Winner in the Academic Setting Category:

Memorial Hermann Medical Group Physicians at Sugar Creek and Memorial Family Medicine Residency Program

Editor’s note: TAFP conducted the Behavioral Health Integration Innovators Competition in 2019 after the Academy identified the need for greater integration of behavioral health services in primary care. The TAFP Behavioral Health Task Force put out a call, asking Texas primary care practices to submit their models of behavioral health integration for the chance to win $10,000. The task force also developed TAFP’s new Behavioral Health Integration Toolkit to help members provide these services to their patients.

The winners were the Memorial Hermann Medical Group Physicians at Sugar Creek and Memorial Family Medicine Residency Program of Sugar Land in the academic setting category, the Heart of Texas Community Health Center of Waco in the integrated health systems category, and the Hope Clinic of McKinney in the small group and solo practice category.

The Memorial Hermann Medical Group Physicians at Sugar Creek has been providing integrated behavioral health services to their patients through a collaborative care model since 2009. Their collaborative care team includes more than 50 primary care physicians, a full-time psychologist, and a clinical care manager, along with support and administrative staff. The clinical care managers they’ve employed have been licensed clinical social workers and licensed professional counselors. They also retain a few hours each week with an off-site psychiatrist who consults with the care team about the registry of enrolled patients, with a special focus on challenging cases.

According to their contest entry form: “The broad goals of the program are to more effectively meet the mental health needs of patients, improve the physical health and overall functioning of patients with co-morbid physical and mental health problems, and improve the efficiency of the clinic by more accurately targeting services.”

The program focuses on depression and anxiety, and it is based on the IMPACT model, or Improving Mood: Providing Access to Collaborative Treatment. The AIMS Center at the University of Washington Department of Psychiatry and Behavioral Sciences developed the model during the IMPACT study, which was the “first large randomized controlled trial of treatment of depression,” according to the center’s website. It took place from 1998 to 2002 with results published in JAMA in December 2002. Patients who received the IMPACT collaborative care were twice as likely to show improvement in their depression and total health care costs were lower for them. The AIMS Center says it has trained more than 6,000 clinicians around the world to implement collaborative care.

The model involves:

• care coordination using a behavioral health coordinator who is embedded in the practice;
• monitoring patients to make sure they are meeting goals;
• treating patients to target; and
• sharing progress and information regularly with the care team.

When new patients come to the clinic or each time they come in for a wellness visit, they complete a PHQ-2. If they screen positive, they proceed to screen with the PHQ-9 and GAD-7 assessments. Once the care team identifies someone as having depression or anxiety, the physician invites the patient to participate in what they call the Care Program. If the patient agrees, they are introduced to the therapist and scheduled for an intake visit.

After the initial consultation, the clinical care manager generates a summary of the visit that includes PHQ-9 and GAD-7 scores along with suggestions for interventions. The referring physician receives the report in their EHR. Patients can be treated with medication, therapy or both. A psychiatrist provides consultation to the care manager and primary care physicians, especially focusing on cases in which patients aren’t responding as hoped. Patients receive follow-up visits in person or by phone from the care manager and the care team tracks patients using a data registry system.

Back in 2008, Bauer says the clinic saw many patients with chronic diseases compounded by depression and anxiety, and the usual practice of prescribing and referring them out for treatment of those behavioral health disorders wasn’t working sufficiently. “It had been such a huge problem. Terrible outcomes for patients and very unsatisfying.”

Then they learned about IMPACT and secured a grant to bring a representative from the University of Washington to demonstrate the model. “Once we knew the process, we had to make sure we were getting patients identified,” Bauer says. That’s when they began universal screening of patients for depression and anxiety, embedded a behavioral health specialist, and launched the program.

From 2009 to 2017, grant funding covered the cost of the program. The end of the grant coincided with the introduction of the CMS psychiatric collaborative care codes so they can now bill monthly for services in the program.

For more than 10 years, the Memorial Hermann Medical Group Physicians at Sugar Creek has maintained an excellent and consistent record of success in improving their patients’ health through the Care Program. Before its implementation, they report patients achieved a 29% reduction in PHQ-9 scores, whereas with the program, patients’ scores go down by 50% after three months. Patients in the program have significantly fewer primary care visits than they did before enrollment, going from 1.8 visits per month to 0.5 visits per month after being enrolled for three to six months. The clinic reports that after six months in the program, 67% of patients are at goal for LDL cholesterol, up from 50% at intake. They report similar results in diabetes control, with the percentage of their patient population having HbA1c levels of less than 9% improving from 59% to 80% after six months.

One question from the contest application asked how integrating behavioral health services had changed their practice, and the response from the Physicians at Sugar Creek reveals another reason to implement such a program. “Our integrated behavioral health program has given us the opportunity to work side by side with a variety of behavioral health providers. In addition to the improved outcomes, it has made our physicians more comfortable handling the treatment of mood disorders as part of routine primary care. Given that we are a residency training site, having integrated behavioral health has exposed hundreds of trainees to the model. We hope this will normalize working with behavioral health providers as well as increase our residents’ confidence in handling patients with mood disorders as they go out into practice.”

Every year, 14 new residents gather for orientation at the Memorial Family Medicine Residency Program and they are told about the Care Program, “along with about 6,000 other things,” Bauer says. “So, of course, they’re shell shocked. The first time we precept with them when there’s a patient they’ve identified as depressed, one of the things we’ll say is, ‘Have you thought about the Care Program?’ and their eyes just light up. It really is so well accepted now and the residents are grateful for it, to have that resource for their patients.”

Even though MHMG Physicians at Sugar Creek is a large practice with more than 50,000 patient visits a year, Bauer believes integrating a similar collaborative care model in small and even rural practices can be achieved. A few practices could share the services of a behavioral health care manager and a psychiatric consultant, and employing telemedicine for the therapy sessions and behavioral interventions is an option for remote areas.

In the closing statement of their contest application, the MHMG Physicians at Sugar Creek expressed the same sentiment that led TAFP to host the innovation competition. “We have seen the effect collaborative care has had on patients’ health, physicians’ comfort treating behavioral health conditions, and on tightening the connection between mental and physical health. We hope our experience can convince our family physician colleagues that a collaborative care model is effective, feasible, and financially viable for a variety of practice settings and patient populations so that we can increase access to behavioral health services and effective treatment of depression throughout the state of Texas.”