Cherokee Health Systems is a National Leader in Primary Care and Behavioral Health

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Cherokee Health Systems is widely acclaimed as a national leader in integrated primary and behavioral healthcare delivery. Their integrated practice teams boast extensive expertise, continually innovate to enhance service delivery and conduct integration training.

Integration workflow includes behavioral health screening in primary care visits and telehealth visits. Medical assistants frequently screen patients before seeing their PCP or take warm handoffs from PCPs to BHCs.

Integrating Primary Care and Behavioral Health

Cherokee FQHC/CMHC has become a pioneer in integrating primary care and behavioral health services. Their model embeds behavioral health consultants, often psychologists or clinical social workers, within direct care teams; these professionals screen all patients for depression or substance abuse symptoms and co-manage those that do not improve with primary care providers. They also work closely with primary care providers to address patient barriers such as transportation or subspecialty care services.

Interviewees at Cherokee emphasize how this organization recruits staff who embody its core values first, then trains them with the necessary skills for their roles. There are weekly and monthly training calls tailored specifically to roles at Cherokee; meetings provide inspiration and informal learning opportunities. Furthermore, Cherokee offers training for other organizations or clinics looking to implement its model.

Cherokee utilizes technology to complement its integrated team approach by supporting a central care coordination function that searches for gaps in care. Their Behavioral Health Screening and Assessment (BPSA) tool, developed over two years, has improved quality care delivery and increased efficiency; data is displayed on patient dashboards, with reports generated for providers based on various quality metrics.

BPSA can be utilized for in-person and telehealth appointments, with most usage coming from traditional primary care settings such as Center City Clinic. A typical workflow typically entails rooming patients into an exam room before conducting preventive screenings (PHQ-9, Spirometry) followed by a medical visit with nurse/CNA assistant(s)/providers; an exception report will then be reviewed by providers to identify any gaps in care that need bridging.

The BPSA scores are included in each patient’s electronic health record and used to notify providers about additional follow-up needed. A separate team, comprised of psychiatric nurses and clinical social worker members, conducts outreach to help follow up on care utilizing in-person and telehealth visits to meet the needs of a highly rural, underserved patient population.

Telemedicine

Cherokee Health Systems is a Federally Qualified Health Center and Community Mental Health Center with a long tradition of offering integrated primary care/behavioral health. Due to its flexible structure, they have provided care for a diverse patient population while successfully meeting patient needs, such as behavioral issues. Furthermore, Cherokee is a model for training others on primary care/behavioral health integration.

The system operates 22 clinics, 13 offering fully integrated clinical locations and telehealth sites serving schools and other settings. Their Behavioral Health Department places particular emphasis on prevention and early intervention strategies.

The BHC accomplishes this goal by screening all patients for substance use at every visit, regardless of whether they see their primary care provider. A medical assistant (MA) may screen patients by asking questions and measuring distress levels; if she suspects psychiatric issues may exist in any patient, she contacts the BHC and arranges an appointment if necessary – otherwise a physician will follow up based on BHC reports or arrange home visits from nurse specialists.

All Cherokee patients are also screened for depression by BHCs trained to recognize risk factors and help patients seek treatment for depression. BHCs work closely with primary care to monitor progress; should more intensive support be necessary, they may refer the patient for evaluation by psychiatrists, psychologists, or social workers.

Cherokee also uses telemedicine to connect patients to providers at its integrated clinics and specialists. Telemedicine has been utilized for 15 years in psychiatry alone, and they’re starting to use it more extensively across primary care.

Cherokee places great importance on reaching remote areas with services that may not otherwise be available through school health sites, telehealth and outreach workers, and bilingual staff – and has successfully treated students for everything from ear infections to seasonal flu via this model.

Population Health Management

Population health management combines public and behavioral/mental health. This field relies on data gleaned from health care claims, hospital, and emergency room visits to identify populations at high risk of poor outcomes or in need of specialty medical services, using claims data as well as hospital, ER visits, claims data from claims, hospital, and emergency room visits to target these specific patients and then considers social and environmental influences that might impact these health outcomes and use of healthcare resources, including housing, education, income security food security transportation, etc. This allows population health managers to develop interventions based on these factors that improve results further.

Cherokee Health’s approach utilizes an informatics department that performs regular downloads from its hospitals and emergency rooms. It uses this data to populate a patient dashboard, making it available to each clinic’s primary and behavioral healthcare providers. Interviewees reported that patient dashboards have made tracking quality measures, identifying gaps in care, and communicating more meaningfully and relevantly with patients more straightforwardly and easier.

Cherokee also provides a community health coordination function that works to identify barriers to care by searching its registries and documenting issues arising therein. Once identified, this team documents and reports these to clinics so they can contact patients to address these problems and update care plans as necessary. Furthermore, centralized care coordination functions offer support services to patients having difficulty connecting with primary or behavioral health teams.

Cherokee stands out in its workflow with the speed with which behavioral health personnel can be integrated into primary care visits. They may meet with patients before or after medical holidays for therapy sessions or provide short behavioral change interventions during visits with primary care practitioners (PCP). BHCs may even work independently of them if desired.

Cherokee staff members have extensive training in numerous behavioral/mental health disciplines and offer services at all levels of the organization, creating a cohesive team that can support patients while simultaneously addressing multiple issues. It has also built trust between staff members, making it easier for patients to open up about sensitive personal matters.

Community Outreach

Cherokee Healthcare Services’ CEO, Dennis Freeman, stresses the organization’s dedication to meeting where needs are most significant, which drove their decision to integrate behavioral health services with primary care, hire outreach workers, and incorporate school health sites as well as utilize telemedicine and other modalities in meeting population health.

Cherokee Health Center provides primary medical services, including well-child visits, diagnosis and treatment of acute illnesses, immunizations, school and sports physicals, and management of chronic conditions such as asthma and gynecological issues. They also offer counseling for behavioral health issues like depression and anxiety, stress management strategies, parenting support needs, and help dealing with life traumas.

Behavioral Health Consultants (BHCs) are integral members of primary care teams, often acting on an on-call basis like their primary care colleagues. Primarily psychologists with mental health backgrounds, BHCs are available during direct care visits for assessment, triage, and intervention as part of assessment triage and intervention, should a psychiatric referral be necessary, as well as medication support therapy as indicated.

Pediatric therapists work within clinics to assess and treat various behavioral disorders in children and adolescents, such as depression and anxiety, poor social skills, oppositional defiance behavior, and trauma and stress. Additionally, they treat behavioral problems such as attention deficit disorder and conduct psychoeducational group therapy sessions for young children. Their services are assisted by behavioral health assistants who aid them with patient assessments and education.

Therapists in school settings offer services including individual and family therapy, crisis management as clinically indicated, parent training/collaboration programs, and consultation with teachers/counselors. Their schedule can also offer consultation and collaboration with these groups of individuals in Anderson, Blount, Hancock Knox Sevier & Alcoa city schools.

The leadership team regularly reviews clinical data. The data team meets regularly to customize EHR fields and reports to support behavioral health needs better, track high-risk patients, inform PCPs when their appointment is due, and increase adherence after psychiatric discharge by linking patients directly to programs before leaving the hospital.