Transcript Document

Integrated Behavioral
Healthcare Models
Module 2
W. Patrick Sullivan, PhD
Indiana University
Objectives of Module
1. Demonstrate how various definitions of a problem or
need impact social policy formulation, social program
design, and the allocation of social resources
2. Introduce various models central to integrated care
and demonstrate how these models impact how one
views mental health, physical health, mental illness,
physical illness, and addictions
3. Consider how each module contributes to the effort to
integrate care and produce positive outcomes for
individuals and society
Defining the Problem
How a problem is defined is a crucial social policy
decision – when problems are defined broadly, based
on the current assumptions that undergird our system,
the scope of the problem always outstrips the
resources dedicated to deal with the problem.
Therefore, social policy centers on the allocation of
scarce resources or is described as “Distributive
Justice.”1
Social Policy
Social policies ultimately reflect one of myriad ways one
can understand the causes and consequences of a
defined social problem and one of myriad ways this
problem can be addressed.
Social policies can define target populations, entitlement
rules, forms of benefit, and directly or indirectly impact
the design of social programs, the selection of services
to be delivered, and how those services are delivered.
Mental Health or Mental Illness
• What are the implications for policy focused in mental
health?
• Key issues: prevention, resilience, enrichment, opportunities,
capabilities
• What are the implications for policy focused on mental
illness?
• Key issues: treatment, locus of care, cost
What is Mental Illness?
• Is it real or a myth – is it language – a social construct a matter of social control?
• If real – where is the line between health and illness?
• What do terms like schizophrenia, bi-polar disorder, or
borderline personality really mean? Can we truly
assess them with the tools at our disposal?
What is Addiction?
Is addiction a disease?
Is it a personal problem?
Is it influenced by social forces?
Is it defined by social norms?
How Policy Makers Distribute Resources
They make decisions based on:
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Knowledge of need and sense of effectiveness of service
options
Perceptions of resource scarcity
Political ideology of individual decision makers
Perception of recipients’ responsibility for problems that
require service2
Consider this……
Mental health problems range from problems in living
to those considered severe and persistent. While those
who have less severe illnesses may recover at a
greater rate than those facing greater challenges, the
latter have far greater needs and are the most costly to
serve. How should scarce resources be allocated and
why?
Or…..
Consider those challenged by addictions. How do
various models of addiction and even public perception
of this problem impact resource allocation and the
nature of the services that are delivered?
Who Is Deserving of Resources
Those who advocated for populations who are
commonly viewed as responsible for their own plight
will likely face stiff resistance to their cause.
“Responsibility” can be assessed on the basis of:
• Notions of internal versus external locus of control
• Whether the causal event was viewed controllable
Mental Health & Mental Illness
Mental health is a state of successful performance of mental
function, resulting in productive activities, fulfilling relationships
with other people, and the ability to adapt to change and to
cope with adversity -- but what constitutes health is rooted in
value judgments and impacted by culture.
Mental illness is marked alterations in thinking, mood and
behavior that contributes to distress, impaired functioning, or
heightened risk of death, pain, disability, or loss of freedom.3
Integrated Behavioral Health Models
The various models described reflect a range of lenses
one can use to view mental health, physical health,
mental illness, physical illness, and addictions.
Each of theses models inform health care policy, and
ultimately the nature of the services commonly offered
in behavioral health, mental health, and in integrated
care.
As you review these models consider how the can
contribute to the integration of physical and behavioral
health care.
In addition, given the interest in “recovery” in both mental
health and addiction consider how each model can
help and/or hinder this goal.
The Medical Model
The primary focus is on illness and disease
According to Ludwig (1975) mental illness is defined as
“any debilitating, cognitive-affective behavior disorder
due primarily to known, suggestive, or presumed
biological brain dysfunction, either biochemical or
neurophysiological in nature”4 (p.603)
Medical Model Intervention
Key professional responsibilities include:
1) Differential diagnosis
2) Diagnosis made on basis of specific “symptoms and
signs, laboratory tests, and knowledge of the natural
history and prognosis of the condition.”5
3) Choice of “therapeutic environment”
4) Selection of therapy (including medication)
Medical Model Approach
• Scientific – or based on the scientific method
• Objective
• Reductionist - thus only those conditions that met the
definition of mental illness were within the purview of
psychiatry – the “whole person” including other
contextual factors that impact the nature of the
individual’s situation are thus largely ignored.
