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Integrated Care: Why it Matters and How to Achieve it

“Integrated care” is a term that has begun showing up more in healthcare settings as something desired and positive. You may have also heard of it referred to as “whole-person care” or “coordinated care,” but those terms don’t tell us what it is, why we want it, or how to get it. This article will give you a brief introduction to integrated care and some ideas of how you can begin to advocate for a more integrated approach. In this blog, we will use the terms “integrated care,” “whole-person care,” and “coordinated care” interchangeably.


What Is Integrated Care?

The term “integrated care,” at its core, is attempting to achieve connection among anyone working to help you, regardless of their specialty or role. Coordinated care means your doctors, your pharmacist, your psychiatrist, and your therapists, among others, will talk to each other about what you need, how they can help, and what your goals are. Whole-person care means these professionals also consider who you are, what is important to you, and what your culture is, and they infuse respect and dignity into every interaction with you. Integrated care means your system is informed and supported by people with lived experience with the things you are seeking support for, be it mental health diagnoses, stressful life experiences, parenting a child with a disability, transitioning to adulthood, gender diversity, or autism spectrum disorder. Whole-person care means your supports are treating who you are as a complete person, which means also supporting your needs for housing, financial assistance, social support, community safety, and your ability to understand sometimes complex medical information. Who you are, what you need, and your experience is the focus in an coordinated care system.

If your current healthcare experience feels different or feels disconnected, you are not alone. In a disconnected system, we have to be the messenger to all of our providers, and we don’t always know what is important for each doctor or specialist to know. Does my PCP need to know about my dental pain or my recent depressed thoughts? Does my psychiatrist need to know about my new pre-diabetic status or that my in-home provider has been sick? Does the staff who come to my home need to know that I’m changing medications soon and I’m feeling anxious about that? And if I feel unsafe at home or feel lonely, who needs to know and who can actually help? It’s challenging and tiring to try and figure out the current system and it often leads to important information not getting to the providers who can help you the most.


Why Does Integrated Care Matter?

Not only does it sound good, but research has shown that integrated care leads to better outcomes in several ways. As a client, patient, or person seeking support, coordinated care can reduce our confusion and the number of times we need to share our story and needs to ask for support. It can also reduce how long we need to wait for support. When a team approach is used, and when all team members are aware of and accountable to one another, you’re less likely to spend time waiting and feeling forgotten. Research also shows that integrated care systems cause patients to feel more involved in their own care, more educated about their options, and more confident to voice their questions or concerns. Lastly, whole-person care can create strong positive outcomes for the entire system: team-based integrated care settings have shown lower costs than those using a more traditional disconnected method, and from a public health perspective, whole-person care provides better clinical outcomes for complex and chronic needs.


How Can We Achieve Integrated Care?

One of the first things you can do as a client, patient, or person receiving other services is to ask for your providers to talk with each other about your care. You can specify what information you’d like for them to share, how often you’d like for them to share it, and for what purpose. In most cases, you will need to sign a Release of Information document verifying you approve for them to speak to one another. In some cases, you may also request all of your providers or doctors talk together in a larger conference call or phone meeting where you can be present and express the importance of them working together as a team. During your regularly scheduled appointments, you can ask your nurse, doctor, or specialist when they last spoke to the others on your team. You can request, at any time, that they ensure to follow-up with one another so that you won’t be the only person attempting to relay important information about your needs or care.

You can also encourage your providers to broaden their understanding of your culture, your identity, your diagnoses, and your needs. While our medical and behavioral health providers receive a lot of specialized training, they aren’t considered experts in everything. We can’t always assume they know our experience, our culture, or our needs if we don’t state them and give them an opportunity to learn about them.

Sometimes, especially when you have a lot of different providers, it can be too much for you to do alone. If you have Medicaid, you can call the Managed Care Organization for your county to see if they can assign someone to help. One role that may help is called a Community Guide or Community Navigator, but you should ask the MCO if you are eligible for one. If you have private insurance, you can ask your insurance company if someone can be assigned to help – these people are usually called Care Coordinators. And of course, you can always call the Autism Resource Specialists at ASNC for help and support.

There also may be clinics, agencies, and providers in your area who have adopted an integrated care approach, and you might choose to transfer your care to them. These clinics or agencies typically have Care Navigators or Care Coordinators on staff whose job it is to ensure everyone on your team is communicating and to make sure your various needs are not unmet. Clinics that are integrated tend to have people working there from various backgrounds like medicine, psychology/psychiatry, counseling or social work, and nursing.

Lastly, here at the Autism Society of NC, we are working toward a more integrated approach to the clients and families we work with. We now have a Registered Nurse and Licensed Social Worker on staff to begin to ensure we can support you and your families more wholly. If you or your family wants to talk more about how to achieve integrated care in your system, start by calling the Autism Resource Specialist for your area.


Additional Resources



Jenna Flynn joined ASNC in January 2022 as an Integrated Care Professional and is a Licensed Clinical Social Worker (LCSW). She has a Bachelor’s in Psychology from Indiana University of Pennsylvania and received her MSW from UNC Chapel Hill in 2011. Jenna has worked for almost 9 years in the NC Managed Care Organization (MCO) system and she maintains a robust knowledge and understanding of the service system for those with IDD, ASD, TBI, and mental health diagnoses. Jenna most recently worked at the TEACCH Autism Program where she provided psychotherapy utilizing CBT, DBT, ESDM, and Structured TEACCHing evidence-based practices for clients across the lifespan. She also previously worked for ASNC as a Direct Care Professional in the community as well as at the Creative Living Day Program.  Jenna is excited to support the Clinical Team to ensure ASNC participants and families across the State are able to meet their goals and lead fulfilling lives.

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