BY: J. TODD WAHRENBERGER, MD, M.P.H.; STEPHANIE MURTAUGH, M.A., M.B.A., L.P.C., C.A.D.C., AND LINDA K. ROSS
Pittsburgh Mercy Health System opened Pittsburgh Mercy Family Health Center in May 2012, to address the significant disparities in health care for some of the community's most vulnerable individuals, many of whom were already being served by the health system's extensive behavioral health care continuum.
Pittsburgh Mercy Health System is part of Catholic Health East and is sponsored by the Sisters of Mercy. The new Pittsburgh Mercy Family Health Center is an extension of the Catholic health care ministry to all people in southwestern Pennsylvania. It is a patient-centered medical home and fully integrated primary health care center serving people with mental illnesses, intellectual disabilities, people who are homeless and children who are abused or neglected, among others. It is embedded into a robust, community-based mental health system and features a location within walking distance of other Pittsburgh Mercy Health System programs that serve more than 26,000 people annually in 60 locations.
The city of Pittsburgh is located in Pennsylvania's Allegheny County, the second largest county in the state. Data from the latest Allegheny County health survey "show significant health disparities persist for many indicators by education, household income, race, including: general health, disability, emotional and mental health, health care access, physical activity, diabetes, cholesterol awareness, hypertension, and cigarette smoking. Black residents, as well as those with lower household incomes or less education, fared worse on these indicators."1
Significantly more adults surveyed lacked routine health care. Thirteen percent of adults surveyed reported that they do not have a personal health care provider. Eleven percent of adults surveyed said there was an instance in the past year for which they needed to see a doctor, but could not due to cost.
Over time, Pittsburgh Mercy Health System hopes to demonstrate a decline in hospitalizations and improved health outcomes for chronic health conditions in its target population. The center is collaborating with insurance providers to monitor and track health care utilization, cost and outcomes data.
For more than 40 years, the system has provided services to people with mental illnesses and intellectual disabilities through Mercy Behavioral Health and Mercy Intellectual Disabilities Services, two of Pittsburgh Mercy Health System's largest programs. Additionally, since 1992, an award-winning, innovative medical and social services outreach program, Operation Safety Net®, has addressed the needs of individuals who are chronically homeless.
Funding for Pittsburgh Mercy Family Health Center and the patient-centered medical home initiatives (see page 33) comes primarily from the Pittsburgh Mercy Health System, along with some funds from federal, state and county governments and fee-for-service. The health system continuously seeks new and creative sources of funds, talking with payers about increasing financial support for team-based models of care and seeking corporate and private grants and donations to support the comprehensive mental health and other services the system provides for this challenging population of at-risk, marginalized and vulnerable individuals.
The need is great. According to National Institute of Mental Health research, individuals with serious mental illness die on average 25 years earlier than the general population. The cause of premature death is frequently the result of chronic, but highly treatable, medical conditions, including cardiovascular disease, diabetes, pulmonary disease, hypertension and cancer. These conditions can be further exacerbated by obesity; a sedentary lifestyle; poor nutrition; tobacco, alcohol and other drug use; and other unhealthy lifestyle behaviors.
In Allegheny County, more than 1 in 4 (26 percent) of the adults who participated in the latest county health survey said they were limited in their activities because of physical, mental, or emotional problems. Sixty-two percent of Allegheny County adults surveyed were found to be overweight or obese when their Body Mass Index was calculated for height and weight information they provided to surveyors. Additionally, 23 percent of Allegheny County adults surveyed said they were current smokers.2
The Pittsburgh Mercy Health System's extensive experience serving vulnerable populations supports the research. Many of these individuals do not easily access conventional health care services; some have not seen a health care professional for preventive health needs for years. Those who had sought health care have described often fragmented, uncoordinated services and, on average, poorer quality physical health care — and at a higher cost — than the general population. Many saw one health care provider for their behavioral health needs and another for their physical health needs. Many also reported feeling disenfranchised by health care providers who do not always understand the unique and complex needs of this population. Until now, the majority of the individuals Pittsburgh Mercy Health System serves have never had a patient-centered medical home to address their unique needs.
In many ways, Pittsburgh Mercy Family Health Center operates similarly to a traditional family medicine physician practice. The center serves adults, children and families in one location, offering routine physicals, well-child checkups, screenings and immunizations, management of chronic illnesses, preventive care, on-site lab services and peer wellness coaches.
