Enhancing Primary Care for Mental Health Patients – at a Lower Cost
Intermountain Healthcare, a non-profit integrated healthcare system with 22 hospitals in Utah and Idaho, has had a long-established clinical integration structure, which enables physicians, nurses, and medical assistants to collaboratively treat most patients with chronic illnesses. However, doctors in primary care often struggle with the burden of demand. In particular, these physicians felt ill-equipped to meet the needs of patients with co-occurring mental health conditions.
To address this issue, over the past decade, Intermountain has introduced a new model of mental health integration (MHI), radically changing the way in which primary care is delivered by improving coordination of services between the various parties involved. As of early 2010, the program has been implemented in over half (69) of Intermountain’s 130 primary care clinics. A leadership team has been established at each regional site to design, implement, and evaluate the program across all clinic sites.
Enhancing Primary Care for Mental Health Patients – at a Lower Cost The introduction of an integrated model of care has brought considerable benefits to patients, their families, healthcare providers and community partners in the US states of Utah and Idaho. By focusing on routine primary care for patients with mental health conditions, Intermountain Healthcare has achieved demonstrable improvements in quality with financial savings.
Patients treated in mental health integration (MHI) clinics have a lower rate of growth in charges for all services, with savings of 30% to 80%. In addition, the number of emergency visits for depressed patients fell by over half. The program places mental health at the heart of primary health care and is being replicated by local community health clinics in several other states.
Intermountain Healthcare is a non-profit integrated healthcare system with 22 hospitals in Utah and Idaho. It has more than 2900 affiliated physicians, 700 of whom are employed with the medical group. Intermountain also has over 130 ambulatory care practices and its own health plan.
The group’s long-established clinical integration structure enables physicians, nurses and medical assistants to collaboratively treat most patients with chronic illnesses. However by the late 1990s it became clear that doctors in primary care were struggling with the burden of demand. In particular these physicians felt ill-equipped to meet the needs of patients with co-occurring mental health conditions. Dealing with such patients is inevitably more complex and often involves their wider families.
Over the past decade, Intermountain has introduced a new model of mental health integration (MHI), radically changing the way in which primary care is delivered by improving coordination of services between the various parties involved. As of early 2010 the program has been implemented in over half (69) of Intermountain’s 130 primary care clinics. A leadership team has been established at each regional site to design, implement, and evaluate the program across all clinic sites.
How the program works
When a patient arrives at the primary care clinic he or she automatically receives both a physical and mental health assessment via a questionnaire. This helps the primary care physician, the patient, and their family to identify and determine the nature and extent of any mental health problem, classified as:
- Mild: requiring routine care with care management or peer advocacy
- Moderate: requiring care management with additional mental health support from a mental health specialist or peer advocates within the team
- Severe: requiring direct consultation with a mental health specialist and support from all team members.
The assessment also notes how much support is available to a patient and family to help them manage their chronic condition. Keeping everyone informed is vital, so information is exchanged routinely between all members of the team including patient, families, and specialized mental health providers. The team has a number of common tools available and results are reported centrally, which encourages consistency of practice based upon evidence. As Brenda Reiss-Brennan, the Director of MHI observes: “Standardized assessment tools and meaningful data really drive the clinical decision making that is matched to the appropriate level of team resource.”
Such a team-based approach considers the needs and satisfaction of all parties involved: patient, family, physician and staff, ensuring:
- True integration: mental health becomes a fundamental feature of primary health care and is accessible to all patients, regardless of complexity of condition or financing. A mutually agreed treatment plan reflects the assessments and any observed problems
- Real support to physicians: although patients and their families are the focus, the program also recognizes the challenges facing doctors, both in terms of work load and complexity
- All contributions are acknowledged: reflecting the involvement of all members of the team in improving the quality of care, including the patients, carers and community members
The importance of training
A vital feature of Mental Health Integration is a standardized ongoing training program. This is offered to all team members, with dedicated implementation specialists and analysts working alongside to achieve continuous quality improvement. There are five key components of mental health integration:
- Leadership and cultural integration: to identify and integrate leadership ‘champions’ — people with mental health and medical backgrounds — to provide institutional commitment and accountability for the integration goals
- Workflow integration: training all staff from different provider backgrounds to work together as a team in the primary care setting, utilizing standardized clinical tools and creating complementary team roles. This also helps change the culture, reducing the stigma associated with mental health conditions and helping people identify the physical symptoms linked to such conditions
- Information systems integration: a secure, centralized data repository for data enables all team members to access and update clinical and financial records and communicate with each other. This creates coordination between clinic administrators, physicians, nurses, and medical assistants, bringing greater continuity in patient and family care. Patients also have the facility to email their primary physician.
