By Andrea J. Wanat, MA, CPP
Director of Behavioral Health
Millennium’s Behavioral Health Partners have been diligently working together to advance System Transformation.
In October of 2016, two separate workgroups gathered in Erie and Niagara Counties to begin a process to identify barriers to healthcare for our Medicaid clients and to develop strategies to address those challenges.
One of the first steps taken was to create and administer a short survey to our Medicaid recipients via our hospital and behavioral health partners to assess what perceived barriers existed regarding their transitions of care across the system.
Not surprisingly, one of the main barriers identified was “transportation”; followed up closely by patients not seeing the need to follow up with a specialist because they “feel fine”.
The workgroups assessed the information gathered and then began the process to brainstorm ideas and research best practices to address the identified areas of concern.
Both groups decided to focus first on the need to enhance communication across settings; especially from a hospital to a behavioral health provider.
Partner agencies devised strategies including:
- Creating a universal email for behavioral health clinics to use to stay up to date on patient progress.
- Developing an “Open Access Hours” brochure for Behavioral Health hospital discharge staff to utilize.
- Identifying Relationship Managers at each Behavioral Health and Acute Care site to ensure improved communication across settings.
Another key area of focus is working on strategies to improve health outcomes for high need patients identified with either schizophrenia or bipolar disorder.
Since co-morbid health conditions such as cardiovascular disease (CVD) and diabetes are common with patients identified with these mental health conditions, the work groups have devised workflows, plans and collaborations to help Medicaid patients who have the identified diagnoses to be monitored for both CVD and diabetes.
At Horizon Health, Michelle Curto, Vice President, Administrative Operations, helped to organize educational groups that took place over an eight-week period and informed participants of the importance of healthy eating, exercise and of monitoring for various health conditions due to the comorbidity/risk associated with the medications taken for their mental health diagnoses.
“Knowing that our clients presenting with metabolic syndrome and other medical conditions often receive inadequate care, we were pleased to see that we made a positive impact to their understanding and follow through with medical appointments and health-related activities,” said Michelle.
Other BH organizations have collaborated with phlebotomists or have altered job responsibilities for existing nursing professionals on staff to include blood draws for patients identified as being at risk for CVD and/or Diabetes.
“At Niagara Falls Memorial here in the Outpatient Behavior Health Clinic, we have been tracking patients with a diagnosis of Schizophrenia and Bipolar, or related disorders, and cross referencing that list with whether or not those patients have had routine blood work done in the last 12 months,” explained Kevin Burgess, Clinical Director of Behavioral Health.
“We are doing this because patients who are diagnosed with Schizophrenia and Bipolar, or related disorders, have higher rates of diabetes and cardiovascular disease. The routine blood work we are tracking is A1C and LDL profile. In doing this, we have found that we have roughly 500 patients with these diagnosis in our clinic. We have been able to get our compliance rate with this lab work up to over 85 percent with these 500 identified patients.
“We have done this by training an LPN to do blood draws and including that service for these patients when they come in for their next behavior health appointment,” Kevin continued. “To date, we have completed 53 blood draws within our outpatient behavior health clinic. One of these patients screened had an A1C of 14.3. We were able to link this patient to our integrated Primary Care site within our behavior health clinic so that this patient could have easy access to primary care for appropriate monitoring and follow-up moving forward.”
Although the strategies may not be the same, Millennium BH partners are ensuring that education about the risks associated with the co-morbid health conditions are addressed with their patients, and that tests are ordered, administered, and coordinated with their Primary Care Physicians.