Cherokee Health Systems is both a community mental health center (CMHC) and a federally qualified health center (FQHC) 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 followup 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.
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.
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.