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A Workforce Innovation for Behavioral Health Integration: Insights from the Idaho Health Neighborhood Center

Date

Idaho has one of the highest rates of suicide and faces severe healthcare workforce challenges, particularly in its rural areas.1,2,3 Idaho’s rural and frontier communities have a high need for medical and behavioral health services but do not have sufficient resources or access to services.4 The State’s largest city and capital, Boise, is a sanctuary city for refugees and has many international medical graduates.5 These highly trained individuals are physicians in their home countries but lack the qualifications to become physicians in the United States. They often must settle for low-paying, low-skill jobs to support their families.6 

Cornerstone Whole Healthcare Organization (C-WHO) recognized the community needs and untapped human resources and created a program to bridge the gap. They created the Idaho Health Neighborhood Center (IHNC) to address the provider workforce shortage and improve access to care. C-WHO's innovative approach to addressing workforce shortage provides an excellent example that other organizations may be able to take inspiration from.

"The Idaho Health Neighborhood Center (IHNC) “provides primary care services integrated with behavioral health and clinical pharmacy. [It employs] multi-lingual international medical graduates to train and retain medical professionals in Idaho."7

Development of the IHNC

To create the IHNC, C-WHO adapted the Patient Centered Medical Home and Primary Care Behavioral Health models to incorporate team-based care and provide comprehensive and integrated (primary care with medical, behavioral, and clinical pharmacy professionals) services to patients. The two main goals of the intervention were to:

  • Create a community-based, full-service neighborhood health center to provide immediate/same-day access to medical, behavioral health, and clinical pharmacy services in the at-risk areas of Canyon County and surrounding rural communities.
  • Develop a training program to create a pathway for international medical graduates (IMGs) to receive the necessary training and supervision to allow them to sit for the U.S. medical examinations and provide medical services in underserved rural communities.  

The IHNC serves low-income, rural, migrant, and refugee community members in Canyon County and surrounding areas. To assist with meeting the needs of this population, it employs and supports international medical graduates needing opportunities to be trained and supervised in U.S. medical practice to pass their boards and be placed in residency in the United States.

Funding and Staffing

Initial funds were secured through various methods, including company savings, consulting contracts, donations, foundation dollars, and federal grants. The clinic was staffed with a full-time physician assistant, a full-time behavioral health provider, three full-time IMGs, one full-time office manager, and one receptionist.  All clinic staff reported to the chief medical officer of C-WHO. 

Execution and Contributing Success Factors

C-WHO developed a sustainable business model by carefully analyzing financial needs and revenue streams. The clinic now not only sustains its team-based care model but is financially stable, growing, and continues to provide high-quality, accessible healthcare services to its patients. Below are key contributing factors to how they now sustain a team-based model:

  • Patient Volume and Billing: By calculating the number of patients needed to break even for staff compensation and other clinic expenses, the clinic ensures that it operates efficiently and remains financially viable. Credentialed providers seeing approximately 20 patients a day helps meet this target, ensuring the clinic generates sufficient revenue to cover its costs. 
  • Insurance Coverage and Sliding Fee Scale: Accepting almost all insurance plans expands the clinic's patient base and ensures it can bill for services provided to insured patients. The clinic also offers a sliding fee scale for patients who meet poverty guideline. There are self-pay options for patients who have no insurance but do not meet the sliding fee scale. This provides an alternative revenue stream and increases accessibility to care for individuals who may not have traditional insurance coverage. 
  • Diversification of Services: The clinic diversifies its revenue sources by engaging in contracts with Employee Assistance Programs (EAP), the Idaho Department of Health and Welfare to provide refugee health screenings, and REE Medical to review military disability screenings. These contracts generate income and expand the clinic's reach and impact within the community. 
  • Community Engagement and Partnerships: Partnering with the State of Idaho for refugee health screenings and military disability screenings demonstrates the clinic's commitment to serving diverse populations and meeting specific healthcare needs. These partnerships not only contribute to revenue generation but also enhance the clinic's reputation and visibility within the community. 

Results

Overall, the intervention has been met with enthusiasm and appreciation from both staff and patients. Since the clinic opened in February 2023, the impact on patient outcomes has not yet been fully analyzed. But data is currently being gathered on several screening metrics including annual wellness, opioid use disorder (OUD), substance use disorder (SUD), social determinants of health (SDOH), the Patient Health Questionnaire-9 (PHQ-9), and General Anxiety Disorder-7 (GAD-7). Formal data analysis has been planned to begin in fall of 2024, but the clinic has already collected narrative feedback from patients and providers. 

Patient Feedback

Patient testimonials reaffirm the effectiveness of the team-based care model in providing accessible, respectful, and comprehensive healthcare services that meet the diverse needs of the community. The clinic has provided care to over 1,700 patients as of October 2024. Data collected through patient internet reviews and in-person feedback consistently show high levels of patient satisfaction with the services provided. Patients valued the personalized attention, collaborative approach, and efficiency of the team-based care model. Specifically, patients spoke to the:

  • Accessibility of Services: Patients have expressed astonishment at the ease of accessing both primary care and behavioral health services under one roof. This integrated approach eliminates barriers to care and ensures that patients receive comprehensive support for their physical and mental health needs. 
  • Respectful and Comprehensive Care: Many patients have shared experiences of feeling disregarded or disrespected by previous healthcare providers. They appreciate the compassionate and attentive approach of the IHNC team, who take the time to listen, accurately diagnose, and develop appropriate treatment plans tailored to everyone’s needs. 
  • Collaborative Care for Chronic Conditions: Patients managing chronic conditions have experienced significant improvements in their health outcomes due to the collaborative efforts of the healthcare team. They value the convenience of having multiple professionals working together to address their complex needs, resulting in better disease management and overall well-being. 
  • Cultural Sensitivity and Accommodation: Refugee patients have highlighted the importance of multilingual and culturally sensitive staff understanding their backgrounds and unique needs. This cultural competency fosters trust and enhances the patient-provider relationship, leading to more effective communication and better health outcomes. 

