Journal Entry #7: Integrating Primary and Behavioral Health Care Services in the Community Health Center Setting

Of the many challenges faced by Community Health Centers (CHC) in supporting the health of their diverse and often high-risk client population is meeting the complex needs of individuals with co-occurring mental disorders, such as serious mental illness and substance use, and chronic physical conditions, such as diabetes, hypertension, and cardiovascular disease. Addressing this need is the focus of one of the CHC Innovation Mission Project’s four CHC partners. Cherry Street Health Services (CSHS) in Grand Rapids, Michigan and its partners, Touchstone Innovarè and Proaction Behavioral Health Alliance, are working on implementing a team approach to care that integrates behavioral and primary health care services to meet both the physical and psychological needs of patients.

The project recently reached the important milestone of launching a pilot of a new approach to patient care which focuses on the creation of a treatment team anchored by a lead physician and a health coach who has behavioral health training. In this way, the team coordinates care in collaboration with the patient so that all needs are taken into account during the screening, diagnosis, treatment, and recovery phases of their chronic condition. This team is known as the “integration development team” and includes an internist, psychiatrist, nurse, medical assistant, nutritionist, occupational therapist, physical therapist, and several health coaches (i.e., licensed clinical social workers). The pilot is improvement oriented, such that the information obtained through a process evaluation will be used to inform changes as to how care is delivered through this model in future phases where larger numbers of patients are seen. The pilot phase is expected to last through December 2010, with plans to build this integrated health system by expanding the number of staff and patients involved during 2011.

Altarum has been providing technical assistance for this community systems change effort by, among other things, providing ongoing evaluation support to assess the development of the integrated approach and integration pilot. The evaluation information will help CSHS and its partners, and the broader CHC community, to learn from these integration efforts and how they can be further strengthened. Stay tuned for future updates as evaluation findings become available.

Journal Entry #6: Communication is Key

The CHC Innovation Mission Project recently completed Lean value stream mapping events at two of our partner CHCs. These events brought together CHC staff involved in every step of the patient visit process, such as receptionists, office coordinators, medical assistants, nurses, providers, medical directors, pharmacists, billing managers, referrals staff, information technology specialists, and executive leadership. For three days, these individuals worked together to examine how a patient typically navigates through their health center and identify ways to improve this process.

Here is what some had to say about the experience:

“Brought communication between departments to another level.”
“Great opportunity for collaboration with other practices.”
“Wide range of participation from many departments at all levels.”
 “Worked together as an agency not as our separate clinics.”
“Respectful and collegial interaction.”
 “Sharing of ideas/brainstorming.”
“Everyone had a chance to provide input.”
“Equal voices for everyone.”
 “Learning new things from other practices.”

Communication is the common thread running through these comments. Participants valued the opportunity to interact with colleagues across different disciplines and departments (some of whom they were meeting for the first time), share ideas and concerns, and learn from one another. In addition to serving as a problem-solving tool, value stream mapping helped to build relationships and foster cohesion among CHC staff. This open communication—critical to the success of any change initiative—will continue to be important as team members collaborate with each other over the next several months to complete action items and achieve shared goals.
 

Journal Entry #5: Implementing Systems Change Within CHCs

The CHC Innovation Mission Project is pleased to share the following updates and accomplishments:

Improving the Patient Visit Process: Over the past several months, an Altarum Lean Six Sigma (LSS) coach has been working with our partners at Baldwin Family Health Care to improve the patient visit process. Our coach has trained many providers and staff at the center’s White Cloud Clinic on LSS principles and successfully guided them through a three-day value stream mapping (VSM) event. VSM is a tool used to understand the problems in a current process and work toward creating a new and improved process. The center has reported immediate impact from the VSM events in the form of enhanced communication and improved cooperation and teamwork, elements critical to the functioning of any organization. Participants are now working to implement the action items needed to achieve an improved patient visit process. The results of this VSM at the White Cloud clinic will be used to inform the design of a new building to replace the aging clinic. Over the coming weeks, a separate LSS project will be conducted to improve the efficiency of the White Cloud pharmacy, which is the only pharmacy in the community.

