"Bright Spots" are stories about successes. Originally used as a reporting tool, we are sharing them now to highlight the great work being done by our staff and our partners. This month's Bright Spot was written by Glenda Meeks, P²'s Clinical Care Coordination Manager.
Bright Spot: the Integrated Care Coordination Pilot
Can you explain the pilot to us?
Supported by The Peter and Elizabeth C. Tower Foundation, the Integrated Care Coordination Pilot is designed to test the efficacy of a care coordination model in primary care settings, specifically for young adults (age 18-26) with depression and a history of substance misuse. The goal of this initiative is to implement a care coordination model to improve outcomes for individuals who participate in the Integrated Care Coordination Pilot, by incorporating universal screening for depression and substance abuse in primary care, using evidence-based tools such as the Patient Health Questionnaire (PHQ-9) and Screening Brief Intervention and Referral to Treatment (SBIRT). This care coordination model includes a care coordinator and a community health worker shared among the three primary care sites: the Community Health Center of Niagara Falls, a Federally Qualified Health Center; Mount St. Mary’s Neighborhood Health Center and Niagara Falls Memorial Primary Care Clinic (both hospital-based primary care clinics).
What was the problem or issue you were trying to solve?
The City of Niagara Falls is plagued by high rates of behavioral health issues: number of poor mental health days reported; smoking; and heavy and binge drinking amongst adults, according to the most recent Niagara County Community Health Assessment. The cost of behavioral health care can be taxing to the health care system. A review of hospital utilization data from the two hospitals in Niagara Falls, which are linked with two of the primary care practices in this initiative, revealed that “super utilizers,” or patients who frequent the emergency department (ED), often have co-occurring medical, behavioral health and substance abuse diagnoses.
There is strong evidence that effective care for common mental health problems such as depression and anxiety, can be delivered in the primary care setting. This care, when combined with coordinated support, results in improved access to treatment, quality of care, and health outcomes. As such, P² facilitated the implementation of an integrated, collaborative patient-centered care model in primary care to serve young adults with behavioral health needs in the three primary care sites in Niagara Falls.
What successes have you had so far? What results?
In partnership with the primary care pilot sites, the integrated care coordination model has been successfully implemented in two of the three primary care sites. The two practices have reported that the implementation of the care coordinator and community health worker model has:
Describe the outcomes, value, results, impact of this project.
During the first quarter, 87% of eligible patients were screened for depression and/or substance misuse. Of those patients, 55% screened positive for depression and/or substance misuse in the initial screen. Using the PHQ-9, 36 % were positive for depression and 41% screened positive for substance misuse using the AUDIT or DAST. Additionally, 27% received a brief intervention (BI) by the care coordinator and 22% were referred for behavioral health or substance use disorder treatment. In addition to carrying out the screenings, the Care Coordination Team currently has a case load of 48 patients. Many of these patients that make up this caseload may likely not have been identified or managed appropriately if it were not for the implementation of the integrated care coordination pilot and the work of the care coordination team in the primary care setting.
In addition to the quantitative successes of the program to date, there have also been a number of anecdotal successes. One example occurred during a routine office visit for a patient who screened positive for moderate depression. The care coordinator was concerned about the patient and discussed the case with the provider. As a result of that conversation, the provider provided an in-depth evaluation of the patient and determined that an emergency intervention was necessary. The patient was transferred immediately via ambulance to an appropriate level of care and is currently in treatment for depression and substance misuse.
Care Coordination support has proven to be a valuable resource in the primary care setting. The care coordination team worked collaboratively with staff at each site to enhance office work flow and increase screening rates for depression and substance use, striving to improve behavioral health care by integrating it into the primary health care setting. Sharing of best practices between the two sites has provided learning and opportunities for improved quality of care.
What advice do you have for others implementing similar programs?
Planning and education is essential: It was critically important to have key stakeholders like the front-line staff involved with planning the pilot. This includes defining processes, protocols and procedures for workflow, hand-offs and referrals. For sites that are sharing a care coordinator and community health worker, recognize that each primary care site functions differently and adjust plans accordingly.