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A Profile of Three Approaches to Integration















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Behavioral Health providers are increasingly moving toward integrating primary care services into their program offerings. Many organizations point to statistics showing that people diagnosed with a mental illness die 25 years younger than the general population because of problems accessing health care. Other behavioral health leaders view an integrated care approach as the key to their ongoing survival in the age of health care reform. They understand that by delivering these much needed services into the communities this also brings great opportunity for new partnerships. In addition it provides access to new revenue streams. Whatever the motivation, it is becoming resoundingly clear that integrated care will be part of our future.


In late 2011, The Echo Group met with a group of customer organizations for its first Primary Care Integration Summit. Customers involved with primary care initiatives came together to share the details of their projects to generate a better understanding of the requirements, concerns and opportunities they have as Behavioral Health providers in an integrated care world. The group was diverse, ranging from organizations evaluating integrated care approaches to customers who had drafted plans for integrated care to Substance Abuse and Mental Health Services Administration Primary and Behavioral Health Care Integration (PBHCI) Program Grant awardees. Here is a deeper look at three of the organizations that participated in the Summit.



The Kent Center’s Total Care Integration Project (TCIP) focuses on health and wellness by developing a primary care practice in the Kent Center’s main facility. Leaders at The Kent Center recognize the importance to provide a total wellness approach to care for all of their clients, whether they originate as Behavioral Health clients or Primary Care clients. With few FQHC’s (Federally Qualified Health Centers) in the area, opening a clinic offered the best route to fulfilling The Kent Center’s vision of Total Wellness. The first steps were rehabilitating an area of their building to include nine exam rooms, choosing a local Primary Care Physician as Medical Director and partnering with the YMCA to implement fitness and wellness programming.

Currently, the clinic is staffed with one doctor, one nurse practitioner and two medical assistants. Community Support staff coordinate Behavioral Health services. TCIP is planning to grow to serve approximately 4,000 patients per year with three doctors on staff. A unique aspect of The Kent Center’s approach is that one does not have to be a client of their Community Support Program to receive primary care services. The Center’s goal is that the population receiving primary care services is 85% insured to sustain the viability of the clinic’s services.

An important part of the project is establishing the right technical platform and electronic health record (EHR). The Kent Center upgraded their network infrastructure to support the project. When it came to finalize an EHR


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strategy, they decided to expand their utilization of The Echo Group’s Visual Health Record (VHR) EHR for

Behavioral Health services but chose to adopt the medical practice management system preferred by their Primary Care Physician. While using two separate EHR systems, The Kent Center will take advantage of both systems’ ability to exchange Continuity of Care Documents to make sure up to date information is available in both EHRs. While The Kent Center is a long time Echo customer, their use of the system had been primarily focused on billing and demographics. David Lauterbach, CEO, cites adjusting to new software configurations as a primary challenge. This is a common theme for any organization expanding their use of electronic health records as staff integrate new tools into their day to day workflow.

Lauterbach is enthusiastic about the development of the clinic and support from the community has been strong. He summarized reaction of other medical providers in his area as “You can’t have too many primary care

providers”. While much has been done, he knows that these first steps to advance integrated care and expand the use of technology in his organization are part of an ongoing process to refine their use of EHR.


Heritage Behavioral Health Center has collaborated with their local Federally Qualified Health Center for several years to coordinate primary health care services for their behavioral health clients. Their efforts to establish a medical home and improve the overall wellness and physical health of individuals with serious mental illness were boosted this year when they too were awarded PCBHI funding for their project. They have expanded wellness programming and now have a Physician’s Assistant at their primary location to work with individuals with identified health issues like diabetes, obesity and high blood pressure. They are beginning to participate in local conversations about health information exchange.

