A Forty-Year Perspective on Community Behavioral Health Care
By David R. Stone, Ph.D.
Retiring CEO
Sound Mental Health
Original Publish Date: July 12, 2016
Upon hearing of my upcoming retirement from a 42-year career in community behavioral health, 27 of which took place at Sound Mental Health in Washington State, friends began asking me to compare the two ends of that time continuum. As I began to write down my thoughts on the subject, I realized just how much the field has changed during that time. I will only focus on key highlights which I believe demonstrate the greatest influence on behavioral health and today’s health care environment.
ACA, Payment and Evolving Models of Care
The Affordable Care Act (ACA), a law which community mental health executives could only think of in abstract terms in the 70s, is clearly the most significant event to happen in behavioral health care since the 1960s. The ACA paved the way for mental health parity provisions, expanded health coverage, federally subsidized health insurance plans and health care marketplaces—offering for the first time, improved options and hope for hundreds of thousands. It is a proud moment for the behavioral health community to see this milestone achieved, and it is one that likely will yield a level of change in health care that will be felt for generations to come.
Since 1974, models of care have evolved in ways that offer great promise to those experiencing complex mental and physical health challenges. While individual and group therapies for the mentally ill are still a vital aspect of care plans, care management, which evolved from the case management model of the past several decades, is becoming more widely utilized. This is true especially in areas that have moved into integrated health systems and risk-based payment models.
The days of the fee-for-service paradigms that have dominated health care in the past are numbered. The indefinite service regimen that was fostered from the fee-for-service model focused on delivering services rather than outcomes is losing ground to incentives-based treatment and system outcomes. In this regard, behavioral health care stands to gain much-warranted traction with primary care and other health partners, which recognize that treating people holistically is good business. Meaningful partnerships are beginning to form, investments in treating the whole person are being made and the tangible contributions of mental health care to address complex patient needs are being recognized.
Technology and Integration
The consumer movement, and its focus upon patient rights, is influencing the health care industry in ways that for many of us have been a long-held dream. Similarly, the movement toward integration of behavioral healthcare and primary care is making a huge impact upon health care in general and behavioral health in particular. Decreasing stigma and greater information and awareness regarding mental illness have played a role. But the increasing commitment by leaders in health care to find meaningful ways to improve patient care and health outcomes, while also easing health care costs, are the real drivers.
Truly collaborative relationships between primary care and behavioral health care, which may range from referral-based partnerships on one end of the spectrum to more complex transition supportive services on the other, is an unexplored frontier, which I believe can make great business sense. Utilizing compatible health information technology to diagnose and address complex physical, emotional and behavioral health issues holistically, working cooperatively and closely with the patient to improve their opportunities for successful outcomes, as well as real-time sharing of vital mental health and physical health information are hallmarks of true integration and collaboration. It is gratifying to see these partnerships to improve patient care finally becoming a reality.
Telehealth, too, is changing the way behavioral health engages clients, since it can eliminate many of the common barriers that undermine a patient’s ability and motivation to adhere to care plans. Because it can reduce costs for both provider and patient, telehealth is steadily gaining traction in rural communities. For the same reasons, it is increasingly becoming a vital tool in urban areas as well.
The behavioral health industry’s increasing investments in compatible technologies facilitates long distance patient/clinician contact and consultation, patient education, medical intervention, effective care plan monitoring and remote admissions. It will truly allow better care and better support to people who often cannot or will not typically engage in their own health outcomes.
Words of Caution
One area in behavioral health that has changed substantially over the years is psychiatric medication. While medications have greatly improved and have enhanced the quality of life for countless individuals, the decreasing availability of psychiatrists should be a concern. The numbers of these highly trained prescribers, who possess an optimal understanding of these complex medications and their interactions with other drugs, are in decline. The increasing use of other health care professionals (primary care physicians, nurse practitioners, psychologists, etc.) as prescribers assists with the access problem, but does not solve it. In addition, the belief among some payers that a medication-only regimen constitutes sufficient care for many behavioral health conditions is naïve and short-sighted, in my opinion.
Similarly, a decline in the availability of trained, Masters-level mental health professionals is especially concerning -- especially when the prevalence of behavioral health conditions in the community appears to be on the increase. Various studies indicate that approximately 25 percent of American adults experience a mental condition sometime during their lives. Only about 40 percent of those people receive some type of treatment for their condition. The Affordable Care Act, the advent of Health Care Exchanges and the liberalizing of community attitudes about mental illness have increased the number of people seeking and receiving mental health support. The coming draught of qualified behavioral health professionals is sure to further burden the current generation of people who work in the industry unless more can be done to attract and retain talent.
The trend toward more governmental contracting with for-profit care companies to manage community behavioral health systems is troublesome, and in my opinion, requires greater vigilance by the behavioral health and primary care sectors. The corporate values and priorities of these managed care companies are not always very compatible with the communities that they serve, and many wonder if the services that managed care companies offer are worth the additional cost they often impose upon the community.
While there is great excitement and support for the integration of primary care and mental health, and the level of support for it is considerable, it is crucial for health care leaders and policy-makers to proceed carefully. We all must work together to understand and appreciate the many unique and nuanced competencies that behavioral health brings to the relationship. We must embrace the role behavioral health plays in improving patient outcomes. I do not believe that patient care or health care outcomes ultimately would benefit if behavioral health were to become immersed within the general medical service spectrum.
Conclusion
Like many seasoned behavioral health care executives, I am fairly optimistic about the future of our field. As I reflect upon the past 42 years, witnessing the changes in access to care, technology, medication administration, the strategic integration of care and the changes in community attitudes, it is clear that behavioral health care has come a long way. Still, as the industry evolves, as we embrace strategic health care partnerships, and as we advance in ways that could not previously be imagined, we must not lose sight of mental health’s core mission to serve a vulnerable population, while still continuing to embrace our unique role in shaping health care for years to come.
David Stone, Ph.D., is the retiring CEO of Sound Mental Health, Washington state’s largest and most comprehensive mental health services providers. With more than 40 years of experience developing and managing award-winning community mental health services, Dr. Stone’s leadership has enabled Sound Mental Health to grow to 80 + programs, supporting more than 20,000 people and generating millions in annual revenue. The organization is sought nationally to present on industry best practices and emerging therapies in community mental health. He received a B.A. in Psychology from Eckerd College, followed by an M.A. and Ph.D. in Clinical Psychology from the University of Florida.