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.
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.
Leslie Scherl, M.D., pediatrician at EBNHC, adds that when this model was introduced, there was pushback. “There is a sentiment here that if something is hard to do, we pretty much just tell the primary care providers to do it,” Scherl says. “But I do feel that those of us who can utilize these services now see how beneficial it is. Like everything else you have early resisters, early adopters, and people in the middle.” Scherl notes how the benefits are seen on the patient side as well, as they often lead chaotic lives so getting to see clinicians on both sides in the same day “can be amazing.”
A Worthy Endeavor
Six months into the project’s launch, the health center was able to increase its screening capture rate by 53 percent due to the alert and screening tools being available to the entire team. Also during the first six months, EBNHC was able to provide 233 warm handoff visits.
Chris Ascencio, behavioral health program manager, notes, “We have seen a much higher rate of completed appointments with this project as well, so [that means] the amount of patients served in behavioral health has increased dramatically in this program.” All of the project’s leaders especially touted its potential impact on the identification and treatment of behavioral health in adolescents and its likely positive impact on the rate at which patients return for critically needed follow-up visits after an initial warm handoff.
Indeed, EBNHC’s own internal data indicates a return rate of approximately 80 percent following a warm handoff whereas the return rate without one is approximately 30 percent. “It is not enough to build tracking tools and workflows; we need ways to ensure that these patients are not lost to care and with our dashboards we will be able to closely monitor future follow up and improvement based on interventions,” Rogers says, adding that the goal is to increase the number of patients seen for behavioral health within primary care by 10 percent in the first year as well as a reduction of 20 percent in PH9 scores (a depression test questionnaire) for follow-up screenings.
Mancusi references NIMH [National Institute of Mental Health] statistics which found that approximately 13 percent of children ages 8 to 15 had a diagnosable mental disorder this past year. “The data compellingly justifies the need to create programs such as ours embedded within the pediatrics team to together identify and treat this cohort in an effort to change lifetime outcomes,” he says.