Heritage has used the Clinician’s Desktop EHR for over ten years and is expanding their EHR implementation to collect data on primary care activities and use the Visual Health Record. “Collecting reportable, discrete data elements is important for us to understand the impact we are creating through integrated care” said Candace Clevenger, CFO. “We want to correlate weight loss, blood pressure and other health indicators to behavioral health outcomes. This is a unique and valuable aspect of delivering integrated care. After all, there is no blood test for depression. Good data will be critical as we look at evolving reimbursement models for medical homes, managing risk and how we can ensure sustainability of our services”.

The FQHC currently provides Heritage scanned copies of service documentation for identified integrated care clients. As their EHR can send and receive Continuity of Care Documents (CCD), they are anxious to move in this direction as the health center works to expand the use of this technology. When it comes to using one

information system for all services, Ms. Clevenger explained that “in our state, primary care and behavioral health billing requirements are so different that we may need to utilize two software solutions to address the needs, although our goal is an integrated system.” Heritage is looking for this opportunity as they follow the evolution of integrated care closely by working with State and National Associations.


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As part of a strong commitment to extend the lives of individuals with serious mental illness, Grand Lake Mental Health Center (GLMHC) set a vision to establish health homes for their consumers. GLMHC’s work was kick started last year when they took advantage of Echo’s fully certified electronic health record to be the first behavioral health organization in the nation to garner Meaningful Use EHR Incentive funding.

The organization is a true success story in this regard as in just a little over 12 months from their meaningful use funding, they are actively providing primary care services to people they serve with mental illness. GLMHC took an approach that was a bit different than their peer organizations in the state of Oklahoma. Instead of a Case

Management approach with a focus on linkage to services, GLMHC chose to open their own primary care clinic and a recent evaluation by the State of Oklahoma has drawn an increased interest in the model.

Early in the process, GLMHC hired Sandy Kiefner, RN as their Integrated Services Program Administrator and, aided by her experience in managing primary care practices, GLMHC determined that their existing Echo EHR and billing system could support their needs when delivering basic primary care services. “Our goal is integrated care and we felt strongly that this meant an integrated record. The EHR is the biggest piece of the puzzle in providing

integrated treatment,” said Steve LaFleur, CIO. “In reviewing medical EHR products at HIMSS, they don’t have a solution for core behavioral health record components like assessment, treatment planning and decision support. Once Echo’s Clinician’s Desktop VHR was a fully certified record with functionality for vital signs, labs and

Continuity of Care Documents, we knew it could be a platform for our primary care efforts.” LaFleur described the integrated care doctor’s note as key to their organization’s approach, “The flexibility of the product allowed us to create a doctor’s note format that captures all the information required during a medical visit. This includes reportable structured data elements for all aspects of the visit. ”


The integrated care movement in behavioral health has just begun and the customer stories outlined here demonstrate that a standard approach isn’t defined yet. This lack of a clear model is true for not only how organizations deliver primary care services but also for how electronic health records will be used to support integrated care. Enhanced care and new revenue streams are common motivations, but the approaches are all different. Service delivery is being addressed with contract medical care, partnerships with health care providers or by developing and owning a primary care clinic. EHR approaches are equally diverse including using behavioral health and primary care EHR’s by provider type, using CCD data exchange to move data between two disparate records or focusing all work in Echo’s behavioral health EHR and billing system.

The learning is really nothing new for Behavioral Health organizations and software vendors alike. The future of integrated care in Behavioral Health is yet to be written and change will be the norm. This will demand an opportunistic, creative and flexible mind set. For The Echo Group and the customers outlined here, flexibility of the product to support unique opportunities has been critical to success. It has allowed them to adapt to local needs, regulations and grant requirements to make their vision of primary care integration a reality.


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5 About The Echo Group

Since 1980, The Echo Group has been developing enterprise software applications that have been used

nationwide to address the needs of Behavioral Health organizations. Echo offers a suite of

Windows-based and Web-Windows-based applications for Administrative, Fully Certified Clinical EHR and Billing

functions. They also offer a suite of services, including Transaction Management Billing Services and

Fiscal and Clinical Process Workflow Analysis.

The Echo Group