Abstract
Background: Our team has worked over the past decade with a local insurance company and our hospital to develop innovative programs to meet the needs of vulnerable and underserved patients in Western Colorado in the US. The team has built on our previous work addressing the mental health needs of patients in rural primary care (2015-2018) to addressing the needs of high utilizing, low SES patients with complex biopsychosocial needs (2022-Current).
Approach: Project IMPAC (Integration to Minimize Potentially Avoidable Costs) was created to flexibly adapt to the needs of a marginalized and vulnerable population. Services include a multi-disciplinary integrated team approach to meeting patients where they experience the most need, including in the ED/Hospital, in their homes, and in the outpatient setting and developing a highly tailored treatment plan based on the idiosyncratic needs of the patients. Treatment plans range from complex trauma-based therapy to weekly social ""walks” by a trained therapist and are aimed at patient-led goals.
A further objective is to train family medicine residents and masters of social work students in both the inpatient and outpatient settings to be competent in complex patient management through integrated teams. By providing direct service to at risk patients, training for future providers, and partnering with insurance systems, higher education and community-based groups, the IMPAC project aims to make an impact on macro, mezzo and microlevel systems. Using an Implementation Research Logic model, this program design was shaped by grant proposal guidelines, clinic/hospital policies/workflows/barriers, and most importantly, patients.
To address the heterogenous needs of the target population, IMPAC was designed with maximal flexibility. This iterative program design allows for continuous input from patients, providers and key stakeholders, thereby permitting change according to shifting needs and data. For example, in response to input from providers and patients, our team created a separate Inpatient Behavioral-Health Consultant service to serve a larger number of high-risk patients during their hospital admission. Progress and outcomes of the project are monitored by the partnering insurance company and hospital administration.
Results: ED visits have been significantly reduced for patients involved in the IMPAC project as well as improved healthcare experience and mental health outcomes. Pts report increased cohesion of their team, better medication management, new coping skills, and higher ability to self-regulate. Further, provider frustration has decreased while residents report increased confidence in working with a difficult population.
Implications: When programs are adaptive and able to meet patients where they are (e.g., domicile, other location if unhoused, hospital, outpatient clinic, etc.), patients are more likely to get better. By having trained mental health therapists meet patients in multiple settings and provide continuity of care (wrap-around services) across these settings, patients can better trust their team and navigate the myriad obstacles toward optimal healthcare, including reduction in crisis care/emergency department services. The next steps for the IMPAC project are to identify specific interventions within the program that can be replicated and scaled.