TN Health Center Links Behavioral Health, Primary Care

Regardless of whether patients come in for primary care or behavioral care, they get both. "People were showing up with physical, social, and psychological needs that we had to address if we were going to provide comprehensive care," says a health system's COO.

Decades before population health, patient-centered care, promoting wellness, and improving care access became focal points of healthcare reforms, federally qualified health centers were already doing that.

And long before the value of integrating and coordinating behavioral health and primary care services became universally apparent, FQHCs were doing that too.

Knoxville, TN-based Cherokee Health Systems has been ahead of the curve for more than 30 years, although they came at that linkage from a slightly different direction. The FQHC began as a provider of pediatric behavioral health service back in 1968 but came to see from firsthand experience that many patients had no access to primary care.

"We started primary care services in 1983, mostly because our patients needed primary care," says Parinda Khatri, PhD, a clinical psychologist and CCO at Cherokee Health. "We were in rural areas working with vulnerable safety net populations and we saw a tremendous need for primary care. People were showing up with physical, social, and psychological needs that we had to address if we were going to provide comprehensive care."

Cherokee Health opened as one behavioral health clinic in Morristown, TN. It now has a staff of more than 600 people in 14 counties in East Tennessee. Residents of this part of Appalachia, which includes some of the most economically challenged areas of the country, now has access to integrated behavioral health, dental, primary care, and pharmacy services for more than 64,000 low-income and vulnerable Tennesseans.

"We strive to organize a team to partner with the patients to cover a spectrum of care over their lifetime," Khatri says.

'Give Everybody a Primary Care Home'
Regardless of whether a patient comes in for primary care or behavioral care, Khatri says the patients get both. The behavioral health staff ask patients if they have a primary care home, and the primary care staff ask patients if they have access behavioral health services.

"We're building a mindset of comprehensive care with primary care and behavioral health providers. We believe strongly in access. We say there's no wrong door," she says. "People can come through the primary care door and they will be asked about their behavioral health status, they will get behavioral health screenings. That is standard."

"Our goal is to give everybody a primary care home. The therapists are trained to ask if you have a primary care provider. If the answer is no, they ask, 'can we be your home?' The entire team is trained and willing to talk to them about their health and how they're functioning in life. If someone feels they have a behavioral health issue, at the point of care a behaviorist is brought to them. Substance misuse, depression, smoke cessation, stress management; the moment the patient is asking for help, we provide it in the care setting."

Khatri says finding the clinicians to provide primary care and behavioral health in a largely rural, economically distressed region is particularly challenging. "I would go so far to say that it's harder for people working in the safety net because with our population we have to address significant health disparities and multiple complexities and social considerations beyond diagnostic complexities," she says.

The clinic uses integrated charts that can be read by all members of the care team to ensure that behavioral and primary care needs are being addressed.

"We try to be as creative and innovative as possible," Khatri says. "This is very counter to the way healthcare has been organized traditionally, where it's siloed and patients have to navigate their way through it.

With staffing always a challenge, Cherokee Health has formed clinical partnerships with the University of Tennessee to provide physicians, residents, nurses, pharmacists, behavioral health clinicians, and other health professionals. That affiliation has created a valuable pipeline for recruiting staff.

"We've hired quite a few people who have trained with us because they get to know us and we get to know them," Khatri says. "I don't know how we could have built and staffed this model without doing our own training. We catch them early and train them in our model and build those relationships, but staffing remains a significant challenge."

Over the next decade, Cherokee will expand its telemedicine services to improve access for patients who are unable to visit a clinic in person.

"We are going to be heavily reliant on technology to expand access to care," Khatri says. "We want to get away from the fee-for-service, face-to-face visit. We want to use technology so people can call in on a cell phone or Skype. The majority of our care is going to be provided via electronic technical devices and not in a traditional office setting."

Khatri also wants to use predictive analytics to reach at-risk patients earlier. "Our goal is not to wait until someone becomes sick. We want to be able to track them and reach out before they get sick," she says. "Using this clinical information and predictive analysis we can become more strategic in how we provide care. We can deal more with prevention and not always chasing the high utilizers. We don't want to wait until we have a diagnosis. We want to reach them before that. That is the only way we can bend the cost curve."

The National Committee on Quality Assurance honored Cherokee Health last week for its "whole health approach. "The work they do is especially noteworthy given the challenges of the patient population they serve, which includes migrant farmworkers and a growing homeless population," NCQA noted.

Khatri says the NCQA award is an acknowledgement Cherokee's efforts "to enhance a culture of health."

"We are not content to say that we will meet the basic criteria to be a patient-centered medical home. We call ourselves a behaviorally enhanced healthcare home," she says. "We look at the overall needs of the patients and try to be as creative and innovative as possible to meet those needs."

HealthLeaders Media Webcast: How Health Systems Prep for ICD-10—Physician Alignment, Support and Technology, will be broadcast on Tuesday, October 20, 2015, from 1:00 to 2:00 p.m. ET. Hear from the University of Mississippi Medical Center's chief health information officer as he describes how to overcome the obstacles of implementing ICD-10.