Cracking the Health Integration Code

A report by 
Health Policy Solutions 

By Katie Kerwin McCrimmon

CORTEZ – A large touch-screen monitor on the wall of an exam room flashes a grim health picture.

Data charts show that the 14-year-old boy is severely depressed and obese. His blood pressure is high. In the waiting room, he has punched in answers to screening tests on a digital tablet. By the time he arrives in the exam room, the results have been tabulated and are accessible on the monitor. His frank answers reveal a teen who needs help fast. He is suicidal, coping with poor physical health, and abusing alcohol and marijuana.

Providers can use the touch-screen panel to drill deeper into the data or to give the boy and his family health resources on the spot.

An entirely new type of clinic in an unlikely place — one of Colorado’s poorest counties in the southwestern corner of the state — could provide help for this boy and countless people who are struggling with both physical and behavioral health challenges.

To understand Axis Health System’s Cortez Integrated Healthcare Clinic, you must first understand what it is not. It is not a medical clinic with some behavioral health experts who float around. And, it is not a mental health facility with a few doctors on staff.

Rather, it is an entirely new model of care in a facility designed from the ground up to give patients “whole person,” “technology-enabled” care. That means that during each visit, patients get fully integrated behavioral and physical health care in a single building. The patient’s needs drive the visit. A team of providers – including both behavioral health experts and medical staff – can work together in extra-large exam rooms, flowing in and out of flexible spaces as necessary.

So, the 14-year-old boy can receive medication and nutrition counseling from medical providers to help with his weight and blood pressure problems along with substance use treatment and therapy for his depression. The physical and behavioral health problems profoundly affect each other, so it only makes sense to treat both.

“We can’t let this kid leave before we have a safety plan,” said Pam Wise Romero, Axis’ chief clinical officer and one of the leaders who developed the design and technology concepts for the clinic.

“This is fairly radical. Nationally, there are not a lot of models like these,” said Dr. Larry Green, a national expert on integration of behavioral and physical health and a faculty member at the University of Colorado’s Department of Family Medicine.

Green is director of Advancing Care Together (ACT), a $3.9 million, four-year demonstration project, which is funding 11 innovation sites across Colorado. The ACT program aims to find “secret formulas” so Colorado sites can provide a playbook for integration across the country. The Colorado Health Foundation is funding the ACT program.

Health Policy Solutions (which also receives funding from the Colorado Health Foundation) is monitoring progress and challenges at the innovation sites. The projects launched in September. (See related coverage: Treating mental health woes could save billions and Behavioral health coaching key to doctors’ success)

Pam Wise Romero uses a touch-screen monitor in an exam room at the Cortez Integrated Healthcare Clinic to view a patient's personal health profile. The profile blends both behavioral health and medical data to give providers and patients a better picture of their overall health. The clinic, which opened this year, aims to provide "whole person," "technology enabled" care. Many of the patients are low-income people with behavioral health challenges.

Green likens Wise Romero and the leaders at Axis Health System to pioneers who have already ventured into the frontier.

“To the extent that ACT and these innovators are trying to get across a river that has been a boundary holding everyone back, they are on the far bank. They’re settling new territory,” Green said. “This is an example of stunning leadership.”

Certainly, there are profound challenges with the Cortez model that range from technology snafus to billing problems, but Green and others view the concept as ambitious and revolutionary.

“While there’s a wow factor in the brand new building and the flat screens  — and that symbolizes and signals that it’s modern, new and fresh— all of those things are accoutrements of what’s really going on. Their thinking really starts with the patient. What does the patient need? They are not adding a room on to a house. They have built an entirely new house.”

Blended visits for ADHD and allergies

On a recent Friday afternoon, three high-energy children dart around an exam room at the Cortez clinic for a visit with their pediatrician. Stephen is 12, Jason is 11 and Samantha is 8. All three have ADHD and need checkups every three months because their medication can have adverse effects on the children’s hearts. So doctors must constantly monitor their health and fine-tune the prescriptions. Along with ADHD, Samantha has asthma, Stephen has allergies and all three have learning disabilities.

Their mother had the children on her own. She has bipolar disorder and when she was failing to take her medication, her own mother had to step in to care for the kids. Judy Mead, 52, is now the full-time guardian for her grandkids on top of her full-time job at Wal-Mart. Life is chaotic, to say the least.

“I’ve had them for five years now. My own kids had ADD. The hyperactivity along with it was new,” said Mead, who lives in nearby Dolores.

While she relishes caring for the children, she says it would be nice if they were calmer.

“Two are constantly fighting. If you have all three together, it’s that much more nerve-racking. Every day is a challenge.”

Before the Cortez clinic opened this year, Mead had to take the children for behavioral health appointments to the old mental health building, which was dark and musty with sagging floors. Then, she would cross town to take the children to their doctor. While her bosses at Wal-Mart accommodate her need to leave work for medical appointments, the separate health systems meant taking twice the time off.

Walking into the new integrated health center, with its vaulted ceilings, natural light and spacious exam rooms is soothing. Getting all the care for the children in one location is a lifesaver.

