This article is part of State of Health, a series examining integrated care and its potential to improve Michiganders' health. It is made possible with funding from the Michigan Health Endowment Fund.

We’re all used to the idea that primary, behavioral, dental, vision, and substance abuse care are separate disciplines housed in separate facilities. But many in the healthcare world are beginning to see that model as not just inefficient, but costly and even detrimental to patients’ health.

Benjamin F. Miller, Psy.D and chief strategy officer of the California-based Well Being Trust (WBT), says fragmented care has tremendous costs.

“If you’re an individual seeking care and someone tells you that you have to wait, or see five different providers — and you work, go to school, or provide your family transportation — when you don’t show up for that appointment, that creates costs for the system,” he says.

Miller says that can then create a “crisis” for the patient, leading them to seek higher-cost forms of care like emergency room treatment – or even possibly leading to their arrest, if substance abuse or behavioral health issues are involved.

“Essentially, it’s costing you more as an individual and costing the healthcare system and the community more because outcomes are not achieved,” he says.

To Miller and many others in the healthcare world, the solution is integrated care, a model that promotes a more holistic approach to health. Integration involves not just physical co-location of services, but also broader community-based solutions that emphasize care in unconventional places and promote understanding of the way factors like nutrition, housing, and social engagement can impact health.

Although Miller approaches the issue of integrated care from a national perspective, he applauds the state of Michigan and many of its providers for making great strides in advancing integration. One Michigan physician at the forefront of this movement, Dr. Michael Klinkman, opened his first family practice in 1987.

Michael Klinkman.

“My patients’ problems were never clean, simple medical problems. I had to learn, as a primary care doctor, how to help them with their needs and their needs weren’t strictly medical,” Klinkman says. “It’s an upstream sort of thing that’s hard to do, but it’s important.”

Integration in action

Despite that “upstream” challenge, some Michigan providers have already found success with integrating care. COO Julie Tatko says Grand Rapids-based Cherry Health places “special value” on integration as a way to answer the question “How do we better serve patients?”

Julie Tatko.

“People who live in poverty experience more complex care needs, tied back to the social determinants of health,” she says. “They are going to prioritize, and that priority may not be their health. There’s food, paying rent, gas for their car. Our model makes it as easy as it can be.”

Some Cherry Health clinics integrate many services in one location. For example, Cherry Health’s Wyoming clinic offers medical, dental, behavioral, and vision services. Others may offer only dental or medical. However, co-locating services within one building is not the only way to integrate care.

A member of Cherry Health's integrated care team takes a blood pressure reading.

“In our services, we have a person devoted to connecting people to resources in the community,” Tatko says. “We ask, ‘What do you need help with?’ Maybe it’s access to food or clothing. Our health worker talks with them about resources and helps them get those resources. We help them at the level of need that they have.”

Making the connections between substance abuse, medical problems, and mental health issues is another way that integrating care can serve individuals, families, and communities. Catholic Human Services in the northern Lower Peninsula has begun co-locating substance abuse therapists within primary care practices. Catholic Human Services clinical director Larry LaCross cites Thunder Bay Community Health Service as one example where this approach has improved treatment success.

“Substance abuse treatment has been integrated into the medical home model, part of the menu of services available to every patient,” LaCross says. “We’ve seen a lot better retention and treatment and more people getting into remission.”

Larry LaCross.

Catholic Human Services’ work has demonstrated that a culture of substance abuse prevention requires buy-in from multiple sectors of a community – very much an integrated approach. The organization implemented a program to provide the overdose-reversing drug naloxone to emergency responders and law enforcement, so they can provide first response to an opioid overdose. Catholic Human Services is also teaching providers about safe prescribing. In the past two years, more than 100 opioid overdose deaths have been prevented as a result.

“I think that research will show that integrated care saves costs and produces much better outcomes,” LaCross says.

Developing new models

In addition to his family practice and teaching role at the University of Michigan Medical School, Klinkman works on integrated care initiatives being developed via the Michigan State Innovation Model (SIM). SIM is a federally-funded Michigan Department of Health and Human Services program aimed at developing and testing new models to improve care coordination, among other goals.

“Michigan has been successful finding support to do some experiments that other states have not,” Klinkman says. “Michigan took a different route, dug in a little deeper, to do basic community groundwork. They’ve learned a lot and it’s much harder than they expected. It’s like fixing up a foundational problem. We’ve built silos that are really effective within a domain and yet we haven’t put as much energy into solving the problem of connecting them to the other silos.”

Recognizing that socioeconomic, environmental, and behavioral factors are four times more likely to influence a person’s health outcomes than access and quality of care, the state is focusing its efforts on strengthening connections among providers and community-based organizations that address social determinants of health. The state is developing the models within five Community Health Innovation Regions in Genesee County, Jackson County, Livingston and Washtenaw counties, Muskegon County, and the northwestern Lower Peninsula. Klinkman serves as medical director for the Jackson Health Network and consults with the Northern Michigan and Livingston/Washtenaw regions.

“We were given funding, support, and infrastructure so we could organize and work together with community service agencies to design a system of care that really did integrate better for people who have social problems, behavioral health, and medical problems,” he says. “That demo project was allowed to grow in each community in organic ways. The state’s learning a lot about what things might work.”

While advanced software that more seamlessly shares electronic patient records seems the high-tech answer to integrating care, Klinkman believes building the human infrastructure between silos is the true key to success. Because government and private insurers rely on a piecemeal billing strategy, payment remains a huge barrier to providing integrated care.

“We take care of whole people, but we are funding them in pieces,” he says. “We need to have a budget that can be flexible and follow the needs (and) allow some crossover between medical, social, and behavioral health. This requires a really thoughtful, long-term vision.”

And the result is worth working for.

“Here’s my vision,” Klinkman says. “A community will be a much better place to live, grow, and have opportunities if you can more systematically address social issues and understand where social problems, social determinants, get in the way of people succeeding. If you can help people find a pathway to get needs met, they become more able to participate fully in the life of their communities.”

A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is development news editor for Rapid Growth Media, communications manager for Our Kitchen Table, and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at [email protected] or www.constellations.biz.

Julie Tatko and Cherry Health staff photos by Adam Bird. Michael Klinkman photo by Doug Coombe. Larry LaCross photo courtesy of Larry LaCross.