Center for Improving Value in Health Care
Aug 6, 2012 | 1 comments | Posted by
Integrated Care, Safety Net Clinics, Delivery System Redesign
Potentially preventing a teen from suicide by cleaning her teeth might seem like a far-fetched connection. But this was just one example of the power of an integrated team based approach to primary care at safety net clinics that was highlighted at this year’s Colorado Health Symposium. August commemorates clinics serving vulnerable populations through both National Health Center Week and Colorado’s Safety Net Clinic Week. In an effort to identify and promote effective, patient-centered delivery systems, CIVHC has learned that clinics like these that are treating the whole patient – mind, body and spirit – through a multi-disciplinary team approach are finding benefits they never imagined.
Traditional medicine treats distinct acute health care episodes or specific diseases. Most primary care physicians wouldn’t necessarily think of asking about your mental health if you came in to their office with a sore throat or to have your annual diabetic exam. That’s starting to change as health care reform efforts are testing new payment and delivery system models that shift the focus on improving outcomes and quality of care and financially rewarding providers for keeping patients healthy beyond the clinic walls. CIVHC’s inventory contains over 60 payment and delivery system initiatives in Colorado alone, and we hear about more efforts to improve the system almost daily.
Safety net clinics like Community-Funded Safety Net Clinics (CSNCs), Community Health Centers (CHCs), family medicine residency programs and others are working on innovative ways to provide excellent care to their patient population. These clinics serve a large proportion of poor, uninsured/underinsured patients that often have multiple chronic health issues and behavioral health needs.
Summit Community Care Clinic (SCCC), a CSNC in Summit County, Colorado, serves uninsured and underinsured low-income people in their community and surrounding areas. Their integrated care model includes screening for depression, anxiety and substance abuse for every patient, every visit, regardless of the purpose of the visit.
At the Health Symposium, Sarah Vaine, SCCC’s Executive Director, shared one of her “most proud moments” that demonstrates the power of integrated care.
“A few months ago, a 15 year old girl came into the clinic for a dental hygiene appointment. Like all patients at Summit Community Care, she was asked if there were any changes in her health history since her last appointment and also asked if there had been any changes in her mood in the last two weeks. She answered “yes” to the second question which prompted the dental assistant to provide her with a written questionnaire, the “PHQ-9”, a nine-item depression assessment tool. This young woman answered questions in a manner consistent with symptoms of depression and anxiety and also answered “some days” to the question about suicidal ideation.
All patients who fill out a PHQ meet with a staff member to discuss the answers and any time any patient answers yes to the question about suicidal ideation, a licensed mental health professional enters the exam room to do a safety assessment and offer services. In this situation, the patient indicated that things had been stressful between herself and her mother recently and that she was feeling so down about it that she sometimes thought she would be “better off dead”.
The therapist acknowledged the seriousness of her statements and expressed her concern and asked if the young woman would be willing to have a conversation with her mother with the help of the therapist. The patient agreed and the mother and daughter were moved to one of our behavioral health rooms where the daughter was able to share her feelings with her mother. Her mother was very upset and concerned and had no idea that her daughter was feeling so badly about their relationship. Both mother and daughter were offered counseling resources and they both felt better after discussing the difficulties between them.
It is our belief that if you do not ask the questions, you will not get the full picture of what is happening with the patient. The beauty of integrated care is that we ask the questions and then we make sure we are prepared for the answers.”
I believe that most primary care providers would agree that it makes sense to treat the whole person, not just the individual disease or acute episode. I’ve heard many providers say they often know there is more going on with a patient that is keeping them perpetually ill, but they don’t have the time or resources to identify or address underlying issues. Our current payment system just doesn’t support doing “deeper dive” assessments, making it difficult for clinicians to identify needs, much less be able to afford to have a multi-disciplinary team on staff at the ready to address concerns.
As mentioned, across Colorado new payment models and approaches to delivering care are being tested and implemented to support providing integrated care. The goal of these programs is to identify effective ways to deliver and pay for team-based care that save money and keep Coloradans healthy. For example, Rocky Mountain Health Plans’ Comprehensive Care Payment Demonstration is aimed at transforming the delivery system using advanced health information technology and integrating physical and behavioral health. For safety net clinics like Summit County that don’t get reimbursed for care because their patients are uninsured and can’t afford to pay, grant funding from local foundations is essential to be able to provide enhanced care coordination for their community.
August 20-24th is Safety Net Clinic Week for CSNCs and Rural Health Clinics, and August 5-11th is National Health Center Week. Please join CIVHC and others across the state in celebrating these clinics focused on providing high quality access to care for Coloradans most in need.
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