Whole-person health: A SIM blog (03/30/2018)

Bridging the gap: Integrated care improves patient health

By Heather Grimshaw


I recently described the Colorado State Innovation Model (SIM) as a hybrid approach to healthcare reform that blends practice management and public health because it includes clinical redesign, the business aspects of healthcare and it stretches beyond the traditional walls of clinics to include communities of care.

SIM — a federally funded, governor’s office initiative — helps primary care practice sites integrate physical and behavioral health with practice coaching and myriad supports, investments in local public health agencies and the development of a new workforce that connects practices with community resources.

There are signs that the initiative, which runs through July 2019, and takes a multi-faceted approach to healthcare reform has been successful. Data shows improvement in some patient outcomes yet it’s the stories from patients, who say they feel cared for and safe in SIM practices that represents true success.

“I called and she [a behavioral health specialist at the primary care practice] picked up the phone and she had the time and was able to talk with me,” explains Mary Catherine Conger during a SIM podcast with members of the primary care practice team where she received her care. “She helped me at the time with my anxiety I was experiencing. She got back to me in 24 hours with the info that I needed. That was life-changing for me.”

Increasing access
Conger has said she feels blessed to receive integrated care. “I want everyone to be able to experience this type of care,” she told a group of SIM stakeholders recently.

And that is becoming more of a possibility. A total of 246 primary care practice sites and four community mental health centers are engaged in SIM and deliver 3, 342,018 patient visits annually.

These practices, called healthcare innovators by Gov. John Hickenlooper, invest time and energy to revamp processes, revise care teams and engage patients differently to deliver whole-person care that includes the head and body. It’s the only way to tap into a patient’s full health potential, says Barbara Martin, RN, MSN, ACNP-BC, MPH, SIM director in a short video.

As SIM cohort-1 practices complete practice transformation work this month, data shows that integrated care results in better patient outcomes, which will help practices succeed in value-based payment models that reward the value (versus volume) of care delivered:

  • Lowered A1c levels (good news) in patients who have diabetes
  • More patients are screened for depression and receive appropriate follow-up care
  • More children are being screened for developmental, behavioral and social delays

To get credit practice teams must prove that the work they’ve done has the intended results. And that requires data. Integrated care practices that can collect, report and analyze data effectively are poised for greater success in the evolving payment landscape that rewards value over volume.

Integrating mental health, substance use treatment and healthy behaviors counseling (behavioral health) and physical health in primary care settings is a powerful way to keep patients healthier and to avoid or reduce unnecessary costs.

The approach also resonates with patients as Conger shares during her podcast. And it resonates with a growing number of healthcare providers.

"I tell all my residents, 'You can't be a good primary care doc without treating mental illness,'" said a physician panelist at the Cigna Behavioral Health Forum last month. “We need every one of us who works in healthcare to see themselves as an integrated care manager. That is the only way to bridge the gap.”