In 2006, the National Association of State Mental Health Program Directors published a report stating that adults suffering from a serious mental illness were dying, on average, 25 years earlier than the general population. Deeply shocked and disturbed by these findings, Missouri officials knew they had to shift the way the state delivered health care services to those suffering from mental illnesses and chronic conditions. Their response? Developing a new model of integrated medical and behavioral care for Missouri’s most vulnerable Medicaid population. They started small and successfully implemented a narrowly focused, integrative care program that produced favorable outcomes for a small population of high-cost Medicaid patients. With the passage of the Affordable Care Act in 2010, Missouri officials saw an opportunity to expand this coordinated service delivery model. However, they didn’t want to simply create a bigger program; they wanted to facilitate a statewide paradigm shift in the way health care facilities delivered care.
Missouri was facing a formidable challenge. The changes needed would impact traditional organizational structures, operating models and systems, as well as workforce composition, roles, and identities. Underpinning this initiative would be new data structures to capture the information needed to guide decisions and measure outcomes, robust partnerships with public and private entities to coordinate various aspects of care and ensure data was shared in a timely manner, and a new workforce model to offer integrative care. Furthermore, new positions would need to integrate into existing health care agencies, staff would have to alter the way they delivered care, and sweeping budget cuts meant resources would be scarce. Lastly, Missouri officials would need to design a sustainable funding model to ensure long term viability for their vision and to secure support from the General Assembly.