Success Stories

Cherokee Health Systems is both a community mental health center (CMHC) and a federally qualified health center (FQHC) in East Tennessee that embeds behavioral health care providers in its primary care clinics. By emphasizing behavioral health integration, Cherokee strives to apply the Patient-Centered Medical Home model across all its sites.

Behavioral Health Consultants in the Primary Care Team

At Cherokee, behavioral health consultants (BHCs) are members of the primary care team and routinely address behavioral health needs in the primary care setting. In addition to checking patient blood pressure, height, and weight, nurses conduct patient screenings for depression, substance use, and other relevant behavioral health conditions as part of their typical triage, using the screening tools that are embedded in Cherokee’s electronic health system. If there is a positive screening, the primary care provider will inform the BHC, and the BHC will come in to see the patient. Through this integration, Cherokee is able to systematically screen its entire population for behavioral health needs.

The incorporation of BHCs into the primary care team allows the vast majority of patients to receive follow up and brief targeted interventions in the primary care setting. Cherokee encourages nurses and clinicians to work together with the patient to create self-management goals. The BHCs at Cherokee are increasingly used for self-management goal development and medication adherence. BHCs also play a role in well-child exams where they regularly use developmental milestone templates as guides to ensuring appropriate domains are assessed.

Coordinated Transitions of Care

In the event that a patient needs more specialty mental health care than is available through the primary care team’s BHCs, a patient will be transitioned to see a psychologist at Cherokee who works outside of the primary care team. Since Cherokee is both a CMHC and an FQHC, specialty mental health is co-located in the same building as the primary care team, which allows frequent face-to-face communication between providers and limits the need for out-of-system referrals.

To ease the transition process, Cherokee has developed an electronic clinical change template that allows the primary care team to alert the new provider, describe the diagnosis and target goals, and explain the reason for the transfer all within the electronic health record. In addition to being able to review progress notes, Cherokee can use a tasking system in which a provider can send a specific task to another provider relating to anything from diagnostic and medicine information to targeted self-management goals. The electronic health record’s (EHR's) tasking functionality allows for providers to pick up treatment seamlessly in transition and communicate with one another in real time. The tasking system also promotes shared clinical decision-making that is informed by the screening tools within the EHR.

One Unified Electronic Health Record

All of Cherokee Health Systems uses the same EHR technology.  Cherokee aims for the EHR to serve as a central repository of clinical information.  All providers can contribute to the EHR and access it in real time. Therefore, Cherokee’s EHR is used for behavioral health, substance use, primary care, and medical specialties. All information is stored together and everyone on the care team has full access to the patient’s record. The EHR even features a shared medication module in which all medications are listed together, regardless of discipline. When using the EHR, all providers begin at the Cherokee Health System homepage which provides up-to-date pertinent information and standardizes the workflow.

Due to the integrated nature of Cherokee’s healthcare model, patients must sign an integrated consent document when they establish primary care at Cherokee. Patients are informed of the electronic and team approach and the use of within-system referrals. Although Cherokee’s internal records are integrated, patient records are separated for out-of-system release. For example there could be a behavioral health release in which only the behavioral health information gets released or a medical release in which only medical information would be released to the out-of-system provider.

Population Management

Cherokee’s EHR system includes a population-based management system that allows providers to mine data about specific criteria from their patient populations. The electronic health record can be used similarly to a registry. Primary care clinicians are able to view patient data, use their clinical judgment to determine which of their patients could most benefit from a behavioral health consultation, and refer those patients to behavioral health clinicians. Cherokee also has independent registries for non-behavioral health chronic conditions. These are often used in relation to behavioral health for diabetes care plans, hypertension management, and various other primary care needs.

Clinician-Informed Workflow

Cherokee aims to maintain a clinician-informed EHR system and workflow. The EHR team at Cherokee consists of IT professionals, a behavioral health care representative, and a primary care representative team. All of the behavioral health templates used in Cherokee’s electronic health records are test and design templates made in-house at Cherokee. Cherokee strives to ensure good clinical decision-making always drives the utilization of information technology.  As such, integration is always a product in development and Cherokee continues to explore additional ways patients can interact and be empowered in their healthcare using patients as the guides.

Presently, Cherokee is piloting a patient portal through which patients can request records, schedule appointments, and ask questions. Cherokee is also in the midst of preparing to launch an iPad pilot program. While waiting for a provider in the exam room, patients will be able to fill out screening forms on an iPad that loads the information directly into their electronic health record through a secure web browser. The iPad workflow will reduce the need for duplicate data entry from paper to computer. Cherokee is also exploring the ability to have the iPad read the screening forms to the patient to provide an extra tool for low literacy level populations. Cherokee hopes the iPads can eventually be utilized to improve patient self-management engagement and goal setting. The iPads may also serve to expand Cherokee’s telehealth efforts since psychiatrists could be called through the iPad during primary care visits, allowing the behavioral health provider to see and engage with the patient. Cherokee hopes that the new iPad efforts will lead to efficient documentation, thorough capture of discrete data, and enhanced patient engagement.

