Integration, or the active coordination of behavior and decision-making across clinical disciplines and providers, is a buzzword in health care and is more of a continuum than a singular action. Integration involves more than simply co-locating team members and services. One of the University of Utah’s clinics, the Neurobehavior Healthy Outcomes, Medical Excellence (HOME) Program, made the leap from simple co-location to full team integration by taking concrete steps to change its culture, including compensating physicians for time spent in care coordination, reducing power differentials through the creation of provider partnerships, designing a new role to facilitate the coordination of health care services, and hiring on the basis of passion and collaboration.
Integration is essential for providing value to this population of complex patients.
Integration is not something that is arrived at but rather something that is constantly nurtured.
Culture based on teamwork must be constantly reinforced.
It is important to resist the tendency to fill positions with “bodies” as a matter of urgency; take the time to hire people with the right fit. Caring for individuals with complex medical and mental health needs often requires creative problem-solving; the inclusion of multiple disciplines is vital to caring for the whole patient.
Scheduling dedicated time and reimbursing for coordination activities are necessary to ensure that full care integration occurs.
Hiring the right team and engaging all team members in continuous quality improvement provides better value to the patient.
Integrating patient care in clinical practices sounds appealing but involves changing traditional reporting relationships and patterns of care delivery. Co-location of personnel and services is often considered to be adequate for the proper coordination of health care but does not by itself lead to fully integrated care. Many co-located practices operate as separate entities in which providers merely share the same work space. While co-location increases the opportunities for the communication that is necessary for integration, other steps are required to promote a culture of integrated care.
Patients with developmental disabilities and comorbid behavioral health concerns frequently experience uncoordinated care efforts and frequently are managed in high acuity settings. Because of the lack of coordination, health care providers who work within already strained family systems function as their own care coordinators, often leading to premature burnout and a higher need for respite care and other expensive habilitative services. Better integration alleviates these problems.
To provide one example from our experience, Mr. F was a 53-year-old man with bipolar disorder, an autism spectrum disorder, intellectual disabilities, and multiple chronic illnesses that contributed to behavioral issues. Before enrollment in the HOME Program, the patient did not have access to a psychiatrist, and the caregivers in his community group home had struggled to keep his aggressive outbursts and frequent episodes of running away under control. The patient often received subspecialty care with little coordination with primary care and frequently visited the emergency department (ED) because of emphysema, intermittent confusion, and frequent suicidal ideation. However, after his enrollment in the HOME Program and the resultant integration of his care services across psychiatry, primary care, case management, therapy, and behavioral support, his psychiatric and medical issues stabilized and he quit smoking. He visited the ED only twice in the year following enrollment and stated that he had not felt this happy “in a really long time.”
The HOME Program was established in 2000 to provide full-scope primary care and behavioral health services for patients with neurodevelopmental disabilities, such as autism spectrum disorder, intellectual disabilities, cerebral palsy, Down syndrome, and others. The HOME Program serves some of the state’s highest-risk Medicaid patients, with enrollees now numbering over 1,200 children and adults. The program is part of the University of Utah and is funded completely through capitation as a distinct health maintenance organization (HMO) in the Utah Medicaid Program. HOME was started in response to the frustration experienced by many mental health providers over not being able to fully address the conditions of patients in this complex population because of considerable crossover of their psychiatric, behavioral, and medical problems. The integration of care provides greater support to patients, caregivers, and staff through improved communication, opportunities for joint visits, consistent messaging, and the convenience of a singular location. The goal was to create a culture that fosters such integration.
1. Incorporate (and Compensate for) Time for Care Integration
Co-location is necessary for integration, but there are other structural mechanisms that can be used to promote integration in a health care system that gravitates toward siloing. For example, the HOME Program incorporated time for integrative care coordination into each provider’s productivity expectation. When providers are measured solely on the basis of their billable time, these activities are one of the first things to suffer. All providers at HOME are paid a salary rather than via a production-based mechanism. By incorporating daily time for expected integration activities into each team member’s schedule and salary, the system facilitates the coordination of care across disciplines.
One of the key mechanisms for coordinating care at HOME is a daily rounding meeting, held each morning, that all members of the clinical team are required to attend when possible. During this meeting, the schedule for the day is reviewed so that the multiple providers of any patient can discuss ongoing concerns. A major benefit of these meetings is that they enable case analysts (team members who have worked as nurses or social workers or who have had experience working with this population in the community) to have predictable access to providers for the purpose of reviewing care plans and addressing patient questions.
To provide another example from our experience, Ms. Q was a 57-year-old woman with Down syndrome who was having significant rectal bleeding but was extremely resistant to undergo the bowel cleansing that was needed for a colonoscopy. She was nonverbal and could not understand why she was not allowed to eat regular food for 1 to 2 days and had to drink so much of something that she did not like, which led to aggressive behavior. The staff at her group home also did not want to push the bowel cleanse because of the need to change the patient’s adult diaper too frequently. During our daily rounds, her case was discussed with the various care team members in order to come to the best solution. The case analysts provided their input, discussed the proposed solution with the caregivers, and actively assisted in the implementation of the treatment plan.