Provider Testimonial

A Physician's Assistant (PA) for the IHNC shared an analogy of transitioning to a team-based care clinic, stating “it’s like upgrading from a base-model car with manual windows and no AC to a brand-new model with all the bells and whistles.” This sentiment was shared by many staff members and highlights the transformative impact that integrated team-based care can have on patient management and professional satisfaction. In his previous practice, this PA faced the challenges of managing patients single-handedly, often leaving him uncertain about their outcomes. 

Under the current integrated team-based model, this PA now has access to a diverse range of healthcare professionals who contribute to comprehensive patient care. They may now collaborate with international medical graduates to assist in patient follow-ups, ensuring continuity of care and improved patient outcomes. He may choose to involve the behavioral health provider for patients in crisis, struggling with anxiety or depression, or just in need of lifestyle change. 

Furthermore, he may involve the clinical pharmacist for patients struggling with medication management or in need of a medication review. The clinical pharmacist plays a crucial role in medication reconciliation, patient education, and implementing a stepped-care process to address polypharmacy issues. This interdisciplinary collaboration enhances medication management and reduces the risk of adverse drug interactions, ultimately benefiting patient health. Overall, this PA's testimony emphasizes how the team-based care model not only enhances patient care but also provides invaluable support to healthcare professionals, fostering a collaborative and fulfilling work environment.

"It's like upgrading from a base-model car with manual windows and no AC to a brand-new model with all the bells and whistles." - Physician's Assistant at the IHNC

Key Takeaways

Lessons from the IHNC underscore the importance of strategic planning, effective management practices, and a patient-centered approach in successfully implementing and sustaining healthcare interventions. Takeaways from the current progress of this intervention include:

  • Creative Workforce Solutions: Thinking outside the box to address workforce needs can result in innovative solutions that benefit staff, patients, and the community. The relationship between C-WHO and the international medical graduates they hire is mutually beneficial.
  • Effective Practice Management: Hiring a skilled practice manager who understands the dynamics of running a primary care practice is crucial. They play a pivotal role in ensuring smooth operations, financial management, and staff coordination. 
  • Adaptability and Change Management: Being comfortable with change and expecting the unexpected are essential attitudes in healthcare. Psychological flexibility allows the clinic staff to adapt to evolving patient needs, industry trends, and external factors while maintaining focus on clinical excellence. 
  • Financial Management: Managing expenses and revenue is vital for financial stability, especially with the potential inconsistency in cash flow in healthcare settings. Having a robust financial management system ensures the clinic can weather financial challenges effectively. 
  • Diversification of Services and Revenue Streams: Relying solely on fee-for-service may not be sustainable. Diversifying services and revenue streams help mitigate risks and enhances financial resilience. 
  • Patient Panel Development: Building a patient panel can be challenging. Hiring providers who can bring their patient base with them can expedite this process and boost clinic growth. 
  • Community Engagement and Partnerships: Openness to partnerships and community involvement strengthens the clinic's connections and fosters trust within the community. Inviting community members to tour the clinic promotes transparency and enhances community relations. 
  • Continuous Quality Improvement (CQI) and Quality Assurance (QA): Implementing a robust CQI and QA process ensures that the clinic maintains high standards of care and performance. Regular assessment and improvement initiatives enhance patient outcomes and overall clinic effectiveness.

Credits and Contact Info

The content of this case study was contributed by C-WHO's Amy Walters, PhD and edited by Alec Hester at Westat, and Integration Academy Principal Investigator Garrett Moran, PhD. We also thank NIAC member Jennifer Yturriondobeitia, MSW, DBH for her contributions. For more information on C-WHO and the IHNC, please contact jeny@c-who.org. 

References

  1. National Center for Health Statistics. Health, United States, 2020-2021: Physicians. https://www.cdc.gov/nchs/data/hus/hus20-21.pdf Accessed July 5, 2024.
  2. Idaho Department of Health and Welfare. About Suicide Prevention. https://healthandwelfare.idaho.gov/services-programs/behavioral-health/about-suicide-prevention. Accessed July 5, 2024.
  3. Idaho Department of Health and Welfare. Rural Health and Underserved Areas. https://healthandwelfare.idaho.gov/providers/rural-health-and-underserved-areas/rural-health-and-underserved-areas. Accessed July 5, 2024.
  4. Kaiser Family Foundation. Mental Health in Idaho. https://www.kff.org/statedata/mental-health-and-substance-use-state-fact-sheets/idaho/. Accessed July 5, 2024.
  5. Amanda Peacher. Despite Doctor Shortage, Refugee Physicians Face Big Hurdles To Practicing. https://www.ypradio.org/2018-04-30/despite-doctor-shortage-refugee-physicians-face-big-hurdles-to-practicing. Accessed July 5, 2024.
  6. Ramesh T, Horvitz-Lennon M, Yu H. Opening the Door Wider to International Medical Graduates - The Significance of a New Tennessee Law. N Engl J Med. 2023 Nov 23;389(21):1925-1928. https://doi.org/10.1056/NEJMp2310001. Accessed July 5, 2024.
  7. Idaho Health Neighborhood Center. Homepage. https://healthneighborhoodcenter.org/. Accessed July 5, 2024.