systems building

Home visitation as a component of primary care

Behavioral health as a component of primary care

The Children’s Center

T

Behavioral HealthServices

Pediatric

Medical Home Care

Evidence-basedHome VisitationServices

The Children’s

Center

Integrated services to promote the health and well-being of

children Carolina Health Centers’ pediatric

associates provide a comprehensive primary care medical home.

Carolina Health Centers’ Division of Family Resources and Child Development Services provide early child development and parenting services including evidence-based home visitation.

The Beckman Center for Mental Health Services provides on-site mental and behavioral health care.

Prenatal assessment of

risksyes

First Time Families

YesLow incomePrior to 28

weeks NoHealthy Families

Nurse-Family Partnership

Specialcircumstances

Yesno

BirthAssessment

of risks

no

Reach OutAnd Read

yes

Tier 1Risks

Healthy Steps forYoung Children

Tier 2Risks

Yes

Edgefield, Saluda, McCormick, Laurens Co.

Greenwood or AbbevilleCounty Resident yes

Yes

yes

yes

Our behavioral health model:

• Behavioral health counselor employed by Beckman Center but located at The Children’s Center and fully integrated in the care team

• Carolina Health Centers manages the clinical operation

• Beckman Center manages the revenue cycle• Carolina Health Centers pays a modest annual fee to

Beckman to offset the cost of otherwise uncompensated care resulting in expanded access for home visited families

• If needed, the behavioral health specialist will accompany the home visitor on home visits to engage the family in mental health services

• 5 year track record with excellent results

Reasons to play togetherImproved Outcomes for Individuals, for Providers, for Systems

Better experience of care Better patient compliance with medical providers’ instructionsReductions in risk factors that lead to chronic health conditionsReductions in costs due to ED visits

Improved Access to CareImproved recruitment, engagement and retention in home visitationReductions in “no show” rates in medical settingsOral health example

Improved opportunities for pay for performance and other quality incentives

Increased sustainability for home visitationCombined voice for advocacyEnhanced professional development opportunitiesImproved accountability

System improvements

• Provision of a continuum of services to provide the “best fit” for families.

• Increased access and decreased barriers to services

• Seamless team approach utilizing medical providers, home visitation providers and behavioral health providers. Families hear consistent messaging.

• Use of evidence-based guidelines

System improvements

• Shared use of electronic records for communication

• Improved family identification, engagement and retention.

• Use of a standardized screening and assessment process prenatally and at birth

• Continuous quality improvement across services using Institute for Healthcare Improvement Breakthrough Series format..

System improvements

• Electronic record keeping / shared staff for reporting/tracking• Identification of high-risk customers• Enhanced care coordination• Support family self-care and enhance

problem-solving capacity• Reporting on performance/evaluation• Improved referral pathways to additional

community resources

Collaboration Continuum

• Compete• Co-exist HC and GCCC until 2001• Communicate• Cooperate • Coordinate GCCC peds sold to CHC 2001• Collaborate Multiple legal agreements• Integrate Full merger 2011 after 2 year pilot – still working to improve

Questions ????

Sally Baggett, Director of Patient and Family Services

Carolina Health Centers, Inc.113 Liner DriveGreenwood, SC 29646

sbaggett@carolinahealthcenters.org

(864) 941-8105