By Carolyn McCoy, MPH
Senior Policy Manager, AMCHP
Kate Howe, MPH
Program Manager, Child Health, AMCHP
Systems integration is an important priority in achieving maximum public health benefit. With most public and private health care insurance and delivery systems historically operating in parallel, there has been little or no coordination among providers or payers. As a result, families often have to navigate complex systems unassisted. Providers are often reluctant to refer patients for additional services and supports, such as home visiting and care coordination, from community-based agencies that they know little about, and public and private systems risk duplication of effort. This issue is even more critical for CYSHCN who require level of services beyond other children. Title V programs have long recognized this priority and worked to provide comprehensive, collaborative systems of care for women, children, families and children with special health care needs. Recent efforts at federal, state and local levels have underscored this need. Dr. Michael Lu, associate administrator for maternal and child health at HRSA, has outlined the MCHB approach to integration of the MCH system as one that is "vertical (appropriate levels of care), horizontal (service coordination and systems integration) and longitudinal (the continuum of care across the life course)." This focus, along with other efforts, present important opportunities for state MCH programs to take leadership in systems integration.
The ACA gives states new tools and funding to integrate public and private delivery of health care services. Also at the national level, the Institute of Medicine (IOM) of the National Academies, recently published a framework and recommendations for how primary care systems and public health departments can improve integration. The IOM committee selected health topics that follow the life course perspective, involve mental and behavioral health and there are evident health disparities. One of the selected examples is MCH and within that topic, the Maternal, Infant, Early Childhood Home Visiting Program (MIECHV). The IOM report delineates a set of recommendations on how agencies can work toward systems integration, all of which are functions that Title V programs encompass nationally and have traditionally been the nexus for systems integration of population health and primary care.
State MCH programs are well positioned to optimize the opportunities availed by the ACA through such provisions as MIECHV, Community Transformation Grants and the Centers for Medicare and Medicaid Services (CMS) Strong Start for Newborns and Mothers Initiative and national momentum brought by the IOM report to further integrate public health and primary care. Some of that work has already begun through national and federal efforts. The Commonwealth Fund/AMCHP issue brief and webinar, "New Opportunities for Integrating and Improving Health Care for Women, Children and Their Families" highlights the efforts of states to integrate health care services for low-income women and children, especially through state Title V maternal and child health programs. The MCHB-launched the COIN to reduce infant mortality in the 13 southern states of Regions IV and VI represents another effort to bridge silos across programs and states in order to share practices and innovation to improve birth outcomes. The COIN builds on the success of the Infant Mortality Summit held in January 2012, at which the 13 states in Public Health Regions IV and VI developed plans to reduce infant mortality and improve systems.
In addition to the myriad of opportunities for systems integration presented through home visiting and other MCH programs, Title V programs also are assisting in integrating behavioral health and primary care. The Substance Abuse and Mental Health Services Administration (SAMHSA) is currently convening efforts to promote this integration and has engaged state MCH programs in this work. Title V programs are important partners in this work given the focus on state populations and program design that requires collaboration noted above, as well as efforts to create systems of care for CYSCHN. Additionally, through current initiatives on improving birth outcomes, such as the infant mortality summit and COIN meetings, issues including maternal depression and tobacco use and the harmful impacts on birth outcomes, women’s health and child development have been identified and discussed.
SAMHSA in conjunction with the Region VI U.S. Department of Health and Human Services (HHS) Operating Divisions brought a team of nine individuals from each of the states in Region VI together for the purpose of providing an opportunity to develop state plans to enhance existing efforts of integrating primary care and behavioral health. The meeting was held in Dallas, Texas on Sept. 27-28 at the Department of Health and Human Services, which allowed for the participation of all the federal partners. The state teams consisted of representatives from: primary care association directors, primary care organization directors, maternal and child health directors, state Medicaid directors, provider association directors, recovery oriented association directors, state mental health directors, state substance abuse directors, and national prevention network directors. The emphasis on integration was to begin to think of behavioral health issues as a chronic illness with potential for relapse, which requires a chronic disease management model, utilizes a primary preventive approach, and includes strategies for long-term recovery.
In establishing the state teams, it was understood that inclusion of MCH directors was a crucial component to the success of any integrated health model. This is especially salient in Region VI, where geography remains a large deterrent to accessing quality maternal health care and where affordable access to transportation is a challenge for many. This, combined with increased rates of recreational substance use among women of child-bearing age, drove forward the necessity to think of all aspects of health care in any innovative health care models that improve the health outcomes and lives of people in the region.
The meeting also afforded states the opportunity to hear of the evidence-based models for integration and from three existing grantees currently involved in integration efforts within Region VI. One model that was presented for consideration among the state teams is the "4Ps Plus Screening Tool for Perinatal Substance Abuse, Depression and Domestic Violence" (Ira Chasnoff, MD, University of Illinois-Chicago), which has shown success in Louisiana. The "4Ps" provides primary care physicians with a tool to routinely and consistently screen for behavioral health needs, thereby providing an opportunity for targeted intervention in a non-threatening and holistic way. There also were presentations from the Hogg Foundation and the Louisiana Public Health Institute to illustrate the role that philanthropy and foundations can play as partners in integration. There will be follow up calls with each of the state teams, federal partners and the National Council for Behavioral Health to discuss progress on each of the state plans and any technical assistance that might be necessary.
This meeting and subsequent follow up presents a great opportunity for the enhancement of federal, state, private and local partnerships. For MCH/CYSHCN programs, the meeting offered states the opportunity to begin to discuss and identify collaborative strategies to address the behavioral health needs of women and children. If you have any questions about primary and behavioral health care integration efforts in Region VI, please contact Michael Duffy, SAMHSA regional administrator (Region VI).
Efforts at all levels, federal, state and local, to integrate public health and primary care in the public and private sector have great potential to not only create more efficient, effective systems of care, but also improve the health of our nation. State MCH programs are situated at the crossroads of public health and primary care, have shown to be leaders in systems integration in the past, and can continue to do so in this era of health care reform.