2019-03-05

Medical Home Network is advancing integrated behavioral health

All health is healthcare. Yet many healthcare organizations struggle to deliver holistic, coordinated care inclusive of behavioral health—the consequences of which can be devastating.

Most healthcare organizations know they need to address behavioral health but aren’t sure how to do so. That’s why we interviewed Leana Lopez, Senior Manager of Clinical Integration and Innovation at Medical Home Network (MHN), to understand the innovative strategies adopted and implemented at the MHN ACO to better integrate behavioral health across the care continuum. Here’s what we learned.

Connectivity to Medical Home

MHN has embraced the “medical home” care delivery model. The medical home is a patient-centered, team-based care delivery model, where a team of providers (e.g., physicians, nurses, nutritionists, pharmacists, social workers) is assembled to meet a person’s healthcare needs. One provider, typically the primary care physician, heads this team and coordinates care around the patient.

MHN seamlessly integrates behavioral health into this multi-stakeholder team by ensuring patients are always connected back to the medical home—no matter where they access the healthcare system. Lopez uses the ER as an example. Traditionally, patients are admitted to the ER, stabilized and then released without a care plan. With MHN’s medical home, once the care team is notified of an ER visit, the care coordinator can create a discharge plan and/or follow-up care plan—as well as connect the patient with other resources, such as transportation, housing or a social worker.

It’s all about building bridges between various care settings and community resources to improve outcomes.

Embedded Resources

Core to the MHN strategy is the placement of licensed behavioral health professionals directly into the practice, whether that’s a Federally Qualified Health Center (FQHC) or primary care site.

According to Lopez, the close proximity of a behavioral health professional to the primary care physician (PCP) has huge benefits. Behavioral health care coordinators can help PCPs with medication management, facilitate psychiatric consultations and collaborate on care planning.

Beyond that, embedding behavioral health resources into the primary care practice helps improve compliance from patients. The likelihood that a patient follows up with a behavioral health professional on a PCP’s recommendation is slim—only about 65% of adults with a serious mental illness receive treatment. Having BH professionals integrated into the PCP setting reduces the risk of skipping or avoiding appointments.

Financial Incentives and Accountability

Behavioral health programs fall flat without participation, which is why accountability matters. MHN uses specific outcomes and incentives to ensure patients are diagnosed, treated, prescribed and monitored on an ongoing basis for mental illness. If the practice does not achieve the required outcomes, they can potentially lose staffing and funding.

Technology is a key element of outcomes tracking and holding the medical homes accountable. “The more information you have about patients that can be shared, accessed and transferred in the same place, the better,” Lopez said. “However, more technology isn’t always the answer. Finding smart technology—something that is relevant to workflows and streamlines activities—enriches behavioral health programs.”

Leana Lopez is a licensed clinical social worker, providing clinical support and oversight to Medical Home Network. She offers consultation and training for care management programs, creates community social service partnerships, and leads behavioral health initiatives for the 12 hospitals and health centers in the MHN ACO. To learn more about MHN, visit http://medicalhomenetwork.org/.


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