People with complex health and social needs often have behavioral health diagnoses — mental illnesses and substance use disorders — that are not being well-addressed. Since we launched our National Center for Complex Health and Social Needs in 2016, initiatives to address the social drivers of health have become more common in the healthcare sector, but healthcare still does not give adequate attention or resources to behavioral health.
That’s why we chose Elevating behavioral health in whole-person care as the theme for Putting Care at the Center 2023, the annual conference for the complex care field. This year’s event takes place November 1-3 in Boston, MA.
Complex care has been described as a radically person-centered approach to care, serving populations whose significant bio-psycho-social needs are not being met by current health systems. Many complex care principles and approaches, such as multidisciplinary teaming, motivational interviewing, and supportive housing, were first developed by the behavioral health community.
The Camden Coalition’s own care management model was inspired by The Assertive Community Treatment (ACT) teams that emerged in the 1970s. Still used today, multidisciplinary ACT teams engage individuals with serious mental illness in the community to provide whole-person care and supports. The advocacy and methods of the behavioral health community established a vision for peer leadership and providing services holistically — what we in the complex care field have been calling an ecosystem of care.
Putting Care at the Center 2023 seeks to honor and uplift the contributions of behavioral health to the field of complex care. At the conference, we will explore how the behavioral health peer movement called out inhumane treatment, social stigma, and underinvestment in mental health services; recognized the interdependence of mind, body, and spirit; and advanced peer support models that leverage lived experience as a source of treatment and support.
We will review emerging models for the coordination and expansion of behavioral health services within the healthcare sector and discuss how to better support the diverse workforce delivering those services. Each day, discussions will center around the following themes:
The United States has a shameful history of warehousing individuals with mental illness in state institutions and providing cruel forms of “treatment” without individual consent. The efforts of consumer leaders, including Judi Chamberlin, Sally Zinman, Steve Harrington, and many more helped achieve significant advancements in the treatment of behavioral health conditions. The passage of the Community Mental Health Act (1963) and its subsequent reiteration by the U.S. Supreme Court ruling in Olmstead v. L.C. (1999), resulted in federal and state policy that favored de institutionalization and community treatment of those in need of behavioral health services.
The corresponding divestment in psychiatric hospitals (there are currently less than 10% of the number of psychiatric beds per person as there was in 1950) did not result in a proportional investment in community-based behavioral health services and support, leaving many without access to treatment. Services that did exist were limited in scope and emphasized pharmaceutical interventions, with little attention or support given to an individual’s physical or social needs. For some, the impacts of their untreated behavioral health diagnoses on their health and well-being were significant, leading to poorly managed medical conditions and homelessness.
A robust network of behavioral health patients and families emerged that envisioned a person-centered, recovery model of care. Those with experience living with a psychiatric disorder and/or addiction began providing mentoring, education, advocacy, and support to one another. Today, “offer emotional support, share knowledge, teach skills, provide practical assistance, and connect people with resources, opportunities, communities of support, and other people.”
The phrase “nothing about us without us” was originally coined in the disability rights community and has since been adopted in behavioral health and other spaces to emphasize the need for the leadership of people with lived experience. Complex care has embraced the wisdom and power of lived experience, incorporating peers as navigators, community health workers, and promotores. Complex care consumers are increasingly serving on advisory boards and governing bodies. In May 2022, the Centers for Medicare & Medicaid Services (CMS) began requiring Dual Eligible Special Needs Plans (D-SNPS) to establish enrollee advisory committees.
It is essential that we continue to expand and strengthen the role of consumers in complex care by ensuring representation in leadership roles, including care delivery, program design and management, organizational governance, evaluation, and policy development.
Achieving whole person care
Despite the promise of behavioral health parity — legally, financial requirements and treatment limits for behavioral health should be no more restrictive than for physical health — there is an inadequate supply of behavioral health providers and services, particularly for low-income populations. The services that do exist are poorly integrated with the rest of the healthcare system.
Given the limitations of resources, care providers need to find opportunities for efficiency and prioritization within and across programs and organizations. In short, we need to figure out how to be good partners. In Camden, our Pledge to Connect initiative aims to improve access to outpatient behavioral health services for individuals seeking care from a local emergency room. Working with a local Certified Community Behavioral Health Clinic (CCBHC), Oaks Integrated Care, and a health system, Cooper University Health Care, the Camden Coalition manages a two-tiered model (high and low acuity) to navigate patients to appropriate outpatient support.
Organizations and communities across the country are piloting and scaling approaches to increase coordination and improve access to behavioral health services for those with complex health and social needs.
Most notable is the emergence, as a demonstration program in 2017 and then nationwide in October 2022, of Certified Community Behavioral Health Clinics (CCBHCs). CCBHCs are “designed to ensure access to coordinated comprehensive behavioral health care… [and] are required to serve anyone who requests care for mental health or substance use, regardless of their ability to pay, place of residence, or age.” A Medicaid prospective funding model, paired with corresponding service requirements that include home and community services, expanded hours, and investment in health IT , enable CCBHCs to go beyond service delivery and invest in collaboration.
CCBHCs are already an important resource in many communities’ ecosystems of care. The coordinated approach between physical and behavioral healthcare that they enable promotes value-based reimbursement and consolidation of limited resources, and leverages existing technologies. There are currently more than 500 CCBHCs that are increasing collaboration with healthcare, schools, and police in their communities, improving access to behavioral health resources, and preventing hospital admissions — and that number is set to grow.
Integrating behavioral health throughout the ecosystem of care
We are in the midst of a behavioral health crisis, with unprecedented rates of anxiety, depression, addiction, and overdose. This crisis has been exacerbated by the social isolation of the pandemic response, growing police and gun violence, and economic inequality. Yet, this crisis also creates opportunities — including new investment, greater recognition and reduced stigma, and innovation.
- The opioid epidemic that continues to plague communities across the country led to significant investments in addiction treatment, including an increase of medical providers trained in medications for addiction treatment (MAT) and other therapies for opioid use disorder.
- Police shootings of individuals in crisis emphasize how the behavioral health conditions of those with complex needs drive interactions with non-behavioral health providers, including EMS and police, who may have little to no training in mental healthcare. This has inspired the creation of behavioral health response teams working in close collaboration with police departments.
- The bipartisan Gun Bill, passed in June 2022 shortly after a mass shooting at Robb Elementary School in Uvalde, Texas, secured $2.16B in funds for behavioral health initiatives, including CCBHCs. In October of 2022, the Biden administration announced that the model will be expanded nationwide.
This national commitment reflects a growing understanding of the need for a comprehensive and coordinated behavioral health response.
From grassroots programs to national initiatives, significant investments and innovations are happening in the delivery and integration of behavioral health services in complex care. Join us to explore these topics and more at Putting Care at the Center 2023.