“I won’t have to make so many appointments. We can all touch base at once and get a full picture at the same time. Any problems can be taken care of right then and there with some very knowledgeable people.

“I have a very positive feeling,” Mead said. “The doctors are always so kind. They take the time to see what the kids are like, what’s going on with them. They’re not just asking me the questions. They’re actually listening to the children and getting feedback from them.”

Asking the right questions

Dr. Kristen Roessler is one of the pediatricians at the Cortez clinic. She used to work in private practice in New York and also trained at the University of Chicago and worked for the Indian Health Service.

“Integrated care is smart medicine. It’s holistic medicine. It gets at the root cause of what’s going on,” Roessler said. “In private practice, I would see 40 patients a day. I felt like it was a factory.”

In contrast, appointments are longer at the Cortez clinic and at Axis’ integrated school-based health clinics in Durango where Roessler also works.

In the past, working as a pediatrician in private practice, Roessler said she and her partners never asked questions about behavioral health problems.

“In the town in New York, we had no child psychiatrist, no child therapist, only one psychiatrist. There was nowhere for me to send kids. To put it bluntly, we just didn’t ask because we had no resources to handle all the answers we would get.”

Caring for newborns, Roessler urged her partners in New York to follow recommendations from the American Academy of Pediatrics and screen the mothers for post-partum depression. While the mothers have their own doctors, they don’t see them nearly as frequently as they see their baby’s doctor.

Roessler said her partners voted her down.

They couldn’t bill to screen the mothers, and while a healthy mom is certainly essential for a healthy baby, the pediatricians felt they had little to offer depressed moms.

Now in Cortez and Durango, working for a nonprofit health system, Roessler operates on an entirely different paradigm. Multiple screening tests are standard for patients of all ages. If a child comes in for strep throat, that child will also be screened for emotional issues. If students are referred to clinics for problem behavior at school, they automatically will get screened for health issues. Depression screening is as basic as obtaining vital signs.

“I don’t feel uncomfortable asking the questions anymore. If someone gives me positive answers (indicating behavioral health problems), I can help them,” Roessler said.

Even though Cortez is a rural area far from specialists, the clinic can tap in-house behavioral health experts and a psychiatrist who staffs the office at least once a week. State-of-the-art video conferencing also enables providers to consult with specialists who don’t live in the area.

Roessler has been working in integrated medicine for four years now and said she and her co-workers improvise all the time.

“We’ve been working out the bugs. Sometimes, we will see the patients together or if I have to do a procedure and the child is scared, the behavioral health person can come in and talk with them and do breathing exercises. It’s been very successful to defuse family tensions,” she said.

Integrated care also helps her prevent and correct medical mistakes. For instance, Roessler saw a teen girl who was told she had ADHD and was given medication for that. She was having chest pains and heart problems. Working with a behavioral health counselor, Roessler figured out the girl didn’t have ADHD. She had a thyroid problem. And the wrong medication was making her sick.

“(With integrated care) we’re going to look at you as the whole person. We’re going to look at your body and your emotions,” Roessler said. “I really don’t think you can look at anyone of any age and not ask about what’s going on in their life.”

Erasing stigma

Janice Christiansen oversees the nursing department at the Cortez clinic and also has an adult child who relies on the center for care.

“When I heard about this concept, it was ‘Hallelujah,’ ” she said. “It’s all about what the patient needs.”

Stephen, 12, Jason, 11, and Samantha, 8, need frequent checkups to ensure that medication for ADHD is not harming their hearts. Their grandmother, Judy Mead, is their guardian. Before the Cortez clinic opened, she had to visit both the old mental health clinic and the doctor's office. Now all three children can get care for both behavioral and physical health at the Cortez Integrated Healthcare Clinic.

Christiansen has a 27-year-old son, Randon, who is schizophrenic. He was doing well until his senior year in high school. Christiansen and her husband at the time were going through problems in their marriage and Randon’s behavior started to become erratic. He had always been a star athlete. He was on track to attend college on a baseball scholarship. Then, he lost interest in school and pulled away from his family. Christiansen feared that he was into drugs and frustrated with his parents’ problems. Soon she learned he had moved to Phoenix and was living on the streets. Her older son found him and brought him home. One bitter cold January night, Christiansen found the door to her house wide open. Randon was gone. She jumped in the car and found him walking in bare feet.

“Look mom, I found your golden rings,” he said.

Her heart sank. Suddenly it was obvious. He wasn’t on drugs. He was having a psychiatric crisis. Soon after, she got the diagnosis of schizophrenia.

“I was devastated. He was a totally different person. I had to come to terms with the fact that he would never be who he was. I had to accept the new Randon. It’s been up and down.”

The family lives in Mancos. Finding adequate care in a rural area can be a huge challenge and Christiansen felt like all of Randon’s friends abandoned him because they didn’t understand his mental illness. He now lives in an apartment adjacent to his mother’s house.

The first time Christiansen walked into the new Cortez clinic, she was awed by the new construction and the new concept.

“It’s beautiful. It’s spacious. It’s clean. It’s inviting and there’s no stigma.”