2. Reduce Perceived Power Differentials by Creating Meaningful Provider Partnerships
In order to extend the reach of expert physicians, HOME implemented a system of provider partnerships, whereby physicians are partnered with an advanced practice clinician (APC) such as a nurse practitioner. Rather than having the APC act as a physician extender or simply “tee up” visits for the physician, the team acts as a partnership, sharing responsibility for patient care and outcomes. Visits are determined on the basis of patient complexity and provider availability, and it is not unusual for both partners on the team to see the patient together if needed.
Both providers have a relationship with the patient, facilitating better physician utilization and provider coverage. The partners meet weekly during a designated coordination time to discuss complex patients and directions of care. This relationship is not intended to be one of “supervision.” Both providers share ideas so that care is consistent, regardless of which provider the patient sees during a given visit.
Recently, one partnership discussed the case of Mr. J, a man in his forties with autism and an intellectual disability who was having recurrent syncopal episodes. The patient was minimally verbal and thus could not provide an appropriate history. The partners discussed how to work up the patient’s condition, keeping in mind the restrictions of what he could and could not tolerate. Although the patient was unable to undergo ambulatory cardiac monitoring or an electroencephalogram for diagnosis, he was evaluated with an electrocardiogram in clinic. The partners were then able to coordinate further workup with a cardiologist and neurologist given the patient’s limitations.
3. Design a New Role to Enable Team Integration and Care Coordination
In most medical home settings, the primary care physician functions as the main coordinator of care. By contrast, in the HOME Program, the case analyst orchestrates the integration of care, with the primary care physician serving as a member of the team rather than as its leader. This model enables all team members to focus on their areas of expertise, allowing the entire team to function in an integrated fashion to care for the patient.
HOME Program case analysts are hired on the basis of their experience in the language and logistics of medical and mental health care, their expertise in community resources, and their problem-solving skills. They are not hired solely on the basis of their training as a nurse or social worker; rather, their experience and attitude play a central role in the selection process. Most case analysts do not have a specific clinical background but typically have experience working with this population in community settings and thus have a greater appreciation of the patients’ needs and struggles.
The case analyst is responsible for the whole person, not just individual diagnoses, and coordinates care between the patient’s family and multiple team members, external specialists, and community agencies. A provider naturally may feel overwhelmed because of time constraints, whereas the case analyst is able to focus almost all of his or her energy on integrating the entire team for the purpose of optimizing the care of these complex patients.
4. Hire on the Basis of Passion and Collaboration
In terms of the people, and by extension, the culture of the program, HOME is decidedly selective in the hiring process. Less concerned with skills that can be taught, HOME emphasizes hiring highly competent individuals with a track record of commitment to their work and a focus on working collaboratively with other team members. HOME is made up of people who identify with the vision of the program and the mission to provide world-class services to individuals with developmental disabilities.
In return, the leadership of the program insists on an open-door policy, open disagreement among members at all levels, and mining the skills and interests of its employees. The result is a culture of integrated care in which every person’s perspective is valued. Every member of the team is allowed a voice and is expected to contribute to the broader mission and vision of the program to improve patient care.
The HOME Program includes professionals of varying levels of experience but a strong willingness to work together. The program includes 10 behavioral experts, 6 case managers (from both behavioral and medical backgrounds), 5 licensed clinical social workers who provide therapy, 5 psychiatrists, 4 nurse practitioners, 2 family physicians, 2 pediatricians, 1 dietician, and a utilization management team of 3 individuals who assist with claims through the HMO. The program is led by a services director who oversees the clinical enterprise and the HMO in conjunction with other University of Utah Health leadership.
The HOME Program has demonstrated positive outcomes in multiple areas of quality. Over 95% of enrollees and caregivers believe that the HOME Program is improving lives and prefer it to the enrollees’ previous places of medical and mental health care. Since 2013, HOME has decreased the length of inpatient stays by 18% while also decreasing the 30-day readmission rate by nearly 7%. The number of ambulatory care-sensitive ED visits for HOME enrollees has decreased by 4%, despite the total number of ED visits per 1,000 patients increasing by 6% during this same time frame.
The rate of recommended immunizations among HOME enrollees is >90%, which is higher than both nationwide and statewide rates. In addition, the rate of monitoring for metabolic side effects among those using antipsychotic medications is significantly higher than the rates in other health care settings. Our scores for all metabolic quality measures meet the Centers for Medicare and Medicaid Services benchmarks, even with certain evaluations, such as diabetic eye exams, that can be difficult to perform in this population.
Where to Start
- Promote predictable access to team members and dedicated time for coordination and communication.
- Hire to support the culture, and cull those who do not fit the culture.
- Invest in a role to enable coordination, such as a case analyst.