History and service overview. Chase Brexton Health Services was founded in 1978 as a gay health clinic, and by the early 1980s was largely focused on serving a targeted population of individuals with HIV/AIDS. In 1991, they received a HSRA grant to add mental health and case management services and, by 1995, expanded to offer primary care services to a more universal population of all eligible persons in the communities they serve. Chase Brexton became an FQHC in 1999, soon began to offer dental services, and expanded their mental health and substance use services to all populations. Within a few years, they earned Joint Commission accreditation. Chase Brexton began its exploration of integrated care in 2002 as a result of participation in the Federal Bureau of Primary Care’s Health Disparities Collaborative. Chase Brexton recognized the importance of using their FQHC as a base for colocated services, which were developed into fully integrated care to respond to their own patient’s experience and the emerging evidence that most people access health care, including behavioral health care, via primary care.

Chase Brexton is one of the largest FQHCs in Maryland, serving nearly 20,000 children and adults in 2011, with just fewer than 150,000 patient visits (Annual Report, 2011). Chase Brexton has four comprehensive clinic sites serving Baltimore City, Baltimore County, Howard County, and Talbot County providing: primary medical care, dental services, mental health services, substance use services, HIV/AIDS testing and medical care, sub-specialty medicine, women’s wellness services, on-site pharmacy, nutritional services, case management including entitlement counseling; nursing services, and chronic disease care management. Care management services, provided by the treatment team, are targeted to three areas: chronic disease management, cancer prevention/screening, and HIV. Behavioral health services provide frontline care, specialty services, and behavioral medicine delivered by health psychologists who have been trained to work with medical patients on psychosocial conditions affecting their treatment (www.chasebrexton.org). They offer intensive case management service and care management, as noted above, for individuals with serious mental illness. Case managers assist patients with entitlement enrollment, health and wellness program linkages, access to transportation, and other required referrals. Staff members work with clients to identify barriers to health care and implement mitigation strategies to overcome them.

HOW: Team-based care/staffing roles and communication. Chase Brexton employs multidisciplinary team-based care, integrated care protocols, cross-training for staff, and shared communication and medical record functions. The integrated behavioral health care team includes nurses, medical assistants, pharmacists, psychologists, psychiatrists, dentists, therapists, and case managers. The intensive case management and care management teams include licensed clinical social workers, peer advocates, and patient navigators. In addition to cross-training their own staff, Chase Brexton has implemented a training program with 16 colleges and universities in their area to develop students interested in their integrated care approach. The EHR contains a number of tools to support the assessment, diagnosis, and treatment of persons with complex health conditions. Treatment planning encompasses both primary care and behavioral health care screening, assessment, diagnosis, and health and wellness services.

Shared patient population/targeted or universal. As detailed in the Overview above, Chase Brexton began serving a targeted patient population of gay persons, began providing more comprehensive and integrated care in response to the complex needs of patients with HIV/AIDS, and then extended their services to the broader, more universal community population.

Systematic clinical protocols and pathways. Systematic clinical approach Communications among clinical staff are facilitated by interdisciplinary team meetings and a shared and integrated electronic health record, Centricity. Chase Brexton is renovating a recently purchased physical plant to reconfigure office and treatment space to support delivery of integrated care, using a “pod” model of care, based on work in a Denver, Colorado FHQC, where the configuration of space, called “collocation,” situates the treatment team (medical providers, case/care managers, behavioral health psychologist, nurse, and adjunct specialties) in an open, central room, surrounded by exam rooms, thus actually supporting a coordinated team approach to care.

SUPPORTED BY: Office practice, leadership alignment and business model. Chase Brexton’s high commercial insurance rate may be attributable to mission to serve the Lesbian, Gay, Bisexual, and Transgender community in Baltimore, many of whom are employed and insured (See Fig. 7.1). Supporting an integrated care model is made difficult by Maryland Medicaid’s policy prohibiting same-day billing for medical and behavioral care, even though the health and behavior codes exist to cover integrated care. In order to support integrated care and remain fiscally sound, Chase Brexton relies on reimbursement for its services eligible for fee-for-service payment and on federal and foundation grants to support the remainder of its health care services, as well as close management of care, expenses, and staff productivity. Patients on integrated teams are more likely to attend appointments, reducing losses associated with “no-show” appointments.

