The best way to integrate behavioral health with physical health is to gather the providers into one clinical space where the comprehensive health experience can be delivered seamlessly for patients. In early September, the Colorado Coalition for the Homeless did just that when it opened the Stout Street Health Center. The 50,000 square foot, multiservice center replaces an aging site and allows care teams to provide broader assistance for the homeless in Denver.
The health center can serve up to 18,000 individuals per year. Previously, the group of providers treated 12,000 unique patients, with some 2,400 of those accessing mental health or SUD services, according to Elizabeth Cookson, MD, Distinguished Fellow of the American Psychiatric Association, who is the coalition’s director of psychiatry.
“We shared a number of patients with the medical clinic but did not integrate as much as we wanted to,” Cookson says.
She says the existing EHR system has helped in care coordination efforts, and providers will be able to continue to leverage the shared data. Workflows made it possible to deliver coordinated care within patient privacy regulations.
“We made it clear to our patients that all of the record is accessible to all providers,” she says.
Additionally, the SUD patients are asked to sign a waiver for 42 CFR Part 2 to allow clinicians to document notes in the patients’ EHRs. Patients can decline, of course, but the permission process is necessary to balance the need for provider data sharing with the need for patient privacy.
Within the new facility, the team-based clinical delivery system includes cubical areas where the behavioral and medical staff are side-by-side. Cookson says in most integrated facilities in other cities, there is often one dominant offering—for example, primary care—and the complementary services—such as behavioral health—are added on, or vice versa. At Stout Street, the two disciplines are equally emphasized among patients who need such care.
“The entry to mental health is all through primary care,” Cookson says. “Before, we’d see patients on request if they were not involved in our health system, but often with long wait times.”
Staffing in each of the three currently open suites includes:
· Two full-time primary care providers;
· Two psychiatric prescribers; and
· Three behavioral health providers who offer brief intervention, brief assessment, group treatment and longer-term group and individual treatment.
Now the behavioral health referral is immediate and not just under the same roof, but within the same care suite. In fact, the treatment rooms are universally design to adapt to either model as needs change. For example, a room set up with a table and chairs for behavioral health interactions could be converted to a medical exam room by swapping out the furniture for an exam table, Cookson says. All the rooms are equipped with sinks and storage.
A fourth care suite will be opened in the future.
“This is a huge culture shock for both the mental health and physical health providers,” she says. “Really getting it to work is challenging and time consuming, but we’ve already seen exciting changes in terms of quickly accessing behavioral health or physical health.”
While there are plenty of integrated health sites nationwide, the Stout Street facility is different in that it combines a complex network of funding to support health and social needs of the homeless in the Denver area. For example, the Stout Street Lofts located on the upper floors of the facility can provide living space for 78 formerly homeless households.
Support includes more than $35 million in combined funds from individual donors, the Affordable Care Act capital, Low Income Housing Tax Credits and New Market Tax Credits. Created under President Clinton, the New Market Tax Credit program provides tax breaks for local projects geared toward job creation in distressed areas. It accounts for $17 million of the funding.
“We are able to make use of a number of tax credit and financing schemes because we work with the Department of Housing and Urban Development, the Health Resources and Services Administration and the Substance Abuse and Mental Health Services Administration,” Cookson says.
She recommends that behavioral health providers work closely with their local primary care communities and create wholesale changes to care models to drive integration in their local areas.