Editor’s Note: The Partnership Health Center (PHC) 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 in Washington, Wyoming, Alaska, Montana, and Idaho.
Surrounded by five distinct mountain ranges, Missoula, Montana has been dubbed the Garden City, attracting vacationers and newcomers lured by its natural beauty. It also is considered a hub for services for the surrounding rural and frontier counties.
Since its inception in 1989, Partnership Health Center, a federally qualified health center (FQHC) in Missoula, has primarily served the working poor, and the demand for services has grown each year. Of nearly 13,000 patients served in 2014, about 10 percent identified as homeless.
From its humble beginnings in a single room at the health department, PHC has grown to inhabit a repurposed, historic brick Creamery building facing the railroad in an area central to our target population. Awarded a Historic Preservation Award for repurposing in 2014, the renovation and expansion of the old Creamery building contains two large medical clinics, 11 dental operatories, pharmacy and clinical pharmacy services, nutrition services, a group room for group therapy and diabetes and pre-natal group visits, and a robust integrated behavioral health (BH) program.
Our journey to the Social Innovation Fund (SIF) began modestly. In 2004, depression was the number one diagnosis in our clinic population. For four years, our BH program consisted of volunteer therapists and post graduates. In 2008, we were awarded a Behavioral Health Expansion grant by the Health Resources Services Administration (HRSA). Finally able to hire three therapists and a part-time psychiatric nurse prescriber, we felt, at least briefly, we had solved our problems.
As our community health center’s population continued to grow, especially in the wake of the severe recession that struck in 2008, depression never left the top three diagnoses among our patients. Although we had co-located services, there was a persistent disconnect between behavioral health and primary medical care.
We were eager for true integration and the SIF/IMPACT opportunity was the most logical next step for us. As is true for many community health centers, the urgent need for depression care among our patients required building a response driven by creativity and imagination. The ability to have support to implement an evidence-based model, with structured technical assistance and guidance, was a dream.
Over the past two years, as a SIF/IMPACT site, we have been able to implement universal screening for depression, serving 2,290 unduplicated patients in behavioral health. Of those, 1,334 (58 percent) were specifically referred to IMPACT after their “warm handoff”—the term used to describe the process where a patient with depression is introduced to a behavioral health provider during his or her visit to the clinic.
Our technical assistance from the AIMS Center at the University of Washington in Seattle was critical, especially during the early phases, when there was confusion about how to best work with patients—should they be offered more “traditional” therapy or be served in IMPACT? A true collaboration was the end result, as both patients and medical providers now have a greater understanding of the need for teamwork in depression treatment.
Our original design was to utilize community health specialists as depression screeners and schedulers, and to preserve the care management role for the therapist. In hindsight, if we were to do anything differently, we would have started the program with our paraprofessional in the care management role.
However, with the guidance of the AIMS Center, we were able to see the community health specialists as playing a more critical role in the patients’ treatment. This change resulted in the ability to successfully manage a greater number of patients, to make sure someone was always available for patient follow-up, and to allow the therapist to see patients for billable visits, increasing the likelihood of long-term sustainability for the program.
Change takes time, and the IMPACT model does bring a cultural shift to the patient visit.
We also learned to be patient with ourselves and our clinical staff. Change takes time, and the IMPACT model does bring a cultural shift to the patient visit. Warm handoffs delay room turnover. Medical providers are used to turning over the care of people with depression to therapists; they have now learned that the medical provider drives the treatment plan. After two years, we all agree, there is no going back to the old model of depression care.
We found, in the first two years, it was easy to track success stories. We also found that the IMPACT model is especially helpful in treating older adults. For example, a 65-year-old woman presented with depression after her last child “left the nest,” saying she didn’t know what to do with herself. She had spent 40 years taking care of her children, and now “they have all moved away.” She was unable to travel to Missoula for counseling, so she was started on an antidepressant at that initial medical appointment, and the care manager continued to follow up with her.
Her motivation increased and she started to have a positive outlook on things. She was able to cope with the loss of a relationship. After 10 weeks, she went to visit a friend in Arizona, where she got involved in the community, went to gatherings and dances, and started swimming. The patient recently relocated to Arizona, and currently has no signs of depression.
The program works for younger adults as well. A 19-year-old female with severe depression presented with several social stressors, including a difficult situation with a roommate, a stressful job, and relationship struggles. She was not interested in counseling, but was willing to start an antidepressant. She received medication and care management. After 10 weeks, she left the roommate situation, returned to school, had improved communication with her partner and friends, and has seen a 12-point decrease in her depression score—even while dealing with the unexpected death of her grandmother. She recently graduated from massage school and has been accepted to Montana State University to study Human Performance & Exercise Physiology.
Another woman, who is 30 years old, was referred to PHC by her probation officer. The patient was experiencing depression and social anxiety that interfered with completing substance abuse treatment. Through the course of problem-solving therapy, the patient was able to improve her communication decision-making skills. She has now completed a drug rehabilitation program and started aftercare. She is also on a positive track to complete probation. This patient is currently looking for employment and has scheduled two job interviews.
These are just a few stories of success among hundreds that staff are able to share with each other on a regular basis, which helps offset the challenge of hearing stories every day that are filled with hardship and heartbreak. We are grateful for the opportunity, as a SIF grantee, to bring such a critical service to our underserved community.
For more information on the John A. Hartford Foundation’s SIF projects, visit our Social Innovation Fund page.
This is the third in an occasional series of Health AGEnda posts on the Hartford Foundation’s Social Innovation Fund projects. Read the previous post: