“Without the team, you’re just an island. You’re trying to cover psychological issues, medication adherence, dietary control. But by using your care team, you know that your patient’s going to be in good hands. And if you impact enough patients, you’re impacting a whole community, and that’s essentially what ACCESS’ goal is,” said Vincent Botta, N.P. at ACCESS Martin T. Russo Family Health Center in Bloomingdale, IL.

Just a few years ago, most primary care practices could not envision such a concept: a coordinated care team. As the health care landscape began to shift though, ACCESS’ leadership knew that the business was changing and it would need to transform its care delivery model.

“We know that at ACCESS it’s more than just the number of people we take care of.”

“We know that at ACCESS it’s more than just the number of people we take care of. It’s really about the value that our care teams bring to our patients. More and more, you’ll hear the terminology value-based care, which really means how well you’re managing a patient’s care to get the outcomes that are needed to keep them healthy and out of those expensive, often unnecessary portals of care,” said Jairo Mejia, M.D., ACCESS’ Chief Medical Officer.

When developing this new care model, ACCESS knew that a one-off program here or there wouldn’t take hold and be successful. Therefore, since 2012, ACCESS has made deliberate, strategic investments to change the way it universally provides patient care. And it’s made those changes always with an eye on building effective, efficient systems around innovation and constant improvement. “This practice transformation did not come overnight. We went through deliberate planning with a focus on long-term sustainability in mind,” said Kathleen Gregory, ACCESS’ Vice President of Strategy and Business Development.

We treat the whole person so that patients can achieve the most optimal health possible.

Two programs that focused on integrated care coordination for high-risk patients helped illuminate the systemic changes that ACCESS needed to make. In 2012, ACCESS secured a grant from the Center for Medicare & Medicaid Innovation to improve the health outcomes for a high-risk population: pregnant African-American women. Through this initiative, ACCESS realized the value of care coordinators — dedicated providers who serve as patient advocates and resource partners, connecting patients to the often complicated, wide range of health care services they need.

The second program touched a population that ACCESS has long been committed to serving: people with HIV/AIDS. ACCESS’ Ryan White program shed light on the importance of providers who consider the impact of behavioral health and social determinants such as nutrition and housing on patients’ physical health. It also demonstrated the value of behavioral health consultants who work not in isolation from other providers but in tandem with them.

ACCESS took the valuable lessons it learned from these programs to improve care for patients across its network. “We used the innovation programs as platforms for learning and business planning,” Ms. Gregory said. “We are grounded in a patient-centered approach and the reality that it’s really about how patients live a healthy life and how we as a health system are designed to support that.”

Leveraging technology for support

As there is no longer one lone provider managing a patient’s care, ACCESS also had to address how communication would be shared both across ACCESS and with its health care partners. Recognized at HIMSS Level Stage 6 for its EHR adoption, ACCESS has continued to invest in its Epic clinical tools to increase knowledge-sharing among its care teams; share medical information across networks with hospitals and other health care providers; and build out Epic’s managed care tools to put as much information about patients’ medical history at the fingertips of their providers. The vision is that all providers will one day have one dashboard to view all critical patient information including utilization data, screening results and key risk areas.

A monologue becomes a dialogue 

After ACCESS improved access to care by creating efficient systems, it looked to the next frontier to move beyond access to impact health outcomes. With generous support from the Lloyd A. Fry Foundation and the Searle Funds at The Chicago Community Trust, ACCESS care teams are partnering with patients on a shared decision making approach to care.

Patients and providers see the benefits every day. Now, whenever patients visit ACCESS, their care team treats their total health and they are partners with their providers. Patients aren’t simply told what to do. They talk through their care plan with their provider. Through continued investment in shared decision making and an initiative to adopt motivational interviewing, providers are being trained how to engage and effectively prompt patients to talk about issues in their lives that might positively or negatively affect their well-being — whether it’s a history of domestic violence or a desire to quit smoking or lose weight.

This way, providers no longer simply dictate the course of care. They partner with their patients to determine the appropriate care plan. “Our goal is to empower our patients,“ said Dr. Mejia. “It must be a collaboration — that’s the only way we can succeed.”

Integrating Behavioral health

It could have been a routine visit with a patient who needed a new prescription. But in talking with the patient, her psychiatrist, Dr. Sharon Lieteau at ACCESS Westside Family Health Center, learned she was now in one of the longest drug-free periods of her life — but she was also anxious about an upcoming surgery. Dr. Lieteau recognized the patient would be susceptible to misusing pain medications, so she reached out to another member of the patient’s ACCESS care team, her primary care physician.

Together, both doctors closely monitored their patient’s post-surgery recovery. “With that collaboration, she was able to stay drug-free,” Dr. Lieteau said.

That successful intervention — and countless others like it — was enabled by ACCESS’ transformation into a Level 3 patient-centered medical home (PCMH). ACCESS has one overarching goal: putting patients’ needs first.

To achieve that, ACCESS’ teams of health care providers collaborate closely with each other to coordinate the care they provide. And this coordination goes beyond treating patients’ physical needs. They look at a person from all key aspects — behavioral, medical and social. Those areas truly define a patient’s total health.

