Posted By Amy C. Gallagher,
Thursday, July 17, 2014
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• Rocky Mountain Health Plans (RMHP)
|Yes, this title is borrowed from Jerry Seinfeld’s web-series, Comedians in Cars Drinking Coffee. However, Mr. Seinfeld has it correct- there is a strong opportunity to connect with someone while driving in the car. |
In western Colorado, collaboration occurs in order to create strong communication lines and transparency between organizations. The following visionary organizations drive the program:
• Foresight Family Physicians (medical practice)
• Peach Valley Medical Practice (medical practice)
• Primary Care Partners (medical practice)
• Mountain Family Medical Center (medical practice)
• Miller & Peterson (medical practice)
• Stangebye (medical practice)
• Mind Springs Health (mental health center)
• The Center for Mental Health (mental health center)
• Emergency Departments (EDs)
• Independent Physician’s Associations (IPA) in Mesa & Montrose counties
Based upon transformative work in other states, a team of Community Health Workers (CHWs) was recently created. The main goal focuses on a small group of patients identified as “high ER utilizers”. With the steering committee comprised of membership from all of these organizations, cooperation drives the creation of work flows, brainstorming, and celebration of successes.
Due to the fact that healthy behavior change is a focus of this pilot program, it made sense to house the program within the mental health centers- the experts in behavioral change. However, stipulations regarding confidentiality and sharing of information can be a challenge to strong communication. To solve this problem, Whole Health, LLC was born! This subsidiary of Mind Springs Health eases and enhances communication with the primary care physicians. Housed within the LLC, the CHWs do not fall under the mental health centers’ strict interpretations of HIPAA and 42-CFR (privacy law for individuals receiving substance abuse treatment).
Through positive communication and rapport building, the CHWs identify patient health needs and goals. Work with the patients may include transportation, attending appointments, addressing psychosocial needs, and finding resources. These resources range from helping patients complete and submit applications for free cell phones, to obtaining free or low-cost medical supplies, to securing transportation to, and housing in, Denver (a four-hour trip away) for crucial medical appointments. Information is shared between the medical practices and the CHWs as per coordination-of-care. This includes progress on goals, resources obtained, medical and/or screening information, and updates regarding ER utilization.
|Preliminary data suggest that the CHWs have influenced patients’ decisions to visit the ED ||How do patients get from being identified as “high ER utilizers” to the passenger seats of the CHWs’ vehicles? RMHP identifies potential participants through claims data. The medical practices review the potential patient list to ensure a strong fit to the program. Next, the medical practices invite the CHWs to “warm-hand-off” appointments with the patients. The CHWs explain the program and offer a longer appointment to meet with the patients in a different setting (e.g. home, coffee shop, etc.). |
Personnel from local EDs are also involved. They maintain lists of the patients involved with the program and are able to contact the CHWs if an ED visit occurs. The CHWs respond in a timely manner (either that day or the next business day) in order to understand what brought the patient to the ED and brainstorm ways that an ED visit could be avoided in the future. While the program is barely six-months-old, preliminary data suggest that the CHWs have influenced patients’ decisions to visit the ED. Calling the primary care physician and visiting “urgent care” offices are now realistic and viable options.
Further, many of the patients involved with the program have significant mental health and/or substance abuse challenges. Some have not accessed services. The CHWs help facilitate access due to their close relationships with the mental health centers. For example, one patient had an extensive amount of trauma. Her anxiety was so crippling that it prevented her from seeking treatment. After many days and several attempts, the CHW helped the patient enter the building and sit through the intake. While the road to recovery may be long, she is now receiving the treatment that she needs.
|Having access to agency fleet cars has proven to be effective, given that reliable transportation may be a road block to care. Additionally, driving together creates opportunities for conversation. For example, one patient lived within walking distance to an ED, making it easier for him to visit the ED instead of his primary care physician. While driving the patient to a medical appointment, the CHW brainstormed ways to decrease ED visits. Success occurred when the patient called the PCP prior to going to the ED. The CHWs build upon these small successes and encourage the patient to make other changes that may positively affect their life journeys.||CHWs build upon small successes and encourage positive changes |
Driving and transporting patients are clearly important, however, goodness-of-fit is vital. Successful CHWs are energetic, extroverted, persistent, and creative. These qualities are fundamental for building relationships, finding local resources, and communicating with a variety of medical and non-medical providers.
|Finding resources, attending appointments, and driving together all relate to the goals of the Triple Aim. By reducing ED use, health care costs are decreased. This patient-centered approach allows for all involved to be aware of the whole person. Money spent on these types of services will positively impact population health as individuals’ physical and psychosocial needs are addressed. |
Yes, the CHW spend time, in cars, driving patients. However, the relationship building, the conversations, and the brainstorming provide the essence of their time. The road may be bumpy at times and the CHWs have their hands on the steering wheels.
Amy Gallagher, Psy.D. is a Licensed Psychologist with Whole Health, LLC, a subsidiary of Mind Springs Health, Inc. in Grand Junction, CO. As Director of Integrated Care, she provides support, consultation, and training to community agencies focusing on the integration of mental/behavioral health services. Along with managing a multi-county team of Community Health Workers, she provides supervision to Post Doctoral Fellows and Integrated Care Specialists. Her research interests include integrated care initiatives, affective supervision and consultation, and autistic spectrum disorders. Dr. Gallagher received her Psy.D. in Clinical Psychology from Argosy University in Seattle, WA, a MS in Clinical Psychology from Loyola College (now University) in Baltimore, MD, and a BA in Psychology from Le Moyne College in Syracuse, NY.
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