Grant Partners

The Department of Family Medicine and Community Health (FMCH), operates primary care practices in which Family Medicine residents are trained alongside clinical health psychology trainees. The development of the integrated behavioral health curriculum and clinical practice has been guided by Alexander Blount, EdD, a nationally recognized leader in advancing integrated primary care. The Center for Integrated Primary Care (CIPC), which he established and runs, is a resource that most of the applicants for this grant have utilized for training their team members. This grant supports integrated care in two of the three family practice residency sites – Hahnemann Family Health Center in Worcester and Barre Family Health Center in the East Quabbin region – and the efforts to use data to assess and improve the role of behavioral health in these practices. Both clinics screen for depression using the PHQ-9, as well as a ten item audit for screening for anxiety, PTSD and physical pain.  The centers have had behavioral health clinicians practicing in the clinics for the past 20 years. In the past four years, these practices have coalesced into more organized integrated models that are leveraging their co-located services to deliver patient-centered care.  Each center has NCQA recognition as Level 3 Patient Centered Medical Homes, and both are participants in the state’s Primary Care Payment Reform Initiative (PCPR).

Healthy Lives:  Brookline Community Mental Health Center will serve 200 low-income adults living in Brookline or Boston who present with serious mental illness (schizophrenia, bipolar disorder, major depression, severe anxiety, or PTSD) and at least two chronic medical conditions (including diabetes, cardiovascular disease, or COPD).  The health center will engage patients in their care, help them coordinate the services they receive, provide wellness interventions, offer disease management programs, home visits, and individual and group counseling. The intent of the project is to help patients move from passive recipients to active participants in their health care and by doing so, reduce cost and improve quality.

Dimock’s approach to delivering integrated care is to focus on interventions designed for specific patient segments – pediatrics, adult medicine, and OB/GYN. Integrated care practices are at different levels of maturity, with pediatric integration having begun in 2011, adult medicine in 2012, and OB/GYN in October 2013. The health center has more 14,000 patients, and expansion of integrated care to adult medicine and OB/GYN marks the launch of routine screening for depression of all patients with the PHQ-9 instrument. As part of universal prevention protocols, patients with no initial behavioral health symptoms will have periodic screenings during medical appointments. Those at risk will receive appropriate behavioral health approaches through co-management with primary care providers (PCPs) and resource coordinators (RCs). Others will require basic interventions, such as peer specialist-led groups for brief episodic interventions from the behavioral health team. Those patients with a mental health disorder will receive treatment from the full behavioral health team (Medical Social Worker, psychiatrist, therapist, and/or substance use clinicians), in partnership with PCPs and RCs. The integrated team will coordinate care with external specialists for patients with severe mental illness who require subspecialty, intensive or home-based care.

CHL is the largest provider of mental health, substance use disorders and homeless services in Central MA, serving more than 19,000 unique individuals each year. In October 2010, CHL received a four-year SAMHSA grant to implement the Primary and Behavioral Health Care Integration (PBHCI) program to improve access to and engagement in primary care and wellness services for more than 400 adults seeking mental health and substance abuse treatment at CHL. To meet these service needs, the Wellness Center was developed at CHL wherein primary care physicians, nurses, nurse case managers and peer specialists delivered medical care and a variety of wellness interventions for adult consumersbetween the ages of 18 and 72 with behavioral health needs. Key goals of the initiative are to continue to enhance (a) care coordination and communication between the providers at the Wellness Center, the CHL outpatient clinic, and those in the community who provide other types of services to CHL consumers, and (b) electronic health record infrastructure and processes.   

CHC of Cape Cod is a patient-centered medical home that has organized its 15,000 patients into primary care teams consisting of physicians, nurse practitioners, nurses, behavioral health counselors, and non-clinical support personnel for the purposes of providing comprehensive integrated care. The health center is implementing a center-wide risk stratification system to identify the most at-risk patients. They are utilizing a combination of national best practices and center-designed tools to identify patients with significant behavioral and medical health co-morbidities, uncontrolled chronic diseases, increased risk for hospitalization, and a history of frequent ED visits. This grant will help support the full implementation of the risk stratification process, and a Complex Care Management program, which a RN has recently been hired to lead. Patients with such indicators as CVD malignancies, positive M3 screens (screens for depression, PTSD, anxiety, bipolar disorder, suicidal thinking, and functionality), a positive SBIRT screen, active drug or alcohol dependency, frequent hospitalizations, difficulty with medication management, and other issues will be treated through the Complex Care Management program. Other patients with lower risk indicators will receive individualized care management from their usual providers and the integration teams, as described above.  Integrated care teams will design care plans with the active involvement of the patient and their family members; progress and follow-up plans will be documented. When a patient with complex behavioral health needs is referred to another community partner (e.g. Gosnold, Bayview, Falmouth Hospital, Cape Cod Behavioral Health), the health center tracks to see if the patient schedules an appointment, and requests a ‘release of information’ to include in the patient’s EHR for better continuity of care.