Interviewer:
Tell us about yourself and your position as the VP for the Whole Health at Mind Springs. What you do, how you have gotten involved, all of that.
Amy Gallagher:
I’m Dr. Amy Gallagher, licensed psychologist, and my title is Vice President of Whole Health LLC. Whole Health was a way in which we could house a specialized workforce of community health workers, and we did that in response to a demonstration project in Medicaid payment reform. Community health workers by nature are not licensed employees, so housing them in an LLC allowed us to have increased freedom to communicate and the ability to more easily coordinate care. The Community Mental Health Center regulations are more strict.
Our program was boots on the ground from January 2014 through December of 2019. At the end of December, unfortunately, the contract was eliminated due to financial reasons, and in the interim, I’ve been working on special projects for Mind Springs Health and West Springs Hospital. We hope to be able to resurrect some type of program like this in the future.
Interviewer:
Why don’t you tell us a little bit about the Whole Health program with Rocky PRIME?
Amy Gallagher:
Whole Health had a workforce of community health workers in several counties across western Colorado, including Mesa, Garfield, Pitkin, Eagle, Delta, and Montrose, and we worked directly with Rocky Mountain Health Plans through their Rocky PRIME initiative, as well as with designated medical practices in those communities, in order to provide the community health worker resources to patients of those specific practices. We also worked with RMHP patients who were not attributed to any practice, and were having difficulty with finding a viable practice. We assisted with that search in order to help them succeed as patients in new practices. Many of the patients with whom we worked were also high ED or emergency department utilizers.
RMHP provided the medical practices with patient lists of high ER utilizers, and then the practices had the opportunity to review those lists and see if those patients might potentially benefit from a community health worker, or from working with some additional support. Since the practices knew their patients, they would be able to discern if ER usage was higher than typical. Similarly, if a patient was starting to struggle, the practice could offer the CHW resources as well. This gave the practices some ownership in the program.
Interviewer:
So you guys are partnering with Rocky Mountain Health Insurance to try to find those patients that are not getting the correct care they need, and trying to partner them with the specific practice that could help?
Amy Gallagher:
Yes, exactly. The ones who did not have medical practices, we were able to get them into medical practices. For the patients who were already in medical practices, we were able to work with the medical practice to meet with the patients and be introduced to the patients. Then the community health worker could kind of take it from there if the patient was interested in getting additional support outside of their doctor’s office.
Some of this was done via, a warm handoff. The doctor or nurse or behavioralist at the practice invited the CHW to meet with the patient during an appointment. The CHW introduced the program and the patient could agree to working with the CHW or not. If the patient was agreeable, the CHW scheduled a time to meet with the patient outside of the practice, in a place that was comfortable—usually at the patient’s home, or in a community space.
Interviewer:
Excellent. I think that explains the major points.
And how did this idea germinate? How did this all come to fruition?
Amy Gallagher:
Around 2011-2012, Sharon Raggio, the CEO at Mind Springs, and Patrick Gordon—who’s the current CEO of Rocky Mountain Health Plans, and was a VP at Rocky at the time. read the “tea leaves” in healthcare, and basically knew that the future of Colorado Medicaid payment would combine the behavioral and physical health care “buckets” of money. Since then, the future happened, and the RAEs (Regional Accountability Entity) are based on the premise that one payer controls the combined money for Medicaid physical and behavioral health care.
So basically, the conversations between Sharon and Patrick really were pretty innovative at the time. Their conversations focused on how the two organizations could start working together. Mind Springs Health demonstrated expertise in how to manage people’s behaviors, while RMHP understood how to handle the physical health care spend. Many of these patients were known to both organizations, so finding ways in which to coordinate care would be beneficial.
Rocky Mountain Health Plans, Mind Springs Health, and the Center for Mental Health, which is the mental health center to the south of MSH, shared their utilization data with each other, using actuaries representing each organization. The fact that these 3 organizations shared this data was significant as that was not a common practice.
What resulted included four different types of patients: patients who have both high behavioral health and high physical health needs, patients who have high behavioral health and low physical health needs, patients with low behavioral health and high physical health needs, and patients who have both low behavioral and low physical health needs. Conceptually, if there was greater spend in less expensive services like case management, and support, and primary care intervention for those individuals in the high, high quadrant, there would be decreased utilization, and expense, of higher cost services like ER visits. The most complex patients were also the patients using the ER most often, when maybe other interventions might have been appropriate.
