Integrated Care at Center for Health Care Services

The Center’s Northwest (NW) Integrated Care Clinic strives to provide treatment that encompasses an individual’s behavioral health and primary care needs. The team has a dual mission – to establish care and stabilize both behavioral health and physical health needs. The Integrated Care Clinic offers several services and programs, including:

• Psychiatric Services. Evaluation, diagnosis and treatment of mental health conditions.
• Primary Care Services. Services for common, acute and chronic disease that affects general health.
• Center Pharmacy at Legacy Oaks. All CHCS clients can get their prescriptions filled and dispensed at the NW Integrated Care Clinic.
• Group Therapy. The program provides a comprehensive array of behavioral health groups utilizing trauma-informed and evidence-based practices. Wellness groups are designed to promote healthy living and client empowerment by teaching life skills to improve the lives of clients with chronic health conditions.
• Peer Support. Peers demonstrate self-help strategies based on their own recovery experience and help clients achieve recovery goals.
• Trauma-Informed Care. Treatment teams and programs seek to understand, recognize and respond to the effects of all types of trauma affecting an individual’s overall life functioning.
• Program offers trauma-informed evidence-based psychotherapy practices including cognitive and dialectical behavioral therapy.
• High Utilizer/Integrated Care Program. A dedicated team of behavioral and primary care clinicians work together to provide comprehensive integrated health care for people living with serious mental illness. The Integrated Care Team (ICT) serves individuals identified as “high utilizers” — clients with multiple co-occurring issues resulting in extensive acute care utilization at emergency departments and inpatient care. ICT works collaboratively with local hospitals as well as health care and law enforcement agencies to reduce over-utilization of emergency care resources. ICT provides wrap-around clinical services to help people identify healthy recovery goals and progress toward stable, productive independence.
• Assertive Community Team Program (ACT). ACT is a highly integrated outpatient approach for community mental health service delivery. ACT serves individuals whose mental illness results in serious functional difficulties, that can include work, social relationships, residential independence, money management, and physical health and wellness.

The NW Integrated Care Clinic is operated by the Adult Behavioral Health Division of the Center for Health Care Services. The Adult Behavioral Health Services Integrated Care team provides holistic medical, psychiatric and recovery services that empower clients to make positive life changes. The team works with each person to set and achieve goals for restoring and maintaining health and personal well-being.

Several staff members support the NW Integrated Care Clinic and ensure high quality and efficient services. These staff members provide direct clinical care, ensure that health information systems are operational and functional and help guide the overall direction of the program. Key staff include:

• Vice President – Adult Behavioral Health Services
• Clinical Practitioner
• Programmer Analyst
• Database Administrator

Integrated services are supported at CHCS by a robust health information technology (HIT) structure. CHCS utilizes two independent electronic health records (EHR) that operate independently of one another – Anasazi is the EHR for behavioral health services, and Cerner’s PowerChart is the EHR for primary care services. While each system is independently reliable as a stand-alone unit, integrating the two has required effort. With information exchange/sharing being paramount to patient care planning in an integrated setting, CHCS’ IT department created a format where information from both units could be extracted, routed and combined in a data warehouse. As a result, CHCS is now able to depend on more accurate and comprehensive data exchange and reporting.

CHCS is also engaged with HASA Health Information Organization, a state-wide Health Information Exchange where local and statewide organizations come together through technology to provide shared data on clients served.

The complexity of managing “whole health” can be overwhelming without the appropriate educational materials to guide them. Health literacy training provides information to clients and providers to help prevent and manage disease, promote mental wellness and follow an all-inclusive treatment plan. NW Integrated Care Clinic training material is gathered from vetted evidence-based and research-driven organizations. Examples of health literacy material disseminated to clients and providers include:

For clinicians:

• Hypertension Protocol
• Identifying and Treating Patients Who Use Tobacco

For clients:

• What is Diabetes? (Spanish, English)
• Self-Monitoring Blood Pressure
• Be Active Your Way (Spanish, English)

• Proper Staffing. It is vital to have the right team members with the right personalities in place. When interviewing potential employees, it is important to focus on the ability to problem-solve, work collaboratively as well as specific skillsets. The right team: Generates a wider range of ideas and innovation than individuals.
  • Motivates themselves.
  • Bounces ideas off each team member.
  • Takes more risks than individuals.
  • Has a range of personalities such as workers, thinkers and leaders that results in the right balance of skills necessary to achieve high performance.
  • Supports each other and are not just task-orientated.
  • Serves as a support mechanism to provide mentoring and allow others to grow in self-confidence.

• Invest in Culture Change. CHCS currently educates every new employee about our integrated care services and the importance of holistic care. We educate staff about the group services offered, as well as the client referral process. Through a qualified care coordinator, CHCS is creating an online training course to educate employees about the important role primary care services play in the overall integration of client care. Leadership at our Integrated Care Clinic sends monthly emails reminding staff in other departments about all the integrated care services being offered.