Sustaining our integrated care program for residents with complex medical, social, and behavioral health needs

To improve the health of Washtenaw County’s most vulnerable populations, we need to provide access to high quality health care, but also to an array of supportive services that go beyond health care to address safe and affordable housing, healthy foods, mental health counseling, substance use recovery support, education, case management, and more.  This is the problem the Washtenaw Health Initiative has sought to address through its community-wide care coordination program for frequent emergency department users. For the past two years, the Washtenaw Health Initiative and participating organizations, with funding from the Michigan Department of Health and Human Services, have been providing patient-centered, coordinated care management to frequent utilizers of emergency department services who and are more likely to be low-income, have multiple chronic diseases, and suffer from mental illness or substance use disorders.

Unfortunately, the original source of funding for this care coordination pilot sunset in January. However, we are pleased to report that we have now received funding, or firm pledges, to support aspects of the intervention for an additional year. These contributions will come from the Michigan Department of Health and Human Services, the St. Joseph Mercy Health System, and Michigan Medicine. 

While the sum of these resources is enough to maintain the intervention at some level, leaders have prioritized funding for community health workers, organizations that clearly require additional financial support to maintain enough staff to participate in the program, and critical administrative functions. SIM leaders have identified the organizations in greatest need of resources and to make individual funding proposals that reflect the availability of funds, the financial condition of the organization, and the importance of the organization’s services to program participants. 

This regional social and medical care program, often referred to as the State Innovation Model (SIM) due to the original source of MDHHS support (a U.S. Centers for Medicare and Medicaid Services initiative to allow states to test innovations), was built on the strength of community partnersStaff from more than a dozen health and human service organizations–including housing providers, substance use counselors, social service agencies, mental health providers, and health clinics–were intimately involved in designing the intervention model. They began the process in the summer of 2016 and started to serve the first participants–identified through community referrals and a predictive model that prospectively identified local residents with complex health, behavioral health, and social needs and who frequently used our county’s emergency departments–in the fall of 2017.

Importantly, the predictive model has not only allowed the Washtenaw Health Initiative to proactively identify individuals who might benefit from the program, but has also allowed us to offer services to a random selection of participants who meet similar characteristics. 

Once individuals agree to participate in the program, and sign shared consent forms that allow multiple care managers to work together, three-dozen care coordinators who work for the participating health and human service organizations–in conjunction with three full-time community health workers who have been employed by the Washtenaw Health Plan to assist with the pilot–provide coordinated care. Hundreds of local residents with complex concerns are now being served. And care coordinators meet regularly to refine and improve the program based on the lessons they have learned since implementation.

On average, the intervention participants make 12 trips to the emergency department in a given year, are admitted to the hospital two to three times annually, and are more likely than not to suffer from mental illness or substance use disorders. The initiative works to improve the health and quality of life of participants and, through a rigorous impact evaluation, to demonstrate that true patient-centered care–care that addresses people’s health, mental health, and social needs in concert–can reduce the need for costly emergency department services.

On some level, we already know that the intervention is working in a variety of ways. Most immediately, care managers at participating agencies have strengthened relationships with each other, learned about each others’ programs and values, and built a strong network that allows them to work together to address the complex needs of their clients. 

The intervention is also improving mental health and substance use treatment for participants. During pre-participation needs assessments that set the stage for individualized care plans, 55 percent of the individuals served indicated a self-perceived need for mental health treatment and 24 percent indicated a self-perceived need for substance use treatment. When reassessed after six months of participation, the number receiving services had increased and the self-perceived need for services had diminished. And particularly telling, many had lower PHQ-9 scores once they had engaged with the program.