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Alliance formed to improve care for high-risk, low-income patients with mental illness

Currently, patients are sometimes seen by a patchwork of providers who have limited access to their medical records, creating opportunities for unintentional error.

These days, most physicians and health plans believe in the power of integrative care, or the use of enhanced physician communication combined with electronic medical records to ensure coordinated and effective treatment for patients across medical systems.

But for many people with serious and chronic mental illness, cross-system integrated care has seemed just out of reach.

This winter, a new alliance of five Twin Cities community mental health providers has come together to form the Minnesota Community Healthcare Network (MCHN), a health information exchange that will link the medical records of the more than 22,000 patients they serve and provide secure access to those records for health-care providers and emergency personnel around the state.

If health providers have access to a patient’s full health history, integrative care proponents believe, patients will receive the best possible health care.

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“Integrated and coordinated care is important for everyone,” said Grace Tangjerd Schmitt, MCHN chair and president of St. Paul community mental health provider Guild Incorporated. “If you go to a heart specialist, you are going to hope that your cardiologist will coordinate any care and treatment that they prescribe with your primary physician. The same goes for a person with schizophrenia or bipolar disorder who’s been seen in a hospital’s psychiatric department.”

Clients served by the five MCHN organizations — Guild Incorporated; Canvas Health; Mental Health Resources, Inc.; RESOURCE, Inc.; and Touchstone Mental Health — often face complex health problems that impact their housing, health and lifestyle choices, Schmitt explained. They are sometimes seen by a patchwork of providers who have limited access to their medical records, creating opportunities for unintentional error.

Illustrating the need

To explain the importance of coordinated care for people with serious mental illness, Schmitt tells the story of Charles, a 40-year-old African-American man with a history of seizures, psychosis and major depression. A client of Guild Incorporated, Charles, who has completed a high school degree and barber training, has experienced homelessness on and off since 2004.

Grace Tangjerd Schmitt
Photo by Jen Kelly
Grace Tangjerd Schmitt

Charles’ Guild Incorporated case manager worked with him to find an apartment, a primary care doctor and pharmacy. When a recent psychotic episode landed Charles in a hospital psych department, physicians there were unable to access his medical records, and Charles was unable to fully explain his health history. Unaware that he was a Guild client, workers at the hospital prescribed antipsychotic medications that were different from the medications Charles had been taking before his episode.

When Charles was finally discharged from the hospital, he and his Guild Incorporated nurse had to spend hours untangling the efforts of the well-intentioned hospital physicians.

“Everyone at the hospital had Charles’ best interests in mind,” Schmitt said, “but without access to his medical records, they weren’t working from the same playbook as we were.”

If everyone — from the EMTs in the ambulance to the nurses and physicians in the hospital — had access to his complex medical history, Charles would have had better care at a lower cost, Schmitt said.

Improved health, better efficiency

“The opportunity that our alliance is excited about is the potential for improved health and quality of life for the population we serve,” she said “We know we can use this health information exchange to reduce waste and increase efficiency in our systems.”

Automating and linking patient records from all five agencies will require months of work and many thousands of dollars. The alliance has been awarded a $567,597 State Innovation Model (SIM) grant from the Minnesota Department of Health  to complete the project. The target completion date is March 2016.

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“By that time, we should have all the processes in place for sharing information to support continuity of care,” Schmitt said. “Once we’ve got our system up and running, a hospital could query a health information exchange with the name of a patient like Charles and learn that in fact he is being served by our team. We will be able to securely share health information across systems.”

Schmitt and her fellow MCHN members are excited by this project’s potential. They see it as a great equalizer, an opportunity for patients facing serious mental illness to get the same quality of care as other Minnesotans.

“Some people are saying that the blockbuster drug of the century is patient engagement,” Schmitt said. “When patients are engaged in their health care, when their physicians are aware of their histories, patient outcomes will be better and they will be able to live healthier lives. At MCHN, we want people with serious mental illness to have the same opportunity to be engaged in their health care and have the same positive outcomes.”