When Hennepin Health launched in 2012 to serve as a safety-net ACO for Minnesota’s early Medicaid expansion population, it sought to reinvent the way it identified, engaged, and cared for its vulnerable and homeless populations. This included hiring Amber Morgan to bring primary care to Hennepin County Mental Health Center—where these patients seek most of their services.
Amber Morgan begins each day sorting through numerous telephone and email messages left by the mental health center’s providers asking for help directing, providing, or connecting patients to needed health care services—a role that one psychiatrist described as “quarterbacking.”
Today, this includes a call to a pharmacist about prescription refills and to a county shelter to secure housing for a homeless patient being discharged from a hospital after hip surgery.
As the “quarterback,” Amber consults face-to-face with clinical social workers and psychiatrists to discuss medication management and housing issues. She coordinates referrals for her caseload of patients by making appointments with specialists and briefing the specialists’ offices about the patients’ medical, behavioral health, and social history. In the past 6 months, she has had a “rolling caseload” of about 70 patients.
Her job didn’t start out this way. When Amber began in February 2013, her main responsibility was to find patients with unmet primary care needs. At Hennepin Health, there are community health workers on staff who perform Medicaid outreach and enrollment; Amber’s role is to connect enrolled patients to primary care services. Without this connection, patients will often seek primary care in places like the emergency department or go without any health care services.
When first hired, Amber began with cold calling potential patients to come into the mental health center so that she could assess their medical, dental, social, and behavioral health needs. But this effort turned out to be mostly unsuccessful. She changed strategies and more strongly promoted her role and service options to the clinical staff. She also began co-facilitating a group for homeless men, called “Connections,” two times per week with a clinical social worker. This group allowed her to meet and link with potential patients. Amber added “drop-in” hours directly following each meeting, and these now allow her to meet with patients while they are already at the mental health center.
Amber’s first patient of the day is having total hip surgery in 2 days. She reviews his pre-op directions and gives him a bus pass to get to the hospital. Her second patient is an uncontrolled diabetic, who is now seeing dramatic improvement in his blood sugar levels after making dietary changes. Amber provides dietary counseling routinely to patients, but she also offers counseling to the mental health center staff to promote “a culture of wellness” for the patients.
Afterward a social worker asks Amber to evaluate a patient scheduled for later in the day who has been complaining of vision changes. Integrating a care coordinator into the team at the mental health center took a little time, but now, according to the social worker, the team sees the value of having a behavioral health nurse care coordinator in the office. “Amber is here for the warm handoff. With our population, you will lose them if you don’t make the connection right away,” the social worker explains.
Now that the mental health center has Amber on staff, referrals from psychologists, psychiatrists, and others on staff have also increased; emergency department services are down; and primary care visits are up. No-show rates at both the mental health center and primary care practices have fallen since Amber joined the team.
Next, Amber quickly makes a connection with a new patient who has been waiting to see her. This patient has been referred by his therapist and has been complaining of chest pain. She takes his vital signs and completes an assessment, during which the patient denies current symptoms, but acknowledges discomfort several days before. She determines that he can wait to be seen by a primary care provider until later in the week. She makes the appointment for him, sets up transportation services through Medicaid, and reviews with him an emergency plan should his symptoms recur or worsen.
Running the Drop-In Clinic
The drop-in clinic that follows the homeless men’s “Connections” group has been an important source for identifying patients in need of brief primary care interventions. After these brief drop-in visits, Amber will often set up a subsequent 1-hour appointment to perform a comprehensive health and lifestyle assessment or to provide educational counseling about medication adherence.
This afternoon, Amber has a 1-hour scheduled appointment to review blood sugar glucometer readers with a patient that she has been seeing for a few months. The patient has been making steady progress with checking his blood sugar several times a day. She provides him with positive feedback about his blood sugar monitoring and listens to him as he talks about how he thinks he is ready to find a job. She makes a note about getting a referral for an “Employment” group and schedules the next visit before the patient leaves. She tells the patient he will receive a gift card as an incentive to return. “Offering bus tokens and gift cards,” explains Amber, “can be an enormous incentive to connect patients to needed services.”
The steady stream of patients continues, and Amber makes time to see the patient whom the social worker described as having vision changes. Amber performs an exam that includes checking the patient’s blood glucose and taking her blood pressure. The patient’s blood glucose and blood pressure are both above normal. Amber picks up the phone and makes a prompt referral to a primary care practice and sends the patient on her way with a cab voucher.
“Working in this position has been eye-opening for me,” says Amber. “It has been rewarding and intense. It requires me to problem solve and think creatively to keep patients engaged and keep them coming back.”
“As a behavioral health care coordinator, I try to resolve urgent needs as necessary. For ongoing concerns, I make the connections to get them on the road to health. Whether or not I can solve the problem, patients are reassured simply by knowing someone is there to help.”