- Economic and financing integration: linking clinical and financial outcomes brings together payers and providers, giving a comprehensive overview of all financial costs in the context of improved quality
- Integration with the community: one of the most challenging and critical aspects of integration, this training encourages members of the community to become active partners with the MHI team and leaders and offer enhanced community support to patients and families beyond the clinic.
Continuous improvement is a key objective, according to Dr. Charles Sorenson, CEO of Intermountain Healthcare: “… our organization sets goals around six dimensions of care — clinical care and service, physician and employee engagement, operational excellence and community stewardship. What is so promising about the Mental Health Integration initiative is the opportunity it gives us to demonstrate benefit and add value in virtually every one of these dimensions.
The model developed by Intermountain Healthcare is now being taken up by local community health clinics across the US in Mississippi, Maine, New Hampshire, Oregon and Utah.
Intermountain Healthcare is now internationally recognized as a high performing system, with US President Barack Obama, speaking at a recent 2010 joint session of congress on healthcare, citing the organization as offering “high-quality care at costs below average”. Evidence of this can be found in improved physician, staff and patient satisfaction, lower costs and better quality outcomes.
A more robust evaluation carried out in 2009 aimed to understand the impact of the MHI on quality (as measured by reduced in-patient admissions and emergency room visits) and cost (measured by allowable charges to the health plan). These findings are published in a 2010 edition of the Journal of Healthcare Management:
- Lower average growth in patient charges:
Patients treated in an MHI clinic have a lower rate of growth in charges for all services (with the exception of outpatient psychiatry charges, and prescriptions for anti-depressants, indicating more timely treatment and referral) – In the 12-month period following diagnosis average patient charges increased by 73% for MHI patients compared with 100% for usual care clinics patients – Patients with one other diagnosis in addition to depression had only an 8% increase in average charges in the 12-month period following initial diagnosis, while similar patients treated in a traditional care clinic have a 90% increase – For all levels of complexity (mild, moderate and severe) and overall, patients with depression treated in a MHI clinic cost less in the year following their diagnosis than those treated in usual care clinics. The rate of growth of expenses was $405 US less than for patients in the traditional care group — a 10% reduction – In the 12 months following diagnosis of depression, the 429 patients in the traditional care group in the study would have saved almost US$300,000 in charges, had they been treated in an MHI clinic
- Lower utilization of emergency room services:
Depressed patients treated in MHI clinics are 54% less likely to have emergency room visits than depressed patients treated in non-MHI clinics
As Dr Linda Leckman, CEO, Intermountain Healthcare Medical Group, explains: “Physicians not only have a higher level of sensitivity to mental health issues, they are more confident in their own ability to provide care because they have these resources at hand. So it not only results in better care for the patient, but higher physician satisfaction as well.”
- Interview with Brenda Reiss-Brennan, Mental Health Integration Director, Intermountain Healthcare Medical Group, February 2010
- Conis, E  A model for mental health integration. Health Policy Monitor, October.
- Reiss-Brennan B et al [forthcoming] Cost and quality of Intermountain’s Mental Health Integration Program Journal of Healthcare Management
- Health Policy Monitor  USA/Utah: Mental health — from isolation to routine healthcare www.HealthPolicyMonitor.org
Keywords: behavioral health, care coordination, care teams, clinical integration, cost, EMR, electronic medical records, evidence-based medicine, health information technology, Intermountain Healthcare, mental health integration, prevention, Salt Lake City, Utah, safety, treatment, value
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