To sum up, spending money on less expensive interventions, especially when using a workforce that is paid at a much lower rate than, say, an ER doctor or a specialist, will result in savings across the entire patient population.
Interviewer:
Excellent. Then they are getting care that is actually effective.
Amy Gallagher:
Yes. Effective care, lower costs, and better health in the population, as well as increasing the providers’ experience of their work. These patients are often labeled the most challenging. If the providers know that their patients are receiving the appropriate interventions outside of the practice, the burden of taking care of the patients is shared.
Because they’re communicating with others to make sure.
Amy Gallagher:
Yes.
Interviewer:
They’re not all just trying to figure it out on their own anymore.
Amy Gallagher:
Exactly. And that really is the basis of the triple aim (e.g. increased patient experience, better population health, and lower costs), or the quadruple aim, if you add in the provider satisfaction and experience.
Interviewer:
Yes. Everyone in medicine that we’ve talked to is like, you’d think this is such a no-brainer situation, where it’s like, let’s work together, let’s share data. As the family doctor and the specialty expert and the mental health doctor, let’s have everybody communicate and talk together so we know what’s actually going on with this patient. And you’d think that this would’ve been something that happened a long time ago, but it’s so innovative and new, and it’s actually happening now.
Amy Gallagher:
Yep. Yes, exactly.
Interviewer:
Yeah, we get it.
Amy Gallagher:
I’m so excited to hear you say this.
Interviewer:
It just makes sense. You look at the data, you see you have a patient who obviously needs some kind of mental health care, and you refer them to go see this mental health expert, and you say here’s the doctor, here’s the location, here’s the time, go set up your appointment and go to it. The vast majority of people don’t go because as soon as they leave that doctor’s office, they’re like, “I don’t want to actively figure this out on my own.” But if you have everybody working together, and make sure you have that warm handoff of, here’s the patient, I’m the doctor, I’m going to introduce you to this person, this person is an expert in their field and they know how to help you in a way that I can’t.
Amy Gallagher:
Yes! And what we did is, we took transportation out as the barrier.
We gave all the community health workers vehicles so they could drive the people around to where they needed to go.
Interviewer:
Yes, that’s it. If you remove the barriers to the access of care, people actually get it. Nobody’s actively trying to stay … I mean they’re struggling. Very few people are like, “I need to go do this, this, and this so I can be as healthy as possible.” No, they’re obviously struggling with things, there’s no reason you want to add onto their plate.
Amy Gallagher:
Yep, exactly.
Interviewer:
Awesome. So next question, what were the components of an intervention? Can you help break this down?
Amy Gallagher:
Basically the community health workers were committed to looking at the bio-psycho-social variables of an individual’s health. So when first working with them, they would screen patients for needs across the healthcare spectrum, really concentrating on the social determinants of health, like housing and food and transportation. They also looked at access to care issues if they needed access to specialty care for physical health, or certainly for behavioral health needs. By being patient-centered, the community health workers would help the individuals get their needs met, focusing first on the needs that were most relevant to that individual.
An example of that might be that the medical provider might have concerns about a patient’s blood glucose levels if they have a diagnosis of diabetes. However the patient might have concerns about teetering on the brink of homelessness, or where their next meal is going to come from. So by addressing housing or food issues first, which the patient identified as their most pressing need, then we could really just build some better rapport and deeper rapport with the patient. Then from there, once the ball was rolling on some of the things that the patient was most concerned about, the community health workers could then address some of the other issues that might be impacting the person’s life.
Interviewer:
Great explanation.
Amy Gallagher:
So we were building rapport, we were focusing on things that the patient really identified as being the most pressing need, and then maybe working up to other aspects in their life that could be impacted as well.
Interviewer:
That makes sense. I think that was a great way of explaining it. I followed that perfectly.
Amy Gallagher:
The CHWs were able to be very flexible in terms of communication with the patient, so if the patient preferred to have face-to-face visits at home, we could accommodate that. We could meet people in the community, or drive people around the community. If people were more comfortable talking on the phone, we would do that. If they were wanting to text, we could accommodate texting. Trying to be flexible to meet the patients where they were at was a huge part of the intervention as well.
