As such, tools were built in the EHR to alert the care team members to perform screenings at regular intervals. Tools to allow patients, along with providers, to document their goals for improving symptoms were also built. And workflows were created to allow for immediate outreach and to track outcomes and follow-up plans. But even then, it was not enough to just track and store this data. EBNHC needed a way to make the data actionable so it could ensure patients were not falling through the cracks. So IT leaders then built an interactive dashboard in the EHR that aggregates all of the data collected through workflows for review, administration and monitoring. This dashboard allows all members of the care team to view overdue screenings and then drill down for outreach.
The data that’s being captured, says Corey Hanson, director of clinical applications, includes: how many patients were being referred to a behavioral health clinician; out of all those referrals, how many led to a warm handoff; what percentage of patients referred that got the warm handoff had a depression assessment performed initially; and how many of those with the depression assessment have had a follow-up assessment within a certain time period. “With the dashboards and reporting, we can put reports in front of users proactively to tell them what patients are due for follow-up assessments,” says Hanson. “We capture all of this data from a department perspective, compare pediatrics to family medicine, and to the whole organization, and when it spreads to the adult population, eventually we’ll be able to compare all departments together,” he says.
Hanson says he quickly realized how much of a need there was for EHRs to be able to support a behavioral health program. Most EHRs are good at the clinical side of life, but have less functionality available for the behavioral health side, he notes. “As we started to put this together to see our numbers and what teams were asking for in terms of tools for support, it really became obvious that what we were doing would improve clinicians’ lives which we hoped would directly improve patients’ lives.”
While there increasingly are more models and approaches to integrating behavioral and primary health, such integration has been difficult to achieve enterprise-wide. Mancusi says that in a primary care environment, philosophically it makes great sense to integrate, but “changing hearts and minds, and making the shift culturally that is necessary, is no easy thing on either end.” He adds, “People are finding themselves as key team members despite being trained on one side or the other. In order to support that adoption, we have to provide good solid evidence of change, and this makes a big difference in peoples’ lives.”
To this end, Mancusi calls for the creation of models that can be replicated nationwide. He gives an example of behavioral health clinicians, including psychiatrists, being embedded into a primary care practice, and making everyone team members using the core practices developed. “We say the basic principle behind the warm handoff is that most of these kids have great relationships with the pediatrician. But the kids and their families are reluctant to come see the behavioral health clinician, so in the model we leverage that relationship that the pediatrician has with the child and the family. The behavioral health doctor is now being described in the warm handoff as a colleague or team member,” he says. And what does that do? Mancusi says it better ensures the visit will take place and much better ensures a follow-up visit. “With our population, these kids and their families will come in during crisis, and of course life goes on after the visit, so they don’t come back. But because of this model and the alerts that are built into the system, we can follow up on the kids we are concerned about and track progress over time,” he says.
The model that EBNHC has developed wasn’t entirely from scratch, either. The health center worked very closely with Cherokee Health Systems in Knoxville, Tennessee, whose behavioral health integration model is considered a blueprint for others to replicate. As such, EBNHC sent 22 individuals from its organization to Knoxville to witness Cherokee’s integrated care model training. In that group there were clinical leaders, physicians, administrative leaders, and behavioral health clinicians, Mancusi recalls. “What’s fascinating about them is that they began as community mental health organization, and then added primary care. So on a national level they know a lot about [integration]—maybe the most of any organization in the U.S.,” Mancusi says. “That’s the model we have built ours around, and also other models that feature the warm handoff. But Cherokee is where we started from,” he says.
Nonetheless, Mancusi still notes that one of the biggest challenges for the health center was actually getting clinicians to see the value in the warm handoff. “Providers are naturally very busy, so to interrupt them when they are already behind is tough, but it’s necessary in order to really do this right. The behavioral health and medical providers have to meet together about the patient, and meet briefly with the patient together, to endorse the purpose and to talk about the symptoms. And then the behavioral clinician needs to meet with the patient, initiate care, and in the best of all possible worlds, goes back to the medical provider for a reverse handoff,” he explains. This “purist model” can be hard to pull off, Mancusi admits. “People have to be convinced of the value added,” he says.
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