The Community Health Plan of Washington (CHPW) has been administering the Mental Health Integration Program (MHIP) at federally qualified community health clinics statewide since 2009. Presently, CHPW oversees MHIP at about 150 clinics spanning several independent medical services organizations. CHPW funds staffing and training to support integrated behavioral health in these primary care clinics through a licensed mental health professional who serves as an onsite behavioral health care manager. This care manager acts as the primary linkage in care coordination between primary care and behavioral health providers. Behavioral health integration at CHPW occurs via the support of a web-based registry known as the Mental Health Integrated Tracking System (MHITS) available through the Care Management Tracking System (CMTS) hosted by the University of Washington.

The Care Management Tracking System

Care integration in the state of Washington has traditionally faced challenges due to multiple electronic medical record (EMR) systems across health clinics. To address this challenge, the CMTS is not linked to a specific EMR system. As a freestanding, centralized registry the CMTS provides psychiatrists all of the relevant information that guides consultation with the care coordinator regardless of the EMR used by each clinic.

The CMTS contains a wealth of information both at the patient level and caseload perspective. The registry supports many of the most common adult behavioral health diagnoses and has recently expanded to use on child conditions well. The CMTS includes a clinical dashboard to guide clinicians through the vast array of information provided at the patient level. Additionally, the registry can show caseload summaries so physicians can use a population-based approach to see which of their patients are not improving and adjust treatments accordingly. Finally, the registry incorporates an appointment scheduling and referral tracking functionality.

Since use of the registry tool is managed directly by CHPW, the information in the CMTS is able to be hosted centrally with clinical team access without need of extensive use of release of information efforts unless referring outside of the provider group’s treatment teams. Business associate agreements have been established with the University of Washington consulting psychiatrists and the clinics to allow for information release. To further address privacy laws, the registry tool itself does not include substance use treatment information.

Integration through a Care Coordinator

Registry data at CHPW is managed primarily by the care coordinator at the primary care practice. The CMTS is utilized as a workflow support tool between the primary care physician and behavioral health providers. After a psychiatric consult, the care coordinator ensures that relevant notes from the registry are entered into the EHR in which the primary care physician can then access. The registry tool is also designed to produce brief reports specifically tailored for certain members of the care team. For example, there is a specific report designed for the primary care physician after the patient has seen the consulting psychiatrist. The case coordinator can send the report to the primary care physician through the primary care practice’s EMR or in print form to the primary care physician.

In addition to the care coordinator, the registry is also accessible to behavioral health providers. The tool supports remote population psychiatric consultation allowing psychiatrists to log on and review their entire caseload and efficiently share information with the care coordinator from very remote distances.

Tracking Mental Health over Time

The CMTS registry acts as a clinical decision making support tool at CHPW by tracking patient progress over time. Clinicians and patients work together to select either established tracking scales within the registry or develop their own tracking systems for behavioral health conditions. The registry incorporates a number of embedded screening and tracking tools including the PHQ9 for depression, GAD7 for anxiety and the PCL for PSTD. Most recently, CWPH has added the unique ability to track A1C blood glucose and LDL cholesterol levels over time as well. The ability to track patients from the first visit to the most recent allows for easy assessment by primary care and behavioral health providers to see if a patient is improving. The registry provides data that is actionable, ensuring that care delivery remains focused on engagement and improvement.

Promoting Patient Engagement and Education

CHPW is committed to prioritizing patient engagement in behavioral health. CHPW has a series of quality measures built into the CMTS registry tool. On a weekly or monthly basis the care coordinator can view their quality measures, many of which are specifically targeted at patient engagement.  The CMTS then allows for the care coordinator to click on measures that inform them which patients are failing to meet the benchmark. Furthermore, when a patient has not been engaged at designated levels of specific periods of time, the registry tool enacts a flag to remind the care coordinator that certain benchmarks have not been achieved with those patients. Additionally, the caseload view in the CMTS sorts patients according to dates of key milestones which makes it easy for care coordinators to prioritize their work and see which patients are falling through the cracks.

CHPW emphasizes that the registry is not simply a work support tool; it is also a patient’s psycho-education tool. The care coordinator can create graphics through the registry so they can turn the computer screen toward the patient and help them understand their symptoms and expectations for treatment.  Specialized patient summary reports can also be produced by the registry and given to the patient. The registry promotes a patient centered care plan in which care coordinators and patients work together to develop goals that can be documented over time scored on a 1-10 scale which further allows for graphical progress reports that are made available to the patient.

