From left, Bighorn Valley Health Center (BVHC) board members Luella Brien and Cari McCleary; U.S. Sen. Jon Tester of Montana; Bighorn County Commissioner Sidney Fitzpatrick; BVHC Medical Director Earl Sutherland (front); BVHC CEO David Mark, MD; and board members Carlene Old Elk and Alma McCormick. From left, Bighorn Valley Health Center (BVHC) board members Luella Brien and Cari McCleary; U.S. Sen. Jon Tester of Montana; Bighorn County Commissioner Sidney Fitzpatrick; BVHC Medical Director Earl Sutherland (front); BVHC CEO David Mark, MD; and board members Carlene Old Elk and Alma McCormick.

Editor’s Note: The Bighorn Valley Health Clinic in Hardin, Montana, is one of eight primary care community clinics receiving funding through the federal Social Innovation Fund (SIF) initiative to spread the IMPACT program, also known as Collaborative Care, in the rural Pacific Northwest.

The John A. Hartford Foundation was one of just four new awardees chosen in 2012 to serve as an intermediary between SIF and subgrantees implementing innovative care models. As a result, a $3 million federal grant has been matched by $3 million from the John A. Hartford Foundation, with additional matching grants from the subgrantees, to spread the IMPACT/Collaborative Care model of depression treatment in Washington, Wyoming, Alaska, Montana, and Idaho.

Bighorn County, located in the south central part of Montana, is 9 square miles larger than the state of Connecticut, with a population density of just 2.6 people per square mile.

It ranks 46th out of 46 counties in the state for health outcomes, clinical care, and social economic factors. Health resources are very limited and our patient population has a high level of chronic illnesses. Since many chronic illnesses have comorbid depression, implementing an evidence-based program for integrated primary care/behavioral health was clearly the best way to address many of our area’s health care needs.

That made developing an integrated primary care program a critically important goal for Bighorn Valley Health Center (BVHC). Our small, very rural, federally qualified health center (FQHC) is in Hardin, the county seat of Bighorn County situated adjacent to the Crow Reservation. Seventy percent of our patient population is Native American.

A search for resources led to the Social Innovation Fund (SIF) and the work of the John A. Hartford Foundation. BVHC was very pleased to have been selected as a grantee.

Being a new SIF site has been exciting, challenging, and humbling all at the same time. Ultimately, it is incredibly gratifying to be bringing a proven treatment program to a greatly underserved population and to track the improvements that our patients make.

The problems of severe unemployment, critical housing shortages, and limited communication services have made for unique challenges in scheduling and follow-up with our patients. Many do not have access to reliable transportation and sometimes face a difficult choice between buying food and having gas money. Many of those we serve must depend on other family members for housing and frequently have to move between multiple relatives as needs for a place to stay wax and wane.

Cell phone and internet services vary greatly in accessibility and function across the area. Many families do not have internet access and rely on a prepaid phone plan for communication. If a family shares a prepaid phone, some people may suddenly become unreachable if no one can quickly purchase more minutes of service. Many families may also share one post office box. Timely receipt of mailed notices can vary greatly depending on where a family is staying and when someone goes to town to check the mail box.

Sometimes, the most effective means of patient contact is through another family member. Not surprisingly, such a process requires careful advance planning in order to ensure that appropriate release authorizations have been obtained.

bvhc_logo_150pAs an organization, it is easy to feel burdened and sometimes overwhelmed by the responsibility of implementing a new program. There are new skills to learn and new ways of conceptualizing patient care to be mastered. There are standards of program fidelity to be met and documented. When feelings of stress do surface, it is comforting to remember that there is ongoing support, expertise, and consultation readily available from the University of Washington's AIMS Center.

It is very humbling to realize that our patients do not have a program manual or webinars or on-site training to guide them through the implementation of their healing and recovery. Remembering our patients’ struggles to access service makes the work of implementing services seem easy.

During our training in Seattle, we collectively realized that we did not fully understand some of the information presented in the first day until we had completed additional training on the second day. In large part, we needed the additional context that came with the additional training and, lacking that, did not know the most useful questions to ask.

A similar process has occurred in our implementation.

Starting our program with a mental health provider who had extensive experience in traditional care offered the benefit of clinical experience, but has required a greater degree of adjustment in learning how to work within the IMPACT model. Previous learning can sometimes make new learning more difficult. Having our mental health provider also continue to be a half-time provider of traditional services increased the effort needed to separate out the differences in the models of care. The IMPACT model is not in any way a reconfiguration of traditional mental health treatment. And while the IMPACT training is very clear in stating this up front, it turns out that fully absorbing and understanding this reality has proven challenging!

Controlling and coordinating the schedules for our two Care Managers—one a medical provider, the other a medical assistant—and Psychiatric Consultant has proven to be another area of unanticipated challenge. Provider scheduling is contained within our electronic health record. However, medical assistant and nursing schedules are coordinated outside of our electronic health record, leaving open the possibility of discrepancies arising. Building in blocks of time dedicated to IMPACT has not worked smoothly because of the need to coordinate the parts of the medical assistant care manager‘s time with the mental health provider care manager’s time and the two separate scheduling processes. Creative solutions were required to match these unanticipated complexities.

One of the most important lessons learned has been the value of an onsite review and training. Having our training consultant visit our center and walk through every step of our program provided invaluable information and tailored strategies to improve our processes. The review was so helpful that an additional follow-up has also been scheduled.

Identifying and overcoming challenges are the work necessary to meet our program purpose and our rewards for hard work are the successes of our patients.

The challenges of implementing the IMPACT program have been useful and sometimes difficult learning experiences and we will continue to learn as we refine the program. Identifying and overcoming challenges are the work necessary to meet our program purpose and our rewards for hard work are the successes of our patients.

One, who I’ll call SP, came to BVHC after having been dismissed from her previous provider for being too demanding and “whiny.” She is a middle-aged woman with depression and numerous complaints of ill-defined autoimmune disorders, chronic headaches, chronic abdominal pain, and unrelenting low back and shoulder pain. When she first came to our health center, she was rapidly referred to the IMPACT program, where—for the first time in her experience with medical providers—she felt safe enough to disclose her history of childhood trauma. After engaging with our IMPACT team for less than a month, she has decided to cancel three previously-scheduled visits to various medical subspecialists, as she feels like she’s finally getting to the heart of her issues.

After brief participation in the IMPACT program, two other patients have been able to recognize and admit the effects of their substance dependence and request residential substance abuse treatment. Both noted that they had never previously associated their substance abuse as a significant source of both physical and mental problems until working with the IMPACT model.

There are many more success stories I could share. And all of us at BVHC look forward to doing the hard work necessary so that many, many more of the people we serve can benefit from the IMPACT model.

This is the fifth in an occasional series of Health AGEnda posts on the John A. Hartford Foundation’s Social Innovation Fund projects. Read the previous posts:

Fighting ‘Chronic Despair’ in Rural Communities in Washington State

For Missoula Clinic, SIF Program Support Is a Dream Come True

Innovative Depression Treatment Helps Sophie Enjoy Better Mental and Physical Health

Partnership Advances a Revolution in Mental Health Care