CMHCs Collaborate to Launch Integrated Care Initiatives

rot001In a healthcare landscape where we know that integrated care produces the best results for clients, three community mental health centers in Northern Indiana have taken collaboration one step fur­ther. The CMHCs joined forces with two federally qualified health cen­ters in an effort to improve care for hundreds of seriously mentally ill adults across four counties. The CMHCs are Oaklawn (St. Joseph County), Swanson Center (LaPorte County) and Porter-Starke Ser­vices (Porter and Starke counties). The FQHCs are Indiana Health Centers and HealthLinc.

Thanks to a Behavioral and Primary Health Care Integration grant from SAMHSA, the organizations are working toward opening prima­ry care clinics at each CMHC and assigning those patients a health advocate to coordinate their care. Aileen Wehren, Vice President, Systems Administration at Porter-Starke, wrote the grant and initiated the project.

“We’re trying to get away from the ‘silos’ of care,” said Todd Van Buskirk, director of integrated care at Porter-Starke and project director of the grant. “When we’re truly integrated, the question becomes, ‘What does the patient need and what can we do to provide it?’ ”

Integrated care has become an important initiative nationally, said Cindy Schulz, who oversees Oaklawn’s part in the project. People with a serious mental illness die as many as 25 years earlier than the general population, often because of physical health care problems that go untreat­ed. Providing primary care services in an environment where the client is comfortable, such as a CMHC, can greatly improve their overall health.

Oaklawn’s clinic opened on-site in August. The clinic opened one day per week and had 90 clients enrolled. Just four months later, there’s nearly 130 clients enrolled and the clinic will add another half-day starting Dec. 11.

Oaklawn leaders are excited about the success they’ve seen so far. “One consumer who had refused medical treatment for the last 20 years finally agreed to come to the clinic, primarily because she was comfortable with us and trusted her treatment team,” said Schulz. “She agreed to lab work and a prescription for hypertension.”

Oaklawn was the first location to open a new clinic since the grant was awarded about a year and a half ago. Porter-Starke Services operates a clinic in Porter County that was established in 2009, before the grant was funded. There are about 80 clients enrolled in that clinic.

In LaPorte and Starke counties, partnerships to provide primary care at the CMHC are still being developed. In these cases, staff work diligently to coordinate care by transporting clients to their primary care appointments at HealthLinc’s main locations in those communities. There are about 50 clients enrolled in Michigan City and four in Knox.

The 260 clients enrolled in the four programs also receive the benefit of a health advocate, a CMHC employee who helps coordinate care. The health advocate attends each appointment with the client (with their consent) and communicates with everyone on the client’s treatment team, both physical and behavioral.

If the nurse practitioner is recommending a diabetic diet to a consumer struggling with their blood sugar, the health advocate can link with the skills trainer and care facilitator, explained Schulz. The skills trainer can help the client with activities to improve their understanding and follow through, such as creating a diabetic-friendly grocery list, and the care facilitator might refer the client to diabetes classes. The health advocate reinforces the recommendations and links that information with the psychiatrist, as well.

Furthermore, in addition to their education on mental health issues, the health advocates have further training on general health indicators and have completed training to become a Certified Health Worker.

Another part of the project aims to engage clients in their own health, focusing on wellness instead of illness. One of Oaklawn’s health advocates started a walking group that meets twice per week. A psychiatrist joins the group, tracking their progress with a pedometer. Leaders at Porter-Starke teamed up with a local running shop for a 12-week training program leading up to Porter-Starke’s Turkey Trot 5K, which draws nearly 4,000 people. Both clients and employees participated, and nearly 30 people completed the walk/run as part of the training group.

In addition, the grant is funding the design and implementation of a database to track the physical and behavioral health of clients. This reporting will be beneficial to both clients, who can see their progress individually, and healthcare providers, who can track needs of the entire population.

“It’s quite complex, but it’s been great working with everyone,” said Van Buskirk. “It’s rewarding to see how much collaboration enhances the success of the project. And that’s really the spirit of where healthcare is going.”