Treating the Whole Patient: Health IT’s Role in Fully Integrated Care

In recent years, there has been a tremendous amount of innovation happening in health care, and the Health Information Technology industry has been at the forefront of much of it.

Health IT

Health IT has proven one of the core solutions to some of society’s most pressing health care concerns, and the need for innovative Health IT approaches only continues to grow, driven by an increased demand for quality, patient-centric care.

In rural northern New York, where I work in Health IT for a regional health planning organization, a concern for our patient population is lack of access to comprehensive mental and behavioral health care. Data shows that this same concern is felt across the country.

According to the National Institute of Mental Health (NIMH), one in five Americans has a diagnosable mental health disorder, which amounts to roughly 43 million people. Furthermore, nearly 10 million Americans have a serious functional impairment due to a mental illness, such as a psychotic, mood or anxiety disorder. NIMH also estimates that serious mental illness costs America $193 billion in lost earnings per year.

In rural regions like mine, integrating primary care and behavioral health has almost always been out of reach, due to a consistent shortage of health care providers, lack of funding, and a patient community that is largely un-engaged in its own health care. But today, Health IT is helping to bridge that gap in our communities.

“In rural regions like mine, integrating primary care and behavioral health has almost always been out of reach…but today, Health IT is helping to bridge that gap in our communities.”

The process began in 2015, with the advent of New York State’s new Delivery Reform Incentive Payment (DSRIP) Program. DSRIP´s purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25% over five years. New York allocated up to $6.42 billion to this program, offering payouts to networks of providers based on their ability to meet milestones in system transformation, clinical management and population health.

My region’s provider network — which serves Jefferson, Lewis and St. Lawrence counties — jumped at this opportunity and strategically chose projects that would help foster a system of quality, integrated primary and behavioral health care.

Our network has the power to employ three specific models of integration, which gives us the ability to cater each integration to fit a variety of practices, providers, and most importantly, patient needs. Those models are as follows:

Models 1 & 2:
Co-locate behavioral health and primary care in the physical setting. For example, offering a behavioral health screening at a routine primary care visit, or offering help to a patient with a chronic disease during his or her psychiatrist appointment.
Model 3:
Implement the “IMPACT Model” at primary care sites. Short for “Improving Mood — Providing Access to Collaborative Treatment,” this model gives a patient plenty of one-on-one time with his or her primary care provider and an on-site depression care manager, who both work closely with an off-site psychiatrist to determine an individualized treatment plan.

Health IT has played an important role in facilitating all these models — particularly Model 3, which usually requires the primary care provider to telecommunicate with the off-site specialist. Regardless of the model, Health IT allows our providers to use the Electronic Health Record (EHR) to document and track both behavioral health and primary care visits all at once.

In truth, the implementation of these models felt like an uphill battle at times. Health care sites involved in this project faced numerous challenges and what seemed like very few successes up front. However, with increased buy-in, education, engagement, and tremendous collaboration, our region has seen great success within all three models. Administrators, providers, and patients are now seeing the benefits of truly integrated care.

Most importantly, patients that would have otherwise slipped through the cracks are being accounted for and offered the help that they need, both for their body and their mind.


By Vega Nutting, FDRHPO’s PCMH Implementation Project Manager

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