Texas Health and Human Services Commission has committed $1.9 million to support homeless services, including expanding shelter services and shelter redesign, increasing access to mental health and substance use services for families experiencing homelessness, and supporting clinic operations and the expansion of housing services at Terrace at Oak Springs. Set to open in summer 2019, this new permanent supportive housing community includes 50 fully furnished, single occupancy efficiency apartments and an onsite integrated health care clinic – 3000 Oak Springs Clinic. Features include onsite staffing 24 hours a day, onsite laundry facility, outdoor green space, community room with library, computers, and internal and external security cameras. Terrace at Oak Springs is modeled after other successful programs across the country and the first of its kind in Central Texas.

The 3000 Oak Springs location provides integrated primary health care and mental health care to residents of the apartment community. Services include counseling and case management, drug and alcohol treatment, exercise and nutrition programs, medication management and support, employment services, and assistance accessing benefits. Clinic services are also available to adults in the community who are eligible for Integral Care services. The clinic will be open 8 AM to 5 PM Monday through Friday, and will offer scheduled appointments and a limited number of walk-in appointments. Community members will be able to access clinic services through the same intake and assessment process that Integral Care uses for all of its services.

Episcopal Health Foundation has awarded Integral Care $1.5 million to expand our clinical services and implement a new financing and collaborative infrastructure. As our interdisciplinary care teams research new interventions in our clinics, we can demonstrate improved health outcomes and reduced costs of care to managed care organizations and develop a case for a value-based payment structure. Partnering with Episcopal Health Foundation will help us create the infrastructure for this new payment system while providing us flexibility to continue our clinical work by bridging funding streams.

Our new Integrated Practice Unit at Dove Springs, an expansion of services offered by Dell Medical School and Integral Care at the Bipolar Disorder Center at UT Health Austin, will serve as the pilot site for this initiative.  Later this year, Integral Care will bring this collaborative approach to yet another clinic – our 3000 Oak Springs Clinic, which is part of the forthcoming Terrace at Oak Springs permanent supportive housing community.

Integral Care’s integrative, team-based approach provides a strong foundation for implementing a value-based payment structure, which relies on collaboration and coordination throughout the cycle of care. By showing the improved health outcomes and reduced care costs of this care delivery model, we can collaborate with managed care organizations to create a value-based payment system that focuses on improving quality of care, rather than increasing quantity of services.

AUSTIN, Texas — Of the more than 7,000 people who experience homelessness in Travis County each year, many have complex health problems as diverse as heart disease and asthma. To help address these persistent challenges, Dell Medical School at The University of Texas at Austin, CommUnityCare Health Centers and Integral Care, Travis County’s mental health authority, are joining forces to launch an innovative, federally-funded mobile care team that serves homeless individuals where they are.

The collaboration, which is funded by a five-year, $2.3 million grant from the Substance Abuse and Mental Health Services Administration (SAMHSA), will support homeless men and women who have a chronic medical condition along with serious mental illness and/or substance use disorder. The mobile, multidisciplinary team will be staffed by qualified health care providers who integrate comprehensive primary care, mental health care, substance use treatment, intensive case management, and wraparound services such as housing assistance and social programs enrollment into a continuum of care with one single team.

“Homeless Austinites living with multiple complex medical problems are among the most vulnerable and difficult to reach members of our community, but we believe that our innovative approach can work,” said Dell Med’s Tim Mercer, M.D., MPH, assistant professor in the departments of Population Health and Internal Medicine, who is the project director for this grant. Efforts to effectively treat this population require careful coordination among advocates and organizations working in Austin’s health ecosystem, he said.

“Our goal is to fill gaps in care by leveraging the existing strengths and infrastructure of the three collaborating organizations in a whole new way,” Mercer said. It’s also essential to coordinate efforts with other local organizations, such as the Ending Community Homelessness Coalition (ECHO), he added.

A 2017 Point-in-Time Count performed by ECHO found that 2,036 Austin residents experience homelessness on any given night, of whom 553 are chronically homeless, 345 have a substance use disorder and 519 experience serious mental illness. It also found that 61 percent of people experiencing homelessness access health care through an emergency room or not at all.

Meeting People Where They Are

One key design feature of the mobile model is that it allows the team to bring care to patients where they live, unlike the traditional model of requiring patients to seek services in clinics or hospitals to address their health needs.

