For decades now, leaders on the provider side of the U.S. healthcare system have envisioned a time when the physical and behavioral sides of patient care would be better coordinated and integrated, in order to benefit patients and improve outcomes—and yes, at the same time, dent our healthcare system’s cost curve. Yet in practice, the U.S. system remains largely fragmented, with care management and care coordination between physical and behavioral health an area filled with gaps and issues.
Well, some forward-thinking people in the Finger Lakes region of upstate New York have been working on that problem. Indeed, what they’ve come up with offers the promise of replicability nationwide and the advancements they’ve made have earned their team second place in the Healthcare Innovation 2023 Innovators Award program.
As FLIPA’s leaders explain, “Finger Lakes IPA, Inc. (FLIPA) includes fourteen Federally Qualified Health Centers (FQHCs), seven behavioral health organizations (providing outpatient services, peer support, care management, and specialty behavioral healthcare services including long-term residential care, detoxification, rehabilitation and respite beds, peer and family advocacy services, jail release transition programs), and a rural health network that includes eight county health departments as its members. Our diverse membership also includes social determinants of health support, such as housing, employment assistance, and benefits navigators. FLIPA currently spans 28 counties across Upstate New York. FLIPA’s mission is built on the foundation that the integration of behavioral health (BH), social determinants of health (SDOH) and primary care (PC) is essential to improve the health and wellness of patients, and that failing to meet the needs in any one of these areas leads to greater challenges in the other two.”
And, per all that, “FLIPA’s innovative solution centers on the integrated acute contact team (i-ACT). This approach brings together Care Coordinators/Case managers from both behavioral health and primary care settings serving the same patients to function like a single integrated treatment team. I-ACT leverages FLIPA’s state-of-the-art population health management platform (Garage) and a set of integrative standards of care to improve outcomes and reduce barriers for patients with significant BH needs and health-related social risk factors/SDOH needs. Tools used to meet patients’ most urgent needs and stabilize their quality of life include: 1) a risk stratification model to target resources to patients most in need, 2) a universal i-ACT approach that emphasizes best practices in integrated engagement, anti-stigma language, trauma-responsiveness, cultural competence, and person-centered collaborative goal setting, 3) an Integrated Acuity Assessment to identify urgent needs and barriers across physical and behavioral health, and social care needs/SDOH barriers, 4) ongoing integrated care coordination and cross-team communication, and 5) a modest discretionary budget to enhance engagement (e.g., take the patient out for breakfast to enhance engagement) and overcome structural barriers (e.g., pay fee to get a copy of a birth certificate to apply for benefits, buy cell phone minutes, purchase a pair of sneakers or a coat for a patient wanting to start a trail walking program).”
Kirstyn Applin, M.A., CASAC [Credentialed Alcoholism and Substance Abuse Counselor]-AD, care management supervisor at CASA-Trinity, an Elmira-based behavioral care organization that provides addiction, mental health, and social determinants services, explains that “Much of this collaborative work stemmed from the fact that clients or patients who were struggling in the behavioral area were not able to keep up with their primary or preventive care, and they were high ED users. We wanted to make sure all their needs were met; and the social determinants of health [SDOH] are a huge factor; and that’s where the case management and care management came in.”
Brenda Pruden, R.N., director of clinical operations at Tri-County Family Medicine, a primary care clinic based in Dansville, adds that “We wanted to partner to be able to similarly make sure they were following up with their treatment; we only saw pieces here. We wanted a relationship with the folks at CASA, so patients knew they had a full circle of folks looking out for them.” Per that, she says, “Process was the thing we really had to nail down: when we were meeting, what we were bringing to the table, biggest concerns. Another barrier was consent process, so that patients feel safe across both organizations.”
Going back to the origins of the collaborative initiative, Robert Grolling, CASAC, supervisor of the center of excellence at CASA-Trinity, explains that “We applied an integrative care model; and the source of that was that the University of Rochester developed the bio-psychosocial model about 100 years ago; they had concluded that one had to pay attention to all those factors to help a patient recover. And that developed into an integrative care model. Historically,” he says, “medical facilities acted on their own and didn’t connect with addiction and mental health organizations. It was a really fragmented system. This particular model, which has to do with behavioral health and primary care integration, we use a cohort management approach. So rather than connecting a patient to services and disappearing, which usually results in attrition—with the cohort management approach, we enrolled people who are shared between Tri-County Family Medicine and CASA-Trinity. The cohort of patients is comprised of individuals who have had at least one visit with CASA-Trinity in the last two years. And we manage that cohort with care coordination activities. So we put a care coordinator from Tri-County together with care coordinators from CASA-Trinity. We keep patients enrolled and monitor them until they’re stabilized, and then when they’re stabilized, they return to sole primary care management from Tri-County.”
