Editor's note: The following is an excerpt from FierceHealthcare's newest free eBook, Population Health Management: How to Manage High-Risk Patients
Efforts to control healthcare costs and reduce utilization require all hands on deck--from all hospital departments and service lines. The most successful hospitals use multidisciplinary teams to integrate care for better outcomes and lower costs.
One such hospital is Montefiore Medical Center in the Bronx, N.Y. Once it recognized patients who have behavioral health issues on top of chronic illness have poor outcomes and rack up significant healthcare costs, it integrated behavioral health and clinical care.
Montefiore, comprised of four hospitals with 1,491 beds, formed a team to support primary care physicians that included a care manager to educate patients and perform necessary follow-up, a behavioral health manager to conduct onsite evaluation and short-term psychotherapy, a psychiatrist to provide individual consultations with complex patients and psychotropic medication management, and telephone interventions to lower the cost of care, according to Henry Chung, M.D., vice president and chief medical officer, The Care Management Company, Montefiore Medical Center.
"There have been models out there that are quite evidence-based that have demonstrated that if you use a team-based approach … you can really impact both medical outcomes and behavioral outcomes," Chung says.
Thanks to integrated care efforts, Sacred Heart Hospital in Eau Claire, Wis., was able to reduce fragmentation and break down its silos. For instance, in its program, daily patient rounds include the doctor, nurse and therapist, who together develop goals for each day, according to Pat LuCore, assistant administrator for Sacred Heart.
Similarly, its cancer program holds conferences with pathology, imaging, radiology, medical oncology, radiation oncology, nurse navigation and palliative care all participating in the discussions. She notes that having all the disciplines work together has helped the organization take all of the patient's needs into consideration.
While attending one of these conferences, LuCore had what she calls an "a-ha moment," realizing the multidisciplinary meetings involve healthy discussion about what is best for the patient. "That's a pretty wide gamut of disciplines that are there all for the main goal of developing what is truly the best care for that patient."
With similar goals in mind, Montefiore's integrated care program involves nurse coordinators in depression self-management and social workers in the treatment plan and monitoring chronic conditions, according to Chung.
"From [the] patient perspective, they don't see it as 'oh the social worker only cares about the behavioral condition and the nurse only cares about the medical condition.' No, everybody is caring about the whole person and what the total issues are to help them get the best outcome possible," Chung says.
To read the entire article, which includes strategies and best practices to integrate care, download the free FierceHealthcare eBook, Population Health Management: How to Manage High-Risk Patients.