“Normally the burden is entirely on the patient — they have to make appointments, figure out how to get a ride, go to the pharmacy, get their labs processed — they are constantly forced to jump through hoops,” said Audrey Kuang, M.D., clinical director of the homeless health care program at CommUnityCare and assistant professor in the departments of Internal Medicine and Population Health at Dell Med. “It’s tough enough for the average person, but for someone struggling with mental illness or chronically sick or worrying about their next meal, those hoops can be insurmountable obstacles,” she says.

Equipped with mobile medical supplies, laptops to access medical records on site, and well-honed “street medicine” engagement tactics, the team remains unfettered by the need for a building or an exam room to care for patients.

“We can meet with clients on the street, a park bench, under a bridge — wherever we need to be to serve them best,” says Kuang.

When more complex care is needed, the mobile team can also see patients in one of CommUnityCare’s 24 clinics or Integral Care’s four integrated mental and primary care clinics in Travis County.

The community-based mobile care team will consist of at least six health professionals, including:

• A primary care physician or nurse practitioner
• A mental health care psychiatrist or nurse practitioner
• A licensed chemical dependency counselor
• A nurse case manager
• A qualified mental health professional case manager
• A peer navigator

An important part of this community-based program is that it relies on the complementary strengths of the organizations involved. Integral Care has been providing outreach and recovery services to people experiencing co-occurring homelessness, mental illness and substance use disorder for over 20 years. Integral Care also partners with the Austin Police Department and Austin-Travis County EMS to connect individuals living on the street to housing, mental and primary health care and alcohol and drug treatment as part of the Homelessness Outreach Street Team. CommUnityCare, part of Central Health’s enterprise, provides primary care and standard case management services to the homeless as well. Dell Med’s population health experts will augment these existing resources through direct care, coordination among the partners, and research and evaluation efforts.

“We are excited to expand our partnership with Dell Med and CommUnityCare to further support our city’s homeless community,” said Darilynn Cardona-Beiler, director of adult behavioral health systems at Integral Care. “This grant allows us to bring our expertise together and innovate in a unique and effective way. Together, we’re meeting people where they are in the community — providing integrated primary care, mental health care and much needed substance use treatment on the streets of Austin.”

Measuring Success

In addition to serving as orchestrator of the project, researchers from Dell Med’s Department of Population Health will work to measure the success of the effort. Its data integration division will coordinate information from Integral Care’s and CommUnityCare’s electronic health systems and directly from patients to evaluate effectiveness and identify opportunities for improving and expanding this care model.

“By incorporating research into this project, we will be able to understand if this approach to caring for our city’s homeless works and can pay for itself, by reducing hospital and ER visits, for example, and if it can be scaled and replicated to improve the health of communities across the nation,” said William Tierney, M.D., professor and chair of Dell Med’s Department of Population Health.

The HOST team is a partnership between Integral Care, the Austin Police Department, Emergency Medical Services, Downtown Austin Community Court and the Downtown Austin Alliance. An approved increase of funding will cover the cost of a certified peer specialist/peer recovery coach and allow more funding to address immediate needs, like obtaining official ID documents and bus passes.

Find out more in this report from KXAN.

“Mental health services in Austin ISD is an essential part of educating the whole child,” said Tracy Spinner, district director of health services. “We are thankful for dedicated partners like Integral Care who have stepped up to continue services for our students at 16 campus mental health centers. While we are one step closer to supporting our students, the need for additional funds is still present and we are continuing to meet with potential partners to fully fund these services.”

The Austin school board Monday night approved an agreement with Integral Care to keep 16 campus mental health centers open this school year. Read more in the Statesman.

U.S. News and World Report shined a spotlight on Integral Care’s integrated care services. The article features an Integral Care client who lives with bipolar and obsessive-compulsive disorders and benefits from integrated mental and physical health care as well as wellness services. Our client says, “It has really built me up to be a better woman.” The story also features our partners Dell Medical School and CommUnityCare.

Integral Care’s Systems Chief Medical Officer James Baker wrote an article for this month’s TexasMedicine about the ways our state can focus on prevention and early detection of mental illness.

By James G. Baker, MD, MBA

It is far too common in psychiatry for diagnosis to first come in a crisis visit to the emergency department, the equivalent of diabetes being first diagnosed as ketoacidosis. That is why I am very persuaded by the argument that we should focus on early detection and treatment in mental health, just as in other medical specialties.

What if our medical association and our local medical societies took the lead in the development and implementation of strategic population mental health initiatives across the state focused on early detection and intervention of mental illnesses? Our shared vision could be a statewide population mental health initiative with four parts:

Routine screening for depression, anxiety, and post-traumatic stress as a part of every outpatient clinic visit in Texas. Mental health screening could ― and should! ― be just as routine as temperature, pulse, and blood pressure screens for every adult in Texas, whether care is provided in the public or private sector. As an example, The University of Texas Southwestern’s Madhukar Trivedi, MD, has an iPad software program, VitalSIgn6, that screens for depression and can be modified to screen for other common mental health challenges.

