Improve Ambulatory Behavioral Health Care Delivery through Monitoring and Coordination

An interview with Dr. Carl Clark, Mental Health Center of Denver

Across the last few decades, behavioral health care has steadily shifted to the outpatient setting, where all but select high-acuity clinical needs can be met more comprehensively and longitudinally.

Because of this outpatient shift, ambulatory behavioral health care providers must pursue treatment strategies that are both effective and promote improvements over time. For their part, hospitals must forge strong connections with ambulatory mental health providers to connect patients to the right level of care resources at the right site.

Dr. Carl Clark is a leader in the field of behavioral health care and CEO of the Mental Health Center of Denver. In an interview with Dr. Clark, he discusses the behavioral health care continuum and the need for provider collaboration. In his words, "If someone ends up in a psychiatric hospital or in a psychiatric visit to an ED, the outpatient system has really failed them."

Can you share your approach to measuring and monitoring clinical progress for behavioral health patients?

With behavioral health, if you do not measure clinical status, you can’t make improvements. Therefore, we measure everything in our system through our program called Reaching Recovery. We started tracking progress because we had more people who needed services than we had room for and we needed to know when people were clinically improving.

We created a tool called the Recovery Marker, which is a clinician assessment of how the patient is doing. The tool was developed internally, but there are other clinical sites across the country who are starting to use these recovery tools. We track recovery measures every three months for anyone who receives services from us. The tool looks at a variety of elements such as housing, interest in employment, and interest in education. The Recovery Marker assessment is very anchored, so if two different staff are trained to administer the survey, they will arrive at the same results.

We also look at the patient viewpoint. Every three months, patients complete a 17-question survey assessing five categories of mental health: sense of hope, sense of growth, sense of safety, sense of social network, and symptoms.

We have the assessments embedded in the EMR, so the clinician can actually bring up their patient data on a graph and see how their patients are doing. They also know what to expect when someone is getting better—for example, the data has allowed us to track expected improvement over time. We know when people are doing better than average, and we know when people are not doing as well as we would expect, so we can try to determine the reason.

The patients love knowing how they are doing. Most people want to fill out the paperwork to see their progress over time. I take my computer monitor and flip it around to show my patients how they have been doing over the past year. It really helps with motivation.

Can you describe the levels of care available at the Mental Health Center of Denver and how the composition of the care team changes over the course of treatment?

We have multiple levels of care. As people get better, we change their team—they graduate from one level of care to the next level. This is a utilization tool that enables us to see more people at the clinic. Our clinicians use an instrument called the Recovery Needs Level to assess the resources and treatment that each person needs to recover from their illness, and then we match patients with the appropriate level of care. The patient’s team composition changes with the different levels. Patients stay with their nurses and psychiatrists, but change case managers. Their physical treatment site remains the same so that the other important relationships that they have established, such as with office staff, are not disrupted.

Our highest level of care is the Assertive Community Treatment teams. The team has multiple case managers, psychiatrists, nurses, vocational counselors, and support staff. The case manager to patient ratio on these teams might be 1:12. Patients then graduate to Community Treatment teams, where the case manager ratios are closer to 1:20-25.

For those accessing outpatient services on a less frequent basis, the case manager ratios are 1:70. We also have patients who see a psychiatrist only a few times a year. In addition, we have peer specialists–people who have lived with a mental illness.

The coordination of behavioral and physical health care is a top-of-mind issue for hospitals and physicians. How does the Mental Health Center of Denver coordinate with physical health care providers?

We have several partnerships that meet patients’ needs. Fifteen years ago, we found a Federally Qualified Health Center (FQHC) that had high no-show rates for certain time slots, such as early on Monday morning. We asked for these time slots, and found PCPs at the FQHC interested in serving serious and persistently mentally ill patients. The Mental Health Center of Denver provides the behavioral health care, the PCPs provide the primary health care, and our case managers ensure that the PCP appointments are kept.

The PCPs at the FQHC love the partnership because it eliminates the issue of missed appointments. The FQHC benefits because they aren’t paying doctors for empty time slots. Furthermore, a shift occurs with the PCPs—they learn to better meet the unique needs of mentally ill patients. Similarly, we also provide behavioral health support to pediatricians in private practice to increase the number of Medicaid patients they can see. If someone ends up in a psychiatric hospital or in a psychiatric visit to an ED, the outpatient system has really failed them.

What other community stakeholders does Mental Health Center of Denver partner with?

We have individuals whose mental illness results in them interfacing with the criminal justice system. It costs time and money for the police, courts, and jail, so we started a program called Court-to-Community. We assess the person when they are arrested and the judge gives them a choice—go to jail or go to a treatment program. Some go to jail. But for those that choose to go into the treatment program, we have decreased jail days by 80%. The program saves the jail so much money that the sheriff has taken part of his budget and purchased more spots in the program.

When looking for partners, clinical providers have to step back and see the bigger picture. They have to ask, ‘What is the economic burden in our community?’ It might be in the jail, or hospital, or ED. It’s important to take the perspective of, ‘If we do an intervention, how can we shift the savings so we can build up more of what works?’

Care continuum communication is a challenge for many providers. What are your goals regarding this issue?

We try to find out when people go to the hospital as quickly as possible, but there is still a delay when patients are admitted to the general medical ward. It’s a problem we haven’t solved yet.

Interestingly, we have found communications solutions on the criminal justice side. Going to jail is public record, which we leverage for care coordination. In the middle of the night, we have the jail send us an electronic document—which shows all of the admissions/discharges from jail. We run the names through our internal system to see if any of our patients have been in jail or are being released from jail.

A match generates an email that goes to the doctor, supervisor, therapist, and case manager on the patient’s team, so all of the information is in the providers’ mailbox the next morning. Therefore, if we have any patient who goes to jail, we know it the next morning and can do outreach to them, make sure they continue their medication, find out what happened, and coordinate care.

We don’t have that level of transparency on the hospital side. If a patient is admitted to a general hospital for a medical problem, we don’t get that information at all. Although we encourage people to call us when they go to the hospital, unfortunately some are too ill to make that phone call.

For example, one of our diabetic patients was admitted to the community hospital for a diabetic episode and no one contacted our center until day five. The patient had not been given any of his medication and had an acute behavioral health episode. He was doing well mentally up until that point, but the diabetes was the problem. The only way we found out he had been admitted was that our mobile crisis unit happened to check the computer. We’d like to be at a stage where the clinic-hospital relationship is more proactive—it’s an evolving process.

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