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.

Decades of delegating patients to different health providers for different conditions has fragmented health care into pieces that don't add up to whole health. As this siloed approach impedes communication among providers, patients, especially the poor and the marginalized, are left with less than optimal — and sometimes downright deadly — outcomes.

However, the newer model of integrated health is creating positive outcomes for Michigan's providers and the communities they serve. Integrated health promotes a more holistic approach to care through colocation of traditionally siloed services and other innovations, but providers say our society is just beginning a larger shift in mental models that's necessary to realize the full benefits of integration.

The Michigan Public Health Institute (MPHI) Center for Health Equity Practice (CHEP) embraces integrated health modalities as a means of tackling poverty, inequality, and the social systems contributing to their persistence. Julie A. Moore, Ph.D., CHEP senior research scientist, believes integrating health care and social services not only improves health outcomes for those impacted by social determinants of health, but also provides a basis for creating systems change upstream.

Julie Moore.

"A lot of our work ... is trying to recognize and give voice to the fact that disparities in health are often things that have deep roots in communities. Social determinants of health play into that," Moore says. "Broader structural issues that our country and communities face — racism, classism, and sexism — lead to poorer health outcomes for whole groups of people."

CHEP seeks to address the root causes of those social determinants.

"Having integrated health care programs that acknowledge the need for things like legal aid and housing assistance are really important. … Those all weigh into health outcomes," Moore says. "When you start moving upstream and think of the broader social impacts and how all of this operates, you realize that addressing some of these big issues … should improve health across a whole broad spectrum of outcomes."

For example, as Michigan providers recognize that racism is a major contributor to high maternal and infant mortality rates among African-American and indigenous residents, many are now taking steps to address it.

Research scientist Jennifer Torres, Ph.D., works with the MPHI Center for Healthy Communities' Achieving Birth Equity through Systems Transformation (ABEST) Project, which embraces an integrated health approach.

Jennifer Torres.

"The main goal of the ABEST project is to change the way we think about and talk about maternal [and] infant health, recognizing the systems and structures causing inequities," Torres says. "There has been more coverage and discussion of the impact of racism on birth outcomes for women of color. That's a huge first step, recognizing the root cause is racism."

Torres cites another CDC-funded CHEP project that changes the narrative by recognizing that the opioid epidemic is less about individual choice or personal failing — and more about previous upstream factors that create tendencies towards later substance abuse. Shifting the narrative can inspire big-picture changes that hopefully will address those root causes, reduce substance abuse, and inform more successful treatment.

"Funders seem to have more of an appreciation for this type of work, work that has a longer view," Moore says. "[It's] recognizing that these are, of course, intergenerational problems that are not fixed with one intervention."

Another big step is training nurses, physicians, psychologists, and psychiatrists to practice integrated care. Michigan's institutions of higher learning lead the nation with programs like the University of Michigan's Online Certificate in Integrated Behavioral Health and Primary Care program and the Michigan Medicine/Eastern Michigan University (EMU) Integrated Pediatric Behavioral Health Training Collaborative.

"Integrated health is a cost-savings method of health care delivery. It is always a very hard argument to make for insurance companies and hospital systems that you have to invest now to save money later," says Alexandros Maragakis, Ph.D., co-founder of the Integrated Pediatric Behavioral Health Training Collaborative. "Unfortunately, I haven't seen tons of movement in regard to making this happen."

Alex Maragakis.

Maragakis says funders like the Michigan Health Endowment Fund, which funded the Collaborative, play a "pivotal" role in providing an initial investment for integrated clinics and programs to prove themselves.

"After they have been in operation a year or two, they are showing how much money they can save and the impact they can have," he says.

Introducing integrated health concepts to students enrolled in both behavioral and physical health programs provides a foundation that practitioners trained in the siloed approach may have trouble building upon. The Collaborative recently completed a project that trained medical providers to help patients with depression.

"When our trainees graduate and start their own clinics, they will have a nice, solid foundation of meaningful ways to get medical providers on board with behavioral health interventions," Maragakis says. "Training on both ends of the spectrum points us to where we can meet in the middle. I think this is where there has to be a major cultural shift in the U.S. if we want highly effective health care delivery systems to work."

In another collaboration making integrated health care viable for Michiganders, The Judson Center has fully integrated medical health services into its behavioral health programs through a partnership with MedNetOne Health Solutions.

"It's been a very positive year in that patients are learning that they have access to both a medical clinician and a behavioral health clinician at the same time," says Ewa Matuszewski, CEO of MedNetOne. "The relationship with the patient and with the medical and behavioral health side has really continued to evolve at a very quick pace."

In looking at how the current health care system has evolved, Matuszewski says the way insurance companies have structured payments further insulates practitioners from each other, making it difficult for any one of them to treat the whole patient.

"In the health care community, we forgot how to work together," she says, describing integrating health as a dance. "The initial step is to dance separately. Then you get into more of a tango or a waltz, where you are really holding each other up and depending on each other. That's what we are hoping to happen at The Judson Center. And it is really beginning to take root."

Judson Center CEO Susan Salhaney likes how that dance benefits both patients and providers.

"Our providers go home at the end of the day knowing they provided high-quality care by being able to coordinate it, making that phone call or warm handoff to make sure the patient gets seen and gets seen quickly," Salhaney says. "We know, in the end, that we've done everything we can to engage a patient in their own health, being able to provide that full care in a coordinated, well-educated way."

Susan Salhaney at Judson Family Center in Warren.

To better integrate health-centered mentalities into our culture as a whole, an overall shift is required. Health care systems, insurance companies, individual providers, and communities as a whole must shift their mental models to take a bigger-picture look, then take action to dismantle root causes of poor health.

"You can't wake up one morning and say, 'Today I am going to be an integrated health care program.' It takes a while," Matuszewski says. "It takes planning. It takes a lot of understanding. It takes a lot of cooperation. And, above all, it takes great communication among the people that are planning and working in that model."

Torres concurs, noting that changing the mechanics of the system itself won't "create as big an impact as paying attention to relationships, power differentials, and mental models — the ways of thinking that are holding the problem in place."

"A big part is changing the way we are talking about it," she says.

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.

All photos by Nick Hagen, except photos of Julie Moore and Jennifer Torres courtesy of the sources.