Steve Hurd, Ph.D.

steve.hurd@stmarygj.org

970.244.2235

Where Two Great Rivers Meet:

Evolution of Integrated Care

MarillacClinic

Bridging the healthcare gap

AboutMarillacClinic

Clinic Eligibility• 200% of federal poverty level

• Mesa County residents

• Medical program serves uninsured ages 18-64

• Dental program serves uninsured, CHP+, and Medicaid. No age limitation.

Major Depression

Anxiety

Panic Disorder

Alcohol

Binge Eating

Any Diagnosis

0% 15% 30% 45% 60%

Prevalence ComparisonsMarillac Clinic vs. PHQ 3000

AboutMarillacClinic

IntegratedCare

Guiding Philosophy:

Meeting several patient needs in one visit results in greater

efficiency for both patient and provider. Integrated

Care

IntegratedCare

1. Minimalcollaboration

2. Collaboration at a distance

3. Basic on-siteCollaboration

4. Close Collaboration in a partly integrated system

5. Close Collaboration in a fully integrated system

McDaniel, Hepworth, and Doherty (1992)

IntegratedCare

$

$

$$

$$

$$

• Financial investment at start-up.

• Incentives to participate in collaborative care services:

• Single fee for entire office visit• Reduced group fees

• “Carving-in” diverse funding sources removes barriers to care.

IntegratedCare

•1 Medical Director—Physician

• 3 Physician Assistants

• 2 Nurse Practitioners

• 3+ FTE counselor positions• Family Therapist• 2 Licensed Social Workers• Case Manager• Psychiatric Nurse

• Psychiatrist - 8 Hours Weekly

OurStaff

Location Location Location

LessonsLearned

Having mental heath and medical providers in adjacent

offices is essential.

Location Location Location

LessonsLearned

LessonsLearned

PsychologistFamily Therapist

& PsychiatristAddictionsCounselor

CaseManager

MedicalExam

Rooms

MedicalExam

RoomsMedicalProviderStations

MedicalExam

Rooms

MedicalExam

Rooms

MedicalExam

RoomsMedical

AssistantStations

MedicalExam

Rooms

MedicalExam

Rooms

MedicalExam

Rooms

Reception Front Office

The Bathroom

Rule

Bathroom

Enhanced Record Keeping

LessonsLearned

All providers work from the same medical record

Enhanced Record Keeping

LessonsLearned

Crucial for Integrated Care:• Face-sheet• Mental health flowsheet• Health history questionnaire

Case M

anagement

LessonsLearned

Assists providers to stay on schedule

Essential for helping patients access

community resources

Case M

anagement

LessonsLearned

Shared Success Fosters Trust

LessonsLearned

Improved patient outcome becomes the single most

important source of encouragement for functioning

as a single team.

Shared Success Fosters Trust

LessonsLearned

Collegiality rather than Hierarchy

Collegiality rather than Hierarchy

LessonsLearned

Medical and mental health providers have equal status

within the team.

Collegiality rather than Hierarchy

LessonsLearned

Community Collaboration: Inter-agency referral agreements

MarillacClinic

Colorado West Mental

Health

Violence & AddictionsAgencies

CommunityMedicalClinics

LocalHospitalLessons

Learned

0%

7.5%

15.0%

22.5%

30.0%

Year 1 Year 2 Year 3 Year 4 Year 4.5

9.00%6.00%

8.00% 8.00%4.00%

Hospitalization E.R. Visit

Outcomes

Usage of St. Mary’s Services by Marillac’s Integrated Care Patients

0%

7.5%

15.0%

22.5%

30.0%

Year 1 Year 2 Year 3 Year 4 Year 4.5

9.00%6.00%

8.00% 8.00%4.00%

Hospitalization E.R. Visit

Outcomes

Usage of St. Mary’s Services by Marillac’s Integrated Care Patients

0%

7.5%

15.0%

22.5%

30.0%

Year 1 Year 2 Year 3 Year 4 Year 4.5

9.00%6.00%

8.00% 8.00%4.00%

Hospitalization E.R. Visit

Outcomes

During year 4, only 17% of hospital admissions were for mental health or substance

abuse conditions

Usage of St. Mary’s Services by Marillac’s Integrated Care Patients

Change in Hospitalization Rate (per 1,000) for All Marillac Integrated Care Patients

Jan-April 2003Jan-April 2004

Psychiatry Length of Stay January - April 2003 versus 2004

Psychiatry Charges: Jan – Apr 2003 versus Jan – Apr 2004

Stepped Care

Step 1

Screening, diagnostic, and preventative services; parental education

Stepped Care

Stepped Care

Step 2

Active treatment in primary care, involvement of care-giver and allied health professional to prevent relapse

Stepped Care

Stepped Care

Step 3

Psychiatric consultation at the primary-care setting when emotional or behavioral problems persists or

complications occur

Stepped Care

Stepped Care

Step 4

Referral to specialty setting for highly complex presentations or poor outcomes occur at Step 3

Stepped Care

Step 4

Referral to specialty setting for highly complex presentations or poor outcomes occur at Step 3

Stepped Care

More complex presentations may

begin at Step 3 or 4

Marillac Papers to date• Mauksch, L., Reitz, R. Tucker, S., Hurd, S., Russo, J., and Katon, W. Improving quality of

care for mental illness in an uninsured, low-income primary care population. General Hospital Psychiatry, 2007, 29, (4), 302-309.

• Mauksch, LB. Katon, W., Russo, J., Tucker, S., Walker, E Cameron, J. The content of a low income, uninsured primary care population: Including the patient perspective. Journal of the American Board of Family Practice, 2003, (16) 278-289.

• Cameron, J. and Mauksch, L. Collaborative Family Health Care in an Uninsured Primary Care Population: Stages of integration. Families, Systems and Health, 2002, 20(4) 343-363.

• Mauksch, L. B., Tucker, S. M., Katon, W. J., Russo, J., Cameron, J., Walker, E., & Spitzer, R. Mental illness, functional impairment, and patient preferences for collaborative care in an uninsured, primary care population. Journal of American Board of Family Practice 2001, 50(1), 41-47.

MarillacClinic

Bridging the healthcare gap