Interviewer:
Awesome. Very cool. Then what were the results of this? What came out of this? What did you guys learn?
Amy Gallagher:
We used both qualitative and quantitative means of evaluation in the project over the six years, and due to the fact that we were always adding new patients into the program, it was kind of just a continuous door of new people coming in, as well as adding more and more staff that really created some difficulties in how we were collecting data. It was not a very clean data collection environment at all.
We tried to group people into various cohorts in order to compare like individuals to like individuals, so people who were in the beginning part of the program, comparing them to others who were starting the program, versus always comparing them to groups who had finished the program, that type of thing. Because we were doing that, however, our sample sizes of cohorts tended to be on the smaller side, so that sometimes made data collection a challenge as well.
The other thing that was a challenge in data collection was the fact that we kept adding measures to what we wanted to actually measure. So that was not necessarily clean, in terms of a robust research project. However I think out of our project we got great data. We definitely observed trend lines in ER utilization decrease. This was especially prominent in individuals who came to us with very, very high ED utilization. So 80, 90, 100 visits in 12 to 15 months
One patient that we worked with came in to us with about 100 ED visits during the 15 months prior to entering the program. She decreased back to about 30 visits for the year that she worked with the community health worker.
Interviewer:
Wow.
Amy Gallagher:
Yeah. And while 30 is a lot, many of those visits occurred in the first few months of the program and tapered off to about zero when she graduated the program.
Interviewer:
Wow.
Amy Gallagher:
Which is amazing, yeah. I mean that’s a huge success. So overall our cohorts demonstrated about 30% decrease in ER utilization during the time they were in the program, and then there was an additional 18% decrease after that, after being discharged.
Interviewer:
That’s pretty good.
Amy Gallagher:
Yeah. Another challenge to program evaluation, and this gets to the next couple things I’m going to talk about, was using patient reports. They filled out a couple of screeners for us. We actually were aware of several individuals who were not honest with their answers in order to try and stay in the program longer.
Interviewer:
Wow.
Amy Gallagher:
Yeah, which speaks to the great relationship that they had with the community health worker, as well as getting their needs met. However for our data collection, it wasn’t accurate.
Interviewer:
Right.
Amy Gallagher:
We used a couple of measures with the patients, and we did these when they started to work with us, at six months and then at discharge, which was usually around 12 months. Sometimes it was a little sooner than 12 months. Sometimes we kept people 13, 14, or 15 months in order to get a specific issue resolved.
First, we used the Western Colorado Needs Review. This is a home-grown tool from Mesa County. We developed it several years ago and had input from behavioral health, from social health personnel, and the medical personnel, to create lists of questions from each of those three buckets that would typically be asked when first meeting with somebody.
We put those three groups of people in three different rooms, everybody came up with their desired list of questions, and then we all came back into the same room and pared them down to 22 questions focusing on people’s biological, social, and psychological needs. Everyone in the room had to be comfortable asking all of the questions. So, there was a lot about transportation, when did you last visit your doctor or your dentist, how are you feeling most days, food, housing issues, those types of things.
Interviewer:
I understand.
Amy Gallagher:
We then added just a quick raw score in order to track some data with that. By discharge, 70% of the individuals whom we worked with had decreased scores on that measure, so that’s pretty good.
Interviewer:
Wow.
Amy Gallagher:
Yeah.
Interviewer:
Yeah, that’s great. For a trial project, basically.
Amy Gallagher:
Yeah, my CHWs were pretty proud of that one. For the next scale that we did—and we implemented this towards maybe the last 18 months of the program, so we don’t have as much data with this one—it’s the Generalized Self-Efficacy Scale, and it’s just a quick screener that measures someone’s self-efficacy, which is the person’s belief that they can do things for themselves, or get things done for themselves. We had them complete it the same three times when they started working with us, six months in, and discharge. And by discharge, 60% of the individuals increased their scores. A higher score on this one would mean that you identify as having more self-efficacy. So once again, pretty good.
Interviewer:
Yeah. You said 60%?
Amy Gallagher:
Yeah.
Interviewer:
Wow, okay. Then that was over the last 18 months?
Amy Gallagher:
It was mostly the last 18 months. We might have been using it during the final 18 months to two years of the program.
Qualitatively, we surveyed the medical practices at least twice a year in order to understand their usage of the program, their experience of working with a community health worker, and the comprehension of patient successes. Results always trended in positive directions with that.
