Positive results from “Behavioral Health Home” pilot program

May 9, 2014 § Leave a comment

By Peg Ackerman, Clinical Director, Commonwealth Community Care

In June 2012, Commonwealth Care Alliance, in partnership with three leading greater Boston Human Service Provider (HSP) organizations (Vinfen, Bay Cove, and North Suffolk), was awarded a sizable grant by the Center for Medicare and Medicaid Innovation (CMMI) to deploy and test a Behavioral Health Home pilot program.

This three-year pilot project began on July 1, 2012, and, so far, the program has resulted in improvements in diabetes and blood pressure control in its patient population, as well as significant decreases in emergency utilization and hospitalizations. Moreover, the Behavioral Health home model has been warmly embraced by healthcare professionals.  NPs have noted how valuable it is to work with mental health specialists, and mental health specialists report that they have been enlightened about medical issues.

Integrating primary care and mental health

A new comprehensive approach to integrating primary care and mental health for people with serious, disabling mental illness, the pilot embeds nurse practitioners from Commonwealth Community Care into Community Based Flexible Support (CBFS) teams at each HSP organization. The Nurse Practitioners provide primary care and care coordination to the most medically and psychiatrically complex clients.

Under the Behavioral Health Homes pilot, clients are assigned to CBFS teams from transitional housing (i.e., temporary housing between in-patient care and independent living). CBFS teams are comprised of eight to ten staff, all experienced in mental health. Working with clients to meet rehabilitation goals, team members address issues such as housing, employment, and education. They also meet with clients on a regular basis to provide coaching and monitoring.

Until the CMMI grant was awarded, managing health care was not one of the goals of the CBFS teams.  Now, however, the NP sits on the team with other disciplines and provides insight and education into clients’ medical issues and how they may impact daily life and goals.

In addition, data is collated and analyzed on a quarterly basis as part of the program. Metrics include blood sugar control, blood pressure control, weight reduction, hospitalizations, and ED utilization.

Partnering with Dartmouth Medical School and the Bosch Company

Participating in the pilot program are Dartmouth Medical School and the Bosch Company.  Dartmouth has provided training on the Integrated Illness Management and Recovery model to staff members. This training addresses SMI behavioral interventions for improving health and self-management of medical illnesses.

The Bosch Company has developed a technological tool called the “Health Buddy,” which the NPs and Health Outreach Workers (HOWs) use to prioritize visits and empower clients along self -management goals. The Health Buddy is programed to address one psychiatric issue and one medical issue, such as depression and diabetes. The client is asked to complete a series of questions daily that address each of the diagnoses. The HOW checks the Health Buddy daily and alerts the NP of any changes or “flags.” Then, the NP visits patients who require intervention immediately.  The NPs and HOWs provide education and care coordination.

The Health Buddy has proved successful in helping clinicians address client needs. For example, one client with poorly controlled diabetes was found to have no food in her home, which led to hypoglycemia and subsequent visits to the emergency room.  The NP and the health outreach worker developed a plan of care that included members of the CBFS team.  The team created a care plan that included a meal plan, education on food shopping (including trips to the grocery store and label reading), and daily reinforcement of  the meal plan.

The result was improved glycemic control, fewer episodes of hypoglycemia, and fewer ED visits. In addition, a representative payee was appointed to assist the client with budgeting of finances ensuring adequate funds for groceries.

Next steps

The grant will end July 1, 2015. At that point, participants who enroll in Commonwealth Care Alliance’s One Care plan will continue to be part of Commonwealth Community Care’s interdisciplinary care teams.  Data will be used to assist in program development of chronic disease management models at Commonwealth Care Alliance. Based on results so far, it is anticipated that both CBFS teams and primary care teams will have an increased appreciation for integrated primary and behavioral health care and chronic disease management tools used in the grant.

Already, the outcomes of the pilot have assisted CCA in developing Behavioral Health homes with our human service provider partners.  CCA has begun implementation of five behavioral health homes across the state.  Although each of these models is structured differently to meet the needs of the clients served, all models are well -integrated behavioral/ medical models, emphasizing the coordination of medical and psychiatric care.


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