Synchronizing Primary Care and Behavioral Healthcare for Patients

Kentucky Integrated Care was established in September 2017. Embedded within Seven Counties Services, it serves the following counties in Kentucky, which surround the Louisville metropolitan area: Bullitt, Henry, Jefferson, Oldham, Shelby, Spencer, and Trimble counties. The program was launched as a five-year project to synchronize primary care with behavioral healthcare. This mission was implemented by the Kentucky Cabinet for Health and Family Services after the Substance Abuse and Mental Health Services Administration (SAMHSA) identified a substantial need to improve adults’ physical health status with mental illness and those with co-occurring substance use disorders. We provide co-located and combined services that foster an all-inclusive healthy home through the coordination of care and collaboration within clinical practice.

Our services embrace health prevention strategies, evidence-based screenings and assessment, and the diagnosis and treatment of acute and chronic health problems. We offer additional services through mental health counseling, case management, adult peer support, and connection to community resources. Our overall goal is to empower clients in self-management, reduce physical and behavioral health symptomatology, improve functional outcomes, and increase the utilization of integrated care services. Our primary objective occurs according to a shared and individualized care plan and outreach, engagement, and retention strategies.

What does an integrated care patient look like?

Patient Example: 52-year old female with a history of major depression, Post Traumatic Stress Disorder (PTSD), mood disorder, opioid use disorder, methamphetamine use disorder, tobacco use disorder, and Hepatitis C, presented to Kentucky Integrated Care with decreased activity tolerance, dyspnea, daily productive cough, chronic joint pain, and rash. After completing evidence-based program screening/assessment and a comprehensive panel of labs, she had elevated liver enzymes, immunity to hepatitis B, negative hepatitis C viral load, elevated inflammatory markers, and positive antinuclear antibody (ANA). A routine chest x-ray showed mild emphysematous changes and a focal area of atelectasis, and in-office spirometry demonstrated moderate Chronic Obstructive Pulmonary Disorder (COPD) according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. The patient was prescribed a long-acting inhaler and rescue inhaler, administered pneumococcal and flu vaccines, educated on smoking cessation, and referred to rheumatology for further evaluation. While receiving outpatient psychiatric care, suboxone maintenance therapy, and intensive outpatient services for substance abuse, she participated in Whole Health Action Management (WHAM) classes. This class helps an individual develop health literacy skills to influence attitudes and inspire healthy decision-making. After completing WHAM and visiting the rheumatologist, she received a new lupus diagnosis with polyarthritis and a positive connective tissue panel. The client was started on Plaquenil (hydroxychloroquine) twice a day and began to feel better. After multiple interactions with program staff members, she followed up with ophthalmology, completed a screening mammogram, and joined a bridge walking group led by a Kentucky Integrated Care peer support specialist while returning to the workforce with part-time employment. In addition to a sober living home, this job opportunity was made possible through the assistance of our case manager. She eventually attended weekly aftercare meetings as well as individual therapy while gaining a greater sense of independence. Our patient described having more energy, self-fulfillment, and a new perspective on her recovery through this sequence of events.

This patient illustration is merely one case of many within a unique population with a heightened risk for morbidity and mortality. Many of our adult patients began smoking cigarettes at a young age, have poor nutritional habits, and lead sedentary lifestyles. Behaviors such as these, combined with the adverse effects of antipsychotic medications, contribute to obesity, hypertension, diabetes, and high cholesterol. To further impact positive health outcomes, Kentucky Integrated Care recognizes the Million Hearts initiative campaign to prevent cardiovascular events such as heart disease and stroke. We routinely monitor blood pressure, body mass index, waist circumference, breath CO2, A1C, and lipid profile at specified intervals. These health measures are documented within tracking tools to capture data and monitor the progress of biomedical outcomes. Through wellness interventions and routine follow up, we can decrease the number of emergency room visits and inpatient hospital admissions, thus reducing healthcare costs.

While our country is amid a global pandemic, the state of Kentucky continues to battle the opioid crisis in conjunction with alcohol and other psychoactive substances of abuse.

Heart and lung disease remain prevalent, and complications from intravenously related infections such as endocarditis, hepatitis, and osteomyelitis cause patients and their families to suffer an even greater burden. The social isolation, stress, loss of jobs, and relapses in 2020 may have caused a setback. Still, our integrated care team will continue to provide holistic care and persevere for the population we serve.

Written by Candace Shireman, APRN, FNP-C, Seven Counties Services

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