Additionally, we obtained some suggestions on how to enhance the program. That was always a benefit of doing this as well. We also, in order to get this more representative governance, we had monthly meetings with Rocky Mountain Health Plans, with myself, and the medical practices, in order to review the data, brainstorm solutions to problems, and celebrate successes with each other. So we really worked on making sure that all of the relationships with people who are invested in this program were developed and cultivated in an ongoing fashion.
Interviewer:
Okay. Monthly meetings, good time to check in with everyone.
Amy Gallagher:
Yep. And separately I met with the practices monthly or quarterly, as well as met with RMHP monthly, in order to make sure everybody was on the same page. So a lot of what this program demonstrated was how to build and cultivate relationships across organizations.
Interviewer:
It’s too bad it’s … I hope you guys can get this up and running again.
Amy Gallagher:
Yeah. Me too.
Interviewer:
I mean the data’s there, it was working.
Amy Gallagher:
Oh yeah.
Interviewer:
Yeah, so how does that translate into dollars saved?
Amy Gallagher:
This is just on broad strokes terms. When we entered into the project, Mind Springs negotiated a shared savings relationship with Rocky. Basically if the entire Medicaid population of Medicaid PRIME had a decrease in their expenses over the cost of that year, Mind Springs would receive 30% of the savings. Even though we would’ve only worked with a small portion of the members, the ones with the highest needs. We earned savings throughout the program.
We helped save some money, clearly. And we were able to use that money to put back into Mind Springs and West Springs programming, so it was a way in which we could really benefit the overall organization, which was really cool to be able to do that, to be perfectly frank.
Interviewer:
Yeah. Is this why the program ultimately was ended?
Amy Gallagher:
Yep. It was a purely financial decision by RMHP. This was not about anybody not liking what we did.
Interviewer:
Okay. I’m curious with COVID, if this had continued, I wonder what would’ve happened with this. Would it have been even more of a benefit now that people are really struggling with access to care? Would it have been difficult to try to integrate this into something that you no longer can be doing face-to-face stuff? That would’ve been really interesting to see.
Amy Gallagher:
I think that this would’ve been an amazing opportunity for some other type of evaluation if we had kept going during the pandemic. The benefits or the lessons learned from doing this in a pandemic, who knows what would’ve happened?
Interviewer:
Yeah. We’re already seeing just such crazy numbers come out of, mental health skyrocketing, physical health problems skyrocketing, people who just aren’t going to the doctor because they’re afraid, and then now it’s like, what access to care is there when you can’t even see people? You can’t see your support system, it’s just…holy mackerel. Would’ve been interesting.
Amy Gallagher:
Yes, absolutely. I know, it’s so bizarre what happened this year. In general, but also in relationship to this.
Interviewer:
Yes.
Amy Gallagher:
Yeah, you just don’t know.
Interviewer:
Alas, hopefully we can bring it back.
Amy Gallagher:
Once we kind of come out of the more pressing parts of the pandemic and get things under control, I think the need for this, especially with so many people who might be out of work, and not able or not knowing how to navigate systems around housing and food banks and how to get unemployment and things like that, the need for this kind of thing is, I think, going to be pretty pressing.
Interviewer:
Yeah, I agree. This’ll be the time to rebound.
Amy Gallagher:
Yes, exactly.
Interviewer:
Why don’t we go over some of the success stories that came out of this.
Amy Gallagher:
Yeah, of course. I have a couple of examples, and I do want to say first, success is defined so differently for each individual.
Interviewer:
Of course.
Amy Gallagher:
One person’s level of success may be much different from others, and we do have some really big success stories.
The first one is a patient of ours who left town with her partner and found herself in a rural medical clinic in Utah after their car broke down. The clinic was close to closing because it was just the end of the day, and what they wanted to do was air flight her for life back to Grand Junction, thinking that she should be admitted to the ER and then held overnight for observation in a hospital bed for cardiac evaluation, since the patient had a history of some cardio stuff. And the patient said, “My community health worker usually helps me with these kinds of things. Let’s call her first.”