Continuous quality improvement and effectiveness. Chase Brexton employs the PDSA (Plan, Do, Study, Act) model for quality improvement and applies it across their programs. Staff teams meet and discuss needs ranging from modifying the electronic health record and better coordinating scheduling to decreasing no-show rates. Teams develop new approaches, implement them, and evaluate outcomes. They have recently upgraded their electronic health record software, in part to be able to query medical records and produce outcome data, as they currently lack a comprehensive, systematic way of doing so.

Strengths, challenges, and insights. In Chase Brexton’s experience, the strength of the initiative is that integrated care programs address the disparities that continue to surround treatment for mental health and substance use conditions for their historical targeted patient population, as well as for the more recently adopted universal community population. The challenge is that true integrated care requires a philosophical shift from a more traditional, prescriptive doctor-patient paradigm to one that incorporates more dialog between care providers and their patients. Chase Brexton identified two important insights go to the value of tackling challenges to implement integrated care. The first is that when behavioral health is made a part of medical treatment, it reduces stigma and allows diagnoses to be made earlier, which is key to improving health outcomes. The second is that in their experience, involving patients in their care early in the process is essential to engaging them in decision making, and this increases patient support of the care plan and retention in care.

History and services overview. Cherokee Health Systems began its operations as a CMHC in the early 1960s, initiating outreach services for primary care in 1969, a role in which the current CEO was first hired for. Implementing its vision to provide universal access to comprehensive care for needy, underserved populations with “intertwined” conditions and needs, the first primary care clinic at Cherokee was established in 1984. In 1987, they adopted a troubled community health clinic at the request of the federal Bureau of Primary Health Care, leading to federal funding in 2000 and an FQHC grant in 2002. Cherokee is one of a handful of organizations in the country to pioneer the use of both CMHC and FQHC licensure to cover health needs for its client population (D. Freeman, June 12, 2012, personal communication).

HOW: Team-based care/Staffing roles and communication. Cherokee provides team-based comprehensive primary care and specialty behavioral health care services and supports, and addresses acute and chronic health conditions with prevention, treatment, rehabilitation, and care management. Cherokee operates clinics, programs, and support services in 23 locations with a staff composition of more than 500 including psychologists, physicians, social workers, nurses, community public health specialists, and administrative support staff.

The integrated primary care team staff serves individuals who are being screened or have been diagnosed with any mental health or substance use conditions as well as those with serious and disabling conditions who prefer to be served by the primary care team. Behavioral health services provided through the primary care team include patient education, behavioral management, and treatment for all behavioral health conditions. Specialty behavioral health clinics and services are also available, focused mainly on persons with serious and disabling behavioral health conditions.

Shared patient population/Targeted or universal. Cherokee’s patient population is drawn from 13 counties in Eastern Tennessee and last year Cherokee served approximately 55,000 persons. Cherokee patients have a broad range of medical diagnoses. Of those patients served in the primary care clinics, 17 % meet the State of Tennessee’s definition for serious and persistent mental illness (SPMI), yet care is managed in an integrated care setting. In Cherokee’s specialty behavioral health programs, 80 % (25,000 persons) fit this SPMI definition.

Systematic clinical approach. Cherokee used team-based integrated care, well-articulated clinical pathways from the point of intake, evidence-based practices, cross-training, case conferencing, a robust electronic health record, routinely recorded measures, and quality improvement reports to support its behavioral health and primary care integration. As an early adopter of the patient-centered medical home (PCMH) concept, Cherokee has created an integrated “health home” with the behavioral health specialist embedded in the primary health care team, providing timely, on-site assessment, brief intervention and consultation to the team’s patients, with further consultation to the medical staff on treatment plans and referrals for specialty behavioral care. Every team member has care management responsibilities embedded in the team-based treatment process.

