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Integrated Care

Objective

Define, develop, refine, and implement the Dartmouth-Hitchcock Integrated Care Model.

Overview

The co-occurring complexities of mental health, physical health, and substance use in our patient populations are requiring many changes to the health care system so that services effectively meet the demand. With mental health and substance use disorder services, including behavioral health treatment, being listed as one of the 10 categories of essential health benefits in the Affordable Care Act, the integration of primary care and treatment of behavioral health issues, including depression, anxiety, and substance use disorders (including alcohol), has become a more viable option over fragmented disciplines.

Aligning incentives for improved care coordination and supporting the use of multidisciplinary care teams that address individuals’ total health care needs, the evolution of integrated care is being supported. Dartmouth-Hitchcock clinical teams recognize the interwoven impacts of substance use disorders with chronic disease management, and the relationship of mental health disorders and individuals’ use of substances.

This project seeks to support clinical teams with the knowledge and tools for progression of both prevention and intervention strategies within the primary care setting. Integrated care means expanding the range of treatment options for individuals with opioid, alcohol, and other drug addictions as well as supporting coordination of mental health services effectively with multiple providers and departments.

Patients/populations impacted by this project

  • Adults with mental health and/or substance use disorders

Process/systems being improved

  • Integration of primary care and mental health
  • Screening tools and practices
  • Evidence-based addiction treatment
  • Referral patterns
  • Inpatient utilization
  • Alignment with community resources on shared goal

Provider teams involved

  • Lebanon Primary Care
  • Nashua Primary Care
  • Psychiatry
  • Case Management

Economics of care

  • Clinic operational efficiency

Project team

Leaders

  • Dr. Jonathan Thyng, a family physician and the Associate Medical Director for Primary Care at Dartmouth-Hitchcock Nashua.
  • Dr. Matthew Duncan, a psychiatrist at Dartmouth-Hitchcock Medical Center in Lebanon and Assistant Professor of Psychiatry at Geisel School of Medicine at Dartmouth.

Members

  • Jennifer McComisky
  • Charles Brackett
  • Lisa Murphy
  • Mary Fauteax
  • Lora Council
  • Megan Todd
  • Patricia Laliberte
  • Alexandra Zagaria
  • Cara Baskin
  • Inas Khayal
  • Mark McGovern
  • Joanne Wagner
  • Peter Demary
  • Martha Bruce

Learning and data

Initial data collection is focused on a better understanding of primary care panel profiles, the numbers of patients with behavioral health conditions, the rates of mental health screening being done with active patients, and the rates of chronic conditions.

Resources

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