EXECUTIVE SUMMARY
Montefiore Health System’s collaborative care model integrates medical care with treatment for behavioral health issues that can be handled in a primary care setting.
- Patients who are identified with behavioral issues are assigned a care manager at the Montefiore Care Management Organization, who coordinates with the primary care physician and behavioral health team to develop a plan of care.
- The care manager provides telephonic case management follow-up with patients after their primary care visits, educating them on their condition and helping them meet their goals as well as relaying recommendations from the behavioral health team to the primary care provider.
- When the psychiatrist on the behavioral health team recommends medication, the care manager informs the primary care physician, who prescribes it.
To manage the care of patients with chronic illness and behavioral issues, Montefiore Health System in Bronx, NY, takes a collaborative approach that integrates medical and behavioral healthcare.
“For some patients, medical case management is not effective without managing the patient’s mental health issues,” says Daniel Alexander, RN, clinical program manager of Montefiore care management’s integrated behavioral care program.
Montefiore started the collaborative care program 10 years ago, Alexander says. “We wanted to be ahead of the curve in managing care for this patient population. Many other systems have come to talk with us over the years and are adapting our model. We collaborate with each other about what works and what doesn’t,” he says.
The keystone of the program is the Montefiore Care Management Organization (CMO), established by the system and staffed by a psychiatrist, a psychologist, two licensed social workers, and patient educators. Patient educators typically have bachelor’s degrees and many of them are working on master’s degrees in social work or public health.
“Collaborative care addresses patients’ behavioral health needs that can be effectively treated in a primary care setting. Our team at the CMO acts as the bridge between the psychiatrist and the primary care provider. The psychiatrist, care managers, and therapists all work together to keep the primary care provider informed,” Alexander says.
Untreated behavioral health issues, particularly depression, result in huge costs on the medical side. “People who are depressed don’t engage in healthcare. They don’t do the things they need to do to improve their medical conditions,” he says.
It can take months for patients to get an appointment with a psychiatrist in private practice, Alexander points out. Collaborative care gives primary care physicians a virtual team of behavioral specialists to help them with their patients who have behavioral issues.
“In the past, patients went to a primary care provider for medical reasons only. Now, the primary care physician often is the key point of entry into treatment for behavioral health,” he says.
Hospital case managers identify patients with comorbidities or certain diagnoses, including mental health diagnoses. Primary care physicians also identify these patients during the behavioral health screening, which primary care physicians at Montefiore have incorporated into their patient assessments.
“In the past, physicians rarely asked about depression, but now they make it part of the normal screening. Many people who suffer from depression, post-traumatic stress disorder, and other behavioral health disorders don’t see a behavioral health provider, but if they are screened by their primary care doctor, they are more likely to accept behavioral healthcare as part of their routine chronic care,” Alexander says.
In some cases, the primary care physician refers patients to the CMO. It may be a patient with out-of-control diabetes and symptoms of depression. “At this point, the patient will be co-managed by the behavioral side and the medical side,” he says.
Questions about depression are part of the follow-up calls the hospital case management staff make to patients transitioning to a different level of care. If the scores indicate a problem, the case manager refers the patient to the CMO team.
When patients with behavioral health issues are identified, they are assigned to a care manager at the CMO who works with the primary care provider and the behavioral health team to develop a personalized care plan that includes medical and behavioral health goals.
The interventions between patients and case managers are mostly by telephone, Alexander says. They follow up with patients after their primary care visits, reinforce what the physician has told them, provide basic education on their conditions and their healthcare choices, and help them set healthcare goals. “The case manager can help sort things out and answer questions about the visit,” he says.
“When a patient is hospitalized at one of our hospitals, our team makes sure the transition back to the community is smooth and that the primary care physician knows about the hospitalization,” he adds. “We also work with hospitals outside our network to get information from them that could assist the primary care provider.”
When patients make frequent trips to the ED, case managers educate them on how to manage their diseases and what constitutes an emergency.
“If a patient has gone to the emergency department many times in a year and the case manager can help them follow their treatment plan and go to the emergency department only five times, it’s a win all the way around, in terms of the patient’s health status and the cost of care,” Alexander says.
Many of the patients referred to the program have psychosocial needs which are handled by the social workers or the patient educators as soon as they receive the referral. “We take care of their social needs first. If patients are about to be homeless or can’t feed their children, they aren’t going to pay a lot of attention to their healthcare,” Alexander says.
A goal of the program is for staff members to work at the top of their licenses. For instance, if a patient needs housing or other assistance, the patient educator walks them through filling out the applications. “You don’t need an RN to fill out an application, so patients are referred to a patient educator,” he says.
The program’s psychiatrist rarely interacts with the patients directly, seeing patients on a case-by-case basis, but meets regularly with the case managers to discuss cases and patient scores on assessments to determine how patients are managing their conditions and what needs to be done. “The results serve the same purpose as markers on the medical side, such as blood sugar levels and blood pressure readings. The psychiatrist weighs in on the treatment plan through communication with the care manager, who relays the recommendations to the primary care provider,” Alexander says.
When the psychiatrist recommends medications, the case manager communicates this to the primary care provider. “In this model, the psychiatrist recommends medication and the primary care provider prescribes it. We are all working together, but the primary care physician is in control. Our goal is to work together to get the patients to the right treatment, depending on what their needs are,” Alexander says.
An integrated electronic medical record is a key ingredient of the initiative, Alexander says. “When everything is communicated through a single point, all members of the team know what the rest of the team is doing. I can see inpatient notes for the patient and the doctor’s record of a visit in real time,” he says.
Primary care providers like the idea of knowing that they can find out everything that is happening with the patient on the behavioral health side by accessing data in the medical record, he says.
The collaborative care model can be modified to meet whatever organization is using it, Alexander says. “The idea of collaborative care is that it can be instituted in all areas of the health system. It works with oncology, end-stage renal disease, and other conditions that often include behavioral issues. Collaborative care facilitates communication between the medical and behavioral health practitioners, through the care manager and through each other,” he adds.
Montefiore Health System’s collaborative care model integrates medical care with treatment for behavioral health issues that can be handled in a primary care setting.
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