Tags: coordinated care , community , redesigning care , community partnerships

Thanks to a competitive grant from the Massachusetts Health Policy Commission, a new program is taking shape at the Lynn Community Health Center (LCHC) that could have a profound impact on one of our community’s most underserved populations: patients suffering from debilitating mental health and substance abuse issues.

The program, led by Lynn Community Health Center CEO Lori Abrams Berry and Chief of Behavioral Health Mark Alexakos, MD, will test an innovative, patient-centered care delivery model to better meet the needs of the seriously mentally ill. At the core of this program are two key components: remote monitoring technology to dispense medication and improve adherence in the home; and specialized community health workers to help coordinate care inside and outside of the LCHC.     

“These are patients with serious mental illnesses and substance abuse disorders: schizophrenia, major depression, repeat visits to the ER, and they typically live alone or on the street,” Alexakos said. “This is not a patient population that has a lot of support—they’re the most challenging population in the Medicaid program.” 

This is not a patient population that has a lot of support—they’re the most challenging population in the Medicaid program.

The challenges come from many angles. These patients often disproportionately experience unmet needs including stable housing, reliable transportation, food security, social and familial supports. Uncontrolled medical conditions like hypertension, asthma, diabetes, obesity, and tobacco use occur at higher rates, and patients are often disengaged from primary care and/or behavioral health care. These challenges, combined with complex behavioral and medical needs, contribute to difficulty adhering to care plans, managing medications, and making scheduled appointments. Understandably, caring for this population can be costly.

But this new program represents what Berry and others feel is a new, effective direction for a woefully underserved patient population. By working in partnership with Neighborhood Health Plan and Partners Connected Health, the program identified 169 of the most at-risk and expensive patients, and will address their unique needs with a multi-faceted intensive care coordination model using community health workers (CHW).

"The community health worker is a fundamental and key component of this program,” said Emily Johnson, LCHC Director of Community Outreach. “This is the population that is very hard to manage, especially if you’re only using resources found within the health center. You have to have people who will follow the patient into the community as well, including home visits, and develop a relationship so we can quickly identify what is going on when patients don’t show up for appointments.”

And as a fundamental component, you’ll see that the CHW’s play integral roles in every aspect of the expansive plan, including:

  • Neighborhood Health Plan and its behavioral health affiliate, Beacon Health Options, will partner with LCHC to implement Here-for-You. Four specially trained CHWs will improve care coordination for patients, providing personalized care for unmet social determinants of health needs, using motivational interviewing skills to help patients set goals and improve self-care, and supporting their engagement and attendance at scheduled appointments.
  • Partners Connected Health will coordinate the implementation of the remote medication monitoring technology system, train the CHWs, and provide technical and evaluation assistance. The remote monitoring technology system, which looks a lot like a coffee machine, can sit on a patient’s kitchen counter or table, and dispenses daily medication regimens into one cup, eliminating confusion and encouraging daily adherence. The remote monitoring system can communicate with CHWs, who can support the patient in adhering to medication regimens as needed. This new system has shown promise in reducing inpatient emergency admission rates and home health visits, which are often driven by poor medication management.

By working in collaboration with the Partners Center for Connected Health, the new Lynn Community Health Center model will also feature clinical pharmacy consultation to simplify medication regimens. Eaton Apothecary will provide this service, which simplifies medication plans, increases adherence, improves safety, and reduces costs for medication treatment.

With much work still to be done, Berry anticipates that the program will begin sometime in November, with initial program results and viable data expected later in in 2017. She’s hopeful this first-of-its-kind approach will be met with quick success. 

“The overall effect on health care quality and costs in Massachusetts could be profound,” she said. “If you make a dent, even if it’s just with a few patients, it makes a big difference.”

The overall effect on health care quality and costs in Massachusetts could be profound. If you make a dent, even if it’s just with a few patients, it makes a big difference.

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Image credit: Bond Brothers