Cherokee providers employ evidence-based practices with fidelity to practice standards, recruiting properly trained professional staff with the credentials prescribed by fidelity standards. This is reinforced with onsite training, shadowing and supervision, and scheduled case conferences. Providers team together to share coverage and provide availability to their patients around the clock for urgent clinical conditions, keeping the locus of care within Cherokee and avoid unnecessary use of emergency department and hospital care.

SUPPORTED BY: Office practice, leadership and business model. The intake and assessment interview is performed by a designated team member and addresses both behavioral health and primary care needs. For challenging cases, the team will schedule one to one and a half hours to convene the full team and review all information available on the patient, with the team leader facilitating input from all staff and formulating an integrated care plan. Routine treatment team meetings review the most critical 15–25 cases in each meeting. Weekly team meetings and grand rounds provide additional opportunities for cross-fertilization. The director of psychiatry holds grand rounds and provides routine telephonic consultation to PCPs and care teams.

Case Managers provide significant field-based services and handle coordination with other systems of care, particularly for individuals with chronic and disabling conditions. Primary care and specialty clinics operate in the same buildings, further supporting staff and care integration.

Medicaid is the largest payer and Tennessee’s program supports care integration, permitting same-day billing for primary care and behavioral care delivered to the same patient (See Fig. 7.2). When new health behavior and assessment CPT codes were released, Cherokee approached Tennessee Medicaid to implement the codes, which in turn directed the Medicaid HMOs and MCOs to reimburse for the codes under their respective contracts. Case Managers are funded through managed care contract capitations or billed to Medicaid Rehab option.

Cherokee’s financing structure is critical to supporting the integrated care model; global payments are preferred over FFS payments, and align with goals to reduce encounters (See Fig. 7.3).

Continuous quality improvement and effectiveness. The organization uses data to support care team efforts and focus resources; for example, selected clinical and utilization measures are tracked across the patient population and the primary care teams are notified of numbers that exceed established thresholds or benchmarks.

Quality Improvement (QI) and Monitoring is managed by the Cherokee clinical leadership team composed of five directors—Primary Care, Psychiatry, Community Mental Health, Integrated care, and Pharmacy. The HRSA Uniform Data System (UDS) Report and the FQHC Health Plan report drive feedback on selected clinical measures of PCMH, meaningful use, and other measures required by payers and designed by Cherokee staff members. All staff members receive bonuses for hitting QI measures for efficiency, patient satisfaction, and clinical indicators. Tennessee Blue cross-examined Cherokee utilization data and, comparing Cherokee to the mean utilization levels of other regional providers, found that: ER utilization was lower at 32 % of levels used in other primary care systems; hospital days were lower at 63 % of others’ levels; and specialty visits were also lower at 58 % of the number of visits provided by other organizations; while overall costs were lower at only 78 % of what was incurred in other Tennessee provider systems (See Fig. 7.4).

Strengths, challenges, and insights. Cherokee has developed and documented integrated care practice protocols and adheres to evidence-based practices, measures care activities, and reports results that indicate positive impacts on access, utilization, and costs. However, scheduling extended hours for behavioral health consultants and other staff needs to be flexible to provide same-day access to care as needed; otherwise, patients will go to the emergency department. Establishing clinical and administrative workflows that promote alignment and integration of staff is essential. A multidimensional staff communication infrastructure is crucial for coordinated care.

History and services overview. The Cobb County Community Services Board and the Douglas County Community Services Board (CSB) are public agencies serving Cobb, Douglas, and Cherokee Counties, Georgia. The agency provides support to over 14,000 people annually, including approximately 3,000 patients in the Cobb County Jail. Together, the CSBs employ 400 staff at 20 sites.

