SIM practice transformation series

This is the first interview in a series with Colorado State Innovation Model (SIM) practice transformation organizations to illustrate the work SIM practices are doing to integrate behavioral health and primary care.

See also: Part 2 I Part 3

Practice transformation: A personal journey for healthcare professionals

By Heather Grimshaw

One of the first things that BJ Dempsey, practice facilitator, HealthTeamWorks, does before she talks with healthcare teams about integrating behavioral health and primary care is to learn whether they have lost patients to suicide.

“I’ve found that it turns the tide,” says Dempsey, who has five years of experience as a practice coach. “If the practice has lost someone to suicide it’s very upsetting to the staff and they’re motivated to doing something, even if it’s not perfect.”

That something is to start integrating behavioral health and primary care to ensure that patients get the help they need when they need it. HealthTeamWorks is one of 25 practice transformation organizations for the Colorado State Innovation Model (SIM), a federal initiative funded by the Centers for Medicare & Medicaid Services.

Integrating behavioral health and primary care can take different forms as illustrated by the first cohort of SIM practices and community mental health centers that started their work in February. The group represents a sliding scale of integration efforts, which can start with screening patients for depression and other behavioral health issues and culminate, for some, with hiring a behavioral health specialist, who works in the clinic to support providers and ensure patients get the care they need when they need it.

SIM, which will work with 400 primary care practices and four community mental health centers integrate primary care and behavioral health, supports the delivery of whole-person care.

Statistics show that 45% of the people who commit suicide have seen a primary care physician within a month and 20% have seen a primary care physician within 24 hours. Recognizing an opportunity to help these patients at these critical junctures is a powerful impetus for integration, say practice coaches.

“There is a real need for this type of intervention,” Dempsey explains. If a practice has a history of a patient committing suicide [and many do] the staff remembers the patient. It’s personal, she adds.

And while many practice professionals recognize a need to intervene, one of the biggest barriers is apprehension and some fear, explains Emilie Buscaj, MPH, PCMH CCE, program manager, HealthTeamWorks.

“A lot of providers are nervous” to ask questions that might lead in a direction they’re not comfortable with or do not have the training or time to address, she adds. Most “don’t feel comfortable having conversations about depression, anxiety and substance use. They want more opportunity to follow-up on those issues but they’re not getting paid to do that and don’t have the ancillary staff who have the training and skills” in fee-for-service environments.”

In addition, many clinicians also do not know about community resources that can help address behavioral health issues, Buscaj explains, yet many appreciate the fact that behavioral health issues can cause, contribute to or exacerbate physical health issues.

This is one of the reasons why SIM helps providers test value-based reimbursement models that reward patient outcomes. It is also why the initiative provides myriad supports that help extend access to behavioral health resources in communities across the state.

Coaches, who visit SIM practices twice a month on average, help care teams analyze and improve processes, use data to identify areas for efficiency and prepare for value-based reimbursement. They initiate and facilitate discussions about how to provide integrated, patient-centered care.

“One of the things SIM accomplished is putting a spotlight on the behavioral health part of things,” says Jen Miller, practice improvement consultant, HealthTeamWorks, who says some practices need basic help with team huddles while others are ready to create risk-stratifications for patient panels.

In addition to practice coaches, who help care teams identify more efficient ways to operate, SIM provides practices with the following supports:

  • Clinical health information technology advisors, who focus on the optimization of technology
  • Regional Health Connectors, who identify community resources that practices can use
  • Continuing education
  • Small grants to support infrastructure changes
  • A partnership with local public health agencies that widens the scope of integration efforts
  • A partnership with the Colorado Multi-payer Collaborative to align SIM metrics and assessments with value-based payment models that will ensure sustainability

First steps
Infrastructure changes required to provide integrated care can be expensive and time-consuming for practices, Buscaj says. Yet these changes lead to better outcomes and more satisfied providers and staff. A few examples of changes made to integrate care in SIM practices:

  • Designate a care manager to identify high-risk patients and connect them with appropriate care team members for follow-up.
  • Redesign team huddles to review high-risk patients and structure bidirectional communication with leadership to “helps staff align efforts and reduce the feel of chaos in a practice,” Dempsey explains.
  • Develop a team-based culture to streamline processes and improve access for a larger patient base with Health First Colorado (Medicaid) insurance, explains Shelli James, practice facilitator, HealthTeamWorks, who says patients “were falling through the cracks” prior to the change.

Learn more about SIM transformation efforts in a SIM video series, get a list of practices and community mental health centers participating in SIM cohort 1 and learn more about the application for SIM cohort 2, which will be released this winter.