INTEGRATED CARE

INTEGRATED CARE FOCUSING ON INTEGRATED HEALTH CARE SOLUTIONS WITH OUR COMMUNITY PARTNERS

CAPITAL AREA INTEGRATED DELIVERY NETWORK (IDN2)

DEBORAH LIELASUS, PROJECT DIRECTOR

Integrated health care is proven to reduce emergency room visits and the worsening of chronic diseases by providing care to those who need it, when they need it, in an environment that reduces the stigma that is sometimes associated with behavioral health needs. Five years ago, we opened the Integrated Center for Health within our Community Services Program (CSP). Since then, the Center, a collaboration between Riverbend and Concord Hospital, has provided nearly 500 clients with medical and behavioral health care and wellness services. Reports show vastly improved health outcomes.

Shortly after the Center opened, Riverbend, along with Concord Hospital and the Concord Regional Visiting Nurse Association (CRVNA), created the Capital Area Integrated Delivery Network (IDN2) as part of a statewide Delivery System Reform Incentive Payment (DSRIP) program to expand integrated health care projects in the region.

We have since established eleven integrated health care sites and funded 20 direct care behavioral health providers and 10 peer support specialists to carry out the IDN2 programs. We have also invested in technology solutions to improve communication and care coordination.

Seven of the integrated health care sites are within a Concord Hospital primary care office. Providers at each of these sites work closely with an embedded integrated behavioral health clinician (IBHC) and a consultant psychiatrist, both from Riverbend, to identify needs and provide immediate supports and services. Dartmouth

A central part of the integrated health care sites is a comprehensive core standardized assessment (CCSA), which is used by the team to determine the need for mental health, substance use, and/or sociallydetermined health needs. For the six-month period of July through December 2019, 3,306 patients were screened using the CCSA. 1,295 of these individuals screened positive in one or more categories and were able to receive appropriate and timely care.

Choices at Riverbend and Concord Hospital Substance Use Services are key players in the integrated health care projects. They jointly oversee the substance and alcohol use related needs of patients at the integrated health care sites as well as provide leadership to The Doorway, a statewide hub for substance use treatment and recovery. They offer additional support to the 14 medication assisted treatment (MAT) providers who work at seven of the integrated health care sites. Since we began tracking data in mid-2017, these providers have delivered MAT to 534 patients in an effort to combat opioid addictions and potential death. Nearly all of the individuals treated through this project have

IDN2 STATS

IDN2 Funds: • 11 integrated health care sites • 20 direct care behavioral health providers • 10 peer support specialists • 14 MAT providers

July-Dec 2019 • 3,306 patients at integrated health care sites were screened/assessed for mental health, SUD, and socially-determined health needs • 1,295 screened positive in one or more categories and received appropriate care

Since Mid-2017 • 534 patients received MAT either at their primary care office or through one of the SUD continuum of care sites remained in recovery.

IDN2 also provides integrated health care through pre- and post-release services for those in the county jail. To date, 687 individuals reentering the community have received individual and group counseling, job and/or education support, and connection to community supports and services, including primary health care, in order to reduce recidivism and improve health outcomes.

Other areas of integrated health care through IDN2 include enhanced care coordination to high need populations, including pregnant and parenting women with substance use disorders (SUD) and young people who are aging out of youth services. An additional complex care coordination project brings together multiple agencies and individuals to provide comprehensive, planned care to those who frequent the emergency room or are high utilizers of other emergency services.

The partnership to provide integrated health care to our community is an ongoing one. There is recognition, through statistical analysis and primary care physician and patient surveys, that this is the best way to address the overlapping needs of the people we serve, and we are committed to its continuation.

• 687 individuals received Reentry services including pre- and post-release • 101 individuals with SUD and pregnant /parenting OR a transitioning youth/ young adult AND their families received enhanced care coordination and wraparound services

An Average Day in the Life of an Integrated Behavioral Health Clinician • 4 patient visits including warm hand-offs • 3 consultations with the medical care team • 2 phone check-ins with patients under care • 2 calls made to community-based g organizations regarding referrals