We recently spoke with providers and staff from Rose Medical Groups (RMG) and Columbia River Mental Health Services (CRMHS) about their experience with the Integrated Care Collaborative, a program supported by SWACH. RMG is also referred to as “Rose Urgent Care and Family Practices” located in Vancouver and Battle Ground.
The idea of integrating behavioral health with medical care is not a new one to RMG. It’s something they’ve been aspiring to do, on some level, since the clinic’s inception in 2015.
Behavioral Health and Physical Health are Two Sides of the Same Coin
“I have always believed that you could not do family medicine without a behavioral health component. It’s just the key to a patient’s health. We would not be able to survive without direct, flowing collaboration with mental health providers. So for us, making mental health and medical health fully integrated may not be easy, but was absolutely critical to the successful functioning of the practice,” says Dr. Matthew Rose, Medical Director of RMG.
For Columbia River Mental Health Services, it was a new concept. CRMHS Chief Clinical Officer Dr. Jonnie Hyde recalls, “For us, this was our first foray into Integrated Care. It was good for us in many ways, helping everyone understand the relationship between mental health and physical health.”
Being able to keep up with longitudinal care, long-term maintenance and progress, makes for better outcomes for patients. They also agreed that a better system was needed for sharing health information. The Integrated Care Collaborative cemented both organizations’ desire to be part of a health system that prioritizes collaboration and the sharing of health information.
“This is the first time we’ve felt part of the larger healthcare community. We have submitted a proposal to expand the model between our organizations to include social service agencies. This work is important to the overall improvement of public health,” says Changhua Wang, who serves as the Integrated Care Collaborative Project Manager and RMG Business Director.
Healthcare is ever-changing. The ICC Made a Difference.
Acknowledging the dynamic nature of healthcare, especially within vulnerable populations, Dr Rose says, “One of the things we face constantly is the changes we see. Patients’ medications change. Diagnoses can change. Coverage changes. The thing we’ve gained is a continuously dynamic changing model that is able to keep up with the information exchange between our two facilities. It was relatively smooth, but it can always be smoother. I do think our communication and movement of patients has continually improved.”
Dr. Rose and Dr. Hyde agree that having a protocol of interaction and being connected to CRMHS has been vital for the continuity of care between the two. “Without that, managing depression for clients is nearly impossible,” says Dr. Rose. “The ICC project has been everything I was hoping would formulate. We have Stephen, our in-house Behavioral Health Specialist and Keri, our RN Care Coordinator. They are the link that synchronizes various components of the integration and makes sure they don’t drop off. Having the extra funding from SWACH to be able to do this has been enormously helpful.”
COVID-19 Forced a Nimble Response
The arrival of COVID-19 in January 2020 proved to be a powerful test for the ties between RMG and CRMHS. Not only did COVID bring an increased need for medical care, and creative ways of accessing it without putting too many at risk, but it also brought challenges with job security, housing, childcare, and anxiety about the uncertainty of the situation, which affected the mental health of many patients and added stressors to care delivery for clinic’s staff.
Wang says, “COVID shifted our focus quickly, and the SWACH emergency funds were very helpful to build structure for COVID testing. The COVID Cabana (structure for drive-through testing) was stood up in short order, and continues to be an important part of our COVID response.”
Dr Rose agrees, “We are the only medical group in the county doing testing the way we are, without a hassle, and doing it consistently, for everyone, anyone, undocumented or uninsured. The Washington State Department of Health called to ask how we are doing it. People are surprised. But I think it’s very important for a group like ours to be part of a community to fight the pandemic. Doing it outdoors, safely, is the key. Everyone who comes in for COVID-testing is seen by a practitioner. We get additional care for other needs when people need it.”
RMG also has a small Quest lab on site, so that tests can be processed as quickly as Quest systems allowed.Board members of the group are also up to the speed. Being able to meet this important public health need in a way that negates the need of several layers of approval has made all the difference.
Dr Rose concludes, “Our public health demanded that we test anyone who wanted a test. I just wanted to do it. Plus it’s just the right thing to do. The flexibility to be able to do what’s right even if it’s not the smartest thing corporate wise, even if it’s financially stupid, is something I really value. What’s the best thing to do? Let’s do that. SWACH has enabled us to do that best thing, from funding the COVID Cabana to facilitating the collaborative work between RMG and CRMHS.”