Role of Professional in Medical Model
a) Control over the process of care rests with the
professional
b) The professional possesses the most relevant
knowledge and expertise
c) The use of specialized technical language and
nomenclature is omnipresent
d) As a result “the patient” role is largely passive
Arguments for Medical Model
a) Great strides been made in the understanding of mental
illness and the brain
b) A disease or medical perspective can reduce stigma for
those identified as suffering from mental illness and
addictions by removing blame
c) Has produced noteworthy advancement in important areas
of care – in particular, pharmacology
d) Provides a framework to support evidence-based practice
Arguments Against the Medical Model
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Exclusive focus on illness and disease can also lead to stigma and
labeling
Individual strengths and capabilities which can abet recovery are
minimized
The contribution of family, social, and environmental issues in the disease
and health process are largely ignored
The importance of the recipient’s expertise and knowledge about their life
and situation is minimalized
The recipient plays a passive role in their care process
Reflects mind/body dualism
The imprecision of health/illness distinctions and changing nature of
social norms and standards largely ignored
The Biopsychosocial Model
Disease is not solely accounted for by deviations from
the norm of measurable biological or somatic variables
“To provide a basis for understanding the
determinants of disease and arriving at rational
treatments and patterns of health care, a medical
model must also take into account the patient; the
social context in which he (sic) lives; and the
complementary system devised by society to deal
with the disruptive effects of illness.” 6 (p. 132)
The Bio-psycho-social Approach
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Affirms the role of the recipient in the helping encounter, and
acknowledged their key role in understanding and interpreting their
experience
Underscores the importance of the professional relationship beyond
technical expertise and acumen
Underscores the role of social context and conditions as determinants
of disease and as sources of support and healing
Acknowledges that the boundary between health and disease is not
well defined and is socially defined particularly in behavioral health
Informed by General Systems Theory which views the person as a
part of a self-regulating, integrated system
Prevention and Wellness Model7
• Wellness refers to the degree to which one feels
positive and enthusiastic about oneself and life,
whereas illness refers to the presence of disease
• Health care reform: refers to efforts focused on
illness, such as treatment of disease and related
rehabilitation efforts
• Health reform: efforts focused on health, such as
health promotion and the development of positive wellbeing
Prevention and Wellness Model Rationale
• Mental health is frequently intertwined with physical health
and social conditions.
• Negative (health determinants) are disproportionately
distributed among minority populations “Well-being” serves
as a protective influence
• Different interventions and approaches are needed for
different subpopulations
• Recovery is a process that bridges illness and wellness
• A focus on wellness and well-being is important to health
reform – including mental health8
Prevention and Wellness Approach
Takes a public health approach to health care:
We must alter the status quo by changing from illnessoriented medical care to prevention; harmful community
settings to health environments; and health-eroding policies
to one that supports wellness 9(p. 5)
Primary prevention consists of those scientific practices
aimed at simultaneously preventing predictable problems in
individuals or populations at risk; protecting or maintaining
current strengths, competency, or levels of health and
healthy functioning; and promoting desired goals and
enhancing human potential 10 (p. 1895).
Strategies for Prevention and Wellness
Population level
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Monitor the health status of groups of people
Track health risks
Determine sources of disease and transmission
Assess the impact of public policies
Engage in population planning
Help improve physical features of communities11
Prevention and Wellness Activities
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Disease management
Harm reduction
Medication management
Self-care initiatives
Chronic Care Model12
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Due to the aging of the population and greater longevity, more people
live with chronic health conditions than at any time.
Among those challenged by behavioral health conditions some key
chronic conditions have earlier onset, and because of lifestyle, high risk
environments and the lack of access to treatment mortality rates are
extreme
Common issues include diabetes, asthma, hypertension
The term serious and persistent mental illness suggest a course of long
duration, with a non-linear course of recovery
Likewise in treatment for addictions the term “in recovery” is rarely
viewed as an end state but rather a constant state. Accordingly,
substance use can be viewed as a chronic condition regardless of the
individuals current pattern of use
Chronic Care Model Rationale
• While the health care system is largely designed to
address acute and episodic conditions, it is argued that
health systems should also be designed to match the
needs of those facing chronic conditions.
