North Carolina AHEC Program
summer 2009 newsletter | home
North Carolina’s ICARE Partnership: Improving Access to Care Through Integration:
By Sally Smith, RN, LCSW, ICARE project director, Mountain AHEC and Russet Hambrick, MLS, AHIP, VP of regional information & education services, Southern Regional AHEC. (Reprinted from the Spring 2009 National AHEC Bulletin.)
If you ask licensed clinical social worker Mark Boyd why integrated care is a good idea, he won’t point you to research or statistics. He’ll tell you a story:
Recently, a woman met with her primary care provider at Roanoke-Chowan Community Health Center (RCCHC), a Federally Qualified Health Center based in Ahoskie, NC. Struggling to accept the recent loss of her son in a car crash and a more recent separation from her husband of 35 years, she described herself as “overcome” and “at a loss to move forward.” A referral for mental health services was clearly needed.
This would typically require a weeks-long wait for an appointment, completion of pre-certification paperwork, and a lengthy intake procedure at another provider’s office. Not, however, at RCCHC’s Ahoskie office, where Boyd practices full-time. Thanks to provider integration, the patient saw Boyd immediately.
“This is how care is supposed to work,” said Boyd.
Successes like these are the key motivation behind a growing national movement to advance integrated care practices. Nowhere is this movement stronger than in North Carolina, home of The ICARE Partnership.
ICARE (www.icarenc.org) is a grassroots effort that brings together professionals from family practice, pediatrics, psychiatry, psychology, and other disciplines to improve the quality of and access to affordable health care services. Specifically, ICARE seeks to:
- Enable more frequent collaboration among primary care providers (PCPs) and mental health, developmental disability, and substance abuse services (MH/DD/SAS) providers;
- Increase the capacity of PCPs to provide appropriate, evidence-based behavioral health services; and
- Increase the capacity of MH/DD/SAS providers to screen and refer for physical illness.
ICARE’s work is critical in North Carolina, where the availability of public mental health services is declining sharply, and the burden of caring for patients with mental disorders increasingly falls to primary care practices. Established in 2006 by a small group of health professionals – including the North Carolina AHEC Program Office and regional AHECs – ICARE has grown to comprise more than two dozen health care organizations and agencies across the state. It is funded through a mix of private and public sources, including the Duke Endowment, the Kate B. Reynolds Charitable Trust, AstraZeneca, NC AHEC, the North Carolina Department of Health and Human Services, and the North Carolina Foundation for Advanced Health Programs.
The ICARE model
The ICARE program is a natural extension of the pioneering work begun by Jim Bernstein, Tork Wade, Allen Dobson, and other public health visionaries who helped build Community Care of North Carolina (CCNC), a nationally-recognized model of Medicaid care management. ICARE’s statewide approach builds on the CCNC philosophy, developing the infrastructure and tools professionals need to operationalize integration of care. The ICARE model has three major components: training and education, policy change recommendations, and pilot programs.
Through onsite training, clinical consultation services, and Web-based education, ICARE offers instruction on topics such as integrated care models, screening methods, crisis management, and billing and coding for mental health treatment. Through more than 70 training events, ICARE reached nearly 1,500 providers in 2007 alone. In addition, ICARE maintains a Web site with educational Podcasts, billing and coding tools, screening tools and algorithms, and a comprehensive MH/DD/SAS resource directory. The site has received more than 1.6 million hits since October 2006.
ICARE develops policy change recommendations through a policy and process change committee. Composed of providers, stakeholders, and health care experts, the committee studies and recommends practice-based, community, regional, and statewide changes necessary to sustaining the integrated care movement.
ICARE’s third component is a series of integrated care pilots. These pilots employ a local model development approach, allowing each program to implement individualized methods suited to its particular populations and concerns.
AHEC’s essential role
ICARE would not exist in its current form without the strong support of the NC AHEC Program and regional AHECs that provide leadership, personnel, and funding. Playing to their strength, regional AHECs are integrally involved in ICARE’s education initiatives and play key roles in curriculum development and onsite training. Several AHECs have been involved in ICARE pilots as well. Karen Stallings, RN, MEd, associate director of the NC AHEC Program, contributes policy recommendations, and other AHEC officials provide guidance and leadership through ICARE’s two oversight groups: its advisory board and core steering committee.
“The ICARE story is closely linked to the North Carolina AHEC Program, an early champion of integrated care,” said Tom Bacon, DrPH, director of NC AHEC. “ICARE’s three-tiered, locally-focused approach meets a critical and growing need in our state. The AHEC Program looks forward to its continued work with ICARE as it seeks to enhance access to quality health care for North Carolina communities.”
Early success
One example of ICARE’s success is its western region pilot, which concluded in June 2008. The pilot focused on integrating patients with severe, persistent mental illness and at least one chronic physical health condition into primary care practices. The effort was led by case manager April Conner and professionals from Mountain AHEC, the local management entity, and Access II Care of Western North Carolina, the local network of the state’s Medicaid care management organization. Through care coordination, Conner facilitated referrals, helped ensure treatment plan compliance, and made psychiatric consultation available to PCPs.
The pilot supported on average 80 patients, the majority of whom had bipolar diagnoses. At launch in July 2006, fewer than two percent of Conner's clients received integrated care. Within two years, 58 percent of patient charts included documentation from a specialty mental health care provider, a release of medical information, or both. As a result of this success, Access II Care staff are now trained to monitor behavioral health conditions and collaborate regularly with behavioral health staff.
Like RCCHC’s Mark Boyd, however, Conner believes the best proof of success is found in individual cases. After six months of coordinated case management, a bipolar client with a history of crack cocaine use was clean and sober, medically stable and linked with primary care, mental health, and substance abuse services. "Two years ago, there would have been no contact between primary and mental health care, and these problems would have gone unaddressed," said Conner.
While final data are still being gathered through focus groups, self-reporting, and Medicaid claim analysis, early research indicates that these pilot projects improved access to local services. Patients report daily improved medical and mental health and PCPs have increased behavioral health referrals.
Future challenges
For all its success, the ICARE program faces a number of challenges, not the least of which is securing additional funding in an uncertain economy to explore some of the more promising strategies identified in the pilots. While significant progress has been made at local levels, many institutional, regulatory, attitudinal, and reimbursement barriers remain entrenched among the professional and public health communities.
ICARE advocates believe North Carolina needs an intergovernmental task force to address those barriers and they cite the absence of such a group among their primary concerns. A lack of regional leadership also impedes the delivery of integrated care; while two regionally-organized entities have been charged with coordination of services for Medicaid recipients and uninsured residents, there is no statewide directive as to how these organizations should cooperatively meet the needs of the populations they jointly serve.
Further concerns include reimbursement, workforce, and communication issues. No integrated care effort can sustain without adequate provider compensation – professionals must be reimbursed for behavioral health screenings, consultations, and interventions. Secondly, while ICARE has made significant progress in educating PCPs and behavioral health specialists, more must be done to support and promote care integration training in graduate, post-graduate, and continuing education programs. Additionally, obstacles to communication must be removed. ICARE partners suggest legislation that facilitates administrative and clinical information sharing. Stakeholders also cite overly restrictive federal confidentiality regulations and recommend the state lobby for revised statutes.
In the face of these concerns, however, ICARE advocates are encouraged by the program’s considerable success to date and the clear promise of coordinated health services. The partnership plans to continue its work in North Carolina as long as necessary, further uniting North Carolinians behind the valuable integrated care model.