Successes and Challenges

Promoting an integrated model of care through the registry succeeded in introducing functionality that enabled team-based care and access to consulting psychiatry. The largest challenge to implementing the registry was that the tool in its current form requires double data entry, which is burdensome and continues to be a concern moving forward. The MHIP was most difficult to implement in clinics that already had behavioral health programs in place due to the significant transition process. Despite these obstacles, the unique workflow and clinical decision making support provided by the CMTS allows the tool to serve as Washington’s first statewide health information exchange system focused largely on supporting behavioral health integration.

Intermountain Healthcare in Salt Lake City, Utah, promotes consistent systematic behavioral health integration through its own in-house ambulatory and hospital-based information technology systems. Mental Health Integration (MHI) at Intermountain extends from primary care to specialty care clinics including sleep disorder clinics, diabetes care centers, spine clinics, cardiology clinics, and gynecological services.

Integrated Information Technology Workflow

The information technology systems at Intermountain, including the electronic medical record, health information exchange system, and population registries are all linked. The electronic medical record (EMR) contains a message log function through which the primary care physician, the behavioral health provider, and the care manager can communicate and exchange information easily. The patient can also use the patient portal in the EMR to communicate with care team members for follow up questions or any emergency need.

The workflow at Intermountain incorporates MHI as a standard quality of care. Each clinic has a standard scorecard and process for treating mental health as part of a normal routine visit. There are protocols and algorithms in place by which patients are screened with standardized tools for understanding the complexity of the patient’s concerns and acuity of symptoms. The data is then coded into the electronic medical record and a care plan is developed through provider discussions with the patient.  The primary care physician provides about 80 percent of the mental healthcare using clinical protocols and decision aid supports. Care managers and mental health professionals are brought in as needed through either face-to-face communication or the message log of the electronic health record.

Patient responses can be printed from the electronic health record that contains an organized summary of the patient’s self-reported answers to an MHI packet containing over 160 mental physical health validated questions. Results to these questions are recorded into the EMR and used to determine course of treatment and follow up care with the mental health specialist. All information and communication that is stored in the electronic health record is merged into the a data warehouse and supplemented with information from other organization IT systems including patient hospitalizations, emergency visits, patient medications, and chronic disease registries. The registry information is stratified and organized in series of clinical and financial reports that are returned to the care team and clinic administrators creating a continuous information loop.

Achieving Triple Aim Outcomes

Intermountain Healthcare emphasizes five key institutional components that must work together to achieve the MHI Triple Aim Outcomes:

1. Leadership and Culture
2. Workflow Integration
3. Information Systems
4. Financing and Operations
5. Community Resource Integration

Consistent with the Triple Aim, Intermountain uses information technology to facilitate behavioral health integration through population level data. Patient outcome data is tracked and reported to the providers through the information technology system. Intermountain maintains several chronic disease registries in its data warehouse including a depression registry of around 400,000 patients that is among the largest in the nation and has been used to develop risk assessment models. Intermountain recognizes that there is high comorbidity among patients suffering from chronic diseases and is working to make a more complex patient registry that would track all chronic conditions in one place.

The integrated information systems at Intermountain are also used to advance implementation of new medical and operational knowledge. In order to ensure providers are informed and patients are receiving the best treatment, tools have been developed including staffing models, clinical models, quality indicators, and methodologies for measuring cost and outcome longitudinally.

Intermountain strives to use their information technology system to support the Triple Aim by planning to incorporate population health, cost, satisfaction, and outcomes together in one integrated system. Presently, Intermountain is testing a pilot project of regrouping some of the Triple Aim information into one reporting tool for some of their clinics. For MHI this means defining the population through disease registries and administrative databases, gaining data on quality of care through use of protocols on follow up visits, antidepressant use, and talk therapy, and then tracking patient outcomes.  Intermountain also tracks on a yearly basis the budget for MHI at some clinics to gain understanding of the overall costs of care delivery for patients with mental health concerns and link costs to quality metrics for established value added.

Shifting to a New System

Intermountain acknowledges that it is a constant challenge to develop a system that is the most user-friendly for clinicians to access and record information.  Intermountain recently purchased a new electronic medical health record system through a private vendor in response to their growing population and ambulatory needs. The clinicians at Intermountain are working with a new system to replace both their hospital and ambulatory-based electronic health record systems. Intermountain is hopeful that directly involving clinicians in the system development process will help to ensure that the new system will meet provider needs.

The new system will incorporate alerts such as alerting providers if they need to do PHQ2 or PHQ9. Intermountain is also planning to add features that will enhance patient engagement such as tracking patient reported outcomes and patient engagement measures at the time of their visit.

