The Integrated Behavioral Health Continuum: Theory and Practice
New systems for organizing behavioral health care gain life, energy, and converts by doing better than their predecessors; it is only with time that one discovers their shortcomings and the new problems that success creates. The Integrated Behavioral Health Continuum: Theory and Practice espouses the advantages of the latest form of organization—integrated delivery systems—and describes how to create and manage them but says little about their adverse effects. Integrated delivery systems can provide both insurance and treatment, because administrators control a large array of services and influence patient flow between them. In the public sector, such systems have improved both quality and efficiency by assembling programs with progressively more intensive, complementary services into a continuum and directing patients to receive no more services than are necessary. But there is little to prevent powerful clinical managers from overrationing care if the system's fiscal managers underfund it or from expanding administrative procedures that reduce service use while offloading costs to providers.
Most of the chapters in this book provide useful information about the implementation and maintenance of integrated delivery systems without considering their negative consequences. Laurel J. Kiser's chapter, "Toward Integration," is relentlessly upbeat and corporate in tone as it notes the forces in our marketplace and clinical culture that drive change. Chapters by Paul M. Lefkovitz and David E. Ness tell us how to integrate services into a coherent system without warning that the new system is unlikely to tolerate certain traditional values and skills. A chapter by Kiser and Margaret Moran touts centralized access to services without noting the usual disadvantages: reduction in geographic availability and creation of duplicative services.
A chapter by John S. Lyons and Melissa E. Abraham, "Designing Level of Care Criteria," captures the importance of risk assessments in deciding how much treatment is necessary but omits the more controversial—but equally important—assessment of a treatment's potential effectiveness. Michael A. Hoge's chapter on levels of care, the chapter by Kiser and Lawrence L. Kennedy on therapeutic processes across the continuum, and Andres J. Pumariega's chapter, "Behavioral Health Care Systems Relating to Other Systems," offer an ideal view of mutually complementary services forming a seamless continuum of care, without addressing the chaotic impact on care of benefit boundaries and the immense gaps that lie between private and public systems.
Joan Betzold's chapter on document management warns of the dangers of the computerized record and stresses the importance of linking information to patients wherever they go; however, its standard data set exceeds what most clinicians would find practical or cost-effective. Two chapters on reimbursement are helpful and clearly written, but the chapter by Allen S. Daniels and Karl W. Stukenberg— "Assessing Quality of Care"—while comprehensive, does not acknowledge the inefficiency and ineffectiveness of most current quality assessment methods. A chapter on consumerism promotes consumer empowerment without recognizing that underfunding makes empowerment moot.
The authors' administrative experience with and optimism about integrated delivery systems make this book useful and readable, but be warned: you will learn little about the dangers, drawbacks, and limitations of these systems by reading this book.
Dr. Bennett lives in Chestnut Hill, Massachusetts.
