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During an office visit if a patient shares feelings of depression or anxiety, Susan Manzi, MD, MPH, rheumatologist and chair of the Medicine Institute at the Allegheny Health Network (AHN), can simply open a door to invite behavioral health consultant Jenna Boswell, MS, LPC, to join the appointment and provide acute intervention on the spot.
Such a timely and coordinated response to a patient’s behavioral health is very different from the standard process. Typically, a rheumatologist provides the patient with a referral for mental health support that will occur on a different day, in a different location, with little interaction between the two providers.
Dr. Manzi also has access to acute interventions from other team providers, including a pharmacist who can help a patient refine a plan for adhering to medication.
“The traditional healthcare model is broken, especially for people who navigate healthcare for a chronic condition requiring a number of specialists and visits,” Dr. Manzi says. “Many barriers to good outcomes in medicine are unrelated to the disease itself, but more [related to] social determinants of health. Most [rheumatologists] are not equipped to address these difficult issues. And when we try, it often stretches us thin and leads to burnout. That’s why we are working to transform a new care approach for our patients with autoimmune conditions.”
Bridging Gaps in Care
The AHN’s Autoimmunity Institute launched in the spring of 2018, with the opening of a new clinical and research facility dedicated to autoimmune care, where Dr. Manzi and her colleagues are implementing a new model of integrated services. This model includes a physical care environment that literally breaks down the walls between providers.
At the Autoimmunity Institute, no one has an office. Instead, every provider on the care team, which includes a rheumatologist, pharmacist, behavioral health specialist, social worker and nurse navigator, shares an adjacent, open workspace surrounded by patient rooms.1 This office configuration supports collaborative provider pre-visit huddles to discuss patients scheduled for that day and post-visit huddles to assess next steps for integrated care.
Between office visits, providers have open access to team members for acute interventions and patient introductions for follow-up care. This unique model also incorporates specialists in dermatology, nephrology, pulmonology, gastroenterology, allergy, endocrinology and integrative medicine services, such as acupuncture and massage therapy—all in the same location.
Starting soon, a nurse navigator will meet with each patient after a visit to summarize care and plan for follow-up communication with patients between visits.
“In the beginning, losing a dedicated office space was challenging for many providers to accept,” Dr. Manzi says. “That changed [after] we started seeing patients and realized the value of open access [to] other providers to support the many aspects of care a rheumatologist normally tries to take on individually, whether the patient is having difficulty taking their medications, suffers from depression or even struggles to get to their appointments.”
A Coordinated Care Model
To create the Autoimmunity Institute, Dr. Manzi and colleagues borrowed approaches used in other AHN team-based, integrated care models for chronic conditions, such as diabetes. Dr. Manzi created a similar pathway for autoimmunity. Here are some important steps in the process:
- Focus on two autoimmune conditions: In the beginning, the team focused on rheumatoid arthritis (RA) and inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis. Patients with these diagnoses being seen at AHN were tracked and placed on the care pathway.
- Create a team: Pharmacists, behavioral health, consultants, nurse navigators, dieticians, and social workers were identified and trained to work together to manage the panel of patients with the physicians and advanced practitioners.
- Stratify patient risk: RA and IBD patients at highest risk for poor outcomes were identified based on higher acuity disease and social determinants of health, such as depression and poverty, in an effort to allocate resources effectively.
- Develop clinical protocols: The team developed standardized treatment protocols based on published guidelines and best practices to minimize variability. These protocols include first-line treatments, how to monitor efficacy and when to move to a different treatment.
- Align formularies: AHN is also part of an integrated payer network. Thus, the team was able to align medication formularies with the payer, avoiding the setbacks associated with prior authorizations to increase access to medications for their patients.
- Develop a customized care pathway for each patient: With standardized treatment protocols in place, care pathways were tailored to each patient based on their specific needs, such as transportation limitations, behavioral health needs and financial constraints. The pathways enabled the appropriate team members to engage as needed and manage patients during on-site visits, as well as by phone in between visits.
- Coordinate the care pathway electronically: Care pathways were embedded into AHN’s electronic health record system to facilitate care coordination with all team members.
- Invite the patient to be an equal participant: Patients were introduced to the integrated approach to help them understand they might see multiple providers during a single visit, as well as how their providers work together for their care.
“It really comes down to moving away from episodic care with a physician to managing patients within a continuum of care [in which] the patient is interacting with different members of the team during and in between visits,” Dr. Manzi says.
Adapting to Integrated Care
Dr. Manzi says the team’s transition to this integrated approach is an ongoing process requiring flexibility. Each provider must adapt to having more interactions and sharing the responsibility of patient care.
“The relationship between a physician and a patient is sacred, and some physicians are reluctant to change this [aspect of care],” Dr. Manzi says.
In the beginning, discussing the model’s benefits helped win over physicians. They soon experienced the value of team-based care firsthand. Dr. Manzi says, “We were able to show them that medication adherence, treatment for depression, patient satisfaction, physician satisfaction and, ultimately, total cost of care improved.”
As the team approach is developing for the RA and IBD pathway, behavioral health has been the most used piece of care integration, which has been eye opening for Dr. Manzi.
“When you walk in the room and your patient is in tears because there is violence at home, it’s invaluable to have a trusted behavioral health colleague there—someone who can do an acute intervention. The truth is, that patient won’t listen to anything else you say if you don’t manage their psychological state first,” she says. “This team support allows the physician to focus on what they do best for their patients.”
How to Incorporate Behavioral Health
The team’s behavioral health consultant Ms. Boswell also continues to gain new perspectives in her role. As she meets with patients, she is developing a better understanding of how autoimmune disease and mental health are interconnected.
“When I first came into this role, I did not have advanced knowledge of autoimmune diseases. So working directly with Dr. Manzi and the team has been invaluable to gaining this knowledge and applying my behavioral health skills,” Ms. Boswell says. “Being able to speak the language of rheumatology and gastroenterology helps me better connect with my patients.”
Both Ms. Boswell and Dr. Manzi believe any rheumatology practice can adopt a more integrated approach to behavioral health as a first step toward collaborative care. Ms. Boswell offers these tips to make the transition easier for providers and patients:
- Establish a standardized approach to mental health assessment, such as having the patient fill out a mental health questionnaire for depression and anxiety prior to rooming, which will provide insight into mental health issues that may impair the patient’s daily life;
- Next, have a way to respond to this mental health assessment so there can be direct follow up at the time of the visit;
- If a patient needs behavioral health support, assist the patient in connecting with services, whether through a specialist in your practice or a company that specializes in helping doctors connect patients with mental health services; and
- Establish an open line of communication between the physician, behavioral health specialist and patient to track ongoing care.
Carina Stanton is a freelance science journalist based in Denver.
- Michaud J, Beatty J. Quality of gout management in a rheumatology clinic using a provider-pharmacist, team-based approach [abstract]. Arthritis Rheumatol. 2018; 2018 Oct. 70(suppl 10).