So the community health worker was able to coordinate care between the rural clinic, the primary care physician, the patient’s cardiologist, with whom she just happened to have scheduled an appointment the next day, which the patient wasn’t going to get to. But the community health worker then drove two hours to pick her up and brought her back to Grand Junction for the appointments, visiting of the pharmacy, getting food, secured housing for the night, and got a way back to Utah the following day. And the rough estimates believe that the tank of gas to get to Utah and back saved about $50,000.
Interviewer:
Oh, I’m sure. Versus a helicopter, a flight for life situation, to a hospital, and then an ER visit, an overnight visit? I can’t even imagine. Wow.
Amy Gallagher:
Yeah. So that was a pretty big success.
Interviewer:
Yeah. That’s just one person.
Amy Gallagher:
Right, and that’s just one person, one day.
Interviewer:
One day.
Amy Gallagher:
A day in the life of a community health worker, yeah. Certainly we’ve had people who were suffering from chronic homelessness finally secure safe housing and demonstrate success in keeping housing. We know sometimes that the chronically homeless population, individuals who get housing sometimes are overwhelmed by that and unable to keep housing for a long time, so we were helping people keep their housing. Several of our patients who had histories of substance use were able to receive the proper treatment they needed and were maintaining sobriety in different ways than they had before.
There was another individual who worked very directly with the community health worker after his relationship with other organizations were not going well. So the community health worker just kept showing up, whether it was to provide support, just with getting food, discussing that person’s thoughts about going to treatment and transporting him to medical appointments. She just kept showing up to this person’s house. When the patient was ready, the community health worker helped him secure treatment in another part of the state, and then through sobriety the person was able to reconnect with the family members, and secured a stable job in his former field out of state.
Interviewer:
Wow. It really provided a direct focus for each patient.
Amy Gallagher:
Yes, through building the relationships.
Interviewer:
Yeah, but then you think about all the ones that might not be so big and flashy and glitzy, but obviously … Lives were saved. Families, relationships, were saved. And money saved.
Amy Gallagher:
Yeah. Absolutely. We had another person who had experienced some very horrible trauma and just couldn’t get to the mental health center for treatment. And the community health center showed up day after day after day to help get that person the treatment. The first day he didn’t want to get in the car. On the second day they drove to the parking lot and then went home. The third day they got to the front door of the mental health center and then they went back home. Then the next day they picked up paperwork, and she helped him fill out the paperwork, so that over the course of a week or two we could get this person into treatment. Which is great, because he needed that hand-holding of being able to have that support in order to get through the first appointment.
Interviewer:
Yeah, there’s usually not the patience for that, of waiting for the patient to be fully ready to take that step. It’s like, historically it’s been, do you want to do this or do you not? If you don’t, that’s your call, that’s your problem, and we’re on to the next.
Amy Gallagher:
Yeah, exactly. We’re here when you’re ready.
Interviewer:
What were some of the obstacles that you guys ran into with this, aside from financially, but what else?
Amy Gallagher:
Obstacles, of course, are potential lessons learned, right? First off, the patient population whom we worked with is the population that were of highest concern to the medical providers treating them. They demonstrated many needs across the bio-psycho-social continuum. Sometimes, finding a place to start was a challenge, especially with people who have an extreme distrust of systems, or may have had negative experiences in systems before. So we needed to really navigate that gently, and with a lot of relationship building. And because of that, sometimes the timeline to address those issues may have been longer than what people, in general, would’ve liked to have seen. We couldn’t fix everything in three months. And if we were able to do things in three to six months it would’ve been awesome, but sometimes it really took 12 to 14 months to do it, and that’s okay. Because we could get it done.
Interviewer:
Right.
Amy Gallagher:
Yeah. And in our more rural areas, finding resources for the situation sometimes could be really difficult. In the Roaring Fork Valley, housing is incredibly limited, especially for those experiencing poverty. The lessons learned was creativity demonstrated by the community health workers. By being flexible and by thinking out of the box we could engage potential solutions that may not necessarily be the most common solution.
The community health workers were able to create a space for people with the highest level of need. The lesson here with that, though, relates back to funding. That maybe we could think about ways, moving forward, in which to secure funding for this type of work so that the highest need patient population could continue to be served in a hands-on, very direct, patient-centered manner.
Interviewer:
Excellent, those are great responses. Thank you for taking the time to have this interview with me.
I hope you have a wonderful weekend.
Amy Gallagher:
Thank you as well. Take it easy.
Interviewer:
You as well. Stay safe, stay healthy.