Blimey! This was the initial one word response when the United Kingdom’s Norman Lamb and I toured the Institute for Family Health (IFH) Harlem Center in north Manhattan. A long-time member of parliament and prior Minister of Health, MP Norman Lamb is not easily impressed. His Liberal Democrats have pressed for the future in mental health, calling for parity since 2010, with the campaign, “No health without mental health.” The party also inspired a nationwide UK “Zero Suicide in Healthcare” dialogue in early 2015.
But, as Senior Vice-President Virna Little and her team showcased their integrated services, it was impossible not to conclude that we were seeing the third revolution in behavioral healthcare. Three key innovations stood out: collaborative care management, patient-centered technologies and a central focus on suicide care.
Collaborative Care Model
There’s no disputing the evidence. In 2002, Jürgen Unützer’s randomized clinical trial in JAMA showed collaborative care was twice as effective for treating depression, improving physical functioning, and reducing healthcare cost as compared with care as usual. IFH was one of the first in the country to utilize the approach beginning in 2003, and over 80 RCTs have since confirmed the effectiveness of the model.
The experience shows. The transdisciplinary care team-based approach goes far beyond integration, with dentistry, community outreach, and population health all baked into one. My jaw dropped as we toured the first floor and saw 14 dental chairs with services that include cosmetic care.
Exploring the five floors above revealed a remarkable example of near seamless behavioral health and primary care integration. IFH has found this approach essential to combating major chronic illnesses like depression and diabetes, where behavioral health provider staff are elevated to equal contributors alongside primary care physicians, nurses, nutrition, care managers, dental and community health.
There’s a remarkable focus on outcomes with the utilization of tools like the Patient Health Questionnaire 9 (PHQ9) and General Anxiety Disorder 7 (GAD7). Mental health has tended to avoid quantitative measurement altogether or utilize lengthy and burdensome tools that made integration across care silos impractical. These brief and evidence-based best practices have united care teams around a common language and process.
Treatment at IFH is open-access and fast paced, more akin to the primary care culture than traditional long-term mental health care. Appointments are typically between 20 and 30 minutes and the duration is between 8 and 16 weeks. It’s less about a full and complete history and more about the current presentation, utilizing brief and solution oriented therapies or behavioral activation. While this may look very different than where we’ve been, it’s not only more effective but better aligned with compliance audits where documentation of medical necessity is required.
Herculean! The name of this electronic health record (EHR) is fitting, both in terms of market size and ease of use/ functionality. In May 2015, Epic was the top EHR as measured by the most providers nationwide who attested to meaningful use, the certification standards of the Centers for Medicare and Medicaid Services (CMS) to improve care coordination and population health.
IFH’s approximate 100,000 patients are among 190 million worldwide reported to have a current electronic health record in Epic, and these patients have had access to their own records via MyChart MyHealth since 2007. One-third are active users of the portal which supports the following functions:
- Communicating with their physician or other staff
- Scheduling and/or changing appointments
- Reviewing lab results, health information, their problem list and treatment plan
- Viewing an audit of their chart (who has viewed their information and why)
The collaborative care model is activated by the shared treatment planning, community collaboration and patient engagement that is core functionality of the Epic platform. In addition, the IFH medical leadership has developed and customized within the software clinical pathways and automated work-flows which are creating a learning environment for consistent practice and focused outcomes.
Going for Zero Suicides
In 2010, CEO Dr. Neil Calman challenged the leadership to develop a Zero Suicide initiative to save lives for those most at risk within the IFH community. Virna Little and her team did what they do every day- they brought their robust technology platform and transdisciplinary care teams to the task. They also incorporated key evidence based practices like collaborative safety plans to reduce access to lethal means and introduced training to better equip all staff (like LivingWorks safeTALK).
In December, Epic released clinical program guidelines “Preventing Suicides in Primary Care Settings,” based upon IFH’s pioneering work. It included the specifications for screening for risk, and the decision support tools, workflows and SmartForms required to replicate their program. For example, the header banner turns red on every page of the record for an individual with “suicidal thoughts” in their master problem list.
The document also includes implementation guidance, securing buy-in from senior management and physician providers and determining the scope of the program.
Social Justice and the Future of Care
In 2015, the Americans with Disabilities Act (ADA) turned 25 years old. This landmark civil rights legislation determined that confining “persons with disabilities in institutions constitutes unnecessary and illegal segregation.” The 1999 Supreme Court Olmstead ruling verified that individuals with mental health diagnoses were also included under the protections of the ADA and could not be held in asylums simply because the state had not invested the appropriate resources in alternatives.
Since the 1960s, the emergence of the second revolution in behavioral healthcare, the Community Mental Health Construction Act, created a system of outpatient services that seemed substantially improved over the largely state-run institutions that preceded them. However, segregation of individuals with serious mental illness away from the larger primary healthcare system has persisted in very significant ways.
The third wave of behavioral healthcare is full and equal integration. It is empowered by technology. Suicide care is a central focus. And, the future is already here. The saying goes that it’s just not widely distributed. Well, stay tuned. The pioneers at the IFH Family Health Center of Harlem have shown us our future destination, and they have also shared the road map for getting there.