Too often, mental illness goes undiagnosed or untreated — which can also complicate treatment of physical health problems. But clinics that transform themselves to deliver "integrated care" are making sure more Kansans get the type of care they need, when they need it.

However, transformation is not easy. Leaders in two of Kansas’ safety-net clinics — COMCARE and Salina Family Health Center — have developed programs unique to their practice that are working to improve the health of Kansans... 
 

COMCARE
Community Mental Health Center in Wichita

About four years ago, leadership at COMCARE knew they had to do something.

"We were seeing from national reports that the number of people with mental illness was staggering—and yet about half of them weren't being treated," said Joan Tammany, Director of Quality and Innovation at COMCARE, the largest community mental health center in Kansas.

"So we started looking at integrated care as a way to reach more people who weren't seeking behavioral health services like ours, and give them a better chance of having their mental illness identified within a primary care clinic," she said.

This summer, COMCARE opened its first integrated care clinic, working with primary care partner GraceMed. Already it's proving to be a significant success, said Tammany.

"Many of the patients we are now seeing in the integrated clinic would instead be somebody in the community suffering from untreated anxiety or depression," she said. "Integrated care increases access to care by behavioral and primary care providers working hand-in-hand as a team to treat patients' physical and mental health needs."
 

Laying a Strong Foundation

It took years to implement integrated care at COMCARE, but the time was necessary for finding and establishing the model that worked for them, said Executive Director Marilyn Cook.

"We went into this thinking we just needed to hire a physical health care provider," Cook said. However, the challenges to that approach became quickly apparent: they didn't have the expertise in billing primary care services, or the right software and electronic health record. So they took a step back and started exploring options for partnerships.

Several conversations quickly led to GraceMed as a potential primary care partner that shared the vision and long-term commitment to this work, said Cook. The timing proved fortunate, as soon thereafter, Sunflower Foundation began accepting planning proposals.

"It was an easy decision to apply for a planning grant and ask GraceMed to be our partner," Cook said. "The initial grant was critical as it paid for a facilitator needed for having those difficult conversations about creating a true partnership. That helped us talk through and establish the business side of the partnership, which cemented the foundation of the partnership."

‘The Big Turning Point’

The planning process charted the course for the partners' integrated care clinic. COMCARE would supply about 5,000 square feet of space, renovated for six exam rooms, a nurses’ station, huddle space, offices, and small conference room.

GraceMed would supply the medical equipment and supplies needed to operate the clinic. COMCARE would staff a behavioral health consultant, and GraceMed would staff a physician’s assistant, two medical assistants, a receptionist, and an office manager. The facility would be operated by GraceMed as a Federally Qualified Health Center.

"So that meant any work that our behavioral health consultant did became the work of the clinic for GraceMed," said COMCARE's Tammany. "That was really the big turning point. Once we got over that hurdle, that's when we were able to establish the long-term commitment," she said.

The partnership’s next step was to apply for an implementation grant from the Sunflower Foundation, which helped launch the integrated care program.

"What these grants allow us to do is to create momentum by demonstrating how integrated care is truly better for the patient and how it can be more cost effective," she said.

"In a partnership, you often have to give something up to gain something. We knew we might lose some potential revenue but it's the right thing to do for the patient," Tammany said.

Integrated care is the way of the future, GraceMed CEO Dave Sanford said. "More primary care patients have easy access to behavioral health care. And people with depression, anxiety, or other mental health conditions are more likely to get the primary care they need."

"This was our first opportunity to collaborate with behavioral health providers, and we are proud to partner with COMCARE," he said.

Salina Family Healthcare Center
Federally Qualified Health Center

When the Salina Family Healthcare Center decided to transform its practice into an "integrated care" clinic starting in 2014, there were plenty of skeptics among the staff.

"Today, there would be a huge revolt if we took away integrated care," said Dr. Robert Freelove, who practices at the clinic and is CEO of its parent organization Salina Health Education Foundation.

"Integrated care takes more time. It takes more resources to have a behaviorist on staff. It takes learning how to communicate and work together as a team when that's not what you are probably used to," Dr. Freelove said.

"It did not take very long for the skeptics to become champions. Integrated care makes a difference for patients almost immediately. When providers see the benefits, they can't imagine going back to the old way," he said.
 

Team-based, Patient-centered Care

Traditionally, primary care doctors and behavioral health care specialists are trained separately and practice in separate clinics.

"That just creates so many cracks along the way that a patient can fall through and prevent them from getting proper primary or behavioral health care," Dr. Freelove said.

"A patient has to actually believe certain care is necessary, and then has to follow through on that referral and go to a new place sometime in the future. Even once you overcome those challenges, there are frequently communication issues back and forth between those two different clinics," he said.

Integrated care puts both primary and behavioral health care providers on the same team, centered around the patient.

"We can accomplish so much more when we work as a team, rather than as individual clinicians," Dr. Freelove said.

“Instead of communicating through notes in a medical record, I am working directly every day with the behavioral health specialist. I can simply step out of the exam room, grab the behaviorist, and explain what I think is going on, and discuss how to proceed," he said.

"Just that brief dialogue is incredibly important in getting the patient taken care of quickly and effectively. And because it's all right there in one office and in real time, the cracks that patients can fall through go away," Dr. Freelove said.

"Integrated care is real time. It's one location. It's practicing health care as one team focused on the patient."
 

Catalyzing Change

Although the benefits for the patient are clear, change is needed to incentivize more clinics to implement integrated care.

"This is just not how things are traditionally done, and medicine is really slow to adapt," said Dr. Freelove. "But if reimbursement won't let you get paid for it, whether it works becomes irrelevant. If it's not sustaining, you simply can't do it. That's where the support from the Sunflower Foundation has been critical in getting this off the ground, and for advocating for reimbursement changes to make this a sustainable model."

In 2016, Sunflower began funding research and analysis of the systemic barriers to the implementation of integrated care in Kansas. The project is intended to lay groundwork and chart the course for policy changes needed to make integrated care sustainable in Kansas.

"Salina Family Healthcare Center, COMCARE, and others working to integrate care in their clinics are truly at the vanguard of improving health care in Kansas," said Billie Hall, President and CEO of Sunflower Foundation. "But individual clinics can only do so much to affect system-wide change. That's where Sunflower is working to help—to catalyze changes needed to improve health care for Kansans. Working together, we believe will succeed."
 

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Since its inception in 2012, the Integrated Care Initiative has awarded 37 grants totaling nearly $3.3 million. It also founded the Learning Collaborative, where more than 100 participants from grantee organizations and other partners have worked to learn from each other’s efforts. Learn more at SunflowerFoundation.org/ICI.