For people in small towns, walking into a clinic that everyone knows is for people with mental health problems can bring great shame. Integrated clinics help erase that stigma.

Poor health outcomes led to new creation

Axis Health System opened its doors as the Southwest Colorado Mental Health Center in 1960, providing service in Archuleta, Dolores, La Plata, Montezuma and San Juan counties. Traditionally, the system provided mental health and substance abuse treatment.

Then, Pam Wise Romero and Axis CEO Bern Heath started brainstorming about how they could do better. They realized that their clients were dying young of treatable diseases. At first, they tried placing behavioral health providers in primary care practices and federally qualified health centers in their area.

“But there’s only so much you can do when you’re a guest in someone else’s clinic,” Wise Romero said.

About five years ago, Heath met the director of Cherokee Health Systems, a group of clinics in Tennessee that has evolved from a mental health clinic founded, like Axis in 1960, to a national leader in health integration and a provider of physical, dental, behavioral and school-based health care. Axis’ leaders became convinced that integrated health care was the answer to improving outcomes for their patients.

“And, if we really wanted to test our own ideas, we probably needed to have our own clinic,” Wise Romero said.

Among Wise Romero’s ideas was a very muscular IT component. She dreamed up the concept of a “visit card” and a “personal health profile.” The idea was simpler than the reality. Electronic medical records are advancing, but the computer systems designed for behavioral health don’t communicate with the digital systems for physical health. This means that workers at the Cortez clinic have to enter information from one system into the other manually. The Cortez clinic also employs a full-time tech genius to make sure their advanced systems are always working to enhance patient care.

“We didn’t want technology for technology’s sake,” Wise Romero said.

When patients arrive, they fill out a paper visit card, which has a code on it that can then link to each patient’s digital records. On the card, patients write their top three or four goals for the visit. These items can relate to physical or behavioral concerns. Then, clinic workers hand each patient a clunky tablet (deliberately not sleek so it won’t get stolen) called a Patient Tool. This system allows patients to complete screening tests before their visits begin.

As soon as the patient hands the tablet in, clerks upload the information, which gets scored and matched with the patient’s digital record. Once the patient goes back to an exam room, a team of health workers decides how to proceed.

A handful of rooms are designed for specific purposes. For example, there’s a therapy room with a one-way window and walkie-talkies so a therapist can sit in an adjacent room and watch interaction with a parent and child. Then, the therapist can coach the parent on specific responses to help the child. That’s called Parent Child Interaction Therapy.

There are other rooms with couches and Kleenex that look like standard therapy rooms. There are procedure rooms to stitch up cuts. There are toys for play therapy tucked beneath exam tables in rooms that look like extra-large exam rooms. There’s a classroom for group medical visits or group therapy. The key is that the providers don’t “own” any particular space. They move depending upon a patient’s needs.

“The room’s function is to support the care you’re getting,” Wise Romero said.

Once the patient arrives in the appropriate space, providers can swipe the visit card and all the results from screening tests show up on the touch-screen monitor.

Since Axis is a safety net provider, many of their clients are low-income people, some of whom have not received any recent health care. One woman came in for an annual well-woman exam, but it turned out she hadn’t been in for years. Anxiety about the visit may have sparked bizarre behavior. When the doctor stepped into the room, the woman was naked and cleaning the sink.

“In a typical clinic, you wouldn’t know what to do,” Wise Romero said.

At Cortez, the medical provider was able to step out, huddle with the behavioral health expert and change strategies for the visit.

“The behavioral health provider was able to come in, calm the woman down, get her on the exam table and help her have a pap smear, which she hadn’t had in at least five years. Mission accomplished,” Wise Romero said.

Attention then turned to the woman’s behavioral problems. It turned out she had bipolar disorder.

Along with billing and technology challenges, staffing can be tricky. People who work in an integrated setting need to be comfortable with changing roles and on-the-spot decision-making.

“There’s no prescription for how to do this. We want to do what’s best for the patient and all their different needs,” Wise Romero said.

Sometimes providers don’t know how to handle a situation and “want to run screaming from the room,” Wise Romero said.

“You have to be open. We tell people to hang in there because nobody knows how to do this. All I can tell you is that we’re going to put our trust in our care team,” she said.

“The experiment is better than the silos” that have long separated physical and mental health care.

Dr. Green, the ACT director, sees Axis’ high-tech personal health record as the “Rosetta stone” that providers anywhere should use in the future.

Each of the 11 innovation sites is pioneering a different method for integrating behavioral and physical health.

“It’s like a one-animal-at-a-time Noah’s ark,” said Green. “We saw a diverse set of ideas in locations and settings around Colorado. We don’t have two or three of a particular type of integration.”

But, he said, that’s where the real game-changing ideas come from. They bubble up from people desperate for solutions.

“Where did Facebook come from? Where did Apple come from? Where do most brilliant ideas come from?” Green asks, then answers his own questions. “A person or two. Innovation defies institutionalization. Institutions impede innovation. It makes complete sense that a place like Cortez, Colorado would come up with an idea like this.”

5/31/2012 9:14:00 AM

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