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 have an SMI diagnosis and in 2016, the health center provided medication assisted treatment (MAT) services to 700 patients with opioid addiction.
ACCESS aims to establish a virtual integrated health home (IHH) model to transform the delivery of care for individuals with SMI, and co-occurring substance use disorders. Funding will support a patient-centered pilot project serving approximately 50 individuals. ACCESS will serve as the lead entity of the IHH, providing care coordination, primary care and medication assisted treatment services (MAT). The IHH network, comprised of hospital, behavioral health and social service providers, will provide primary care, behavioral health and substance abuse services including crisis management, inpatient mental health treatment, recovery coaching, and supportive housing and employment services.
The goal of ACCESS’ Integrated Health Home project is 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, improve health outcomes and reduces systems costs associated with unnecessary ED use, inpatient hospitalization and incarceration.
Project objectives are 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 of alcohol and other drug dependency treatment;
- Enhance care coordination;
- Develop, test, and refine systems and workflows 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:
- Developed integrated health home (IHH) pilot model;
- 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 partners to access patient’s E.H.R. and send messages and documents to care coordinators;
- Assessed and refined systems of care and workflow;
- Engaged with Illinois Department of Healthcare and Family Services and managed care organizations to plan for formal launch of integrated health homes; and
- Conducted in-depth analysis of the pilot to inform practice improvement and share effective practices across the ACCESS network for program expansion.
- 2017-2018 Key Project Outcomes
- Through outreach to 88 persons eligible for enrollment in the IHH pilot, across five IHH sites, enrolled 40 patients in the program and ended Year 1 with 27 enrolled patients;
- Completed or updated care plan for 92% of enrolled patients within 45 days of enrollment, exceeding the initial goal for care planning;
- Strengthened relationships with IHH partner organizations;
- Reduced time to complete housing placements to approximately 10 days through utilization of common E.H.R and enhanced data collection systems; and
- Initiated workflow development and IHH model in preparation for state-wide launch of IHH.
- 2017-2018 Project Activities:
- 2018-2019 Expected Project Activities
- Scale the pilot program to reach 500 persons through the state’s Medicaid program;
- Refine workflows to address expanded volume, new partnerships, and new patient populations;
- Utilize E.H.R. dashboards or other tools to improve primary care providers’ access to information about patients’ social determinants of health (SDoH);
- Pilot, evaluate, and revise IHH training curriculum as needed, and develop plan to ensure training materials stay relevant as requirements and operations change over time;
- Refine E.H.R. documentation and reporting systems to facilitate timely access to all Medicaid- required quality indicators; and
- Develop mixed methods evaluation plan to assess impact on patient outcomes, effectiveness of collaboration facilitators and barriers to scaling the program.
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.