Winner in the Integrated System Category:

Heart of Texas Community Health Center

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.

Heart of Texas Community Health Center has developed a behavioral health program they call Integrated Health Management, which they employ to care for their 59,000 active patients in Central Texas. Headquartered in Waco, HOTCHC is a federally qualified health center with 14 clinical sites and a family medicine residency program that trains 36 residents. The health center has a long-standing commitment to providing comprehensive care to a socioeconomically vulnerable population.

Lance Kelley, PhD, is a clinical psychologist and the Human Behavior Mental Health Director for HOTCHC. He says seven years ago, he and his colleagues became concerned about the high prevalence of mental health conditions they were seeing among their patients and the relationship between those conditions and the physical health problems patients experienced. Patients were reluctant to seek specialty mental health outside of the primary care setting, and there was a growing lack of access to those services.

In 2014, Kelley and some of his colleagues put together a behavioral health leadership team to plan and implement a behavioral health integration program. They developed a blended model, merging the roles of behavioral health provider and care manager into a single professional position they call the integrated health manager. This person is a licensed clinical social worker who has been trained to perform integrated behavioral health and chronic care management in the primary care setting.

“IHMs are core members of the primary care team, working alongside physicians, nurse practitioners, and physician assistants in a shared-care model to enhance primary care and improve population and behavioral health outcomes,” Kelley wrote in the award application.

Each day, physicians, nursing staff, and the IHM huddle and identify patients on the schedule who would benefit from behavioral health treatment. Then the IHM joins the physician when seeing those patients. The IHM engages the patients in brief psychological interventions, health behavior counseling, chronic disease care planning, and a host of other activities to address their mental health and chronic care needs. The IHM also follows up with patients over the phone or through secure electronic messaging to check on them and make sure they are adhering to their treatment plans.

HOTCHC employs 10 full-time IHMs plus an IHM trainer. “The trainer is key in all of this,” Kelley says. “We spent almost an entire year with our trainer before we went live with our system.” All new IHMs spend eight weeks in a personalized training program, including four weeks working as an apprentice with the trainer in the residency training clinic. For the last month, IHMs train with their intended clinic team while the trainer helps customize the clinic workflow and coaches the team on how to maximize the model.

“We quip around here that we want [IHMs] to be really bright and wear running shoes,” Kelley says. “The work is really fast-paced and you have to have someone who is both going to always have the drive to learn more and know more, but not be so paralyzed by the generalist nature of primary care that they can’t act. They need a tolerance for uncertainty.”

HOTCHC also has developed psychopharmacology decision support tools to ensure their providers can access clinically proven treatment regimens that are consistent with general family medicine practice and vetted by content experts in psychiatry. The academic faculty at HOTCHC collaborated with a team from the Harvard Medical School Department of Psychiatry to develop the treatment algorithms. Kelley says HOTCHC is currently in the process of making these tools available to physicians outside their system. They are even developing an app, so stay tuned.

They have also designed stepped care intervention programs to respond to patients with more complex mental health disorders, including a co-located specialty behavioral health clinic staffed by a physician and a clinical psychologist. “Primary care physicians can refer patients for short-term diagnostic clarification and treatment planning. This consultation clinic does not retain patients long-term, but refers patients back to their family doctor for ongoing management, usually after fewer than four mental health visits,” Kelley wrote in the contest application.

Having such a robust integrated behavioral health program greatly enhances the residency experience for family medicine residents in training. “Here we say the clinic is the curriculum,” Kelley says. Since its founding, the Waco Family Medicine Residency Program has instilled a culture of service dedicated to recruiting and training physicians to care for underserved and vulnerable populations. “Having master experiences while you’re in residency is really empowering for you,” he says. “It gives you the confidence to detect things you might not detect otherwise. We are less likely to look for something if we don’t feel we can offer much if we find it.”

The Integrated Health Management program at HOTCHC hasn’t just been a success for the people of Central Texas. It’s been great for the health care providers, too.

“We have found that implementing this model has increased joy and satisfaction in practice because I think it allows for our family medicine doctors to get closer to providing the kind of care they really want to provide.”