In its first six months, the center provided primary care services to more than 1,100 individuals. Many have serious mental illnesses, including depression, anxiety, autism spectrum, bipolar and other mental health disorders, and live in economically distressed communities in Allegheny County, southwestern Pennsylvania's most populous county. The majority of the patients have complex medical histories that include such illnesses and chronic conditions as diabetes, hypertension and cardiovascular disease, and many take multiple medications.
Ultimately, Pittsburgh Mercy Family Health Center's goals are to empower the individuals it serves to be active, engaged participants in their care and in the community and to reduce admissions to hospitals, where inpatient acute care treatment and services are significantly more costly.
MULTIDISCIPLINARY TEAMS
Care at the health center is patient-centered, team-based and holistic, with a strong emphasis on consumer engagement and intervention strategies. Due to the medial complexity of the individuals served, Pittsburgh Mercy Family Health Center's primary care center staff meets — or "huddles" — each morning to discuss the patients they expect to see that day.
The experienced, multidisciplinary team is composed of a family physician, a certified physician assistant, medical assistants, medical secretaries, care managers, pharmacists, a tobacco cessation specialist and peer specialists. Together, they review and, in hope of gaining greater understanding, discuss all of the reasons the person may be coming that day. Anticipating individuals' needs in advance — do they need a flu shot; are they up to date on their other immunizations; when was their last mammogram, Pap test, or prostate check; are there any test results or other follow-up information that can help to expedite the visit — allows the team to provide more efficient care, share in decision-making and create strategies for chronic disease management.
They also discuss consumer engagement, harm reduction and the plan for who will meet with the patient during the office visit — known in the world of integrated care as the "warm hand-off," that is, one health care professional escorting or introducing the patient to another during the office visit. Such courtesy fosters communication, confers trust, builds rapport between the individual and members of his/her health care team, promotes seamless care, and ensures that the right care is delivered to the individual at the right time.
Thanks to the team model, the health system's mental health consumers who are stable can come to Pittsburgh Mercy Family Health Center for such care as prescription medication maintenance or refills. A consulting psychiatrist is an integral member of the team, readily accessible and available, as needed, for telephone or in-person consultations in addition to the day each week she spends at the center, meeting with the most complex patients.
She also provides behavioral health education to other members of the health care team and participates in weekly high-risk meetings to discuss the care plans of individuals whose biological, psychological, social and health system determinants indicate they may be at very high risk for morbidity and mortality in the near future.
It will take at least 12 months' worth of data to be able to determine if the Pittsburgh Mercy Family Health Center has improved health outcomes for chronic health conditions, reduced disparities in health care delivery by improving care coordination, increased health care literacy or reduced the overall cost of health care by decreasing avoidable use of high-cost health care services, including emergency department visits and inpatient acute care hospitalizations.
However, in this short time, the center has vaccinated individuals, treated them for diabetes, hypertension and other chronic conditions, provided tobacco cessation education and hepatitis C counseling, implemented a risk-stratification system, coordinated office visits with a care manager and consulting psychiatrist and more.
We are confident that these changes are making a positive difference in the lives of the people we serve. Perhaps most importantly, we have remained true to our mission: We have engaged and empowered individuals with serious mental illness, many of whom previously were disenfranchised, to become active participants in their care.
J. TODD WAHRENBERGER, a board-certified family medicine physician, is the medical director of Pittsburgh Mercy Family Health Center. He has more than 17 years of experience working with marginalized, vulnerable, at-risk populations.
STEPHANIE MURTAUGH is the senior director of Mercy Community Health, Pittsburgh.
LINDA K. ROSS is the director of communications for Pittsburgh Mercy Health System.
NOTES
- Patricia I. Documét, Todd M. Bear and Heidi Hauser Green, Results from the 2009-2010 Allegheny County Health Survey (ACHS): Measuring the Health of Adult Residents (Pittsburgh: Allegheny County Health Department, The Evaluation Institute; 2012), www.achd.net/biostats/pubs/pdf/ACHS_2009-2010.pdf.
- Allegheny County Health Survey.
MEDICAL HOME DEFINED
According to the Agency for Healthcare Research and Quality (AHRQ), which is part of the U.S. Department of Health and Human Services, a patient-centered medical home is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a person's lifetime to maximize health outcomes. The agency defines a medical home not simply as a place, but also as "a model of the organization of primary care that delivers the core functions of primary health." Furthermore, it states that a true medical home encompasses five functions and attributes:
- Comprehensive care
- Patient-centered
- Coordinated care
- Accessible services
- Quality and safety
Source: AHRQ Patient-Centered Medical Home Resource Center
FROM DIAGNOSIS TO LIFESTYLE CHANGE
Pittsburgh Mercy Health System recognizes that health is about more than treating a person's diagnosis. It recently implemented several innovative, holistic initiatives to address the needs of the individuals it serves through important lifestyle changes including, but not limited to, exercise, nutrition and tobacco cessation.
