12 May Integrating Substance Use Services into Mainstream Healthcare

Too often, society treats substance misuse as a criminal or social problem rather than a health condition. Treatment and prevention services are traditionally separated from general healthcare. Such separation leaves limited options for addiction treatment. Failure to adequately address addiction has led to a crisis, with an estimated 20 million Americans having substance use disorders. By integrating prevention, treatment, and recovery services, we can address substance use disorders through a wide range of prevention and treatment options. 

A History of Separate Healthcare Systems

The separation of healthcare services has a long history. In 1935, Dr. Bob Smith and Bill Wilson founded Alcoholics Anonymous, in part, due to a lack of psychiatric and general healthcare for alcoholism. At the time, substance disorders were treated in asylums, if they were treated at all. Addiction was generally viewed as a social ill and handled through the criminal justice system. The cultural and political landscape of the 1970s saw high numbers of Vietnam veterans turning to substance use. Arrests and imprisonments were no longer practical—economically or politically. Rather than integrating substance use patients into existing healthcare systems, we saw the emergence of distinct substance abuse treatment centers.

These new programs represented a critical step toward addressing the growing issue of substance abuse problems, however, the lack of care coordination lead to countless individuals slipping through the cracks. Substance misuse rarely occurs in isolation. It’s often intertwined with various other medical problems. Unfortunately, general healthcare providers often don’t always detect substance abuse as a contributing factor, so when drug use is identified, some providers may fail to make referrals or follow-up with their patients. Proper coordination is difficult due to the separation of behavioral and general healthcare.

The Need for Integration 

Separating behavioral healthcare from the mainstream creates obstacles and barriers. We need to make an effort to integrate screenings, assessments, and interventions between health systems. Systematic coordination between primary care and behavioral healthcare is the most effective approach that supports whole-person health and wellness. Clients see the best possible outcomes through integrated services for general care, mental health, and substance use support. Coordination between systems benefits the client as well as healthcare systems. Proper integration can weed-out health disparities, reduce costs, and improve outcomes. 

Diverse healthcare systems play significant roles in addressing our nation’s drug addiction crisis. Various systems must work together to provide a continuum of care. Many individuals with substance use disorders won’t independently seek treatment. They may not be aware such treatment exists, or they don’t know how to access it. However, they enter healthcare systems for other reasons—illness, injury, overdose, or chronic health conditions. Coordination for screening and treatment of substance use disorders include a myriad of players such as:

• Primary care providers
• Specialty services
• Residential and outpatient facilities
• Human service systems
• Mental healthcare
• Infectious disease clinics
• School clinics
• Prison systems
• Community health centers
• Hospitals
• Emergency rooms

General healthcare systems are well-positioned to provide screening for substance use issues. For mild cases of substance use disorders, a primary care provider can offer brief interventions to motivate behavioral changes. In integrated systems, trained behavioral health personnel are available to educate clients about the impacts of substance misuse on overall health. Coordination between primary care and behavioral health provides a seamless experience for clients.

The Elements Successful Integration 

With the right components in place, a health center can make the changeover to a successful integration model that includes buy-in, location of services, and warm handoff.

Without CEO and provider buy-in, you won‘t get very far into the integration process. CEOs and upper-level managers set the tone for the organization. When transitioning toward integration, executives should model a positive, inclusive attitude. Primary care providers also hold influence over how well the integration process will work, and they must view addiction like any other chronic health condition. Healthcare systems need infrastructures for joint meetings between various providers for integrated treatment and follow-up. 

The more services available under one roof, the more likely a client is to receive the care they need. For example, if a substance abuse outpatient facility has a dedicated physician on staff with an office adjacent to the behavioral health department, it allows the provider to give physical exams to every client enrolled in the recovery program. The practitioner is also available to schedule patients before and after their therapy sessions. Co-locations are convenient for both clients and providers—clients can receive multiple services at one place, and the team of providers can collaborate and coordinate care. 

One of the most critical elements of integrated systems is the warm handoff. People tend to build a trusting relationship with their general health provider. Referrals tend to go more smoothly when the doctor introduces the client to the behavioral health clinician. In a shared location, a primary provider can walk the patient over to the substance use department. A warm handoff demonstrates collaboration and ensures a smooth transition between services.

Best Principals for Integration

Transitioning to integrated care may seem overwhelming for some. The history of care separation runs deep, and diverse systems are entrenched in their methods. True integration requires a paradigm shift. Providers must be committed to coordination and internalize new, collaborative roles. A fully integrated system will have shared facilities with seamless services and regular meetings to address collaboration and patient issues.

The National Council for Community Behavioral Healthcare (NCCBH) offers eight principles for integration. These principles can guide behavioral healthcare facilities on the path to coordinated care. 

1. Focus on Consumers and their Families
2. Promote Health, Overcome Disparities, and Address Chronic Illness
3. Standardize Quality and Outcome Measures for Use in Research and Practice
4. Promote Collaboration and Co-location
5. Redesign Financing, the Regulatory Environment and Contracting Methods
6. Develop Best Practice Service Delivery Models
7. Invest in Training
8. Assure Information Technology

Integrating Technology

As healthcare systems evolve, technology is becoming an increasingly important factor in the collaboration of care. Electronic Health Records, telehealth, mobile apps, and other technologies move integration beyond what humans can do alone. By supporting quality measures, electronic systems drive collaborative care forward. They allow practitioners to monitor clients, identify trends, and deliver more effective treatments. The right EHR helps streamline referrals and collaboration between systems. The improved integration assists providers in delivering quality care and follow-up.

The culture of care separation is part of the past. Collaboration is the future for behavioral healthcare and addiction treatment. Severe substance misuse leads to a myriad of chronic health issues, and broad coordination leads to improved outcomes and reduced costs in both behavioral and general healthcare. Open communication allows team members to support each other, and it provides a safety net of care. Integrated systems create a continuity of care where more people get the services they need, and fewer people slip through the cracks.