Isolated from metropolitan Boston by water and tunnel, East Boston Neighborhood Health Center (EBNHC) is no stranger to improving health access and outcomes for underserved populations in the greater Boston area. Indeed, for 45 years, the federally qualified health center (FQHC)—one of the largest of its kind in the U.S. with a yearly visit volume of 294,000 serving over 66,000 patients—has been caring for a mostly lower-income patient population, and has more recently grown up to meet the needs of a constantly changing diverse community, which currently consists of mostly Latino immigrants.
The health center is a primary care facility with various departments including: adult medicine, pediatrics, family medicine, OB/GYN, an entire specialties practice, a chronic disease management program, and a behavioral health integration (BHI) program. Needless to say, senior leaders at the organization recognized early on that it needed to become an early adopter in health IT; EBNHC has been live on its electronic health record (EHR) since 1998.
What’s more, since 1976, EBNHC has provided onsite mental health services without interruption to this culturally diverse, at-risk population challenged by many social determinants of health. But that has not been easy to accomplish; all across the nation, health centers have been changing how they offer mental health services, of which conditions are extremely common, leading to healthcare costs of $57 billion a year, on par with cancer, according to 2014 data from The Commonwealth Fund.
Traditionally, patients have had to get a referral from a primary care provider to then see a mental health counselor in another department or location. But according to EBNHC officials, “That system doesn’t really make sense, because the body and the mind are connected. In order to be healthy, we need to treat the body and mind together.” This basic concept is supported by the Affordable Care Act (ACA) and the Massachusetts Chapter 224 health reform act, which both state the importance of including of behavioral health in primary care, the organization attests.
All About Integration
In December 2015, EBNHC was awarded a three-year grant from the Blue Cross Blue Shield of Massachusetts Foundation to be applied towards improving the effectiveness of its behavioral health integration program. As Michael Mancusi, chief behavioral health officer and practicing behavioral health clinician at EBNHC says, many organizations have a “co-located” behavioral health model, meaning behavioral services are in the same building as primary care services but are not necessarily fully integrated in terms of behavioral health clinicians and medical providers being team members. EBNHC also leveraged the “open access” model in which a patient on a primary care visit who had a mental health need could possibly see a behavioral health physician on that day—if someone was available.
Mancusi says, “We wanted to improve access and outcomes for both behavioral health and primary care patients, knowing perfectly well the behavioral health need is incredible—both here and nationally—but the rate at which people do follow through with the care is not very impressive. We know from the data that exists, that when the medical provider is involved, the rates of follow-up go up enormously and therefore outcomes improve,” he says. Mancusi adds, astoundingly, “That’s one of the biggest innovations here; we have integrated behavioral health into primary care and have shared the same medical records since the beginning.”
Indeed, EBNHC’s BHI program transitioned from an open access/co-located model to a fully functioning BHI program in December 2014. Within the program, each primary care department has an integrated behavioral health consultant. “We didn’t want patients who were coming in for a primary care visit to wait a month to see behavioral health provider,” Mancusi says.
Officials say that a key strategic initiative is to scale to the appropriate level of behavioral health services such that EBNHC can appropriately meet the clinical demands and needs of its patient population. The health center started its work specifically for the grant in January 2016, choosing to focus on the expansion of behavioral health services for children and adolescent patients, ages 5 to 21.
Key leaders of East Boston Neighborhood Health Center who worked on the organization's BHI project
The core goal of this project, recognized with a third-place finish in Healthcare Informatics’ Innovator Awards program this year, is the identification, treatment, management and outcome measurement of children and adolescents with depression and anxiety. Early on, organizational leaders knew they needed a method to ensure depression screenings were completed on a regular basis, that patients received consistent follow-up care, and that the health center provided the appropriate level of behavioral health care at the point of service in primary care.
“We felt like we needed a way to be able to able to track the cohort of patients and also to be able to alert everyone on the care team that there were certain screenings to do for those patients,” says CIO Laura Rogers. “We needed a way of using the EHR to alert physicians if a warm handoff [which EBNHC refers to as a referral and a conversation about the patient between the referral doctor and the behavioral health doctor] was needed between primary care and behavioral health specialists. These were the two areas we needed to focus on,” Rogers says.
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