What innovations drive success in healthcare? Here's a tactic from a leading community health partner.

The problem

More than a third of residents of Trenton, New Jersey — 34 percent — live below the poverty level and struggle on many fronts. Henry J. Austin Health Center, the largest ambulatory center in the city, sees the tangled outcome of adversity in its patients' health: High rates of chronic disease, mental illness, and substance abuse. None can be treated effectively without addressing the others.

Yet without resources or training to treat depression, addiction, and other behavioral issues, Henry J. Austin's providers were feeling overwhelmed and defeated. Kemi Alli, M.D., the organization's CEO, asked, “How can we expect to have improved outcomes and be part of a value-based system if we don't have behavioral healthcare?"

The solution

Alli hired a behavioral health director and embedded a licensed clinical social worker into each primary care team throughout the organization. All patients are screened at every wellness appointment by medical assistants for signs of substance use, depression, anxiety, or insomnia. In the first year of the program, out of nearly 11,000 patients screened at wellness visits, more than a third tested positive for mental or behavioral health issues.

When patients screen positive for mental or behavioral health issues, they are immediately referred to the on-site counselor. The process identifies patients with mild to moderate mental or behavioral health issues who can be treated in primary care, before their conditions worsen and must be treated in an acute facility.

“The mental health system is not set up to accommodate these people," says Alli. “They could have very mild anxiety or depression, but that is going to have a significant impact on their health."

The outcome

Henry J. Austin leaders used the Patient Activation Measure — a highly predictive metric of a patient's ability to manage his or her health — to track whether the new system improved outcomes and lowered utilization of high-cost care.

They found that among patients who received mental or behavioral healthcare during primary care visits, 87.5 percent had higher PAM scores — indicating capability in managing their own care — with an average increase of 14 points. Among diabetic patients, average PAM scores rose 20 percent.

Next up for Alli and her primary care providers: Integrating behavioral and pediatric healthcare.

Lia Novotny is a contributing writer for athenaInsight. Photo credit: Getty Images | DrAfter123