Collaboration Between Mental Health and Physical Health Providers More Important Than Ever
RMG reports that they’ve seen a marked increase in mental health issues since the beginning of COVID in 2020. This increase included patients who previously have not had a mental health diagnosis.
Dr. Rose says, “People are in crisis because the country is in crisis. We have five providers working at Rose Medical Group every day. We could use more.” Sometimes a patient will come in believing the issue is physical, with complaints of stomach pain or headaches, but sometimes it’s determined that the issue is mental health – anxiety, depression, and a response to the pandemic.
“One of the features we added because of SWACH funding was an in-house mental health specialist. That made a huge difference in our work,” says Dr. Rose. “The care coordinators also make an enormous difference because I can take my patient who’s melting down and walk him to our clinical social worker’s office, and Stephen can sit down and make it all come together.”
Teamwork = Essential Ingredient
Stephen Maynard, Behavioral Health Specialist says, “The important piece is the teamwork we have together. I sit and talk with the patient for as long as needed to get a sense of what they need. Sometimes, it’s walking them over to Columbia River’s office. Following up with them to make sure the intake actually happened. It can also mean scheduling additional appointments with them that week or the next week so I can get a better sense of what’s going on. If there’s a suicide risk, I continue to see them until they are engaged with a therapist.”
RMG Care Coordinator Keri Damsgaard says, “We know enough about medical and community resources that we can immediately communicate back and forth and deal with issues around transportation, housing, getting medication, Molina Care, tracking people who have trouble picking up medications at the pharmacy, helping with that, talking directly with whomever we need to.”
Wang adds, “Since Stephen is retiring, hopefully in the future, maybe we can hire another Stephen, another clinical social worker. But no matter what the future brings, we will continue this integration process. We had this on a level before the SWACH funding, but it allowed us to develop protocols and improve work flow, increase the level of efficiency in integrating behavioral health and physical healthcare.”
What does the future hold for RMG and CRMHS?
Dr. Rose sums up his clinic’s experience with the Integrated Care Collaborative succinctly, “Our greatest hope? To continue to develop and make care coordination available. That would be priceless.”
Wang agrees, “We will continue to engage in the community linkage. We will collaborate with other social determinant providers via community linkage. There is health coverage for the Medicaid population we serve, but the community issues also need attention. As we become more aware of that, we continue to keep our minds open, and our clinic open, and contribute to the community as well.”
Jonnie Hyde, Chief Clinical Officer for Columbia River Mental Health Services, says, “There’s no question. The Integrated Care Collaborative has cemented our belief in collaborative care.”
The purpose of the Integrated Care Collaborative is to blend behavioral and physical health so patients have better access and providers have better care coordination.
These providers are establishing a system using ICC specific, measurable objectives:
- RMG primary care providers screened all new adult primary care patients and all patients at annual physical with PHQ-9 to identify individuals with behavioral health issues;
- All patients scoring between 5 and 14 on PHQ-9 were offered treatment by in-house BH specialists;
- All patients scoring 15 or higher on PHQ-9 (or patients identified by our in-house BH Specialist with greater mental health care needs) were offered a referral to outside mental health clinics with a warm hand-off by an in-house BH specialist;
- 90% of our shared patients have had improved depression screening scores on PHQ-9 at their next annual physical;
- RMG and CRMHS providers followed up with shared patients who have had an ED visit for mental or physical reasons.
- More than 90% of our shared patients strongly agreed or agreed that both their physical and behavioral health needs were being addressed; and
- Care delivery was improved by a 10% increase, as measured by MeHAF assessment against baseline at the beginning of this project in April 2019.
Next Steps for Continued Collaboration between Rose Medical Group and Columbia River Mental Health
- RMG and CRMHS will continue to provide training for all providers on the integrated care and its work process in practice
- RMG has decided to expand current integrated care to the next level and is going to submit a proposal for establishing a partnership next network consisting of RMG, CRMHS, Lifeline, the Children’s Center, and Share. The network aims to serve Medicaid patients by integrating primary care and behavioral health care with a strong linkage to social services