Fostering Partnerships to Strengthen Integrated Care for Missouri Members

Swope Health announced the launch of a program to demonstrate the effectiveness of integrated care, a model that teams primary care with behavioral healthcare and community resources funded through an $80,000 grant from UnitedHealthcare.

The program adopts the principles of the Primary Care Behavioral Health Consultation Model, which creates a team for patient care. In the team, primary care providers work hand-in-hand with behavioral health consultants and community health workers. The team approach pays special attention to social determinants of health, such as housing, transportation, food security and other challenges while supporting primary and behavioral healthcare. 

“We know the challenges our patients face – in housing, schools, jobs, transportation, access to food, for example – produce negative health effects that can last a lifetime,” said Jeron Ravin, J.D., president and CEO of Swope Health. “Swope Health is demonstrating that health policy can be changed to address all facets of health equity. We will validate a model practice that integrates medical care, behavioral healthcare and social support resources for our patients.”

Over the course of the year-long program, Swope Health will track the health metrics to demonstrate improvement. There is significant research to indicate the model can improve health outcomes by addressing mental health issues and support behavior changes to improve treatment of chronic disease.

“We fully support a whole-person care model that increases member engagement, fills gaps in care and develops personalized health goals. When we all work together, we can help people get the right care from the right provider at the right time, which all leads to better health,” said Jamie Bruce, CEO, UnitedHealthcare Community Plan of Missouri.

“This model reduces the stigma surrounding mental health and makes it easier to address social and mental health needs with a team-based care approach embedded in primary care,” said Dr. Naiomi Jamal, Swope Health chief quality officer. “With a team approach, we can assist patients with Medicaid enrollment or securing transportation or food resources, as well as providing counseling and medical care. It all happens in the same visit, in the same location.”

The program is a continuation of Swope Health’s steady integration of services, first initiated in 2014 with a grant from the Health Resources and Services Administration, and then expanded in 2018 and 2019.

How it Works

When a patient comes for a visit, in addition to the usual conversation about how the patient is feeling, the clinical team also asks about social factors that can impact health – such as access to food, housing and transportation. Other questions explore behaviors, for example, is there a need for improved adherence to chronic disease management regimens or learning coping skills to better manage anxiety and depression? If a need is identified, a member of the team – a community health worker or behavioral health consultant – offers services on site, often during the same visit.

The model is designed to benefit all participants: patients, providers and insurers. The patients receive improved access to care and resources. The insurers benefit from reduced cost of care through fewer emergency room visits and hospitalizations. And providers benefit by having better workload management and support. 

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