BY: SHARON NEUMEISTER, RN, MA
Partners Forge Links Beyond Hospital Walls
In Mercy's St. Louis region, which contains St. Louis City, St. Louis County, St. Charles County and the more rural Jefferson, Franklin and Lincoln counties, all five of the health system's Community Health Needs Assessments have ranked behavioral health high on the list, survey after survey, data source after data source. However, Mercy leaders knew that the prevalence and complexity of behavioral health issues meant they would need partners to make an impact, collaborating with local health departments, other area health systems, social service agencies and nonprofit organizations focused on mental health and substance abuse issues would be key.
The Behavioral Health Network of Greater St. Louis, the National Alliance on Mental Illness (NAMI–St. Louis), Alive & Well Communities and the National Council on Alcoholism and Drug Abuse are among those that work with Mercy in this critical area.
The Behavioral Health Network of Greater St. Louis is a 501(c)3 organization formed in 2010 and has served as the permanent structure for ongoing regionwide behavioral health system planning and coordination. The network brings key organizations together to implement evidence-based programs, advocate at the local, state and national levels and secure program funding. Patty Morrow, Mercy St. Louis' executive director of behavioral health, serves on the Behavioral Health Network's board.
Mercy has collaborated with BHN on five successful initiatives:
• EPICC Opioid Overdose Response Project Area health departments have declared the opioid epidemic a public health emergency in St. Louis and surrounding counties. The crisis is real, and it is growing. It leaves behind long-term grief and trauma for families who have lost a person they love.
BHN members have been at the forefront of efforts to increase prevention education, access to treatment for high-risk populations such as the uninsured and to expand access to the anti-overdose drug, naloxone.
Through EPICC (Engaging Patients in Care Coordination), BHN provides on-site support to expedite the initiation of and access to Medication-Assisted Treatment. Combined with counseling and behavioral therapy, MAT provides a whole-patient approach to treating substance abuse disorders. At the center of care is the peer recovery coach, who meets the patient and family at the hospital and coordinates care from hospital emergency departments to community-based settings. Coaches "journey with" patients and families to enhance engagement and maintain contact to support the patient's retention in services, foster recovery and reduce overdose rates.
EPICC also works closely with MO Hope Project to provide opioid overdose education and distribute Narcan (the brand-name naloxone medication that blocks opioids and reverses overdose). At 30-day follow-ups, 40 percent of clients were still engaged with the project (compared to a national rate of only 17 percent for similar client populations). All five St. Louis-area Mercy hospital emergency departments refer patients to the program. Between December 2016 and March 2018, Mercy hospitals referred 155 clients to the EPICC project.
• Emergency Room Enhancement Project reduces preventable hospital readmissions through an integrated 24/7 regionwide approach that serves high utilizers of emergency room and inpatient settings. On-site engagement at the hospital at time of referral and a peer support specialist, along with after-hours and weekend scheduling, telephonic and mobile outreach crisis services, are strategies that, when combined, have produced an engagement rate that has risen from 60 percent in FY15 to 70 percent in FY16. Those rates are significantly higher than the 40 percent national average for individuals first connecting to behavioral health care. Mercy has seen an 84 percent engagement rate in the first three quarters of FY18.
• Youth Emergency Room Enhancement Project. ERE partners recently have expanded services to youths ages 6-17 who are identified as high risk and high need. The goal is to engage the youth and their caregivers in ongoing community behavioral health care. In its pilot year, the project achieved an overall engagement rate of 78 percent. Three Mercy hospitals participate in this project, and between Oct. 1, 2017, and May 31, 2018, they accounted for 44 percent of all eligible referrals. Mercy St. Anthony's was an enthusiastic early adopter and has referred more clients than any other hospital or clinic.
• The Hospital Community Linkages Inpatient Project provides a designated liaison per provider and facilitates referrals, ensuring discharge documentation is transferred for continuity of care. Intensive outreach often includes follow-up phone calls, home visits and transportation to the first appointment. As of FY17, the overall project engagement rate was 67 percent, and in the first three quarters of FY18, Mercy's engagement rate averaged 73 percent.
• Bridges to Care and Recovery describes itself as creating "behavioral health-friendly" churches. Collaborating specifically in North St. Louis City and County, BHN works with key partners to include hospital and community behavioral health leadership, advocacy groups and faith leaders in providing a holistic approach to expand the role of faith-based organizations in the identification of mental health and substance use disorders. It also works to reduce the stigma of mental illness in order to increase support of referral and access to behavioral health care. Mercy's Community Health team provides resource and referral training and support for Bridges' clergy and volunteers.
The National Alliance on Mental Illness — St. Louis is another of Mercy's partners in addressing behavioral health needs beyond hospital walls. The nonprofit organization's mission is to improve the quality of life of persons with severe and persistent mental illness and their families, as well as to promote and provide community support, advocacy and understanding. Mercy has partnered with NAMI–St. Louis for many years on a variety of community programs such as the Family-to-Family educational course for caregivers, friends and family of persons living with mental illness. It is led by trained volunteers who are experienced in giving care to a family member living with serious mental illness. The federal Substance Abuse and Mental Health Services Administration designated the Family-to-Family education program an evidence-based practice in 2013.
