Strong & Early Outcomes Illustrate Positive Impact of New Model

Wednesday, January 20, 2016

Ron, a burly long time musician, is a patient at Central City Concern’s Old Town Recovery Center. He tells his story in the office of his counselor, Kelly Fitzpatrick: “Twenty-nine months ago, I set out on a quest to end my life. I was dealing with uncontrollable moods. I sold all my guitars, all my belongings.”

Ron is recovering from heroin addiction and alcoholism. He also lives with bipolar disorder and PTSD. “But now,” he says, “I can say that the last five months have been the best of my last 15 years. I’m comfortable in my own skin. I’m happy.”

He’s both emotionally stronger and in better physical health. Over the last year, he has lost 40 pounds and his blood sugar, once at pre-diabetes levels, has dropped sharply.

He ascribes his dramatic improvement to the “great communication between Kelly, my doctor, and my nurse practitioner.”

Ron is one of 200 patients in Central City Concern’s one year-old Integrated Health and Recovery Treatment (IHART) program. Mental health specialists, addictions counselors, peer wellness counselors and case managers work closely with primary care practitioners to provide wraparound treatment for patients’ mental and physical health.

The program is funded by a federal grant that CCC received in September 2014, with the purpose of developing a health home model for patients with co-occurring severe mental illness and complex medical needs, blending evidence-based models of care from both primary care and mental health. IHART is also participating in the State of Oregon’s Behavioral Health Home Learning Collaborative (BHHLC), which is gathering data to promote the integration of primary care in a behavioral health setting. CCC’s Old Town Recovery Center is one of nine mental health and substance use disorder treatment programs from Oregon participating in the Collaborative. 

All IHART patients, according to team manager Shanako DeVoll, come to the program after being assessed at the Old Town Clinic, a federally recognized patient-centered medical home serving people experiencing homelessness and poverty. People placed in the IHART program are dealing with severe mental illness and addictions as well as medical issues. They also need wraparound care to help them achieve basic needs.

“Traditionally behavioral health (mental illness and substance abuse treatment) is completely separate from primary care. They’re funded separately and delivered much differently,” says CCC’s Psychiatric Medical Director, John Bischof, who is also the team’s psychiatrist.

Sixty-eight percent of people with a mental illness have one or more chronic physical conditions often related to their psychiatric medications or conditions - these include obesity, high blood pressure and high blood sugar. If not monitored closely these can lead to heart disease, type 2 diabetes and early death.

“People with a major mental illness who receive publicly funded health treatment, die, on average, twenty-five years earlier than people in the general population. That’s unacceptable. We have to do something,” says Bischof.

DeVoll explains that 130 of IHART’s 200 patients are on second generation anti-psychotics, which are known to have negative metabolic side effects. “Seventy percent of those had abnormal or missing labs,” she says. The team ensured patients’ metabolic screenings were up to date and determined how best to intervene for those patients with chronic metabolic conditions. The team now more regularly measures patients’ weight, blood pressure, blood sugar, cholesterol and smoking status, and works in concert with primary care providers to improve patients’ health behaviors.


The program aims eventually to be the patient’s primary point of contact for psychiatric and metabolic medical concerns and to reduce the prevalence and impact of metabolic conditions among patients. The behavioral health specialists on the team attend trainings on things such as comprehensive diabetes care and weight management. 

What does this look like in practice?

Every morning, IHART team manager DeVoll leads a rapid-fire 30 minute group meeting. Patient needs are discussed and tasks assigned: patients need help getting housing, cell phones, glasses, bus passes, food boxes. They need reminders and outreach about dental appointments, lab tests, injections. One man hasn’t picked up his medications so a team member is assigned to call the jails and the hospitals to find him and get him back on track.

“It’s a much more holistic view of the patient,” says peer wellness counselor, Jeffrey Yoder, whose daily tasks include things like tracking down homeless patients to remind them about an injection or accompanying people who want to lose weight to the supermarket to help with money management or healthy menu planning.

Delivering care as a team “is far more action-oriented,” says Bischof. It’s also efficient. With the addition of a new staffer the team plans to reach full capacity of 300 patients by adding 100 patients over the next six months.

Right now, there are four mental health clinicians on the team, each with a caseload of about 65 patients – significantly larger than if they were working alone. Because everyone on the team has specific roles, “we can all operate at the top of our skill sets,” says Bischof, who is the psychiatric provider for the majority of IHART patients. “I’m much better able to be present, to think bigger picture.”

Each patient is also supported by a health assistant, case manager, peer wellness counselor and addictions specialist.

Staff check in with each other often and enjoy working as a team. “We’re on the same computer system (with primary care and mental health practitioners) so if you see someone has new medication you can go down the hall and talk to the prescriber. It makes our real-time responses a lot more on the mark,” says Fitzpatrick.

Fitzpatrick is also Ron’s addictions specialist. “About eight months ago she started a campaign to get me to play guitar and sing again,” he says. “She started bringing a guitar to group sessions. I wouldn’t play. But one day I got my hambone up, my hands were shaking, my throat was dry. I’ve played every group since then. I’ve received a lot of love.”

Central City Concern’s leadership are encouraged by such early successes and are evaluating bringing IHART attributes into other programming at the agency. “We’re excited to keep developing this model,” says Tallyn. “It’s bringing together the best of primary care and mental health models, and the potential to improve patients’ lives—and our care system—is huge.”