Project Name: ACCESS’ Integrated Health Home

Project Overview: ACCESS Community Health Network (ACCESS), one of the nation’s largest networks of federally-qualified community health centers, provides primary and preventive care services in Chicago’s south and west side communities, serving a predominantly underserved, low-income, Hispanic and African-American population. A resource-poor community, the health center’s geographic area is affected by high rates of poverty, trauma, and poor health outcomes, and a disproportionate burden of serious mental illness (SMI) and substance abuse disorder. Approximately four percent of ACCESS’ patients had a SMI diagnosis and the health center provided medication assisted treatment (MAT) services to 700 patients with opioid addiction (2016).

In anticipation of a major state-wide Medicaid initiative, ACCESS piloted a virtual integrated health home (IHH) model to transform the delivery of care for individuals with SMI and co-occurring substance use disorders. The project was designed to prototype and evaluate a sustainable system for highly-complex patients that integrates patient and family care at the clinical, functional and organizational levels. The IHH network, comprised of hospital, behavioral health and social service providers, provided primary care, behavioral health and substance abuse services including crisis management, inpatient mental health treatment, recovery coaching, and supportive housing and employment services. ACCESS served as the lead entity of the IHH, providing care coordination, primary care and medication assisted treatment services (MAT) and coordinating the collaboration.

The goal of  ACCESS’ Integrated Health Home project was to establish an integrated community-based health home for individuals with serious mental illness and/or substance use disorder that provides high-quality, trauma informed care, improves health outcomes and reduces systems costs associated with unnecessary ED use, inpatient hospitalization and incarceration.

Project objectives were to:

• Reduce hospital readmissions for the pilot cohort of patients with high behavioral health needs;
• Improve the rate of post-hospitalization follow-up;
• Improve initiation and maintenance of alcohol and other drug dependency treatment;
• Enhance care coordination;
• Develop, test, and refine workflows as well as documentation, reporting and collaboration systems in preparation for the state’s IHH implementation; and
• Identify effective practices that can be shared with the state and other providers to add value to the upcoming Medicaid service transformation.

• • 2017-2018 Project Activities:
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    • Developed integrated health home (IHH) pilot model including the following partners and services: Trilogy, Inc. (mental health), Catholic Charities (employment, housing, and outpatient substance use disorder treatment), Sinai Health System (inpatient psychiatric care), and Gateway (all levels of substance use treatment);
    • Convened network partners to provide ongoing oversight of all project activities;
    • Hired nurse care coordinator with experience in behavioral health to identify patient needs and coordinate care through partner services;
    • Launched cross-organizational “Weekly Huddle” conference calls for coordinated patient care and multidisciplinary team check-ins;
    • Activated online portal enabling all IHH partners to access patient records via a common E.H.R. and send messages and documents to care coordinators;
    • Assessed and refined systems of care and workflows;
    • Engaged with Illinois Department of Healthcare and Family Services and managed care organizations to plan for formal launch of integrated health homes;
    • Conducted in-depth analysis of the pilot to inform practice improvement and share effective practices across the ACCESS network for program expansion.
    • Developed an evaluation framework utilizing the Consolidated Framework for Implementation Research Approach.
  • 2017-2018 Key Project Outcomes
    • Through outreach to 88 persons eligible for enrollment in the IHH pilot across five IHH sites, met patient enrollment goal and enrolled 40 patients in the program. Year 1 ended with 27 enrolled patients across five health center locations;
    • Overall, achieved target metrics for completion of care plans and other project measures. Care plans were completed or updated for 92% of enrolled patients within 45 days of enrollment, exceeding the initial goal of 50%;
    • Completed 50 partner service referrals;
    • Reduced time to complete housing placements to approximately 10 days through utilization of common E.H.R and enhanced data collection systems;
    • Initiated workflow development and IHH model in preparation for state-wide launch of the IHH; and
    • Strengthened ongoing relationships with IHH partner organizations.
• • 2018-2019 Project Activities
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    • Adapted program components to changes in the state’s plan and timeline for IHH implementation;
    • Refined workflows to address expanded volume, new partnerships, and new patient populations;
    • Utilized E.H.R. dashboards or other tools to improve primary care providers’ access to information about patients’ social determinants of health (SDoH);
    • Piloted, evaluated, and revised IHH training curriculum as needed, and developed plan to ensure training materials stay relevant as requirements and operations change over time;
    • Implemented new E.H.R. tools and refined E.H.R. documentation and reporting systems to facilitate timely access to all Medicaid-required quality indicators;
    • Refined evaluation strategies. In addition to collecting quantitative data, conducted key informant interviews; and
    • Developed initial report to assess impact on patient outcomes, effectiveness of collaboration facilitators and barriers to scaling the program.
  • 2018-2019 Project Outcomes
    • Successfully scaled operations to expand the number of health centers providing direct IHH services to five additional sites on the west and south sides of Chicago. In total, nine Access health centers provided direct IHH services;
    • Identified a dedicated IHH manager who developed refinements to protocols and established new workflows to advance implementation of the IHH model;
    • Reached 163 patients through outreach or direct service. Of those patients, 76 consented to share their information with the IHH and received services from the network;
    • Strengthened common tools established in year 1, including integrated workflows, shared care plans, universal partner access to the patient’s chart, weekly interagency “rounds” calls, and oversight from an interagency steering committee; and
    • Produced policy white paper documenting findings and recommendations.

  Project Partners: Sinai Health System, Catholic Charities of the Archdiocese of Chicago, Trilogy, Inc., Behavioral Healthcare, Gateway Foundation and Lurie Children’s Hospital of Chicago

  About the Grantee

  Access Community Health Network is one of the largest networks of community health centers in the nation, offering preventive and primary care services to more than 180,000 patients annually at 36 sites in Chicago and the surrounding suburbs. For more information, visit: www.achn.net.