Routine substance-use screening as part of physical exams for every teenager and adult in Texas. The NIDA Modified Assist (for adults) and the CRAFFT (for adolescents) are examples of quick, easy-to-use screening tools. Significant reductions in alcohol and substance use can result when screening is followed by a nurse or social worker offering brief, evidence-based intervention at the same doctor visit.

Easy access to evidence-based, first-episode psychosis treatment and research protocol for every newly diagnosed patients in Texas. Early and aggressive treatment in programs like RA1SE have been shown to improve markedly the outcome of patients with schizophrenia and other psychiatric disorders that include psychotic symptoms. Its availability currently is limited, but detection and early treatment are just as important with schizophrenia as they are with cancer.

Easy access to mental health first-aid training for everyone in Texas. Mental Health First Aid is a training course started in Australia 15 years ago that is now available statewide for anyone in the community, including first responders. The training reduces stigma, and, just like CPR, Mental Health First Aid has the potential to save lives. Our goal could be to train 750,000 people statewide.

Perhaps our medical association and local medical societies could partner with medical school departments of psychiatry, with local mental health authorities, and with local and statewide philanthropic organizations to demonstrate quick and quantifiable success in our four-part, population mental health initiative. Armed with that data, we could approach policymakers with strategies to improve access and quality of mental-health and substance-use services to everyone in our state, especially to the poor.

The potential impact on our patients and our communities ― and on each one of us ― is huge. As a mother, father, son, or daughter, you are just as likely to have family affected by mental health as by cancer ― up to one in three Texans has a mental health and/or substance use disorder. As a taxpayer, you help fund at least $1.4 billion in emergency department costs from mental illnesses presenting in crisis.

Each of us now knows that mental illness is medical illness, just like diabetes, cancer, or cardiovascular illness. And each of us knows that contemporary mental health care is rooted in science. Next, we must insist upon prevention, early intervention, and aggressive treatment for people who endure these potentially devastating disorders. When all that is required for early detection is a couple of questions asked while taking a pulse, then collectively we must insist that those questions get asked.

James G. Baker, MD, MBA, is a member of the Texas Medical Association Council on Science and Public Health. He also serves as associate chair of clinical integration and services in the Department of Psychiatry at The University of Texas at Austin Dell Medical School and as systems chief medical officer for integral care, the community mental health center for Austin and Travis County. Dr. Baker is a Distinguished Life Fellow of the American Psychiatric Association and a recipient of the National Alliance for the Mentally Ill Exemplary Psychiatrist Award as well as the Mental Health America of Greater Dallas Pamela Blumenthal Memorial Award.  

The commentary article was originally published on the Texas Medical Association’s website here as part of TMA Publication TexasMedicine February 2018.

The Austin Chronicle highlighted how Integral Care works closely with community partners to support the mental health needs of Travis County, particularly those experiencing a mental health crisis. “Anyone can experience a mental health crisis,” said Laura Wilson-Slocum, Integral Care Practice Administrator. This article explores the variety of crisis services Integral Care provides our community – the Judge Guy Herman Center for Mental Health Crisis Care provides short term crisis care in an overnight setting, our Mobile Crisis Outreach Team co-responds with the Austin Police Department and EMS to provide community-bases crisis care, and our Psychiatric Emergency Services provides mental health urgent care seven days  a week. Read the article here.

Spectrum News recently highlighted the impact of our 24/7 Crisis Helpline. They interviewed Ca’Sonya, an Austinite who used the Helpline to get through her darkest hour. After Ca’Sonya lost her husband, she decided to make a life-changing phone call to get the support she needed. “The hardest step is just starting picking up the phone,” said Nicole Warren, Integral Care Helpline Program Manager. “Once you pick up that phone, you’ll find someone who is passionate and dedicated to what we do here.”

Integral Care’s Helpline provides around the clock crisis support and access to all of Integral Care’s programs and services for adults and children, including appointments and billing. Our Helpline recently added free interpretation services in 15 language to meet the needs of our growing and changing community. We have trained medical interpreters who speak Spanish, Chinese, Vietnamese, Arabic, Korean, Filipino, Russian, German, French, Urdu, Farsi, Japanese, Hindi, Gujarati, and Napali. Learn more about the Helpline.