BIMA Health Partnership Program Aims to Coordinate Psych, Medical Care
With support and guidance from Partners’ High Performance Medicine Team 4, primary care physicians in BIMA have launched a cooperative effort with the Department of Psychiatry to improve care for patients with chronic medical and chronic psychiatric conditions. The BIMA Health Partnership Program uses a team approach to support dual diagnosis patients in an effort to improve chronic disease management and to reduce repeat visits to the ED and hospital readmissions.
“With a dedicated care coordinator and consults from Psychiatry and Primary Care, we’re working to make sure there is more outpatient follow up to prevent the crises that bring our patients back to the ED,” said Rebecca Cunningham, MD, who helped develop and implement the pilot program with Brijmohan Phull, MB, MS, of Psychiatry, and Sabrina Van Houten, LCSW, MPH, who began last summer to oversee case management.
“These are our highest risk patients, and because of the combination of medical issues and psychiatric issues, these patients face enormous challenges in managing their conditions,” Phull said.
Based on recent health care utilization data and review of medical records, as many as 120 BIMA patients who meet the program’s criteria for eligibility have been identified. These patients are enrolled in MassHealth or are eligible for free care, now called Health Safety Net. They have been diagnosed with a chronic medical condition as well as psychiatric illness and/or substance abuse, and have had at least one hospital admission or two ED visits in the previous year.
Medical conditions included in the criteria are: asthma/chronic obstructive pulmonary disease, diabetes, coronary artery disease, congestive heart failure, gastrointestinal diseases, chronic musculoskeletal disorders, and gender specific health issues, including gynecologic disorders and osteoporosis.
Van Houten provides intensive case management for these patients. She tracks their appointments with specialists, assists them in getting to appointments, and follows up to make sure they are taking prescribed medications. She communicates with primary care physicians, psychiatrists, and other specialty providers, to ensure that patient concerns are addressed, while helping patients to adhere to recommended interventions. In addition, she may refer patients to other service providers in the community, including local resources, such as fuel assistance programs, which assist patients facing a multitude of hardships that interfere with their abilities to manage complex medical needs.
One of the first patients enrolled in the program is a 55-year-old male suffering from a seizure disorder, depression and long-term alcohol abuse. Van Houten initially met with this patient during an inpatient admission at BWH. Following his discharge, Van Houten accompanied him to his intake appointment for substance abuse treatment at a local health center. This was the first time the patient had attended an intake visit for substance abuse treatment at the center, despite many previous referrals by his health care providers. Though the patient relapsed a few weeks later, Van Houten spoke with him each week, encouraging him to continue outpatient alcohol abuse treatment. Van Houten then referred the patient to speak with an addiction specialist with the Addiction Psychiatry Service at BWH. A short time later, the patient had another seizure, which resulted in an ED visit. Since his discharge, the patient has met with the addiction specialist and Van Houten multiple times. He has remained sober, is attending AA meetings and a substance abuse support group, plans to attend a local church to build a sober support system and, with the guidance and support of his PCP and Outpatient Psychiatry, has begun taking an anti-depressant for the first time in his life. He has also agreed to begin weekly supportive counseling. This is one example of how patient care and referrals are coordinated by the BIMA Health Partnership Program and how the many care providers work together to support patients in the program.
As the pilot program grows and evolves, BIMA Health Partnership leaders may be able to reach out to community health centers and other community leaders to include more patients who would benefit from receiving hands-on case management. The partnership also anticipates receiving referrals from other primary care physicians and psychiatry providers.
This program grew from the success of Partners’ High Performance Medicine Team 4 and its Partners HealthCare Connection Program, led by MGH’s Timothy Ferris, MD. In addition to Cunningham, Phull and Van Houten, the BIMA Health Partnership Program was developed with input from Lisa Whittemore, senior administrator for Primary Care; David Gitlin, MD, director of BWH’s Medical Psychiatry Service; Phyllis Jen, MD, director of BIMA; Jonathan Borus, MD, chair of Psychiatry, and Robert Goldszer, MD, MBA, associate chief medical officer and director of Primary Care.
“Ultimately, as we empower more patients to better manage their chronic medical and psychiatric conditions, we are preventing crises that lead to more costly ED visits and readmissions,” Cunningham said.