Years ago, when I worked as a certified nurse-midwife in a federally qualified health center in the South Bronx in New York City, I worried: Was I actually helping the women that I cared for?

While I provided prenatal, gynecological, and primary care, I often felt I was just scratching the surface of what patients really needed. I prescribed antibiotics for the woman with a urinary tract infection, but what could I do about that black eye? For the 16-year-old pregnant teen, I could make sure her baby’s heart rate was normal, but what about when she told me she was living in a shelter because her family had kicked her out? For the pregnant woman struggling with depression, how could I help her avoid a pre-term birth?

To ignore the “non-medical” issues that profoundly affected my patients’ health made me feel like I was applying band-aids to gaping wounds. We could refer some patients for behavioral health and social services, but access was inadequate, and care was siloed and uncoordinated, with more intensive care management only available for those with multiple chronic conditions. Being pregnant with diabetes would get you transferred to a high-risk clinic, but being pregnant and homeless meant you stayed with us. The care we provided was, by traditional medical standards, high quality, but it was not truly person-centered.

The challenges I experienced are likely familiar to any provider in the safety net system. To address and prevent many of the medical problems seen every day in clinics and health centers across the nation, we need to design a different care model. We need an approach to care where clinicians and payers agree that when we say that someone is “high risk” or “complex,” we arrive at that conclusion by not only assessing their medical conditions, but also by taking into account their behavioral health and health-related social needs. In this reimagined approach, the best care is not when clinicians alone decide what patients need, but rather when we work together with the people we care for to understand their priorities and what they believe will best support their health.

This is exactly the challenge being taken on by Advancing Integrated Models (AIM), a new Center for Health Care Strategies initiative made possible through support from the Robert Wood Johnson Foundation. Through this project, eight organizations are designing and piloting new strategies for integrating innovative, “next-generation” approaches to person-centered care for individuals with complex health and social needs.

Key Elements for Advancing Integrated Care Models

AIM is providing the opportunity to align the delivery of critical components of high-quality care for individuals with complex medical and social needs, including: complex care management; trauma-informed care; physical and behavioral health integration; and mechanisms to address health-related social needs. Innovative plans for supporting integration are emerging across the eight pilot sites who are employing a wide range of creative, “from the ground up” solutions. Those strategies include:

  • Redefining risk algorithms to incorporate social needs and expand eligibility. At places like Maimonides Medical Center in New York City and Hill Country Health and Wellness Center in Northern California, they are expanding their definition of high-risk beyond traditional medical criteria to include behavioral health and health-related social needs, and then providing care management services to individuals who previously have not met required eligibility criteria based on medical conditions alone. OneCare Vermont, a statewide all-payer ACO model, is also working toward integration of social needs data into their complex care coordination platform to better identify individuals that could benefit from enhanced services and supports. Denver Health, as part of its plan to provide better care to individuals with complex needs, is systematizing the way it screens for social risk.
  • Expanding the application of trauma-informed care to provide care that is more equitable and sensitive to the needs of the people being served. The Stephen and Sandra Sheller 11th Street Family Health Services in Philadelphia is training its staff on the relationship between racism and trauma, and is using this lens to explore ways to improve care delivery. In Washington, D.C., Bread for the City is bringing a trauma-informed frame to its “food home” model to reduce food insecurity and improve overall health outcomes.
  • Committing to human-centered design, which involves the community and the people being cared for at the center of the care design process. The Center for the Urban Child and Healthy Family at Boston Medical Center is creating the “Pediatric Practice of the Future,” involving the families it serves at every step as it transforms its care model framework to more closely match with families’ conceptualization of wellness. The new model includes a trauma-informed approach to care, family-driven goal setting, and care offered in a range of locations including at BMC, over teleconference, and in the community. It also pays special attention to key factors that influence well-being, such as economic mobility.
  • Pursuing innovative payment models to support care enhancements and attention to health-related social needs. Each AIM pilot site has enlisted the help of a Medicaid payer partner to identify financing strategies for sustainably supporting their new approaches to care. For example, the Harriet Lane Clinic at Johns Hopkins Children’s Center and its payer partner Priority Partners, are working collaboratively to roll out creative approaches for improving the care of children and families, including providing asthma inhalers for kids at school (in addition to at home), screening mothers for postpartum depression at well-baby visits, and using community health workers to support the behavioral health needs of children and adolescents with sickle cell disease.

“Do differently”

These are just a few key strategies being used by the AIM sites to rethink how care is delivered for populations with complex challenges. As Rishi Manchanda, president and CEO of HealthBegins and one of 12 advisors to the AIM initiative observes, “we need less of ‘do more’ and more of ‘do differently’ [in health care].” At CHCS, we are excited to see the AIM pilot sites “do differently” through this project as they strive to go beyond just “scratching the surface” and work collaboratively with patients to meet their needs and support their health. Over the next two years, these pilot sites and their payer partners will test innovative, integrated care models that strive to more fully address medical, behavioral health, and health-related social needs. These next-generation, holistically integrated models will provide important blueprints for respectful and equitable partnerships with patients and communities. We look forward to sharing these lessons as they emerge.

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Michael Brewer
4 years ago

Congratulations to you and all your colleagues nationwide who are designing and testing data-driven models and advocating for individualized, integrated whole client diagnosis and treatment with the ultimate goal of restoring a sense of independence and agency in each person. One stop diagnosis, treatment, support and financing makes a lot of sense.

P.S. Hope test cases can be expanded to places in fly over country, particularly struggling smaller town, rural, and exurban locations where the needs are also great.

Cynthia Summers
4 years ago

This is wonderful to hear and I look forward to following these efforts and how they progress. There are a lot of organizations focusing on integrated and whole person care, but the greatest challenge is shifting the way we pay for care to support these models.

Jan M Hauser
4 years ago

I think it’s wonderful that Health Care in this country realizes that offering medical treatment in a doctor’s office or clinic and once you leave thé office or clinic that is all the help you are going to get. I can’t tell you how many times I walked into my SMI clinic, saw my doctor for 15-20 min maybe a few minutes with my case manager ( only if you have a good one, bad ones you may never see nor have any other communications) and walked out the door to either go back to living on the streets or… Read more »

Karla Silverman, CHCS
4 years ago
Reply to  Jan M Hauser

Jan, thank you for sharing your story. It is critical that we all fully listen to and understand the first-person accounts of how people like yourself experience the health care system.

Please look for an email from us shortly. Thank you again for sharing your experience with us and our readers.