Raising awareness of a successful model
Briannon O’Connor, Ph.D., chief clinical officer at FLIPA, says that all the members of the team are aware that what they’ve achieved is a model that they believe could be helpful to other provider organizations around the country. “Part of the reason we keep trying to get the word out is to raise awareness that this is a really critical piece about how to support people,” she explains. “These are currently non-billable activities that are expected in a value-based payment contract. They’re expected, but not paid for. So these organizations have to figure out how to make this happen and work.” And, per that, those involved in this model in the FLIPA-affiliated organizations have figured out precisely how to do that.
And, along this journey, what have the major learnings been so far? “One of the major learnings,” CASA-Trinity’s Applin says, “is that one of the best approaches is to keep it simple yet efficient. If you start adding too much or create too many forms or have too many people involved, it can get messy. We’ve always had our core members from each agency heading up this project. But the stability and making it as simple as possible, have made it effective. We’ve kept it simple, and people keep the lead involved in care coordination. That has made it simple and made it easier for the clients [and patients] of the organizations.”
“We try to keep it simple here as well,” says Stephanie Buchinger, R.N., B.S.N., CM, care management supervisor at Tri-County Family Medicine. “There are a lot of people who work with all these patients, but one specific person reports to CASA, so they know how to reach me, I know how to reach them.”
What’s more, O’Connor says, “The fact that team members across our organizations have been able to break down the barriers and silos, is not rocket science, but no one’s been doing it, because of the structural and systemic barriers in place” across the U.S. healthcare system. “But the challenge is to sustain it. It absolutely is sustainable, and we’re planning to replicate it throughout the network.”
Looking at data and analytics
Applin notes that there are ongoing challenges: “We still have to keep our agency and medical records separate, because of legal regulations. But as long as there’s consent on file, we can share information back and forth. At CASA, we have a godsend of a team that has been able to take our medical record, and they can extract all sorts of information from it and build t into a dashboard that makes it so easy for everyone to see what’s being worked on. And our medical record allows us to create our own forms, so we’ve been able to make SDOH assessments, acuity assessments, and so forth. Scores on different questionnaires, surveys, and be able to compile it in one place and therefore share it with FLIPA and everyone else involved. NY is going through a push for value-based payments. And when we first saw that it would be a huge push, we decided we needed to get on this. And in a sense, COVID helped us, because we had to figure things out quickly. And our data team can pull whatever you ask them; it’s incredible.”
O’Connor adds that “FLIPA is in progress on how effectively we share data, but [robust data-sharing] is a significant goal. And we have a shared population health management platform. We’re working towards sharing that information more readily and timely. Per 42CFR, we’re working towards improving consent processes. Scaling it up at a network level within the structural barriers, takes time, energy and resources, but we’re working on having shared data.
Grolling notes that “The data analytics has progressed light years in the last two years. The ability to get information from claims data to see the gaps in care” is advancing rapidly, he reports. “Historically, the only information we had is what patients gave us. And often they’re impaired and don’t have a good way to tell their story. But claims data tells us the exact story. So we’ve been able to mine that data and know exactly what’s going on with that patient.”
Given the marrying of claims and clinical data, Grolling reports, “We can bring a patient up on a screen and see their utilization, and we can make decisions based on that. And let’s say we’re dealing with 100 patients between the two of us, we get that data and analyze it and use it to help them. And we’re trying to expand this integrated care model of behavioral health and primary care will be the model that will be used throughout the state. We’re aware it’s leading-edge, and we’re very excited about it,” he adds. “Data and clinical care have to walk hand in hand in a marriage. Without one or the other, and without that communication between the two, we don’t get that coordination. The data is showing we’re closing gaps, addressing measures, reducing costs, reducing preventable utilization, and improving the quality of patients’ lives.”
And ultimately, Buchinger notes, “Our communication” among individuals in all the collaborating entities “makes it work very well. When patients see us and we make referrals, we can call CASA and say, ‘Can you help get them there?’ The same thing is true on the other end, especially, per ER visits and inpatient. It’s more communication than anything else.”
All those involved in this initiative are certain that it will thrive and expand over time, because it speaks to mission and vision. As O’Connor notes, “Someone recently asked me, ‘How do you incentivize the organizations in your network to do their best work?’ But I don’t need to; we’re mission-aligned. No one says, I don’t want to do an integrated model; some say I lack the resources. And we don’t need to incentivize folks around these best practices, because they know the value of it.”
