Linking Primary Care & Behavioral Health
By CINDY SANDERS
Centerstone Takes a Whole-Person Approach
As healthcare increasingly sheds its silos, the concept of integrated care has gained rapid popularity. After all, most providers readily recognize individuals are more than just the sum of their parts. Comorbid conditions, transitions in care, medication interactions, cultural beliefs, environment, and support systems all have a direct impact on an individual's health and well-being.
An early adopter of the health home model, Centerstone continues to refine their whole-person approach. Mandi Ryan, MSN, RN, director of Healthcare Innovation for Centerstone of Tennessee, said coordinated care is important for everyone, but even more so for those with mental illness.
"Research shows individuals with severe behavioral health illness are dying 25 years younger than the general population, and it's often not related to their behavioral health condition."
Instead, undiagnosed and unrelated medical conditions greatly impact those with serious mental illness (SMI). The most recent research shows 68 percent of those with SMI also have a physical condition (or multiple conditions) ranging from cardiovascular disease and hypertension to asthma and obesity. Barriers to primary care - along with the obstacles inherent in a complex, fragmented health system - exacerbate the problem for those trying to navigate life with mental, emotional and behavioral challenges.
"In a health home, you have to focus on care coordination," she stressed. She said it is critical to communicate across disciplines so that each provider knows the various treatment plans, particularly because some medications to address mental health issues put individuals at higher risk for other conditions such as increased blood pressure. Improved care coordination was one of the reasons Centerstone partnered with Unity Medical Clinics four years ago to have primary care and behavioral health providers under one roof.
In addition to improved outcomes, the whole body approach also helps get a handle on costs. Care for conditions like hypertension and diabetes cost two to four times as much for patients with diagnosed mental illness and substance abuse compared to individuals without those issues. Coordinated care can bend the cost curve by keeping chronic conditions better controlled.
Ryan, who has been with Centerstone for a little more than three years and in her current post for just over a year, has a varied clinical background. A nurse, she has worked in primary and critical care, in the corrections system, and for an inpatient psychiatric facility. She has found that diversity of experience is beneficial in her current role. "It gives you an idea of all the different kinds of healthcare and how they integrate and why you can't have the silos we've had in the past," she explained.
Centerstone has several health home grants and coordinated care projects. One of the most recent initiatives is Health Link, a program rolled out in December 2016 by Tennessee Health Care Finance & Administration for TennCare members with significant behavioral health needs.
Having applied and been approved as a Health Link provider, Ryan said Centerstone's model includes a registered nurse as the lead care coordinator who works with a number of other specialty staff including wellness coaches, primary care providers and mental health providers to meet an individual's needs. Supportive services include comprehensive case management, care coordination, health promotion, transitional care, patient and family support tools, and community referrals to social supports.
"One of the things the state provided to us is a care coordination tool," Ryan noted. She said the team is alerted if an enrolled patient goes to the hospital, which allows Health Link providers to make sure individuals understand discharge instructions and get appropriate follow-up care. Ryan said a key goal is to try to prevent hospitalizations and readmissions, along with teaching the appropriate use of the Emergency Department.
"We've been able to see results behaviorally and on the medical side, as well," she said. Participants have reduced blood pressure and cholesterol levels and improved diabetes control. "Participants have also reported decreases in depression and anxiety and an overall improvement in well-being," she continued.
At enrollment, Centerstone does baseline measures to be able to track outcomes. Interestingly, Ryan said 35 percent of participants self-reported they had diabetes or had been told they had elevated blood sugar. However, when individuals were actually tested, 77 percent had diabetes or pre-diabetes. "A lot of our individuals just weren't having those yearly screenings you really need to have," she said of keeping chronic conditions in check. And, she continued, "It's been shown that diabetes is linked to depression ... you improve one area, your behavioral health improves, as well."
While Health Link is a specific state program, the success of this and other Centerstone integrated health grants and programs has led Ryan and colleagues to actively work to expand the health home model to other populations in order to improve overall health while reducing expenses. That, she said, is the classic win/win for all involved - "Improving quality can save costs."