HOW: Team-based care/Staffing roles and communication. The integrated care team changed from a physician’s assistant, a registered nurse, a nurse care manager, and two care managers (one RN and one social worker) to include an MSW Care Manager, a Wellness Coordinator, a Peer Specialist (20 hours a week, serves as a Health Coach), and an hourly Data Manager, through their partnership contract with West End FQHC. The MSW care manager is actively engaged in the linkage process, as well as in integration and referrals to specialty care.

They are partnered with the West End FQHC, which has a “wing” in the CSB clinic that is supported by a SAMHSA PBHCI grant. Additional alliances have been formed with key health delivery structures in the community to support comprehensive integrated care, complemented by a Medicaid Disease Management Project supported by APS. In 2007, the Cobb and Douglas CSB leaders acted on their concerns about early mortality due to preventable medical conditions among their dual diagnosis and behavioral health clients, and initiated a partnership with Benjamin Druss, MD, at Emory University to apply for and win a NIMH research demonstration grant. The grant allowed them to run a home study demonstration project targeted at bringing FQHC services into the CMHC setting to improve the array of services provided to individuals with SPMI and comorbid cardiometabolic disorders, and funded the services of a doctor, a physician’s assistant (PA), and a registered nurse (RN). The NIMH funding was extended to 2010, at which time the CSB was awarded one of SAMHSA’s Primary Care Behavioral Health Integration (PCBHI) Grants, which allowed them to extend their partnership with the West End FQHC.

Patient population/Targeted or universal. The CSB primarily serves a population diagnosed with serious and persistent mental illness (SPMI). Their integrated care initiative is targeted to their core clients who also have comorbid cardiometabolic conditions.

Systematic clinical approach. The CSB employs the Four Quadrant model, in which wellness is addressed at all levels of care. They employ evidence-based practices, including peer support services targeted at wellness and recovery, integrated dual disorders treatment (IDDT), and they utilize the Best Practice of Chronic Care Model. Four levels of treatment are provided, including universal PCP screening for physical conditions via self-report and lab tests; a staff appointment for one of the screened-for conditions, during which basic follow-up and wellness is provided; then, more intensive services; and finally, wellness services with a focus on preventive measurement and active self-management.

SUPPORTED BY: Office practice, leadership and business model. The Cobb and Douglas CSB has developed what they term a “Primary Care hallway,” which allows them to integrate staff for patient flow. They have made this hallway part of their circle of holistic care to more fully integrate services. Their medical and behavioral staff members shadow each other to learn from one another and become familiar with each approach to care. The Master’s-level social worker is engaged with training on site and they have a certification program pending for integrated care. The Cobb and Douglas CSB participates in the Learning Academy run by the CIHS and Mental Health Corporations of America, which focused on cardiometabolic conditions.

The integrated care program receives PBHCI grant funding, as noted above, and Kaiser Permanente grant funds that supports the partnership with the West End FQHC (See Fig. 7.5).

Continuous Quality Improvement (CQI). The Cobb and Douglas CSB collects SAMHSA’s required TRAC measures and continues to routinely assess and record results of various clinical metrics associated with the NIMH study. They have made their intake process a common point, which drives quality data and efficiency. The Cobb and Douglas CSB focuses on medical metrics because their program aims to address chronic health conditions.

Strengths, challenges, and insights. West End is sophisticated and progressive, and has provided a partnership of equals and strong cultural match in taking informed risks to innovate and improve care for their clients. If this relationship with the West End FQHC continues to evolve positively, they will seek to colocate permanently and will bill Medicare and Medicaid once ACA expands eligibility. This will allow both entities to bill according to their licenses to all third party payers. They are also exploring the idea of sending CSB behavioral health staff to the West End FQHC, which would build on a small study involving West End patients with depression. On the other hand, the CSB cannot bill for PCP services provided to indigent, non-Medicaid and Medicaid clients, but the “out of clinic” rate under the Rehab Option can cover behavioral health services provided at West End clinics at a higher rate of reimbursement than when delivering behavioral health care in the CSB clinics.