MaineHealth is an integrated healthcare system of leading, high-quality providers and other healthcare organizations working together across Central and Southern Maine. The Behavioral Health Integration program, a program of MaineHealth and Maine Behavioral Healthcare (a member of MaineHealth), consists of approximately thirty clinicians working in close to forty different practices within seven hospital system members of MaineHealth. MaineHealth’s integration efforts started with grant funded pilot work in twenty practices around the state. There was great flexibility in trying a variety of models during this pilot work, which allowed the leadership of the integration program at MaineHealth to explore various levels of integration and decide what would work best for their needs. It was deemed that the most effective and efficient method for integration was for providers to be able to work directly in the electronic medical record (EMR) and for those notes to be simultaneously used as a shared form of communication between providers. MaineHealth has since adopted a system that promotes shared medical decision making by allowing providers to easily store and transmit patient information.

Integrative Electronic Medical Records

At MaineHealth all primary care providers operate directly in the EMR with record keeping occurring in relatively real time. The behavioral health specialist also works directly in the EMR and has the ability to view the patient’s entire medical record. The EMR systems at MaineHealth feature a flag alert communication tool in which behavioral health and primary care providers can send messages to each other that are not part of the patient progress notes, but instead serve as internal instant message logs. Primary care physicians receive complete feedback from the behavioral health provider both in person as well as by simply accessing the EMR when behavioral health providers route their notes directly to the primary care provider.

The EMRs at MaineHealth incorporate a series of tools and patient engagement features used by both behavioral health providers and primary care physicians. The system incorporates PHQ9 screening for depression into the EMR as a standard behavioral health assessment. MaineHealth also incorporates PHQ9 into their registries for some chronic health conditions. The registry includes how many patients have been screened using PHQ9 and information regarding PHQ9 follow ups. Although MaineHealth does not possess registries of specific psychiatric conditions, a behavioral health clinician looking for patient information regarding a psychiatric or behavioral health condition is able to do so through the integrated physician’s notes and any documents that come from other agencies around their mental health care. All supplemental documents are scanned and electronically entered into the patient record. Documentation of present behavioral health conditions is stored in the EMR during the patient visit.

The EMR systems at MaineHealth also support the everyday needs of the office. For example, the EMR includes a referral system that supports scheduling patients. To promote integrated care MaineHealth encourages warm handoffs in which the provider directly introduces the patient to the behavioral health provider. These warm handoffs can increase a patient’s trust level in the behavioral health provider and help to ensure the patient will follow up on their behavioral health needs. While the warm handoffs occur in person, the EMR is used to log the order for a referral for behavioral health service so that front office staff can create and schedule the appointment electronically with the patient at check out.

Addressing Confidentiality

MaineHealth recognizes the need to maintain confidentiality of records while employing health information technology for purposes of behavioral health integration. A key priority is to always acknowledge that behavioral health records are sensitive and, as such, MaineHealth has enacted specific procedures for managing behavioral health records. For example, the behavioral health portion of a patient medical record has limited access.  Since behavioral health information is protected by extra levels of sensitivity, there is specific access designated for doctors, nurses, and care managers to be able to access documentation coming from the behavioral health clinician. MaineHealth recognizes the need to balance the ability to coordinate care with the need for privacy by ensuring that behavioral health information gets to the right people without allowing the information to flow unnecessarily to others. Any information that does go outside of a particular hospital system within MaineHealth would need a release of information signed by the patient.

When a patient is referred to a behavioral health clinician at MaineHealth, the patient is informed that information will be shared across their providers both electronically and in person. If a patient is not comfortable with that sharing of information, the patient can be referred elsewhere. The vast majority of patients, however, appreciate the sharing of information between their mental health providers and primary care clinicians. Appreciation of these integrative efforts is part of why patients come to MaineHealth.

Promoting Interoperability

At present there are four different electronic medical record (EMR) systems used by integrated behavioral health clinicians working in the MaineHealth hospital-owned primary care practices, although there are plans to continue to reduce the number of vendors. In the meantime, MaineHealth has enacted efforts to promote interoperability and standardization across systems.

Much progress has been made thus far in standardizing the typical documentation of the behavioral health clinician. The largest challenge in implementing health information technology systems for behavioral health integration has been the need to have someone in the IT systems available to build templates for behavioral health documentation and to create processes for storing behavioral health information. None of the EMR systems in use at MaineHealth came with behavioral health templates that met their needs, so MaineHealth opted to develop their own templates that would be standardized across all of their HIT systems. MaineHealth continues to work toward building templates that span all of behavioral health that can be incorporated into all of the electronic systems. To assist in everyday needs, IT staff are connected to the hospital systems and are available to support primary care providers and behavioral health clinicians in all MaineHealth locations.