Winner in the Small Group and Solo Practice Category:

Hope Clinic of McKinney

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.

Almost four years ago, a pastor in McKinney, Texas, came upon a man lying in a ditch. The man was experiencing homelessness and had mental health problems, along with other chronic health conditions. The pastor wanted to help but, in that moment, he couldn’t find any health resources aside from an emergency room, which the man initially refused, afraid they might amputate his gangrenous legs.

After this encounter, the pastor approached a member of his church, Stephen Twyman, MD, MPH, and said, “Let’s open a clinic and let’s not charge anything.”

That’s how Twyman told the story when he described his award-winning integrated behavioral health program to attendees of TAFP’s 2019 Annual Session and Primary Care Summit.

In 2017, Hope Clinic of McKinney opened its doors to serve uninsured patients who are at or below 200% of the federal poverty level. They provide a medical home to more than 400 patients and are expanding quickly, according to Twyman. They have three full-time staff, two part-time staff, and more than 90 active volunteers, including physicians, nurse practitioners, nurses, social workers, and more. Hope Clinic is a faith-based organization and it is funded entirely through grants and donations.

To assess which patients could benefit from behavioral health services, the clinic has a strategic partnership with UT Southwestern Center for Depression Research and Clinical Care to implement VitalSign6, a comprehensive program the school designed to help identify and treat depression and anxiety in the primary care setting. “The cool thing about VitalSign6 is it really gave us a turnkey solution,” Twyman says. “All the things we needed were already there.”

The platform comes complete with validated assessments, iPads for data entry, measurement-based care tools to track patient progress, and clinical decision support. Plus, Hope Clinic providers can access psychiatric consultation through the partnership.

According to the UTSW website, patients using the VitalSign6 platform complete the PHQ and other systematic assessments “on an iPad during the triage process, thus making screening for depression the sixth vital sign after body temperature, pulse rate, respiration rate, blood pressure, and pain.”

The data is immediately accessible to the clinic’s providers and the VitalSign6 team at UTSW, and the program provides clinical support to the providers as they treat patients with depression, anxiety, and other behavioral and mental health conditions. “What that does is it helps us standardize the care we’re providing and make sure we’re actually following the best evidence for our treatment,” Twyman says.

The clinic employs a bilingual licensed professional counselor who sees patients often in back-to-back visits with their primary care provider. The LPC and provider both have access to the electronic health record, so they can share notes and track progress toward treatment goals. The LPC touches base frequently with patients to encourage medication and treatment adherence, to remind them of upcoming counseling sessions, and just to check in.

Patients can use a patient portal in the EMR to directly contact their providers and clinic staff with concerns, questions, refill requests, and other issues, but many patients of Hope Clinic have limited or sporadic access to the Internet. In January 2019, the clinic introduced a secure messaging platform, Care Message, which lets patients access their providers via text message.

Twyman says implementing an integrated behavioral health program at the heart of a free clinic has helped remove the stigma associated with mental health among patients and providers alike. “I’m a big believer in being as comprehensive of a doctor as I can be. I think there’s good data to suggest that the more comprehensive family doctors can be, the better outcomes their patients have and the lower costs their patients have. Behavioral health interacts with every other aspect of a patient’s life.”

He knows the patients at Hope Clinic are getting better. His data shows that “44% of patients who initially screened positive for and were subsequently diagnosed with major depressive disorder or other mental health disorders have since achieved remission.” That compares to a national rate of about 25%. “Our patients are getting better and we are excited to share what we’ve learned,” Twyman wrote in the contest application.

One such patient in his early 30s came to the clinic with anxiety, depression, high blood pressure, and obesity. Twyman told attendees at TAFP’s 2019 Annual Session and Primary Care Summit: “He came to us and he said, ‘I don’t know what to do. I can’t keep a job. I’m so anxious I can’t do my normal activities. I find myself worrying myself to death and I just can’t work.’”

It took five visits, Twyman says, but through counseling and treatment, he now has had a steady job for almost a year. His blood pressure is under control and he’s lost 30 pounds. His depression and anxiety are much better. “You know, that’s the reason we do this. He is one example of why we cared to integrate behavioral health into our clinic, why we care to try to do wrap-around services. … This has been a really rewarding part of our practice and it’s really enhanced the level of care we can offer to our patients.”