Scattergood Foundation

Advancing Innovative Strategies for Change in Behavioral Health

Bucks County Health Improvement Partnership (BCHIP)

Name of Innovative Program: 
Bucks Clinic Integrated Physical and Behavioral Health Service Program
Sponsoring Organization
Bucks County Health Improvement Partnership (BCHIP)
Name of Innovative Program Lead: 
Sally Fabian, RN, MSN
E-mail Address of Innovative Program Lead: 
sfabian@bchip.org
Physical Address of Innovative Program: 
2547B Knights Road, Bensalem, PA 19020
Project Description: 

Providing wrap around health care, BCHIP has expanded collaboration among private physicians, 6 hospitals and the local health department to include behavioral health. No such services exist for uninsured, low-income persons. Involves: 1] administering a Depression Screening Tool to all new patients and those returning for annual income eligibility visit. 2] identifying patients with modeerate suicide diagnosis. 3] refrral to freeonsite counseling program. 4] referring anyone wo is serusly mentally ill or demonstrates signs/symptoms of suicide to a BCHIP physical or nurse practitioner for immediate cae at Crisis, ER or other appropriate servie. 5] integrated car plan development reflecting primary helth diagnoses, physical and behavioral health treatment goals sed by  mult-disciplinary team to follow up and montor plan execution by the patient providing assistance as necessary. 6] all services (medical and behavioral health) are provided at no charge for uninsured adul ts.

How does the innovative program work to improve behavioral health access?: 

Providing wrap around health care, BCHIP expanded a collaboration among private physicians, 6 hospitals and the local health department to include behavioral health. No such services exist for uninsured, low-income persons. Involves: 1] administering a Depression Screening Tool too all new patients and those returning for annual income eligibility visit. 2] identifying patients with moderate suicide diagnosis. 3] referral to free onsite counseling program. 4] referring anyone who is seriously mentally ill or demonstrates signs/symptoms of suicide to a BCHIP physician or nurse practitioner for immediate care at Crisis, ER or other appropriate service. 5] integrated care plan development reflecting primary health diagnoses, physical and behavioral health treatment goals used by a multi-disciplinary team to follow up and monitor plan execution by the patient providing assistance as necessary. 6] all services (medical and behavioral health) are provided at no charge for uninsured adults.

How does the innovative program work to improve behavioral health quality? : 

ACCESS: Low-income, uninsured adults no qualifying for memdical assistance. Serves a diverse community of minorities, large concentrations of new immigrans and many low-income Americans.

QUALITY: Patients without insuranc delay addressing physical and behavior health problems. They have multiple, serious, chronic illnesses (hig BP, diabetes, high cholesterol, orthdic, pulmonaray and gasrointestinal problems, cardiac issues) compounde by behavioral health issue caused by the effects of poverty. Patients arrive depressed, anxiou and overwhelmed with their increasingly complex medica needs.  BCHIP provides an integrated approach to physica and behavioral health.

COST: Reducespresureon ERs and unrecovered costs, is a safetynet or patients discharged from inpatient or emergency rooms at area hospitals who do not or will never  quality for ACA of Expanded Medical Assistance. The LB Clinic is their only source of free, wrap-aroun, ongoing medical and behavioral healh.

How does the innovative program work to address behavioral health costs? : 

Our innovative program provides free physical and behavioral health care to uninsured, low-income persons. These patients delay treatment for multiple chronic conditions and behavioral health issues until the need is dire and requires hospital/emergency room intervention. Our program prevents health systems from experiencing significant loss of revenue since there is no recourse for cost recovery. Treating earlier in the physical and behavioral health process reduces demand for extended long-term hospitalization or treatment.  This population has significant health care issues straining the physical and behavioral healthcare delivery systems in our area.  The subject populaton is growing with a concomitant growth in health care needs, not the least of which is behavioral health. In addition to the behavioral healthcare at our onsite clinic, the integrated program also provides referals to private behavioral health professionals who provide service at no cost. 

 
Creativity and Innovation: 

A disparaity existed in our community with respect to access to behavioral health care for uninsured low-income persons. Through BCHIP's service to this community, our staff uncovered a great need for behavioral health care. While there were many resources for behavioral health cae for those of better means and those with insurance, this segment of the population had nowhere to turn and could not receive help. Our staff undertook the process of documenting the need and the results of the lack of resources.  We found that these patients were depressed, anixous and overwhelmed with their increasingly complex medical needs.  We found that this depression spilled over into family life, parenting and job attendance and performance. Developing a partnership among health professionals and a certified professional counselor, we brought together profesionals with the common goal of providing wrap-around physical and behavioral health services to this needy population. 

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Leadership: 

Word of our integrated program has spread including to surrounding counties. Organizations have requested seminaras detailing our health care model. We have provided it in a form that can be duplicated.  That format employs collaboration among private physcians, hospitals and local health agencies to include behavioral health into the services they provide to needy populations.  It requires: administering a depression screening tool to all new patients and those returning for an annual visit; identifying patients with moderate suicide diagnosis; referral to free counseling programs; referral for anyone who is serously menally ill or exhibits suicide signs/symptoms to physican/nurse practitioner or immediate care at Crisis, ER or other appropriate service; and, integrated care plan development  reflecting prirmary health diagnoses, physical and behavioral health treatment goals for multi-disciplinary team to follow up and monitor plan execution by the patient.&n

Sustainability: 

The integrated program is supported financally by our partners, foundations, corporations, municipalities and the general public.  We mantain an active funding campaign to assured continued/expanded services.  Our partners include 6 major hospitals, the Bucks County Health Department, Family Service Association of Bucks County (certifed counselors) foundations, corporations, such as Parx Casino, Independence Blue Cross, Foundations Community Partnersip, Genuardi Foundation, Connelly Foundation, etc.  We have determined that we need to screen more patients, utilize more professionl staff employ Spanish-speaking staff, educate our staff in gatheing ad utilizng accurate data.

Replicability: 

We are already seeing the beginnings of duplication of our model by other institutions and organizations serving this needy population.  These organizations are benefiting from our experience.

Results/Outcomes: 

Statistics and outcomes are maintained on all of the measurements below:

Depression Screening Tool.

Depression screen are reviewed immedately.  If there is a concern about the patints' well-being orif the results of the survey indicate a tototal score of 10, patient is referred for immediaeaction.  Patient files are documented with results ad follow-up action

Thoe with moderate depression are offered an oporunity to address their issues with free behaviora health ounseling.  Patient  files are documented wih the results of counseling,

Seriously, mentally ill or who demostrate signs or symptons of suicide are referred to a physcian/nurse practitoner for immediate cae at Crisis, ER or other appropriat service.  Files are documented and information is tansferred with the patient.

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