Mountain Family Health Centers’ Integrated Care Program: Reducing barriers to health improvement with complex Medicaid patients

By Ken Davis PA-C, Ross Brooks, and Jerry Evans, Ph.D.

Mark T. is a patient at Mountain Family Health Centers (MFHC) who faces a variety of health issues, including diabetes, infections in her teeth, kidney problems, and vision challenges. In addition to his physical health, Mark, like many patients at MFHC, experiences financial and transportation barriers that make it difficult for him to access regular treatment and pay for his medications. MFHC has been working with Mark and other patients to address some of the social determinants that can dramatically impact patient’s health. Ken Davis, PA-C Medical Director and Jolene Singer, RN, Care Coordination Manager are aiming to move beyond the “medical home” to the “medical neighborhood.”  One way their team is doing this is by recognizing that community services, like education, skills training, reliable transportation, and legal services, are just as critical as comprehensive medical care. They are always asking, “what is the biggest thing in this patient’s life?”

Launching a new health improvement model

Inspired by patients like Mark, the MFHC health improvement management team has been dedicated to strengthening clinical care quality, making services more accessible, and raising the physical and mental well-being of its patients. In 2014, with support from Rocky Mountain Health Plans and The Colorado Health Foundation, MFHC broadened this approach by developing a new health improvement model specifically for patients with complex health needs in smaller communities.

Called the Integrated Care Program (ICP), its development is guided by the Institute for Healthcare Improvement’s Better Health and Lower Costs for Patients with Complex Needs collaborative. Mountain Family’s ICP model proposes – especially in health disparate populations – that health improvement management should emphasize positive patient engagement that optimizes the benefits of clinic provided services and stabilizes care costs, in addition to raising access to and quality of care. Positive patient engagement is the key to the MFHC model’s success with patients with complex health needs who have difficulty sustaining access to their provider and can be unpredictable in their actual consumption of provided quality care.

An estimated 70 percent of this population live with behavioral health conditions or face adverse social determinants. Many individuals in this population skip doses of medication or fail to fill prescriptions as a result of misunderstanding the role of the medications play in managing their chronic disease, fear of side effects, or lack of funds to pay for drugs. As a result, some patients are required to overuse high-cost, avoidable services, which can also severely reduce their quality of life.  

First year challenges and potential solutions   

First year model testing revealed that multiple barriers interfere with the goal of improving patients’ health engagement. These obstacles restrict patients from having a genuinely collaborative relationship with their provider and following through actively in both disease self-management and wellness self-care.

MFHC model testing is identifying what does and does not work for most patients with all of these barriers:

  1. Barrier and solutions: Enrolling and engaging patients in the ICP.  Typically, patient’s with complex needs experience lower levels of constructive engagement in their health and positive collaboration with their providers. The ICP is testing supplementing the Patient Centered Medical Home model with consumer-oriented engagement and motivational services to address this barrier.
  2. Barrier and solutions: Managing upfront costs. Supplementing the PCMH model will add substantial costs. MFHC is designing a business model that tests the cost-efficacy of these new interventions that can minimize waste and ultimately improve outcomes related to primary care.
  3. Barrier and solutions: Monitoring patient data.  Health information systems are not designed for patients with complex health needs who need PCMH-supplemental services. Experience is showing where these deficits are most problematic and recommended solutions that will increase the utility of systems for these patients.
  4. Barrier and solutions: Application of risk ratings.   Risk ratings are in an early stage of development and are limited in their applicability to the unique circumstances of patients with complex health needs. ICP is learning what rating model would provide the information needed for planning and implementing effective services to these patients.
  5. Barrier and solutions: Community resource access.   Most of the barriers preventing patients with complex needs from achieving better health engagement and health status involve social, psychological, and economic determinants. While clinic providers can assess these needs and identify the necessary links between patients and resources, there is a need for a network of resources that is consumer-oriented, shares health care goals, and includes methods for communication between the consumer, the clinic, and community organizations. This has yet to be developed, but ICP is able to offer promising suggestions based on our experience to date.
  6. Barrier and solutions: Behavioral health services.   Although many patients with complex health needs have mental health or substance abuse problems, the most cost-effective approach to enhancing engagement and physical health status is uncertain. ICP sees the synergy between connecting patients with community resources, and providing integrated behavioral health and care coordination as essential to a solution.

Model development 2015-2016

At first look, the ICP’s three core components: care management, behavioral health intervention, and community resource access seems to meet the complex patient needs.  It is too early and data are not available to assess the overall value they add to the care provided by committed primary care practitioners and their clinical teams.  MFHC plans to continue developing and refining this model in 2015 – 2016 and is participating in year two of the BHLC Collaborative.  It is not yet known what long-term funding will be adequate to sustain cost-effective elements of the three-component ICP care delivery model. The amount and sources of savings, its impact on patients’ health outcomes, and the appropriateness of the selected services given the unique needs of these patients with complex health needs are all under study. Patients with complex health needs very much want and deserve a better quality of life. Without question, there is a primary care model that will help them achieve this reasonable goal.

Mountain Family Health Center