Journey Not a Destination: A Case Study of Integrated Care

Background & Purpose: To combat the significant barriers facing individuals with serious mental illness, resulting in high mortality rates and poor health outcomes, the US government promotes integrated care through behavioral health clinic infrastructure grants. Health researchers assert short-term grant funding strategies are unlikely to be sustainable. This case study examines the sustainability of an integrated care model in a community mental health center (CMHC) one year after a 3-year federal infrastructure grant ended.  This paper addresses questions of which aspects of integrated care were sustained and implementation barriers that effected program maintenance; the findings are used to outline strategies for future grant programs which better prepare agencies for sustainability.   

Methods:   Data sources included 10 semi-structured interviews, 4 months of staff observations, and agency and government documents with the aim of seeking convergence through triangulation of results from multiple sources for (Palinkas et al, 2015).  Applying a critical case sampling design, this CMHC was purposefully selected because it is funded through Medicaid capitation, freed from fee-for-service billing requirements that are linked to hindering integrated care. The first cycle of coding utilized provisional, using the Exploration, Preparation, Intervention and Sustainability implementation framework (Aarons et al., 2011), and process methods simultaneously. Data were then code mapped to reorganize the codes into categories and condensed into central themes or concepts.  Pattern coding was utilized at the second stage which allowed explanatory or inferential codes to arise that could generate emergent themes (Miles et al., 2014). Memo writing occurred throughout to take note of ideas and themes that require attention and reflection developing a logical chain of evidence that supports constructs and synthesized into three main themes.

Results:  One year after the grant ended the CMHC was struggling with staff reductions despite increases in caseloads and client numbers. Though the CMHC maintains aspects of integrated care, primarily using a co-located approach with multi-disciplinary teams, daily huddles, having primary care on-site and health promotion activities; however, utilization fluctuates due to supervisor and worker buy-in and perceived client need. Three themes emerged as barriers to sustaining their model of integrated care:  leadership’s passion can only go so far when it comes to policy systems, old habits die hard for clinicians, and too much of a good thing leads to noncompliance.

Conclusions & Implications: This case study demonstrates that integrated care is a journey rather than a destination. Drawing on the Aarons et al. (2011) EPIS implementation framework, findings characterize the organizational and environmental factors needed for long-term program sustainability described through this case study. The environmental factors support a need for an integrated payment system and standardized policies for data privacy, requirements and outcome expectations across health care service sectors. The organizational factors support the need for on-going consultation, fidelity monitoring and support for integrated care techniques, and targeted hiring and staff selection criteria.  Ongoing federal initiatives should consider funding internal fidelity development plans and partnering with state Medicaid agencies for policy and financial structural support to sustain infrastructure projects.