To further promote healthy lifestyle behaviors among the populations it serves, in 2011 Mercy Community Health and Pittsburgh Mercy Health System adopted the Individual Self-Health Action Plan for Empowerment (In SHAPE) program at several Mercy Behavioral Health sites.1 Created in 2002 by Ken Jue, CEO of Monadnock Family Services in Keene, N.H., In SHAPE combats premature mortality among people with serious mental illness by promoting the integration of physical and mental health through physical fitness, nutrition, smoking cessation and ongoing health education opportunities.
In SHAPE advocates personal control, responsibility, self-determination and community integration. The program assesses participants' health status and lifestyle habits and, using a team-based approach, helps them develop individualized, self-directed and self-managed care plans with such goals as making healthy food choices, increasing physical activity and losing weight.
With a certified exercise physiologist as wellness coordinator, each individual is assigned a certified fitness trainer as a health mentor, wellness coach and motivator. Other members of the health care team act as wellness champions, encouraging positive attitudes and modeling healthy behaviors for In SHAPE participants.
System facilities offer individual and group exercise opportunities. Pittsburgh Mercy Health System also has established partnerships with local fitness centers to encourage In SHAPE participants' social inclusion and community integration. Recognition events on a quarterly basis celebrate individual and group achievement toward personal wellness goals.
HEALTHY FOOD
As a patient-centered medical home, Pittsburgh Mercy Health System also strives to improve nutrition in the population it serves. Through a recent partnership with Springboard Kitchens, a Pittsburgh nonprofit organization, Pittsburgh Mercy Health System has introduced healthier menus at all of its residential facilities.
Springboard Kitchens' trainees, who are also working toward self-sufficiency and community integration goals of their own, prepare healthful, nutritious meals from scratch, using fresh, locally sourced produce whenever possible. In this way, the individuals who are preparing and serving the food are also modeling self-determination, recovery and employment. Menu choices feature foods that are low in fat, sodium and added or refined sugar. Additionally, vegan and vegetarian options are offered, even encouraged.
With the support and encouragement from the wellness champions, residents in a few of the residential programs have started vegetable gardens to grow their own fresh produce.
A consulting nutritionist helps to educate consumers about dietary changes and how food choices can affect physical and mental health. Additionally, a registered nurse who serves as activities director at one facility recently organized a recreational outing to a local supermarket to promote cultural inclusion and encourage healthy food choices. In describing society as "a great melting pot," she also used a salad metaphor, emphasizing the uniqueness, flavor and value of every ingredient.
QUIT SMOKING
Pittsburgh Mercy Health System has offered tobacco cessation resources to employees and patients for more than 10 years. Tobacco cessation specialists provide education and support at 20 different Pittsburgh Mercy Health System sites each week and are a dedicated, on-site resource at Pittsburgh Mercy Family Health Center two days each week. Employees and persons served who are eligible receive free nicotine replacement therapy. All buildings are smoke-free, as are the grounds at most residential facilities.
NATIONAL WELLNESS WEEK
During National Wellness Week, a federal Substance Abuse and Mental Health Services Administration (SAMHSA) observance held every September, Pittsburgh Mercy Health System held a number of health and wellness events to promote the eight dimensions of wellness:2
- Emotional: Developing skills and strategies to cope with stress
- Environmental: Good health by occupying pleasant, stimulating environments that support well-being
- Financial: Satisfaction with current and future financial situations
- Intellectual: Recognizing creative abilities and finding ways to expand knowledge and skills
- Occupational: Personal satisfaction and enrichment derived from one's work
- Physical: Recognizing the need for physical activity, diet, sleep and nutrition
- Social: Developing a sense of connection and a well-developed support system
- Spiritual: Search for meaning and purpose in the human experience
— J. Todd Wahrenberger, Stephanie Murtaugh and Linda K. Ross
NOTES
- National Council for Community Behavioral Healthcare webinar, "InSHAPE: Health Mentors Creating Health and Community Engagement," www.thenationalcouncil.org/galleries/resources-services%20files/BH%20World%20Series%20Dec%205-InShape%20Presentation.pdf.
- Substance Abuse and Mental Health Services Administration, http://www.samhsa.gov/.
Copyright © 2013 by the Catholic Health Association of the United States
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