Integration on the Ground:

Going Deep with an ACT Practice
Photography by
James Chance

LA JUNTA, Colo. — We could describe integrated care in thousands of words, or we could tell a few quick stories.

Integration Body Image 1
P.A. Kali Mae Mendoza-Werner has more time with patients than many primary providers.

Story One

Some months ago, Southeast Health Group took in a new patient who had worn out her welcome at other practices in southeastern Colorado. She reported consistent rectal and belly pain, but also exhibited schizophrenic behaviors that led her to ramble in conversations and try her providers' patience with irrelevant or misleading talk. In short, other providers gave up.

"She'd been labeled a noncompliant patient," said Kali Mae Mendoza-Werner, a physician assistant hired as the first primary medical provider within Southeast Health's traditional behavioral health practice.

But Mendoza-Werner had time for the rambling. It's built into her schedule, which currently has her at 13.5 patient appointments a day, where other primary providers might be pressured into handling 20 to 25. When Mendoza-Werner eventually heard enough to believe the pain in her patient's torso was all too real, she sought specialists. And she didn't just send the patient scared and alone to Pueblo for an appointment her mental health issues might force her to skip. At Southeast Health, there's a "warm handoff" to a navigator, who even drives patients to distant appointments.

Turns out the "noncompliant" patient had Stage IV rectal cancer with a huge mass. "We drove her to Pueblo five days a week for eight weeks for radiation treatment," Mendoza-Werner said. "We were furious at the other practice — do you understand she needs more than a door slammed in her face? Behavioral health patients can be hard to take care of, and you have to be willing to stick to it. She's a classic story. She would have died of unknown causes, and nobody would have helped her."

. . . . . .

Story Two

Southeast Health had been seeing a veteran for years for some behavioral needs, and he had been stable and well on psychiatric medication for a long time. Then his behavior started blowing up again. His regular mental health clinician suspected there might be an answer in an office down the hall, so walked the veteran to a quick appointment with Mendoza-Werner and her medical assistant, Rochelle Peil.

"It turned out he hadn't seen a medical doctor in years, and he had strep throat that had thrown him off," Peil said. "If we weren't talking with behavioral health, they would have just increased his psychiatric meds. That kind of answer doesn't happen if we're not all here together."

Story Three

Before Southeast Health added medical practitioners to its staff, a local resident had been a regular mental health patient for ongoing depression. Each visit, he would park his big, brightly colored pickup truck two blocks away so that small-town friends wouldn't know where he was headed.

Now the whole town knows Southeast Health is the place to go for all forms of medical and behavioral care. The longtime patient summarized it for clinic chief operations officer JC Carrica: "It's good to be able to park in the parking lot," he told Carrica. "Now people don't have to know why I'm here."

. . . . . . .

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Southeast Health Group is now adding physical care to its location for better integration.

Southeast Health, practicing in La Junta (population: 7,500) as well as other farming and ranching communities in the region, is one of the state leaders in integrated health care. The multisite behavioral health group had much experience embedding its mental health practitioners with primary care offices, but was often frustrated with the results. Co-location is not true integration, Carrica said, echoing the declarations of integrated care proponents across the nation.

As part of the Advancing Care Together practice innovation model launched by the University of Colorado Denver and funded by the Colorado Health Foundation in 2011, Southeast Health decided to bring primary medical care in-house to better serve the community. Previously, Southeast Health had concentrated solely on counseling, substance abuse and other mental health needs.

Integration is being tried in many different forms. The more common method, even among ACT's 11 sponsored innovation sites in Colorado, is to bring a behavioral health specialist full or part time into an existing primary care medical practice. A 2013 ACT evaluation of lessons learned at its 11 sites identified advantages and challenges with that format; at some practices, the new behavioral health practitioner lasted only a few weeks before leaving in frustration.

Carrica and other leaders at Southeast Health saw potential in the reverse: A midlevel medical practitioner with experience in the local population could fit right in. A full-time psychiatrist could theoretically balance physical and mental health in one new position, Carrica said, but the salary is steep at $250,000 plus benefits, and even then, it's hard to attract a psychiatrist to La Junta. It's easier for Southeast to "outsource" psychiatric professionals through telemedicine links.

Carrica's dissertation held the answer. "I found that midlevels find more behavioral cases and refer them more often. And that's what we need — identification and referral."

It took a few months to draw enough patients to fill Mendoza-Werner's schedule and to tweak appointment times to leave enough room for the longer conversations at the core of integrated care. The primary care load is now at about 700 patients, with 17 percent of those also using the behavioral health side of Southeast Health.

"She's going to hit 800 patients in July," Carrica said, which is the trigger Southeast Health leaders agreed on for considering another primary care hire. In discussing expansion, Carrica said, the Southeast Health governing board asked him, "What are others doing?"

"And I said, 'There is no standard in this.'"

If we weren't talking with behavioral health, they would have just increased his psychiatric meds. That kind of answer doesn't happen if we're not all here together.

Rochelle Peil, medical assistant

Progress at practices like Southeast Health is solid proof that when behavioral health and primary care practitioners are given the right setting to work closely together, "they will take it," said Larry Green, MD, ACT program director and professor of family medicine at the University of Colorado Denver. "That may sound silly, but these are different cultural tribes, that have lived in separate worlds their entire careers. If you can build a place where the worlds come together, there are members of these tribes chomping at the bit to do it."

For the next step in advancing integration, Carrica said, "Our biggest barrier is paperwork. As a new patient, you may have to fill out two hours of forms. You may have been suffering for two years with depression without coming in, and then when you do, we ask just enough to rip the scar and get it bleeding, and then we say, 'Come back in two weeks and we'll start fixing it.'"

Part of that barrier, Southeast Health officials said, is the doubling of paperwork for its growing population of state Medicaid patients because of the "carve-out" of behavioral health benefits from the standard medical benefit.

"Until we get that intake down to 15 minutes, that patient will not be seeing the advantage of payment reform and practice integration," Carrica said.

Still, the staff is visibly fired up about growing into a fully balanced health center for all of southeast Colorado.

"We are identifying cancer more often here than at the big federally qualified clinics," Mendoza-Werner said, "because we slow it down."

Carrica summed it up even more simply: "You come here for what you need. Everybody is treated the same."

 

This article was originally published in the Spring 2015 issue of Health Elevations.

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