Grant Partners

Lynn Community Health Center (LCHC) has developed and implemented a fully integrated primary care and behavioral health program with (a) the co-location of services, (b) co-management of patients by the medical and behavioral health providers through a ‘shared care’ model, and (c) utilization of a shared EHR. There are five integrated health teams, each with five to nine primary care providers of various types (i.e. family medicine, internists, nurse practitioners, etc.), two to three licensed behavioral health therapists, a psychiatrist or advanced practice psychiatric nurse practitioner to work with the PCPs in prescribing psychotropic medications, and clinical assistants and nurse case managers for care coordination and management of complex patients with multiple co-morbidities and high ED utilization. The health center has a fully integrated EHR with complete patient information available to all providers involved in a patient’s care. Screening tools, including PHQ-2, PHQ-9 and SF-36 are templates in the system. This allows for tracking a patient’s screening scores, and data reporting for quality improvement and evaluation. LCHC utilizes the Quality Improvement (QI) process to identify issues and opportunity for improvements, which are presented and discussed at Integration Team meetings. A team is then designated to undertake a QI project to clarify the problem, utilize the available data to measure the impact of proposed changes, and test the changes using Plan-Do-Study-Act (PDSA) cycles. Successful solutions are then spread throughout the other Integration Teams for adoption as a best practice. This model allows patients to access behavioral health services through their primary care team, effectively reducing the barrier of stigma and ensuring timely access to appropriate 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. 

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.