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.