Creative Integrated Care Models Are Adapted to Special Populations

Integrated care is the future of medicine, so it is said, but that future could look different depending on the patient population being served.

The collaborative care model developed by Jürgen Unützer, M.D., M.P.H., the late Wayne Katon, M.D., and others at the AIMS Center at the University of Washington is the model of integrated care with the most extensive evidence for effectiveness. But a number of other models, building on the principles of collaborative care, have been adapted for special populations requiring intensive interventions.

The HomeBASE Project at the Duke University Outpatient Clinic, targeting “super utilizers” of emergency department (ED) services, and the VA’s Homeless Patient Aligned Care Teams (H-PACTs) addressing homelessness among the country’s veterans, are two alternative integrated care models that have shown early success.

Both models draw on the principles of collaborative care, but they are uniquely designed for high-need patients with psychiatric and comorbid medical conditions. And both models were recognized at the Innovations in Integrated Care symposium last year at the annual meeting of the Association of Medicine and Psychiatry (APM).

“This symposium has been a staple of our yearly meeting for many years, well before the term ‘integrated care’ became the buzzword that it is today,” psychiatrist Jeffrey Rado, M.D., president of APM, told Psychiatric News. “What is interesting is to see how individuals have taken the University of Washington AIMS Center collaborative care model and then adapted, by necessity, to the specific needs of the clinical population they serve. In addition, they have had to adapt to the resources available at their institutions. I am always struck by the ingenuity and resourcefulness of these clinicians.”

In an interview with Psychiatric News, Natasha Cunningham, M.D., said HomeBASE utilizes the principles of assertive community treatment—community outreach with a multidisciplinary team and a recovery-oriented approach—to identify and work with patients who have had six or more ED visits in the past six months and an ongoing pattern of ED utilization. The HomeBASE team consists of Cunningham (board certified in medicine and psychiatry), a full-time registered nurse care manager, a nurse practitioner, and a licensed clinical social worker.

The team develops an individualized care plan focused on improved overall health and reduced dependence on use of the ED. Already, preliminary follow-up research appears to indicate that the program has successfully reduced use of the ED while reducing health care costs and improving patient health.

“What comes to light when engaging with these patients is that the social and behavioral determinants of health are driving their health-seeking behaviors,” Cunningham told Psychiatric News. “By identifying high rates of ED utilization as a marker of psychosocial issues, we are able to target complex issues that are not easily captured through routine medical or psychiatric assessment and diagnosis.

“There is a lot of interest across medical disciplines in high utilizers of emergency services,” Cunningham continued. “Psychiatry has a lot to offer to our medical colleagues by bringing to the table a biopsychosocial perspective and an ability to engage with patients who have multiple needs.”

H-PACTs make up an innovative treatment model at VA medical centers across the country that co-locates medical staff, social workers, mental health (including substance use) counselors, nurses, and homeless program staff to provide veterans with comprehensive, individualized care, including services that lead to permanent housing.

At the Ralph H. Johnson VA Medical Center in Charleston, S.C., the H-PACT team consists of program manager Elizabeth Call, M.D., who is board certified in internal medicine and psychiatry, a nurse practitioner, a registered nurse, and a pharmacist.

Call told Psychiatric News that veterans can walk into H-PACT clinics without an appointment and receive medical care, case management, housing placement supports, mental health/substance use treatment, community referrals, triage services, benefits counseling, and even hot showers and clean clothes. Homeless veterans or those living in temporary housing who do not have a primary care doctor qualify to use this program. 

“All those services can be offered in one day,” Call said. “It’s an extraordinary benefit to patients because they are seen in an open-access model—they don’t have to go to the ED. If you think of mentally ill veterans as being underserved generally, then homeless mentally ill veterans are the underserved of the underserved. H-PACT is specifically designed to meet the needs of that patient population.”

According to the VA website, patients enrolled in H-PACT experience on average 31 percent fewer ED visits and require an average of 24 percent fewer hospitalizations. If duplicated across the entire health care system, this reduction could save the VA about $5 million a year, according to the VA.

Rado said physicians dually trained in internal medicine and psychiatry bring a special expertise to these models of care. “This unique type of clinical training very much informs the integration that we see in these programs and leads to novel ways of employing the collaborative care model, which nonetheless remains very faithful to the core principles of the model,” he said. ■