic way we address cancer? The accepted approach is that early detection leads to better outcomes,” Duprey says. “Why is mental health any different? Why are we siloing mental health, breaking it off, and not serving it in the same kinds of ways?”

The U-M program helps social workers, nurses, and other providers to integrate physical and behavioral health services so that patients receive a continuum of preventive, curative, and palliative care services.

“A lot more health and hospital systems, private practices, and group practices are hearing about integrated health. They are just not quite sure where to start. This program is a great way to jump in, see what it looks like, and prepare staff to do the work,” Duprey says. “We’re getting quite a few participants who aren’t just behavioral health folks. We have people doing nursing, physicians, administrators who want to do integrated health but don’t know where to start.”

Dr. Randolph Rasch, dean of the Michigan State University College of Nursing, is an active proponent of integrated health. He delivered the opening remarks at the 2016 Michigan Health Policy Forum, “Integrating Behavioral Health and Physical Health – Structuring a Delivery System to Meet Michigan’s Needs.” He believes integrating behavioral and physical aspects of health care are at the very core of the nursing profession.
 

Randolph Rasch.“Nursing care is about integrated care, the whole person,” Rasch says. “... When we care for individuals and families comprehensively, we improve communities."

Rasch notes that when people's behavioral health needs aren't well met, they may commit crimes, abuse substances, or lose their homes, jobs, and families. At that point, he says, "they aren’t able to contribute to their own families and it becomes a problem that affects the community."

“When an individual and a family experience certain things, it affects all of us,” Rasch says. “Integrated health really is about understanding that when we speak of health issues, diabetes, heart disease, any of that, it’s not just a physical illness. However we feel physically, our minds and emotions are involved as well. All human beings have behavioral health.”

A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is development news editor for Rapid Growth Media, communications manager for Our Kitchen Table, and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at Estelle.Slootmaker@gmail.com or www.constellations.biz.

David and Megan Sova photos by Adam Bird. All other photos courtesy of the subjects.