Integrated Care at Thresholds
Johnson & Johnson Integration Project
About Thresholds, Inc.
Established in 1959 in Chicago, Thresholds provides health care, housing and hope for thousands of people with serious mental illnesses (SMIs) and substance use disorders (SUDs) in Illinois each year by delivering health and social services that support wellness and flourishing. As such, Thresholds mission is to assist and inspire people to reclaim their lives.
In FY17 Thresholds served 17,285 clients, and provided long-term community based outreach to 6,225 individuals. Primary diagnoses of Thresholds’ clients include schizophrenia and schizoaffective spectrum disorder (43 percent), bipolar disorder (26 percent), major depressive disorder (21 percent) and other diagnoses (10 percent). In addition, close to half of clients served by Thresholds have a co-occurring SUD.
Thresholds’ clients have among the most complex social and health needs, on average, with four medical diagnoses in addition to their mental health diagnosis. Further, 95 percent of clients served at Thresholds have Supplemental Security Income (SSI)/Social Security Disability Income (SSDI) due to mental illness and the vast majority have Medicaid.
Overview of Thresholds
Thresholds’ experience mirrors that of research that has found people with SMI die 25 years earlier than those without SMI. Thresholds has a long history of addressing the mutual impact of physical and mental health.
Beginning in 1992, Thresholds has prioritized improvement to physical health as one of its longstanding list of seven goals. Thresholds began offering primary care services (through a partnership) to its clients in 1998 out of a renovated closet in one of our south side locations. This one room clinic soon became two, and eventually Thresholds was offering collocated care with a Federally Qualified Health Center (FQHC) partner.
By 2015, Thresholds was committed to moving from collocated to integrated care and began to look for partners committed to the same. In 2016, Thresholds established a partnership with three FQHCs, on the north and south sides and in the south suburbs of Chicago.
Thresholds’ Approach to Integrated Care
With our partners, we currently operate three integrated clinics, providing coordinated onsite psychiatric and primary care. In addition, one clinic offers onsite pharmacy services. The remainder of care is provided in the community via 100 outreach teams. This care includes coordinated illness management support, linkage to necessary benefits and in many cases, providing supported housing. This translates to is a virtual team, part that works in the clinic with clients as they come in for physicals and the other part that works on an on-going weekly basis with clients in the community.
Given the complex structure of our organization, including the modular make-up of the team (FQHC clinic staff plus staff from multiple Thresholds outreach teams), work flows are particularly important. Clinic workflows include the workflow within the clinic as well as a workflow that extends out to include the bidirectional sharing of information and coordinating care with outreach staff.
As much as Thresholds is committed to providing quality integrated care, such care is costly and administratively difficult for behavioral health care providers. It requires either becoming an FQHC or finding willing and like-minded primary care partners. Either way, integrating primary and behavioral health care involves expensive start-up investments in build-out costs, information technology (including clinical decision support tools) and staffing. Additionally, the costs of the intensive clinical work of patient engagement and care coordination often cannot be supported by the behavioral health fee-for-service delivery model.
The Importance of Information Management and Integration
However, because information technology and information sharing is the lynchpin of integrated care, it has the potential to provide the biggest return on investment. Without the quick and easy flow of information, coordinating care and working toward shared patient goals requires work-arounds that are administratively burdensome, difficult to standardize and more likely to result in communication/coordination failures.
Thresholds has chosen to facilitate information sharing and care coordination by purchasing an integration engine (IE), Orion Rhapsody, that will lay the foundation for a robust care coordination and population health management approach to improve the health and wellness of Thresholds members.
The Orion Rhapsody Integration Engine is a middleware application that brings systems (internal and external) together through seamless data integration. This software extracts vital data from two health records and allows it to be shared and/or placed in each other’s EHRs. Because providers like Thresholds and FQHCs (and all health care providers and payers) usually have different systems for different aspects of services, they are often unable to communicate directly with each other.
Staff from Thresholds and the FQHCs have read-only access to each other’s EHRs, as agreed upon in our Information Sharing Agreement (an example of this Agreement is available online). Once we fully implement sharing data through the integration engine, most of the access staff currently require will be unnecessary as that information will be in a “read-only” section of Thresholds EHR. This will include diagnoses, medications, medical and psychiatry notes, key health indicators, including blood pressure, weight, lab results and BMI. There are morning huddles in the clinics and ongoing operations and clinical meetings with Thresholds staff and the FQHCs with a focus on care coordination, workflows and processes.
Thresholds participates in co-interviewing new FQHC primary and psychiatry staff and provides new staff orientation (NSO) and ongoing training to all new staff (see “An Introduction to Self-Care” and “Building a Culturally Humble Workforce” for examples). Thresholds has an overall wellness focus and hired national experts to provide a “train-the-trainer” model on improving staff knowledge and engagement around common health issues of persons with serious mental illnesses. In addition, Thresholds has its own training department that conducts both in person and e-trainings, a cultural humility committee, staff wellness committee, leadership training program for all new supervisors and active member council.
Relevant primary and behavioral health staff are cross-trained, with staff going to salient parts of the others’ new staff orientation. In addition, primary care staff complete a Thresholds e-learning “Responding to Symptoms of Mental Illness in Primary Care Settings”. Thresholds conducts both in-person and e-trainings for staff on care coordination, illness management support and knowledge of common health issues.
Key Considerations and Lessons Learned
- The culture of each partner service orientation is of utmost importance. In an integrated care partnership, the leadership and all staff should have a culture of wanting to serve people with SMI with significant primary and psychiatry needs.
- Each partner needs to provide ongoing time and investment in technology, clinical reviews and operational needs. Like any relationship it takes an ongoing commitment of time and resources.
- Since specialty referrals are common and can be slowed down by insurance authorization processes, a system to track them is recommended.
- Activities that promote the spirit of integration between partners is important. This can be as simple as including the FQHC staff in holiday parties and/or luncheons.
- Having a dedicated position at Thresholds that oversees the FQHC partnerships has been essential. It is this position that has as a responsibility to keep the partnership’s best interest at hand.