Changing North Carolina’s Medicaid system has been a major topic of debate the 2014 “short session” of the General Assembly. Common to most of the proposals under consideration is the principle of “integrated health care.” Integrated health care, or “whole person care,” refers to a system that offers coordinated physical and mental/behavioral health care. It generally results in improved health outcomes.
Without this integration, people who have serious mental illness may have a provider who monitors psychiatric medications and provides outpatient therapy but foregoes routine screenings for blood pressure and blood glucose levels. Likewise, people managing chronic physical illnesses like diabetes often do not get the mental health care that would help them implement the lifestyle changes that would help them manage their disease. This approach ignores the relationship between physical well-being and mental health.
One group that would especially benefit from an integrated approach to health care, but that is currently almost entirely excluded from North Carolina’s Medicaid system, is people with traumatic brain injury (TBI). This population receives few services under our current system and clearly should be included in any of the Medicaid overhaul plans.
According to the National Institutes of Health, TBI occurs when a sudden trauma causes damage to the brain. TBI can result from a blunt force to the head with a closed wound, or from an object penetrating the brain. Many TBIs result in long term disability, including problems with cognition (thinking, memory, and reasoning), sensory processing (sight, hearing, touch, taste, and smell), communication (expression and understanding), and behavior or mental health (depression, anxiety, personality changes, aggression, acting out, and social inappropriateness).
In North Carolina, we typically see a traditional, medical approach to treating TBI. Often the initial response involves surgery and other medical interventions to reduce swelling, improve blood flow, and increase the availability of oxygen to the brain. Once stabilized, a high-quality treatment might include physical therapy to regain bodily functions controlled by the injured area of the brain, occupational therapy to learn adaptive skills, cognitive therapy to adapt to changes in mood or thought processes, and a host of other services that span the physical and behavioral health systems. Because of these complex and long-lasting needs, people with TBI stand to benefit greatly from a truly integrated health care system.
Consider “Linda” (not her real name), a worker in a small factory. She sustained a TBI when her car was rolled after a collision with a drunk driver. Linda was treated for the swelling in her brain with surgery and medications. She needed intensive physical therapy in the months after the crash. Although she regained the ability to walk over time, she lost her job and eventually needed to go on Medicaid and Social Security Disability. But she never received any mental health services. When she left rehab, a nurse did give her and her mother a flyer with a few phone numbers in case she wanted counseling, but there was no one who could help her navigate the system. No one warned her about the bouts of intense anger, or even the confusion she sometimes experienced. She thought maybe they were side effects of the medications she took for pain and swelling. She struggled to return to her life before the accident.
In an integrated system she would have received a referral to a mental health provider associated with her primary care provider instead of just a flyer. The two providers would have shared information to prevent medication interactions and other unintended consequences. Her mental and physical health care providers would have been on the same team. And her care would have been better for it.
With all the proposals and accusations flying around, it is easy to dismiss any changes to Medicaid as political theater. Let’s not go down that dead end road. Instead, let’s consider what could be. Whatever other changes might be adopted, integrated health care is a worthy goal. And including people with TBI in our Medicaid system would be a significant and life-enhancing improvement. It would make a critical difference to people like Linda. An integrated system of health care could offer hope of recovering part of a life lost.
Vicki Smith is the Executive Director of Disability Rights North Carolina.