In 2017, a new partnership established Finding Help & Hope: Supporting Loved Ones Fighting Suicide. The program's purpose is to provide families with education and support following their loved one's discharge, a best "Zero Suicide" practice according to the Action Alliance for Suicide Prevention, a public-private partnership supported by SAMHSA.
Over the past two years, Mercy has provided more than $80,000 in funding support to develop and deliver the following programs:
NAMI Family Support Group is a monthly, peer-led support group for family members, caregivers and loved ones of individuals living with mental illness who have suicidal thoughts or actions. By sharing experiences in a safe and confidential setting, participants gain hope and develop supportive relationships and a sense of community. They benefit from others' experiences, discover inner strength and learn to identify local resources and how to use them.
Question, Persuade and Refer is a one-time training session that discusses three steps anyone can learn to help prevent suicide. The session also provides information about local resources.
Supporting Those at Risk of Suicide is a one-time training session that helps participants understand ways to better support and understand people who are at risk of suicide. Local and national resources also are discussed.
ALIVE AND WELL
Alive and Well STL is a communitywide effort focused on reducing the impact of toxic stress and trauma on health and well-being. Toxic stress and traumatic experiences are making many people sick, and together they are a leading cause of poor health outcomes.
Mercy is a founding partner of the Alive and Well STL health learning collaborative and partnered with COMTREA, a Federally Qualified Health Center, to establish Alive and Well Jefferson County. Community conversations, education and evidence-based training is offered in hospitals and clinics, as well as in schools, churches and with other community groups, changing the dialogue from "What's wrong with you?" to the more open-ended "What happened to you?"
The National Council on Alcohol and Drug Abuse works to reduce and prevent alcohol and other drug misuse through education, intervention and advocacy. Partners on several community coalitions, Mercy and NCADA have most recently partnered on the safe disposal of medications. Through drug take-back events and distributing more than 20,000 Deterra Drug Deactivation System bags, nonheroin opioids and other unwanted medications can be safely and properly disposed of, rather than ending up in the wrong hands.
INTERNAL PARTNERSHIPS AND VIRTUAL CARE
Partnering with community organizations has and will continue to be essential in addressing the mental health needs of St. Louis and surrounding communities. However, even with partnerships and collaborative efforts such as those listed above, an overwhelming challenge remains in both mental health provider capacity and access. It's estimated that 18 percent of adults in America have a mental health condition, and more than 24 million Americans do not receive the mental health care they need.1 And, with traditional models, there is no end in sight. It's not uncommon for a patient to wait six to nine months for his or her first appointment with a psychiatrist.
To face these challenges and meet capacity demands, Mercy is developing innovative ways to better partner with its own mental health and primary care providers. For example, the "A New Front Door" program expands provider capacity with tools providers need, such as care pathways and virtual care support.
Mercy's virtual care support for providers caring for children with mental and behavioral health issues, vMentalWellness Kids, went live in January 2018 and has treated more than 700 children to date. Mercy providers are educated and trained to use a new task-sharing model of care, employing care pathways and treatment algorithms to identify common mental health conditions such as depression, anxiety, attention deficit hyperactivity disorder and defiant disorders. These care pathways have been developed to guide the providers. The virtual MentalWellness team includes a child/adolescent psychiatrist as the team leader, guiding the team of mental health professionals. The team includes a mental health nurse practitioner to provide treatment guidance and medication management virtually, a mental health specialist to provide expert video assessments and consultation sessions for patients and families, along with guidance to the provider and a mental health navigator to provide resources and triage.
The new task-sharing care model's benefits for patients and families include:
- Earlier access to mental health care
- Early and accurate diagnosis
- Early initiation of treatment
- More timely resolution of symptoms
- Avoidance of consequences of illness
- Quicker return to baseline health
- Improvements on physical, social and mental well-being
- Improved patient and family satisfaction
For medical providers, the new care model:
- Provides integrated care in the medical home
- Avoids lengthy wait time for specialty referral
- Offers real-time collaborative expert mental health support
- Results in fewer office visits for psychosomatic issues
- Maximizes RVU (relative value unit) with efficient documentation
The virtual care service called vMentalWellness Kids is being offered to pediatric offices across Mercy. The next step will be to provide the same service and virtual support for adult primary care offices.
Just as vMentalWellness connects mental health support to primary care offices, vEngagement — or care at home — connects patients who have chronic medical conditions with mental health professionals when needed. Patients are given iPad tablets and can communicate as often as daily with their integrated medical and mental health team. vEngagement provides many of the same benefits as other virtual solutions, and it is especially helpful with patients who have co-existing medical and mental health conditions.
As Mercy continues to address the mental health needs across its communities, it remains critical to:
- Go beyond hospital walls to care for patients in new ways, in new places
- Build trusting relationships and collaborate with both external and internal partners
- Look for ways in which technology coupled with a redesigned model of care can expand Mercy's scope and build capacity in ways never imagined
- Keep the patient at the center, never losing site of the vision and values of Mercy's founder, Catherine McAuley
SHARON NEUMEISTER is a registered nurse and regional director of community health for Mercy's East community.
NOTE
1. Mental Health America, "Mental Health Facts, Stats, and Data," website, www.mentalhealthamerica.net/issues/state-mental-health-america.