Breaking down barriers to integrated care in Colorado

Physical and behavioral health are closely linked, but for people who experience co-occurring physical and behavioral health conditions, the path to accessing care can be fragmented and complex. Behavioral health conditions are associated with worsened physical health outcomes among people with chronic conditions.1 Conditions can often go undiagnosed among patients with co-occurring physical and behavioral conditions.2

People who have both a behavioral health condition and chronic physical condition are more likely to frequently use the Emergency Department (ED) compared to people who solely have one or the other.3 This reflects the disparities in access to and continuity of care for people experiencing co-occurring conditions, leading to unnecessary ED usage and higher health care costs.

To combat these challenges, St. Mary’s Family Medical Center launched the IMPAC Program. IMPAC, or Integration to Minimize Potentially Avoidable Costs, aims to drive improved health outcomes and patient experiences for people with co-occurring physical and behavioral health conditions. The pilot program launched in 2022 with support from Rocky Mountain Health Plans, a UnitedHealthcare company.

Each patient receives personalized, 1:1 support to evaluate their needs holistically and identify the care, resources and tools to improve their health and quality of life. The program combines high-intensity case management, wraparound care services, and patient advocacy. Services include in-patient and out-patient care, in-home visits, accompaniment to medical appointments and case management between providers.

 

Program Results


 

66%
Decrease in Emergency Department visits across the combined group of patients.


 

100%
Felt that their Emergency Department use had decreased.


Patients reported high satisfaction with the program and an increase in their health care needs being met.

The program generates greater access to care: IMPAC providers can see patients who are in the hospital, in addition to those in outpatient or home-based settings. In doing so, providers are able to meet patients where they are and overcome barriers that can impact patients’ ability to access behavioral health care. Providers also work with patients both individually and relationally, including with their family or key members of their support system, to take a more holistic approach to the factors impacting each patient’s health. Early findings from the pilot program demonstrate its effectiveness in improving access and patient experience. Results from the first year include:

  • A 66% decrease in Emergency Department visits across the combined group of patients. Patients who were in the program for 11 months or more experienced an even higher reduction in ED usage compared to patients in the program for 6 months or fewer.
  • 100% of patients felt that their Emergency Department use had decreased.
  • Patients reported high satisfaction with the program and an increase in their health care needs being met.

Patients noted key takeaways like new skills to manage their mental health and chronic conditions, greater cohesion with their health care providers, and improved medication management.

IMPAC is looking ahead at ways to reach more patients. This includes a streamlined referral process to identify clinic patients with unnecessary ED utilization, new efforts to engage patients’ families, and greater support for Social Drivers of Health such as housing.

Additionally, IMPAC is collaborating with Rocky Mountain Health Plans to work toward systemic improvements to meet the needs of patients with co-occurring physical and behavioral health conditions at a greater scale. Together, IMPAC and Rocky Mountain Health Plans will host upcoming summit in Mesa County to coordinate efforts among stakeholders to better support high ED utilizers in the region. 

Through personalized, high-intensity care and support, IMPAC is driving greater access to care and improving health outcomes for people in Grand Junction. Hear from Maya Obstfeld, a behavioral health provider and IMPAC coordinator, about how the program has impacted one of her patients.

 

Lynn’s Story

I first met Lynn* in a large, empty medical exam room. It was just the two of us, but the room felt full. Lynn’s trauma, from mental health, poverty, mistreatment and more, took up so much space. In this room, Lynn described debilitating seizures, two to five per week, that landed her in the hospital repeatedly. She struggled to identify answers and a treatment plan. She worried about losing her independence and losing custody of her child. Lynn was referred to IMPAC by her primary care doctor, who recognized that the current path was not working.

We discussed her difficulty in receiving a diagnosis, mixed success with therapy, and struggles with medication adherence. We identified two diagnoses that seemed to fit and created a collaborative treatment plan that we shared with her primary care doctor.

Together, we worked through challenges large and small to unpack the relationship between her seizures and her thoughts, emotions and behaviors. We practiced mindfulness, biofeedback, polyvagal theory and psychoeducation. Our once-per-week sessions were not sufficient support, but the flexibility of the IMPAC program allowed me to provide a higher frequency of care. Within one month, Lynn’s seizures had stopped and her ED usage decreased drastically. She made a plan to sustain her mental health and to reunite with her child.

This is just one of the stories of people with complex issues who struggle to access the care they need. Lynn had made attempts to seek treatment previously but was unable to find an effective treatment plan that addressed the root causes of her health conditions. Lynn’s story underscores the value of integrated care teams who can work to untangle, interrupt and reimagine solutions to complex health challenges.

Written by Maya Obstfeld, MS, LMFT; IMPAC Coordinator and Behavioral Health Provider

*Lynn’s name was changed to protect patient privacy.

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