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Carolinas Healthcare: Pursuing 'system savings' through integration

May 30, 2013
by Dennis Grantham, Editor-In-Chief
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John Santopietro, M.D.

John Santopietro, M.D. is the first to tell you that what Carolinas Healthcare System (Charlotte, NC) is doing — integrating behavioral health by way of primary care into a larger hospital and health system — doesn’t make perfect financial sense. At least not yet.

But Santopietro saw enough sense in the approach to become CHS’ Chief Clinical Officer this spring after more than a decade of work in the northeast, most recently as Chief Medical Officer at Community Health Resources (Windsor, Conn.) and as president of the Connecticut Psychiatric Association.

As CCO, Santopietro will oversee a continuum of behavioral health services in the two-state, 40-hospital system — from psychiatric hospitals (one operating, one more in construction) to partial-hospitalization, intensive outpatient and outpatient programs, ACT teams, and more. But his primary concern now is integrating behavioral health, which CHS intends to accomplish through long-term work with its primary care providers.

Primary care represents “a very appropriate way to reach out to the community, since behavioral health is a public health issue, just like watching your cholesterol,” he says, noting that “primary care docs are hungry for this, since they are caring for these patients already.”

He describes CHS’ approach to integration as “a chronic care model” that starts in the outpatient world, with hopes of “catching people upstream, screening as many as possible to identify behavioral health disorders, and getting education and early intervention to them.” The vision, he says, is about realizing the “system savings” that are possible when, for example, depression is detected and treated early or a rehospitalization is avoided for a diabetic with a behavioral health condition.

The approach is built around a continuum of care that reaches across four groups:   
• Healthy
• Healthy but at risk
• Episodic behavioral health condition
• Serious/chronic behavioral health conditions

For people in early or episodic disease, the long-term goal is to develop the ability of PCPs to manage their conditions whenever possible, yet refer to specialty behavioral care as needed. Santopietro foresees the effort feeding patients into growing primary care or behavioral health homes as part of a population health approach.

In the near term, CHS will launch a number of year-long pilots that aim at training and supporting PCPs as they gain comfort in screening and managing behavioral health issues. “The more time primary care docs spend in an integrated system, the more comfortable they become (through repeated consultations) in treating the psychiatric issues themselves,” he explains.

Typically, they begin with training and advance their ability to take on common and complex conditions, often with the help of evidence-based algorithms or protocols. CHS has also launched a behavioral health fellowship for PCPs with an interest in treating behavioral health patients, including those with serious mental illnesses.

Telepsychiatry is integral to the integration effort, says Santopietro. This will involve a psychiatrist or advanced-practice nurse to interface with a patient’s local PCP or care coordinator/care manager. “The technology will leverage our psychiatry resources, making them more widely available.” He cites figures from IMPACT studies that recommend for each PCP in an integrated care setting, there be .5 behavioral health provider and .1 psychiatrist.

While funding the activities of either PCPs or behavioral health providers in integrated programs is often a struggle — and CHS’ program is no exception — Santopietro points out that “a lot of cost savings don’t have anything to do with payment streams.” There’s no doubt, he maintains, that “integration provides great outcomes" and that organizations that have the wherewithal to invest in it “have to commit to this before there’s a ready payment system.” These pioneers can then “go back to the payers and say, look at how much we saved you in pharmacy, in inpatient costs, in rehospitalizations,” and push for payment system changes.