• The cost of caring for those with chronic conditions can
be high given the volume of services needed, and in
some cases the disproportionate use of intensive and
expensive care
The Chronic Care Model Approach
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Self management support
• Clients have a central role in managing their care, which includes Collaborative problem
definition, Goal setting and planning
Self-management training and support services and Active follow-up
Decision support
• The integration of evidence-based guidelines into daily practice
Delivery System Design
• Use of practice teams. Long-term clients remain in primary care or with a behavioral
health team – in all cases the quest is to establish a single source of care
Clinical information Systems
• Manage populations the use of alerts and flags to encourage follow-up, other important
management tools. Client registries may be of use here
Community linkage and polices – noted by the development of partnerships, formal and
informal, with organizations, program, people and resources. Vital to health promotion and
prevention as well as to quality care
The Recovery Model
Recovery refers to the process in which people are able
to live, work, learn, and participate fully in their
communities. For some individuals, recovery is the ability
to live a fulfilling and productive life despite a disability.
For others, recovery implies the reduction or complete
remission of symptoms. Science has shown that having
hope plays an integral role in an individual’s recovery.13
SAMHSA Working Definition of Recovery
A process of change through which individuals improve their health and
wellness, live a self-directed life, and strive to reach their full potential.
SAMHSA has defined the following as essential elements for living a
life of recovery:
Health : overcoming or managing one’s disease(s) as well as living in a
physically and emotionally healthy way;
Home: a stable and safe place to live;
Purpose: meaningful daily activities, such as a job, school,
volunteerism, family caretaking, or creative endeavors, and the
independence, income and resources to participate in society; and
Community : relationships and social networks that provide support,
friendship, love, and hope.
The Role of the Professional in Recovery
Model
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Use hope-inducing behaviors and practices
Believe individuals can and do recover
Amplify client’s voices
Engage in goal-directed treatment
Facilitate individual choice and selfdetermination
Include family and significant others (with permission)
Expect life beyond the mental health system - community and
social inclusion
Emphasize natural community supports
Recommend peer support networks and services
The Recovery Approach
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The focus is on individual strengths not pathology
The relationship is primary and essential
Interventions based on client self-determination
Community is an oasis of resources, not an obstacle
Aggressive outreach is the preferred mode of
intervention
6. People suffering from serious and persistent mental
illnesses can learn grow and change
Recovery and Wellness
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Recovery in mental health also emphasizes health and
disease management in areas such as recognizing and
controlling symptoms, the relationship between healthy
behaviors and mental health, the importance of social
support, and medication management.
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Integrated care can help by attending to the common
health problems that accompany serious mental illness.
Recovery Model for Substance Use Disorders14
There are many models of recovery in the field of
addiction treatment treatment which focus on following
themes
1. Managing symptoms of the disorder
2. The need for personal control or choice
3. Hope
4. Sense of Purpose
5. Sense of achievement
6. The presence of at least one person (support)
SAMHSA’s Center for Substance Abuse Treatment
SAMHSA defined Components of Recovery
1. Self-direction
2. Individualized and person-centered
Guiding Principles of Recovery
1. There are many pathways to recovery.
2. Recovery is self-directed and empowering.
3. Empowerment
3. Recovery involves a personal recognition of
4. Holistic
the need for change and transformation.
4. Recovery is holistic.
5. Non-linear
5. Recovery has cultural dimensions.
6. Strengths-based
7. Peer support
6. Recovery exists on a continuum of
8. Respect
improved health and wellness.
7. Recovery is supported by peers and allies.
9. Responsibility
8. Recovery emerges from hope and gratitude.
10. Hope
9. Recovery involves a process of healing and selfredefinition.
10. Recovery involves addressing
discrimination and transcending
shame and stigma.
11. Recovery involves (re)joining and (re)building
a life in the community.
12. Recovery is a reality. It can, will, and does
happen.
Similarities between the two approaches
Mental Health Components of Recovery
1. Self-direction
2. Individualized and person-centered
Addiction Guiding Principles of Recovery
1. There are many pathways to recovery.
2. Recovery is self-directed and empowering.
3. Empowerment
3. Recovery involves a personal recognition of
4. Holistic
the need for change and transformation.
