Lead Instead of Follow with Integration
By Kelly Dwyer
Photography by James Chance
Something incredible happens each morning inside the clinics operated by Colorado Springs-based Peak Vista Community Health Centers. Small teams of primary care doctors, nurses, medical aides, behavioral therapists and care managers huddle to discuss which patients are coming in that day, pull needed reports and check off which lab or diagnostic tests need to occur. They review the prior day’s visits and map out follow-up steps for certain patients.
This is integrated care at work, in which “we wrap the services around the patient,” said Pam McManus, CPA, MBA, CEO of Peak Vista, a nonprofit Federally Qualified Health Center with 25 clinics. Alongside other safety net clinics in Colorado, Peak Vista is defying perceptions of beleaguered clinics scrambling to merely keep up with demand and is instead leading the integration revolution through better design.
Executing on integrated care generates many new challenges, from managing disparate billing methods to marrying dissimilar workplace cultures. Integration is not intuitive, but it is logical and it is leading to better patient outcomes, according to McManus and her leadership team, making all the hard work and complexities worthwhile.
A fair share of Peak Vista’s patients and their families miss work without pay to get to the doctor’s office. Some ride the bus to get there, which makes it convenient to schedule back-to-back visits with the dentist and pediatrician, for example.
A team-based approach to care allows primary care providers to intervene the moment they recognize a behavioral or dental issue.
“When you get emotional outpouring from a patient, you have a way to say, ‘I can help with that,’” said pediatrician Barbara Divish, MD, who makes frequent “warm handoffs” to a pediatric psychologist on-site. Peak Vista’s behavioral care providers typically spend 10 to 15 minutes with patients on those handoff visits, then schedule longer follow-up visits if needed.
Patients are more likely to see a dentist or therapist on the spot than they are to follow through on a referral at a different office and possibly weeks later. Primary care providers also gain latitude in their practice with a team-based approach, said pediatrician Darvi Rahaman, MD, Peak Vista’s vice president of medical services.
He recently visited with a mother and her teenage son who came in for a flu shot. Rahaman sensed the mother was upset.
“I know I can (ask how she’s feeling) because we have the behavioral support piece here,” he said. “If the parent knows I’ve spent extra time with them, they are more likely to trust me.”
Sid Nichols, a licensed clinical social worker at Peak Vista’s Wahsatch location, meets with patients for a range of mental health needs, but he spends most days tag-teaming with primary care practitioners to help patients who are coping with chronic pain or managing diabetes.
“Chronic pain impacts patients’ moods and how they feel about themselves and life,” Nichols said. “That, in turn, impacts how they care for themselves. With diabetes, people tend not to access the mental health system until their needs are more critical.”
Nichols helps patients to identify obstacles to caring for their health and set goals around lifestyle and behavioral changes, be that cutting down on salt, getting more exercise or breaking free of a negative mindset. Nichols, along with Peak Vista care coordinators and resource navigators, also assists patients with logistical challenges such as accessing affordable, healthy foods and finding reliable transportation to the doctor’s office.
Peak Vista, which opened its doors in 1971 as a part-time clinic run by volunteers, began offering integrated behavioral and primary care services at its Women’s Health Center in 2003, funded by a grant from the federal Health Resources and Services Administration. The clinic partnered with AspenPointe, a local nonprofit mental health practice, for behavioral health services.
“Both leadership entities understood why we were integrating and that we needed to integrate,” said Michael Welch, DO, Peak Vista’s chief medical and dental officer. “It fell apart quickly.”
Behavioral health providers were accustomed to appointments lasting 45 to 60 minutes, not the fast pace of primary care. They bill on a capitation model versus fee-for-service system standard in primary care. And providers got signals crossed communicating about patients. For example, a care plan for a diabetic will include recommendations around diet, exercise, medications and frequency of lab tests and appointments. By contrast, creating a mental health care plan is a lengthy, detailed process that involves a host of parties and documentation.
Leaders on both sides worked to improve communications and train providers on integrated models, a process that continues as the landscape shifts in terms of payer models, Medicaid eligibility and other changes. More than a decade later, Peak Vista successfully operates integrated practices in most of its 25 clinics.
Paying for Progress
Peak Vista credits the recent expansion of Medicaid under the Affordable Care Act for reducing uninsured patient visits from 34 percent of total visits in 2013 to 15 percent in 2014. Last year, 68 percent of patient visits were covered by Medicaid, 10 percent by Medicare, 5 percent by commercial insurance and 2 percent by Child Health Plan Plus (CHP+).
In spite of those changes, the clinic relies on contributions and private donations for more than 20 percent of its annual funding.
Peak Vista has nimbly and strategically invested in areas that improve efficiency and the patient experience, from electronic health records and care coordination to a sophisticated and supportive enrollment system that enrolled more than 10,000 families last year.
“We went from people lining up outside our doors at 6 a.m. to patients being able to make an appointment for enrollment, look online prior to the appointment so they know what materials to bring, and offer walk-in appointments,” McManus said.
Peak Vista also is strategic about staffing investments.
A host of graduate students work under Peak Vista and AspenPointe’s experienced practitioners. Peak Vista plans to launch a nurse practitioner fellowship program in September and a family medicine residency program in June 2016 — moves that will help the clinic address industry workforce shortages head-on and train incoming providers on integrated models and new payer models.
“We’re having a paradigm shift in health care,” explained Kandi Buckland, RN, chief operating officer at Peak Vista. “Care teams are becoming more critical for patients and providers to help connect what’s disconnected.”
Outcome-based payer models will be a welcome change because current payer systems prevent Peak Vista from billing for integrated services.
McManus said she believes Peak Vista’s providers and staff are paid fair wages, but acknowledged that “everyone here could make a lot more money” working elsewhere. “Quality is our focus, whether it’s in our facilities, providers, follow-up or how we work with the community,” she said. “I believe our employees live that.”
Peak Vista is also working on its office architecture to better support integration.
Divish, who joined Peak Vista five years ago, is a case in point.
“For me, the impact is greater where the need is greater,” she said. “It’s hard to be poor. I was poor. I understand that and relate to that.”
Patient-Centered, Start to Finish
While integration is at the heart of patient-centered care, Peak Vista goes several steps further. Several years ago, the pediatric office opened a drop-in child care room for healthy siblings, slashing the clinic’s no-show rate.
More recently, Peak Vista has invested in architecture and design to support integration in functional ways, such as clustering offices for care team members, as well as aesthetic ones.
In the Pediatric Health Center, a dog-size yellow frog and a half dozen colorful birds cover the walls of an expansive waiting area illuminated by large windows. As kids walk to their exam room, they may notice photos of polar bears and penguins lining the hallways. Perhaps seeing a doctor doesn’t seem as scary.
Welch explained that Peak Vista’s recent design focus is inspired by the book “Setting the Table,” in which author Danny Meyer describes the power of hospitality in business. “We want to evoke a patient response of ‘here I will be well cared for’ when they enter our health centers.”