The national healthcare challenges of shifting to population health and achieving the triple aim (better health and better care at reduced costs) require integration of mental health services with other medical care. That integration underscores the increasingly crucial role of business training within healthcare organizations — not to focus only on fiscal outcomes but to improve health outcomes. The role of business executives is, therefore, more important than ever in healthcare, and Intermountain Healthcare's Mental Health Integration program is a case in point.
About 73 percent of patients seeing a primary care physician have a psychological or behavioral health component to their chief complaint. That percentage increases for patients with a chronic disease. Currently 45 percent of aging Americans have a chronic disease and costly chronic diseases are spreading at epidemic rates — chronic diseases are now responsible for 75 percent of the $1 trillion spent on U.S. healthcare, according to the Centers for Disease Control and Prevention.
To address the burden of co-occurring physical and mental health needs, we at Intermountain Healthcare have developed and sustained the MHI program with three basic components. First, we created a mental health assessment tool (in the form of a questionnaire) that activates a team consultation workflow. We then trained physicians and their staffs in our clinics to use team protocols, so that on arrival at a primary care clinic every patient receives a physical and mental health assessment. Second, we designed an operational system in which mental health specialists and nurse care managers are included in the primary care staff — either located in our clinics, depending on their size, or rotating through them frequently. Third, we evaluate the program regularly to monitor patient outcomes, team effectiveness and the culture of healthcare delivery from the perspective of the patient and the care provider.
MHI's team-based care requires a fundamental change in physicians' mindsets. Clinics have often claimed to have teams, but traditionally physicians provide most of the care and delegate tasks to support staff or make referrals to specialists. Too often, the result is fragmented, uncoordinated care and poor health outcomes.
In contrast, the integration model at Intermountain entails a standardized process of care for mental health in which multiple team players, coordinated by the business manager of the clinic and the regional operations director, help patients play active roles in their own recovery. The regional operations director is accountable for projecting staffing needs, aligning resources and setting clinic performance goals for improving patient outcomes. The clinic business manager is accountable for day-to-day monitoring of the team protocols and ensuring team members have the resources and time to perform to their optimal skill.
The results are impressive for MHI clinics, which so far include 82 Intermountain primary care practices, five specialty clinics, and 45 clinics outside of Intermountain Healthcare (through partnerships across the country):
- MHI clinic patients with depression are 54 percent less likely to require emergency department visits than depressed patients treated in non-MHI clinics.
- Patients with depression who are involved with one of the MHI clinics saw their health insurance claims decrease by $667 in the year following their diagnosis.
- Diabetic patients with depression have their diabetes in better control (53.1 percent vs. 47.5 percent) with MHI.
- Patients in MHI clinics reported improved overall functioning in their lives — 81 percent of patients recently surveyed said they were hopeful they could get well or stay well.
As the nation shifts to reimbursing healthcare providers for population health outcomes, the clinic manager — typically with an MBA or MHA — will be increasingly responsible for achieving health outcomes, not just financial ones. Those outcomes will depend on the effective collaboration of diverse and larger healthcare teams. Physicians will head up those teams and determine appropriate medical care, but the clinic manager will ensure that team interactions are consistent and monitor the process steps that promote positive health outcomes.
Intermountain Healthcare has, therefore, operationalized and rewarded team cooperation as a regular expectation. Rewards are established as quality incentives for both the individual physician and the clinic staff group. Clinic teams and individual docs are rewarded with financial quality incentives to improve their care. They are paid on productivity and must have quality measures met to reach these goals.
To reach a high level of effective team functioning, primary care clinics at Intermountain progress through three phases of implementation: planning, adoption and becoming 'routinized.' Routinized clinics have established continuous administrative leadership and clinical teams; MHI workflows are considered a clinic norm. These high-level clinics have fully implemented and sustained for over five years the following five key MHI components:
Leadership and culture. At Intermountain, the senior management leadership provides direction and commitment to sustaining MHI. The delivery framework of MHI receives continuous feedback as regional and clinic champions are identified to monitor quality improvements and outcomes. MHI has changed the culture of primary health care by standardizing a team-based process with mental health as a core element.
Workflow integration. Here is where the clinic managers and regional operations directors become central. They are accountable for training all staff from different provider backgrounds to work together in the primary care setting, utilizing standardized clinical tools and creating complementary team roles.
In each clinic, the mental health team may include the primary care physician and one or more mental health specialists (psychiatrists, psychiatric nurse practitioners, psychologists, social workers and care managers). Those individuals have to work smoothly with each other and with providers of other medical care. The care providers, in turn, work with patients and family members, who are also part of the team. Healthcare insurers must be on board as well.
Regional managers collaborate to shift resources to address any unevenness in healthcare needs. Their data resources enable them to analyze practice and population variation and allocate team resources to meet the complexity (mild, moderate, high) of the patients' identified needs.
Information systems integration. A secure centralized repository for data enables all team members to access and update records, communicate with each other and enhance coordination. Patients can also email their primary physician. In addition, monitoring outcomes data is key to ensuring better health and better care at reduced costs — the three core goals of population health.
Financing and operations integration. MHI requires a commitment of capital upfront — for the addition of the mental health professionals. But they are billable from the outset and their costs can be spread across a clinic (or more than one) as appropriate. Very quickly the increased salary costs are offset by new billings and by decreased costs for unnecessary emergency department visits, unneeded imaging and other waste, as shown above.
Community resource integration. Here it's crucial that community-based social service organizations be integrated into the initiative, so that they understand its value and can coordinate their care delivery with it.
As the MHI clinics have evolved, the time to routinization has drastically declined. It now takes under two years to implement all five components and start operating on a revenue-neutral basis. With further refinement and acceptance, that timeline will shrink further.
Imagine the delivery of better health, better care and reduced costs becoming routine. MHI is key to that vision, and business skills will be central to achieving it.
Brenda Reiss-Brennan, PhD, APRN, CS, is director of MHI at Intermountain Healthcare, the nonprofit healthcare provider based in Salt Lake City.