Cross-Walk: Integrating Behavioral Health and Primary Care
- Need: To address and treat substance abuse and depression in the Upper Great Lakes region.
- Intervention: Cross-Walk, a program that integrates behavioral healthcare into primary care services, was developed in Michigan's Marquette County.
- Results: The collaborative efforts strengthened care management services in local healthcare facilities as 344 patients were referred to a behavioral health specialist.
Promising (About evidence-level criteria)
Since the closing of Michigan's K.I. Sawyer Air Force Base, the area that was once supported by an influx of people lost industry, high paying jobs, residents, and healthcare resources. Affordable housing rates have since attracted uninsured individuals and families with lower incomes. Many of Marquette County’s residents were in need of behavioral health treatments, but the area’s lack of healthcare resources have made accessing these services even more difficult.
In response, a collaboration of agencies along with the Upper Great Lakes (UGL) Family Health Center came together with a vision to integrate behavioral healthcare within a primary care setting. They established these 3 goals to carry out their vision:
- Improve treatment outcomes for patients with depression and/or substance use issues
- Enhance access to specialty treatment
- Develop an effective and sustainable integrated healthcare model
The collaboration adapted the
Four Quadrant Clinical Integration Model to their own
model called Cross-Walk. Through this model, primary care
clinical staff, care managers, and providers are trained
in motivational interviewing and dialectical behavioral
therapy skills to evaluate their patient’s need of
behavioral assistance. Cross-Walk now serves 7 townships
that make up Michigan’s Marquette’s County.
In 2016, the collaboration also opened a dental practice
within the UGL Family Health Center in order to reach
even more people with this integrated model. Now primary,
behavioral, and dental care providers collaborate to
ensure patients are receiving well-rounded care.
Cross-Walk’s partners each contributed to the planning,
development, implementation, personnel, resources, and
evaluation of the program’s efforts:
- Upper Great Lakes Family Health Center
- Great Lakes Recovery Centers
- Upper Peninsula Health Plan
This program received support from a 2012-2015 Federal Office of Rural Health Policy Rural Health Care Services Outreach grant. Since the grant ended, the program no longer operates under the name Cross-Walk, but coordinated care is still available through fee-for-service.
The following are steps that every partnering Cross-Walk clinic takes to ensure that every patient gets behavioral health services if needed:
- Primary and behavioral health staff use screening methods to identify patients in need of behavioral health services
- Once the patient’s screening confirms the necessity
of further assistance, they can enroll in an enhanced
behavioral health treatment plan and see a behavioral health specialist
- A case manager works with the patient, providers, and other staff to coordinate the patient’s care services
- The patient can receive individual and family counseling from behavioral health practitioners to decrease depressive and/or substance abuse symptoms
- The patient can also receive dental care from dentists, hygienists, and dental assistants within their primary care setting
- By the end of 2016, Upper Great Lakes Family Health Center will add a psychiatrist to the healthcare team to provide additional support for their mental/behavioral healthcare team.
Cross-Walk keeps staff, patients, and community members up-to-date about the advantages of integrated primary and behavioral health services.
The effectiveness of Cross-Walk was evaluated through audits, patient surveys, focus groups, and one-on-one feedback. Ultimately, this new structure made collaboration and patient care smoother. Care management services from UPHP were strengthened and referrals increased. Below are some specific successes during the 3-year grant period:
- 344 patients were referred to a case manager
- 95% of patients were compliant with treatment plans
- 76% of patients were screened for depression
- 68% of patients were screened for substance abuse
- 68% improvement in depressive symptoms
- 58% of patients surveyed reported improvement in well-being as a result of integrated care
- 51% reduction in substance abuse symptoms
As of August, 2016, the Upper Great Lakes Family Health Center has:
- Seen over 500 patients for oral health services
- Conducted over 1,000 visits with those patients
- Established telemedicine, bringing support and a level of comfort for primary care physicians
This model of integrated behavioral and primary care has been duplicated by UGL's Hancock Family Practice Health Center.
Cross-Walk encountered several barriers during their implementation, but also took action steps to confront them and build a successful program.
- Providers experienced resistance from patients when
counseling was initially recommended.
Solution: Cross-Walk suggested providers personally introduce patients to a behavioral health practitioner, helping to break the ice for the patients through a "warm hand-off."
- Patients were not as comfortable agreeing to see a
behavioral health practitioner.
Solution: The title, “behavioral health practitioner” was changed to “health coach” to make the specialist seem more approachable. The provider introduced the coach as someone who would teach skills to help cope with the patient’s issues. As a result, patients became more willing to have a direct referral.
- A high number of patients were not showing up for
scheduled behavioral health appointments.
Solution: Cross-Walk implemented the “Plan, Do, Study, Act” quality improvement project, including an appointment automated reminder call system, educating providers, reinforcing processes, and using dialectical behavioral therapy skills with patients. As a result, the no-show rate reduced from 33% to 27% in the next quarter.
- There was a growing need to create an electronic
medical record (EMR) system to host each patient's
behavioral health information.
Solution: Cross-Walk installed eClinical Works, an EMR system built to integrate medical, behavioral health, and dental information. All clinicians are currently using the system.
- Clinical education and patient communication was
Solution: Motivational interviewing methods were used to educate clinical staff on how to help patients use their strengths to help accomplish their health goals.
The following are key principles learned through Cross-Walk:
- Teach new and current employees about the cultural impact of integrated care
- Promote an integrated team model of care by fostering relationships with team members directly involved in patient care
- Routinely assess policies, procedures, and protocols. It is essential to allow these things to evolve to ensure the safety, health, and well-being of patients and staff
- Identify a solid method for measuring, reviewing, and evaluating progress of your program and the patients receiving your services
- Keep an open mind about what you are trying to accomplish. Even small suggestions can transform thoughts and beliefs as to the best means for serving your patients
- Be willing to revise services and procedures in order to accommodate your new system
Cross-Walk materials are available upon request. Contact Elise Bur (information below) to receive a behavioral health procedure manual, a patient letter template, behavioral health services information, and phone calling scripts.
Integrated service delivery
October 13, 2015
October 14, 2016
Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.