Grant Partners

CHD has created a project in partnership with two health centers to provide integrated care to seriously mentally ill adults and individuals with substance use disorders. The health centers – Caring Health Center of Springfield and Holyoke Health Center – provide integrated primary care, care management and wellness services, and the Western MA Recovery Learning Community provides peer-guided wellness groups and peer specialists.  The largest cluster of patients is within the Department of Mental Health funded Community-Based Flexible Supports (CBFS) program, identified as ‘super-utilizers’ with high rates of avoidable ED visits. The program provides primary care services to people with serious mental illness on site at a CHD community mental health center, with a focus on patients with diabetes, pre-metabolic syndrome, and high-risk for cardio-vascular disease.  Chronic disease management and wellness programs are provided by primary care nurses and peer specialists, and patients involved with the integrated care program experience reduced wait-times when seeking medical care at the respective health centers.

The CHA Collaborative Practice Model was developed in 2011 to support children with mental health and substance abuse treatment needs at the Windsor Street Clinic to test the concept that greater and earlier integration of care would improve their physical health. The program is focused on: improving behavioral health services for at-risk children and adolescents by providing timely access to culturally competent evaluation and treatment; enhancing integrated care between pediatricians and mental health providers, including increased understanding of unique family cultures and social dynamics that impact the child’s health; improving family engagement in behavioral health treatment, and building better communication between providers and parents; providing greater outreach and follow-up processes with the children and their parents, through outreach from and involvement of two tri-lingual family support specialists;  reducing unnecessary expense associated with treatment delays or poor quality of care; and, expanding the integrated care model throughout other clinics in the CHA system.

Vinfen is two years into a three-year Center for Medicare & Medicaid Innovation (CMMI) grant to develop Community-Based Health Homes (CBHH) for individuals with serious mental illness to integrate their primary care and behavioral health and address the disparities experienced by the population.  The Vinfen CBHH model achieves close collaboration approaching an integrated practice by embedding nurse practitioners  (NPs) – provided by Commonwealth Care Alliance (CCA) and backed by their primary and specialty medical care – into established Community-Based Flexible Support (CBFS) and outreach teams, funded by the Department of Mental Health. Vinfen has partnered with Bay Cove, North Suffolk and Brookline Community Mental Health Center to create the CBFS teams where the embedded NPs carry a caseload of up to 40 very medically complex adult patients. The NPs are supervised by CCA’s clinical director and behavioral health is provided by the above-mentioned partners with Vinfen also serving as the overall project coordinator for this integrated care model.The teams all include Health Outreach Workers (HOWs) that are employed by each of the community behavioral health providers. They assist the NPs with care coordination and wellness management. The use of an innovative telehealth technology system called Health Buddies allows remote monitoring of psychiatric and medical conditions, and increases the efficiency of the NPs. The HOWs train and support the clients in the use of the telehealth system and assistance with self-management. The program utilizes the Integrated Illness Management and Recovery (IIMR), a health self-management program that incorporates evidence-based health and wellness practices with psychiatric recovery interventions.

The Boston Medical Center (BMC) Campus Clinic of the BHCHP opened in 2008 and serves more than 4000 patients each year; 72% of whom had at least one mental health diagnosis and 77% of whom had either a diagnosis of substance use disorder or a history of overdose. Since opening this site, BHCHP has focused on coordinated care across disciplines and has co-located primary care and behavioral health services. Behavioral health clinicians and psychiatrists are embedded in primary care to promote ease of access for patients, reduce stigmatization, and enhance the level of consultations across disciplines. Behavioral health clinicians have created dedicated “open access” appointments to accommodate referrals from primary care, same-day appointments, and walk-ins.