Advancing Implementation of the Patient-Centered Medical Home: Penobscot Community Health Care (PCHC) is dedicated to transforming primary care to exemplify the patient-centered medical home (PCMH) model. Altarum supports PCHC’s goal of practice transformation and is assisting the center in meeting three key elements of the PCMH model: team-based approach to care, population risk stratification and management, and practice-integrated care management. Members of three PCHC clinical care teams, along with other PCHC leaders and staff, are working with an Altarum LSS coach to identify and eliminate waste in their current processes in order to support the changes that are needed to implement the PCMH model. These individuals received LSS training and recently participated in a VSM event. At the event, they identified problems in the current patient visit process and visualized an “ideal” patient visit process – one that incorporates team-based care, identifies and stratifies patients at risk for adverse outcomes, and integrates care management into the practice team. Over the next several weeks, the group will identify and complete the activities necessary for meeting project goals.

Supporting the Integration of Behavioral Health and Primary Care: Cherry Street Health Services (CSHS) and two partner organizations, Touchstone Innovarè and ProAction Behavioral Health Alliance, are committed to the design of a new model for integrated behavioral and primary health care, guided by the principle “one person, one place, one solution.” Altarum has supported CSHS in these integration efforts in this project by providing behavioral health expertise and evaluation assistance to the center’s pre-pilot integration program. Over the past several months, Altarum has been working to enhance communication across the three organizations and help to build understanding of organizational goals and expectations. Ongoing efforts will focus on the creation of evaluation plans, evaluation of pre-pilot and preliminary pilot data, and exploration and analysis of community health center integration payment models.

Improving the Patient Experience for High-Risk Populations: Alexandria Neighborhood Health Services, Inc. (ANHSI) serves a predominately low-income, uninsured, high-risk population with complex health needs.  Altarum has been working with ANHSI to improve the experience for these patients by creating a better-functioning care delivery system. Altarum and ANHSI are poised to initiate LSS process improvement activities in the coming weeks. This will begin with an LSS training session for project participants drawn from across three practice areas: adult medicine, women’s health, and pediatrics. Following the training, an Altarum LSS coach will guide participants through a VSM process aimed at achieving the following goals: improved preventive care, improved care of chronic conditions, increased patient volume, enhanced provider productivity, and reduced cost per medical encounter.

Strengthening Stakeholder Relationships: Altarum recently convened its advisory council members, executives from participating CHCs, and project team members in a joint meeting in Washington, D.C. This two-day event offered the opportunity for leaders in the CHC and safety net communities to build relationships, share experiences, learn new information and offer insight to ensure the success of the Mission Project.
 

Journal Entry #4: About our CHC Partners

The past few months have been busy for the CHC Innovation Mission Project. We’ve conducted site visits to each of our four partner organizations, refined our goals, and developed work plans to achieve them. In three of our sites, Altarum is applying its expertise in lean six sigma (“lean”) to foster process improvements and systems changes within the FQHC environment, with a particular focus on enhancing implementation of the patient-centered medical home (PCMH) model of health care delivery.  With our fourth site, we are supporting efforts to integrate primary care and behavioral health services.

In this entry of our online journal, we provide an overview of each of our partner organizations and more detail on the focus of our partnerships.

Alexandria Neighborhood Health Services, Inc. (ANHSI) is located in an urban setting in the Washington, D.C. metro area. ANHSI has witnessed significant growth over the past five years. Altarum is working with ANHSI to apply lean tools and quality improvement techniques to improve patient flow processes with the aim of increasing efficiency and provider productivity, and ultimately enhancing patient and staff satisfaction.

Baldwin Family Health Care (FHC) has been in operation since 1967 and currently operates 11 locations in five geographic locations across 95 miles in northwestern Michigan. Together, Altarum and FHC are using lean continuous process improvement techniques to collectively understand, visualize, and improve process flow within the organization. These efforts are aimed at prioritizing components of the PCMH that may be accomplished within our project timeframe and implementing strategies to improve the overall patient experience.

Cherry Street Health Services (CSHS) serves over 45,000 individuals of all economic levels and cultural backgrounds in Grand Rapids, Mich. and the surrounding areas. Altarum is supporting CSHS in its efforts to employ a team-based approach to managing chronic health conditions. This approach uses a multidisciplinary chronic care model to achieve the integration of behavioral and primary health care services.

