A discussion of integrated care should actually start by redefining the term itself. Integrated care is commonly considered the weaving together of physical and behavioral health, but experience has shown that this definition limits the discussion to two dimensions. What dimension is missing? What I call the tough stuff – homelessness, the effects of traumatic experiences, multi-generational poverty along with chronic disease – the things that research has shown contribute to 70% of a person’s health. So, if we are to make meaningful inroads in improving health outcomes, we have to understand – and address – all of the factors we know contribute to poor health.
And when we add this critical dimension, what we are talking about is whole health. A number of years ago, ICL began to introduce a whole health approach to care throughout the agency, starting with incorporating health questions into behavioral health intake and weaving concrete suggestions about self-care into treatment plans. It became routine for ICL staff to talk with a client about their blood pressure and offer to walk them down the street to CVS to have their pressure checked or ask if they were eating better to deal with the anxiety and sleeplessness they had been experiencing.
When we sought to evaluate the impact of what we were doing, the evidence was clear — 97% of people served by ICL felt more connected to community and better about their lives and their future. ER and hospitalizations for mental health reasons were reduced. And a 2017 SAMHSA award recognized ICL as one of only three agencies from around the country having a substantial impact on health outcomes for people with complex needs.
The success of these efforts encouraged us to open a center that could serve as a “whole health” hub in East New York, the physical space to bring integrated/whole health care under one roof. Nowhere would this type of care be more important than in the neighborhoods of East New York.
A Welcoming Center for Care: Last Fall, the ICL Health Hub opened its doors– a three-story, light-filled 43,000 square foot space offering mental health, primary care, housing support, nutrition assistance, and youth and parent advocacy, all grounded in a whole health approach to care. The Hub gave us the chance to work together with community groups to change the trajectory for East New York.
The Community Healthcare Network (CHN) shared our vision and commitment to East New York and were the ideal medical services partner. But because primary care and behavioral health come from very different practice roots, ICL and CHN understood the work we needed to do to ensure that services were not simply co-located but fully integrated. Long before the Hub opened, the two organizations began building the framework and procedures needed to carry out our shared vision for a whole person approach to health and wellness. That work continues thanks to the ongoing support of the Altman Foundation.
ICL and CHN began by looking at the values that would guide clinical practice and ICL’s TRIP principles of trauma-informed, recovery-oriented, integrated, person-centered services; we shared an understanding of using a culturally responsive lens in all services.
This collaborative work has proved invaluable to the success of the Hub. We continue to put the necessary supports in place including ongoing training, joint clinical integration meetings, clinical huddles, and development of a shared Nurse Practitioner Fellowship program. That program has allowed us to launch a pilot integration project for our Hub ACT teams to bring primary care to homebound people with serious mental illness. (See related story)
Engaging Leaders from All Corners: We knew early on that community partnerships were critical to everything we wanted to accomplish. One of our first initiatives was to engage local clergy to help break through the stigma against getting help and supporting clergy as “first responders” to their parishioners. Many faith leaders have taken the “Mental Health First Aid” training at the Hub with the New York City Department of Health and Mental Health to identify signs and symptoms of mental health and substance use challenges. Our work with DOHMH and the clergy continues. And we’re grateful that churches have given ICL their “blessing,” encouraging congregants to use the medical and behavioral health services of the Hub.
We’re breaking down silos in the larger healthcare system as well. ICL Care Coordinators are embedded at Interfaith Medical Center, making hundreds of referrals to services for people with complex mental health needs. We’re making inroads with people with significant health care needs who have not traditionally used mental health support. Our Care Coordinators are on-site at the Rogosin Dialysis Center to connect people to the Hub; many of these patients are dealing with a chronic disease for the first time and need medical and mental health support around self-management of the disease. And we’re working with NYC Department of Homeless Services to connect shelter residents to treatment services and to housing support at the Hub.
People ARE Doing Better with Us: How do we know that what we are doing in the Hub is on the right path? The proof is in the changes we see in the people coming there for care. Here are just two of their stories.
The first week the Hub opened, we received an email about John, a thirty-two-year-old man who was receiving dialysis at a center across the street from the Hub. John was homeless, suffered from depression and the ravages of traumatic losses in many areas of his life. He had no primary care provider. In response to the email, an ICL Peer Consultant and Health Home outreach worker came to see John at the dialysis center. They brought him back to the Hub where, within an hour, each of the issues John was facing was addressed. And he left with appointments with a psychotherapist and primary care provider, was enrolled in Health Home, connected to a shelter with medical resources and given a bag of food because healthy eating was so important to his recovery. And ICL staff have gotten John into the supportive housing “queue”; he’s awaiting an apartment where he can continue his journey to greater health and well-being. He is very grateful to ICL and was especially excited to get help in what he described as “this beautiful building I watched go up over the past two years.”
Another example of how integrated care and relationship-building can change the direction of a person’s life – Reggie is a 65-year-old man diagnosed with schizophrenia and uncontrolled diabetes that is causing him to lose his vision. An ICL ACT client since 2010 (Assertive Community Treatment), Reggie has an extensive history of psychiatric hospitalizations as a result of not complying with treatment. He had not seen a primary care provider for two years because of his psychiatric issues and problems with insurance. That changed when ACT moved into the Hub, just up the stairs from the CHN medical clinic. After some persuasion, Reggie walked with the ICL psychiatrist he had come to trust down to the waiting room of CHN. He was seen immediately and after CHN’s ongoing efforts, Reggie agreed to take oral and then injectable diabetes medications. Within four months, his glucose levels decreased from over 400 to 200’s, and his A1C is 9.4, down from 13.4, significantly lowering the risk of complications from diabetes. The ACT team and CHN continue to fine-tune his treatment and Reggie agreed to consider placement in housing with onsite nursing.
John and Reggie are just two of the thousands of people who have benefited from the holistic, engaging and responsive care of the Hub. And there are many other signs of success. Many clients of ICL ACT and PROS (Personalized Rehabilitation Services) are seeing primary care providers for the first time. In addition to those being seen at the CHN clinic, some 415 participants in ACT and PROs have been served by CHN’s Family Nurse Practitioners consulting with ICL program teams as a first step in engaging participants in quality primary care.
Less than one year out, we’re working with some 4,000 adults, children and families in East New York in integrated behavioral health, medical, care coordination and social support services. Many are learning about self-care through community wellness services like a mobile mammogram scan van, yoga classes, diabetes management groups, and access to a fresh food box program.
There are many lessons we’ve gleaned from our experience at the Hub so far. What stands out most is the day-to-day proof that we CAN do this work – that we are providing integrated, whole health care in a place like East New York that has suffered generations of health disparities. As we mark the first year of the Hub, we look forward to broadening our scope, building on our integrated care model, and engaging more community partners.
And we continue to expand our definition of integrated care – care that is beyond what an individual behavioral health or primary care provider can do. It’s about what we can do as a unified community committed to raising the quality of life for all its members.
