In February of this year WCMHS and UVM CVMC embarked upon a pilot project to start an Integrated Health Home (IHH). Marissa Patrick, ANP, and Gail Wheatley, RN, of UVM CVMC Granite City Primary Care joined the WCMHS Case Management Team, Joanna Stevens, Office Manager and Abigail Tobias, Behavioral Health Integration Coordinator to be the core of this project. Many others from WCMHS had been meeting for approximately a year to iron out the details and when Marissa and Gail said yes we were ready to go!
The mission of the Integrated Health Home is to promote a model of health care that integrates the social determinants of health (see graph below) with specialized treatment for individuals with complex physical health, mental health, developmental, and substance abuse challenges.
New England Journal of Medicine 2007; 357; 1221-8
According to Preventing Chronic Disease (PCD: Public Health Research, Practice and Policy, 3(2) 1-14) individuals living with a serious mental illness face an increased risk of having chronic medical conditions. Furthermore, according to the National Association of State Mental Health Program Directors (NASMHPD) adults living with serious mental illness die on average 25 years earlier than other Americans, largely due to treatable medical conditions. We also know that health status is not only determined by genetics and health care but by behavioral patterns, social circumstances and environmental exposure. Add to this the challenges associated with finding a primary care provider, especially if there have been difficulties with prior providers, and an integrated health home seems to be a logical solution as it provides all involved with the assurance of help and support in providing the best care possible and strong, supported working relationships.
Who is participating?
To be eligible for referral to the IHH participants need to be at least 18, enrolled in services with WCMHS, have challenging health issues and need a primary care physician. Also eligible are those that have a current PCP but mental health or other challenges are preventing a positive working relationship with that medical provider.
What are the expectations?
Clients need to sign releases to allow for access of records for both systems of care and agree that they will participate in a team approach to their care, including the presence of their case manager at all medical appointments. Case managers agree that they will accompany clients to all appointments including referrals to specialists. In the event of an acute appointment case manager will attend or arrange for support staff to attend. The medical provider’s office agrees to work with the client and case manager to schedule appropriately and all involved affirm their willingness to coordinate care and work on plans to reduce high utilization of services through appropriate support referrals and treatment planning.
What is different about the Integrated Health Home?
IHH optimizes person-centered and directed processes for planning and service delivery. Case managers will communicate with the PCP office if there are significant life changes and if the client sees a WCMHS provider for psychiatric medication management, an after visit summary will be sent to the PCPs office. As participants progress in their recoveries and strong therapeutic working relationships are formed, changes can be made to allow for more independence in accessing care, which fosters this person centered approach.
How’s it going?
The current pilot has 15 participants, and all but two have had, at a minimum, an initial appointment to establish care. The majority have begun being seen on a regular basis. Participants come from across the agency inducing the Community Support Program, the Center for Counseling and Psychological Services and Community Developmental Services. Many participants have been referred for testing or assessments that are long overdue. The current group is made up of 5 women and 10 men ranging in age from 25 to 60. Some of the medical conditions being treated are; hypertension, diabetes, fibromyalgia, hypothyroidism, Traumatic Brain Injury, seizures, spinal stenosis, migraines, obesity, addiction, back pain, sleep apnea, chronic pain and COPD.
In order to assess progress clients complete an initial depression screen that the PCP gives at a minimum annually. Case managers complete the Dimensional Client Assessment Scale on 6 month intervals and we will be giving a client satisfaction survey in the very near future. As we have just reached the 6 month mark for this project, we do not yet have data and are in the process of assembling outcomes. Informally participants have shared with their case managers how pleased they have been with the amount of time Marissa has spent with them understanding their needs and how helpful the support of case managers has been in managing anxiety over visits to specialists.
We are excited to see this work continue, and based on early results, the program holds real promise. We hope to see it expand to other primary care offices since mental health is health, and this program demonstrates the importance of treating the whole person and supporting our community partners to provide the best care possible to consumers.
For more information about the Integrated Health Home please contact Abigail Tobias at 479-4083.
Written October 2016
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