4. Recovery is holistic.
5. Non-linear
5. Recovery has cultural dimensions.
6. Strengths-based
7. Peer support
8. Respect
9. Responsibility
10. Hope
6. Recovery exists on a continuum of
improved health and wellness.
7. Recovery is supported by peers and allies.
8. Recovery emerges from hope and gratitude.
9. Recovery involves a process of healing and selfredefinition.
10. Recovery involves addressing
discrimination and transcending
shame and stigma.
11. Recovery involves (re)joining and (re)building
a life in the community.
12. Recovery is a reality. It can, will, and does
happen.
Recovery Model for Addiction Treatment Approach15
Accordingly, the stages and tasks of addiction care provide a platform for
integrated care
1. Mirrors strategies for other chronic disorders – in addiction recovery
lacks an endpoint
2. Effective treatment systems offer a continuum of care
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Pretreatment engagement and motivation strategies
In-treatment retention and support strategies – acquisition of skills
Post-treatment “recovery” - extended follow-up
Continuing care – use of community support, use of technology
including telephone monitoring, computer based assessment,
telemedicine
Why Social Workers Understand IBH
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By adopting a biopsychosocial spiritual frameworks – social work naturally takes a
systems or ecological view of human conditions
Social work respect for individual uniqueness and dignity and well-matched for strengths
and recovery-based practice and to work collaboratively with recipients of care
By virtue of a tradition of drawing form systems and ecological models of human
behavior –social workers understand the importance of social context in understanding
illness and health
With a broad view of resources social work routinely looks to family and peers as
sources of support and to naturally occurring social resources as important aspects of
goals and care planning
By virtue of understanding systems, resources, and by embracing a strengths and
recovery principles social workers can work effectively in health care systems that must
maximize fiscal and human resources, and routinely consider issues of equity,
effectiveness and efficiency when managing care
Conclusion
• Each of the models above helps to understand the
challenges people face
• Integrated care is designed to deal with complex
situations and focus on the whole person
• Rarely do effective services draw from just one of
these models, particularly when making a commitment
to person-centered care
• Social Work is ideally positioned to assume a key role
in the effort to integrate health care
References
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Rawls, J. (1971). A Theory of Justice. Cambridge, MA: Belknap Press of Harvard University Press.
Corrigan, P., & Watson, A. (2003). Factors that explain how policy makers distribute resources to mental health
services. Psychiatric Services, 54(4), 501-507.
U. S. Department of Health and Human Services. (1999). The Reports of the Surgeon General. Retrieved from
http://profiles.nlm.nih.gov/ps/retrieve/ResourceMetadata/NNBBHS
Ludwig, A. (1975). The Psychiatrist as Physician JAMA, 234(6), 603-604.
Ludwig, A. (1975). The Psychiatrist as Physician JAMA, 234(6), 603-604.
Engel, GL. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 4286, 129-136.
Manderscheid, R., Ryff, C., Freeman, E., McKnight-Elly, L., Dhingra, S., & Strine, T. (2010). Evolving definitions
of mental illness and wellness. Preventing Chronic Disease, 7(1), 1-6.
Manderscheid, R., Ryff, C., Freeman, E., McKnight-Elly, L., Dhingra, S., & Strine, T. (2010). Evolving definitions
of mental illness and wellness. Preventing Chronic Disease, 7(1), 1-6.
French, M. (2009, April) Shifting the course our nation’s health: Prevention and wellness as National policy.
Washington D.C.: American Public Health Association.
Bloom, M. (1995). Primary prevention overview. In RL Edwards, ed., Encyclopedia of Social Work, 19th ed.,
1:1895-1905. Washington DC: National Assocation of Social Workers.
French, M. (2009, April) Shifting the course our nation’s health: Prevention and wellness as National policy.
Washington D.C.: American Public Health Association.
Institute of Medicine of the National Academices. (2012, July 10). The mental health and substance use workforce
for older adults: In whose hands? Consensus Report, Board on Health Care Services.
President’s New Freedom Commission on Mental Health. (2003, July). Achieving the promise: Transforming
mental health care in America. Rockville, MD.
Van Wormer, K., & Davis, D. (2008). Addictions treatment: A strengths perspective, 2nd Ed. Belmont, CA:
Thomson Higher Education.
el-Guebaly, N. (2012). The meanings of recovery from addiction. Journal of Addiction Medicine, 6(1), 1-9