Penobscot Community Health Care (PCHC) was founded in 1997 and now serves nearly 50,000 patients—over half of the population of the greater Bangor, Maine region. PCHC has undergone a period of rapid growth and is now focused on improving quality, eliminating waste, and maximizing the effectiveness of clinical and business processes. The goal of the partnership between PCHC and Altarum is to apply lean six sigma continuous process improvement strategies to PCHC care teams to advance implementation of the PCMH model.

Please stay tuned for ongoing updates on the progress of the CHC Innovation Mission Project!

Journal Entry #3: The Project Announces the Selection of Four Partners

The Altarum Institute Community Health Center (CHC) Innovation Mission Project has selected as its partners four community health centers located in Michigan, Maine, and Virginia. The four centers chosen to take part include Alexandria Neighborhood Health Services, Inc. of Alexandria, Va.; Baldwin Family Health Care of Baldwin, Mich.; Cherry Street Health Services of Grand Rapids, Mich.; and Penobscot Community Health Care of Bangor, Maine. The Innovation Mission Project Initiative is a two-year, multi-million dollar collaborative philanthropy effort in which Altarum assists the selected community health centers improve patient care in innovative ways by contributing staff and expertise directly to the centers.
 
Learn more the specific work to be done with each CHC, or read the press releases announcing the site selections.
 

Journal Entry #2: Site Selection Complete, Announcements Coming Soon

The CHC Innovation Mission Project received interest in the project from a remarkable pool of Federally Qualified Health Centers (FQHCs), all working in impressive ways to improve health for our country’s most vulnerable populations.  After careful review, the team selected a total of four FQHCs (located in Virginia, Maine, and Michigan) that present the strongest opportunities for successful collaboration in the project.  We are looking forward to working with our partners to implement health systems change and – ultimately – improve health for the individuals and communities they serve.

Over the summer months, we are conducting site visits to our four partner FQHCs. These visits are an opportunity to build relationships, explore the priority challenges facing each center, and confirm the specific areas in which Altarum Institute may provide assistance to support and enhance the centers. 

Altarum Institute is announcing our partnerships in conjunction with National Health Center Week (August 9-15), a celebration of Community, Migrant, Homeless and Public Housing Health Centers and their important role in our health care system.  Please stay tuned for more information.

What’s Next:  After completing site visits, the project team collaborates with our partner FQHCs to refine our scope of work and develop specific work plans.
 

Journal Entry #1: Partnering with Innovative Community Health Centers to Improve Health

Dr. Jack Geiger, one of the physician-activists who founded the nation’s first Community Health Center (CHC) more than 40 years ago, once said, “Health care alone is not the point. That would be like putting on a Band-Aid and sending our patients back home to the same conditions that made them sick in the first place.” Dr. Geiger and others who spearheaded the CHC movement understood that a patient’s health is influenced by a number of factors. With funding from the federal Office of Economic Opportunity, they used innovative methods to solve the interconnected social, environmental, and economic problems that influenced health in communities: physicians wrote prescriptions for groceries to fight hunger; nurses made house visits to new mothers to demonstrate proper care for newborns; centers established career training programs to combat joblessness.

CHCs focused on improving patient health by empowering the community as a whole. This holistic approach has been widely successful. Today, there are more than 1,200 CHCs operating at 6,600 service delivery sites and serving 18 million people nationwide, regardless of insurance status or ability to pay. (Note: The recent release of stimulus funds supporting 126 new health centers will bring the total to more than 1,300 CHCs nationwide.)

Although CHCs are habitually creative and resilient in solving health care problems, they continue to face challenges. The CHC Innovation Mission Project is a unique opportunity for Altarum Institute to apply its systems research expertise to address some of those challenges and strengthen the CHC system of care. In this initiative, Altarum Institute is partnering with up to six HRSA-supported federally qualified health centers (FQHCs) with an existing culture of innovation located in the District of Columbia, Georgia, Maine, Michigan, Texas, and Virginia. The FQHCs will identify a challenge or opportunity (e.g., workforce recruitment, quality/productivity improvement), and Altarum Institute will provide onsite technical assistance to implement an innovative solution to the targeted area. Lessons learned, research outcomes, and useful insights will be shared with other FQHCs to enact change at a broader level.

Please visit our project information page for more details about the project.

What’s Next: The Project Team is in the process of selecting our FQHC partners and is on schedule to begin developing action plans in early summer.