Before this transformation, Dr. Lieteau’s patient’s substance abuse history may not have been spotted in another treatment setting. Now, that patient — like everyone ACCESS cares for — belongs to a team of caregivers who regularly communicate with each other. “That’s nothing like I’ve ever experienced before in my career,” said Dr. Lieteau.

As part of its focus on treating both the mind and the body, ACCESS has transformed the way it also delivers psychiatric services. It has moved away from a traditional psychiatric model that refers patients to off-site specialists. In its place, ACCESS has adopted a consultative model of psychiatry. Now, psychiatrists work alongside the entire care team to identify both high-risk patients who need a specialist and low-risk patients whose psychiatric needs can be treated by their primary care physician with the psychiatrist’s support.

“There’s improved access to psychiatric expertise across the board, and better communication because we’re not just sending patients out to a specialist,” said ACCESS’ Director of Behavioral Health Suzanne Snyder. As patients utilize and remain within their medical home, their continuity of care results in improved outcomes.

ACCESS also invested in rounding out its behavioral health services. Just over four years ago, ACCESS only had a handful of behavioral health consultants across the network. Today, ACCESS has behavioral health specialists that can cover all 36 of its sites, which span both urban and suburban communities in Cook and DuPage counties. Given the reduced mental health services available locally, this investment could not have come at a better time. One case in point: ACCESS is already leveraging this investment to help support its programs to deal with the growing opiate addiction crisis, which has become a huge issue in the communities ACCESS serves.

Reaching beyond our walls

ACCESS has also invested in care coordinators who work both within and beyond ACCESS’ walls as an integral part of the ACCESS care team.

ACCESS first started small with seeding its care coordination model through its Accountable Care Entity (ACE), HealthCura, which was transitioned to Blue Cross and Blue Shield of Illinois in 2015. During that state-funded initiative, HealthCura was responsible for the care of more than 25,000 members at its peak. “Given our vulnerable population, we needed care coordination — especially for those high-risk members — to stave off ED readmissions, support chronic disease management and simply help patients navigate the complex health care landscape to follow through with their care plans,” said Ann Lundy, former Executive Director of HealthCura and current Chief Operating Officer at ACCESS. “Looking forward as we move from a fee-for-service model to a value-based model, this investment will be even more critical.”

ACCESS currently has approximately 30 dedicated care coordinators, with plans to increase that number over time to serve its entire patient population — regardless of insurance coverage.

The investment is already paying off as patients are responding and surprised by the additional support and attention they are receiving.

Nearly two years ago, 46-year-old ACCESS West Chicago patient Steve S. was waiting at a red light in his car when he was struck by a car going 55 miles per hour. He was hurt pretty badly and quickly began to get lost within all the red tape of doctors’ visits, insurance paperwork and scheduling.

Everything changed when he says JoAnne Siar, R.N., a Nurse Care Coordinator at ACCESS West Chicago Family Health Center, began calling him to offer assistance.

“I was a little caught off guard, because I never had anyone provide me with a coordinator before,” Steve said. “From the get-go, she started helping me with all of my headaches and started making suggestions that I would not have thought of myself. She helped get me mental health care and therapy, arranged appointments, deciphered the insurance billing codes for me, and helped me secure my medications — even getting me dental care.”

Steve says that Ms. Siar also helped him in an unexpected way — with food and housing when he became homeless for a few months because he couldn’t work.

Ms. Siar says that she enjoys advocating for her patients, because they face many barriers. “Sometimes when they try to navigate their own health care, they can become discouraged, and this whittles away at their dignity. With the care coordination here, patients don’t feel helpless and can see the doors opening up for them.”

Care coordination is also helping ACCESS reach its patients beyond our walls in new ways. Hannah Rosenblatt joined ACCESS as its first care coordinator for behavioral health in 2016. She serves as the chief liaison between hospitals and ACCESS’ behavioral health consultants so that, when patients leave the hospital, they know they can turn to ACCESS. “Our goal is to ensure that no patients fall through the cracks and they all know they can go back to their medical home at ACCESS for care,” Ms. Rosenblatt said.

Rounding at local hospitals, Ms. Rosenblatt meets in person with patients who end up in the hospital frequently. She asks about their medical conditions, their diets, their housing — anything that might present a barrier to good health. “If we want to be patient-centered, we need to engage patients to address these larger issues and understand the important connection to their overall health,” she said.

By forming meaningful relationships with care coordinators like Ms. Rosenblatt, patients feel they are getting the personalized attention that health care often lacks. She also educates them about when it’s best to go to ACCESS versus the local emergency room. Patients learn that they can take care of their health on an ongoing basis — and that ACCESS is not just for routine primary care visits. “We want them to see us as a resource, rather than seeing the hospital as their only resource to go to at those most acute times,” Ms. Rosenblatt said. Support for this work has been provided by the Washington Square Health Foundation and, for work in DuPage County, the Alfred Bersted Foundation, Bank of America, N.A., Trustee.

In the future, ACCESS plans to mobilize more care coordinators in the field to help patients better navigate the health system overall and connect back to their medical home.