On December 17th, we convened our Whole Person Care Collaborative at the Carol Milgard Breast Center to a full room of attendees from CHI Franciscan, Consejo Counseling and Referral Service, MultiCare, and Sea Mar Community Health Centers. Prior to attendance, each participant was provided a site self-assessment to ascertain its level of integrated services, patient, and family “centeredness.” Together with the AIMS Center, the workgroup reviewed team progress to date and shared where teams reported experiencing challenges, as well as noted room for improvement.
The self-assessments were very thorough and required participants to reflect on layers of policy and practice. This included screening practices, treatment plans addressing primary and behavioral health, communication with patient and among providers, access to behavioral health practitioners, consensus from leadership on integrated care, continuity of care, data systems management, training practices, and resource development.
Opening discussion addressed the need for readiness to execute upon a collaborative care model (CoCM). This readiness was identified as advocacy from leadership and among care teams, who are the primary care providers and drivers in embracing this new method of healthcare. By hosting a continuous and open dialogue, care teams and organizations will be able to break any stigmas and shift the conversation and practices forward.
There were challenges faced by each participant organization for the integration of services. Tracking groups of patients, collaborative communication practices, and social support of those practices were noted as some of the main obstacles. Some organizations who had the social support, noted they needed additional support in implementing the collaborative care model via training, staffing, and resources in order to be successful.
Despite challenges, there were successes to report around services integration. Through the self-assessment, the participant organizations noted there is now increased access to and availability of behavioral care providers, improved screening practices for emotional health, improved treatment plans, and increased social support among patients, peers, and colleagues. These improvements offered participants the opportunity to share best practices and showcase their successes. This included playing with numbers among implementation to find a manageable workload for each team. By doing so, each clinic or care team can understand how to best manage a core group of patients before scaling and implementing among a broader population.
For the CoCM practice and organization, participants stated they faced challenges such as funding resources, recruitment, patient team coordination, preparation for implementation, and the organization of data systems. There were also improvements to share.
CHI Franciscan shared there was improvement from the point-of-care team in its implementation and was entirely provider driven because there was no behavioral care provider available. After filling the needs of the patient, they identified the resources needed for that individual and coordinated with an offsite case manager. This approach presented mixed results, but both nurses and care providers were succeeding with the tools available to them, while attempting to merge their approaches.
MultiCare stated it was experiencing strong organizational support for its pilot program, meeting on a regular cadence to go over critical needs and taking action to resolve any problems. The representative stated MultiCare was digging deeper into the needs of the care team to make sure any wrinkles it experienced were ironed out. The representative also acknowledged it took a large amount of team work to get the pilot program to where it is today.
Attendees then conversed about where to go next with whole person integrated care. Representatives agreed it was beneficial for participants to go to the behavioral health clinics they worked with in order to meet with and talk to the people they coordinate care with, including the nurse manager and any individuals administering next steps. Representatives also noted that while care teams understand how behavioral health is beneficial to the success of physical health, it doesn’t mean the financial resources are in place to support the model. They noted that the funding for the implementation won’t come immediately. It will be gradual. To foster the potential of financing it’s important to note, record, and reflect an accurate depiction of what they are experiencing within their organization and externally. Last, but not least, the group conversed upon Substance Use Disorders and MAT. The teams agreed that support on this work would be very beneficial for all in attendance and were open to resources on best practices, role dispersal, and caseload tracking.
In closing, the Elevate Health team spent time sharing its appreciation of attendees and recognition of the Collaborative Care teams, before wrapping up and sharing lunch where conversations continued into the early afternoon.