2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

The Critical Role of Relationships in Integrated Health Care Delivery

Integrated care models are now increasingly being adopted across all medical settings, including behavioral health. Their potential to help health care systems attain the triple aim of improving service quality, promoting population health and reducing costs has led policy makers to incentivize these models through policies such as the Affordable Care Act. While integration in behavioral health agencies can take many forms, these models broadly fit into three types: the in-house model, where the behavioral health agency delivers both primary and behavioral health services, the co-located model where behavioral health and primary care share the same space, and the facilitated referral model where a behavioral health agency has links to primary care services and other providers to ensure care coordination. One of the most common models within behavioral health has been the Health Home, funded by Medicaid and designed for people with chronic illnesses, including mental health and substance use disorders. While these models can bring about structural integration which sets the stage for integrated care delivery, they may fall short of achieving integration on the ground. Research has found that systems with structural integration often struggle to demonstrate improvements in quality of care suggesting that integrated models are necessary but not sufficient for clinical integration. What then is needed to ensure clinical integration?

At the heart of integrated care delivery is person-centered care, meaning no longer viewing the service user as an isolated set of symptoms to be treated in separate siloed systems, but instead to see a whole person with individual needs and preferences living in specific set of social circumstances. The ability to deliver person-centered care is shaped by interpersonal processes between providers and service users and between providers and systems to deliver a seamless care experience. This entails moving away from the medical model that has worked well for acute conditions but done a poor job of treating people with complex chronic conditions. Instead, integrated care places the service user at the center of a care system that is delivered by a proactive team of providers who coordinate services across settings and reach out to the community.

Many of the providers delivering integrated care in behavioral health settings are social workers. While this new health care environment does require new skills, the fundamentals of the social work approach are closely aligned with delivering integrated health care – namely a person-in-environment perspective, valuing self-determination, promoting social justice and, importantly, a focus on interpersonal relationships. Social workers frequently use the expression, “it’s all about the relationship” and much of social work training focuses on how to engage and empower people in the clinic and the community. In many ways, this saying holds true also for integrated care – while agencies can invest great time and effort in restructuring their delivery systems, what ensures that these reforms lead to a better service user experience and improved clinical outcomes are the interpersonal processes. The shift from episodic to continuous care gives providers the opportunity to engage with individuals in deeper more meaningful ways. Although these interpersonal aspects of care can be harder to teach and to measure, they occur at every level of care – starting with the core relationship between the individual receiving care and their provider, and relationships with families, natural supports, and community. It also includes relationships between providers—care coordination requires a cohesive team approach and an ability to communicate across a myriad of systems that contribute to a person’s wellbeing.

Person-centered care is, therefore, predicated on the relationship, or as it often referred to in behavioral health – the therapeutic or working alliance. Responding to a person’s individual values, preferences, needs and social context requires understanding the person. And in fact, relationships themselves are not just a way to facilitate health care interventions – they, themselves, are healing. Psychotherapy research has consistently shown that the relationship, itself, is more effective in improving clinical outcomes than any specific treatment modality. Social workers have long understood the value of relationships and are, therefore, well suited to the delivery of integrated care not only within behavioral health agencies but also within primary care settings and across other settings. Practices such as shared decision making, a clinical feature of Health Homes, rely on trusting relationships where people feel seen and heard. Particularly as health care recognizes the need to engage more meaningful in all aspects of a person’s life and promote full citizenship, shared decision making becomes more than simply making technical decisions around treatment, but rather about how to help people think about their life goals.

Part of being seen and heard means providers understand a person’s culture, including how to work with their natural supports and within their community. Cultural competency is considered one of the core integrated health care skills and is defined as delivering care that is responsive to diverse needs and targets disparities in care. However, social workers, along with some other professions, have challenged the idea that any provider can claim to be culturally competent. Instead, they are proposing that providers should strive to have cultural humility. The presumption that one can become competent in a culture, that it is essentially knowable, perpetuates the notion that cultures are monolithic which can lead to stereotyping. Whereas cultural humility acknowledges the complexity of identity, the nature of intersectionality and the role of structural inequalities. The provider’s task then is not to master a culture but to engage in an ongoing reflection about difference and power imbalances both at the individual and system level.

Care coordination is rooted in robust communication among providers. Collaboration and teamwork is a key integrated health care competency, reflecting that these new models frequently employ interdisciplinary teams. This shift requires providers to step out of their own professional hierarchies and cultures to work together to address the needs of the individual. Social workers can play a key role in facilitating communication across disciplines and helping individuals articulate their needs and preferences to the team. At the heart of effective teamwork are relationships based on mutual respect and shared goals. The expectation to engage more proactively across settings and within networks again is greatly facilitated by building solid relationships with other providers.

In conclusion, to reap the rewards of the considerable investment we have seen in meeting the physical health needs of individuals in behavioral health settings we need to pay attention to the common currency of all clinical work – the relationship. Integrated models have created the structures to bring behavioral health and primary care together but now more than ever, agencies need to create the conditions that give their workforce the time and resources to foster meaningful relationships throughout the care continuum.

Dr. Victoria Stanhope is an Associate Professor at the NYU Silver School of Social Work. Her areas of specialization are person-centered care, mental health recovery, and primary and behavioral health care integration. Her research is funded by the National Institute of Mental Health. She is co-editor of Social Work and Integrated Health Care: From Policy to Practice and Back published by Oxford University Press.

Dr. S. Lala Straussner is Professor at NYU Silver School of Social Work where she is the Director of the Post-Master’s Program in the Clinical Approaches to the Addictions and Chair of the Human Behavior in Social Environment Area. She is the Founding Editor of the Journal of Social Work Practice in the Addictions and co-editor of the recently published book Social Work and Integrated Health Care: From Policy to Practice and Back with Dr. Stanhope.

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