InvisALERT Solutions – ObservSMART

Engaging Patients at Critical Moments is Key to Improving Behavioral Health Outcomes

Massachusetts is home to thousands of individuals with behavioral health needs who lack access to quality care. In fact, according to recent estimates, only 54 percent of adults with mental illness in Massachusetts receive any kind of mental or behavioral health treatment (SAMHSA, Behavioral Health Barometer: Massachusetts, 2015). This includes those individuals participating in MassHealth, the state’s Medicaid program.

Understanding the challenges these often-vulnerable patients face, Aspire Health Alliance works as an integrated-care behavioral health provider—dedicated to improving patient outcomes through a team-based approach. Partnering with accountable care organizations (ACOs), clinics and facilities throughout Boston, South Shore and Southeastern Massachusetts, we work to help patients who have fallen through the cracks of an otherwise fragmented healthcare system.

Finding these patients, however, can be a difficult task. Many of our most complex patients are homeless or otherwise transient, which poses unique challenges when finding and helping these individuals.

Strategic Partnerships and Programs: In July 2018, we launched the South Shore Community Partnership with our partner, Spectrum Healthcare. This program is part of a new MassHealth care-delivery transformation initiative called the Behavioral Health Community Partner (BHCP) program.

The BHCP program seeks to improve collaboration across ACOs, managed care organizations, and community organizations addressing social determinants of health by breaking down existing silos to deliver integrated care (MassHealth Community Partners Program: Information for Providers, 2019).

Part of this mission includes a better way to contact hard-to-reach patients through a real-time alert system that enables immediate follow-up. Within a few months, this small update has led to a boost in patient engagement rates for our South Shore Community Partnership, going from as little as 10 percent to 35 percent engagement. For an opt-in only program, this increase is significant.

Timely Interventions: The BHCP program is designed to connect adults (age 19-64) facing behavioral, mental or substance-use disorders to dedicated care coordinators with access to community resources such as primary care providers. To find these patients, Aspire Health Alliance started its search in local emergency departments, or the ED.

The ED provides a safe spot for individuals—particularly vulnerable individuals—who lack resources like primary and mental/behavioral health care. Without access to traditional providers, these patients feel the ED is their only option for receiving care, making them the perfect candidates for the BHCP program.

At first, pulling and cross-referencing the needed demographic information, medical reports, and PDMP data could take hours, which meant many times the patient was discharged before a care coordinator could reach out.

Aspire Health Alliance began working with Collective Medical, a care-collaboration network, to expedite data sharing between the ED and case managers. The platform works by pulling patient data from multiple sources and pushing the most critical details to providers at the point of care. BHCP providers can also opt to receive these real-time notifications when a patient had been admitted to a hospital, enabling quicker follow-up.

For us, this has made a big difference. When we meet patients in the ED during an acute crisis, they are often more open to the help that programs like the BHCP offer. We can then redirect these patients to a more appropriate caregiver or provider so that the next time the patient is in psychological crisis, he or she calls the care coordinator first.

One patient presented in the ED with a blood-alcohol content level above 300. We sent a care coordinator to meet him in the ED, and she helped him schedule his first primary care appointment in years. Now, he works regularly with his primary care doctor and care coordinator toward wellness goals and has only returned to the ED once. It’s changes like this that give our patients a real hope of living sustainably healthy lives.

An Ongoing Process: Of course, there are a number of challenges to implementing patient-engagement initiatives. For instance, our care coordinators do not work around the clock, which sometimes limits our ability to catch patients in the ED. In addition, the BHCP program is “opt in,” which means individuals have to agree to the program before we’re able to help them. While many patients are receptive, there are still those who have had negative experiences in other programs and refuse to participate.

Still, the rewards are worth the efforts. Over the last seven months, we’ve seen a significant rise in primary-care appointments—and the number of patients actively seeking community resources. By supporting more people to get primary and preventable care, we’re giving our patients the help they need, in the most appropriate care settings.

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