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.

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.

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.