Approach to Care
SURHC has been successful in fully integrating behavioral health care with primary care as part of our participation in the Missouri Medicaid primary care Health Home (PCHH) initiative. Our PCHH participation began in 2012 and provides SURHC with the opportunity to benefit from a fully integrated model of care. The initiative serves 300 Missouri Medicaid beneficiaries, providing intense primary care and behavioral health services for patients with 2 or more chronic diseases. The patient centered medical home laid the foundation for PCHH, which relies on a team-based care approach. PCHH employs a holistic approach similar to the medical home model and includes behavioral health as part of the front-line interventions to manage physical and mental health issues, including the determinants of health factors that may be influencing the ability of the patient to adhere to the treatment plan and live a healthy life.
Working with multiple cultures involves developing a staff that is culturally competent. This includes education on the values and beliefs of different cultures which enhances staff’s ability to understand, communicate with, and create an effective learning experience for the patient. Evidence shows that understanding someone’s culture aids in developing trust between patient and team member. This relationship greatly contributes to successful results and the reaching of patient self-management goals.
Working with different cultures also necessitates a multidisciplinary team, comprising a care coordinator, behavioral health consultant, and an RN care manager. The multidisciplinary team works in coordination with the primary care provider, LPN, and medical assistant to address the physical, mental, and social needs of the patient.
The care coordinator maintains current insurance status on patients. Specific doctor-prescribed medical supplies go through the coordinator to be pre-certified through our Cyber Access (electronic health record). The coordinator completes our measures report for meaningful use. The care coordinator answers patient calls and schedules and redirects calls as needed. A newsletter is created and mailed out monthly to our patients.
The behavioral health consultant addresses the mental processes of the patient. An assessment may include an evaluation of the patient’s emotional and spiritual needs as well as possible behavioral modification. The behavioral health consultant also addresses smoking cessation, stress reduction, and exercising. Assessment of motivation and readiness is evaluated to assist the patient in setting goals for the self-management of chronic diseases. The behavioral health consultant and RN care manager work closely together by integrating the behavioral health with the primary medical care of the patient.
The RN care manager sees patients when they come in for appointments with their primary care provider (PCP). The RN uses this time to answer patient questions regarding chronic disease, to check if patients know which medications they are taking and why, and for following up on any previous chronic disease teaching or hospital visits they may have had. This team member also coordinates with other specialists and agencies outside of the clinic to assure the patient is followed up with.
Self-Management Support
The ultimate goal in educating a multicultural patient is to wean them from hands-on support provided by the multidisciplinary staff to be able to effectively self-manage their disease. With effective self-management, the patient understands his or her condition, how it affects the body, and can monitor the condition in order to make any necessary changes to stay healthy.