By Anne Connor, director of community grants

In 2014, Methodist Healthcare Ministries of South Texas, Inc. launched the Sí Texas Project: Social Innovation for a Healthy South Texas (Sí Texas Project) with support from an unprecedented federal investment of $10 million by the Social Innovation Fund, a program of the Corporation for National and Community Service. Through the Sí Texas Project, Methodist Healthcare Ministries is evaluating nine evidence-based models of Integrated Behavioral Health (IBH) care, with some innovative aspects targeted at 12 counties within Methodist Healthcare Ministries' service area.

This week I'd like to take a closer look at the Juntos for Better Health IBH model. Texas A&M International University (TAMIU) and its partners will implement this model in the Laredo area. This model combines prevention and IBH care.

Juntos for Better Health is a partnership of several community service providers, forming the first fully-coordinated health care delivery system among multiple partners in Laredo. It is based on the Dartmouth Prevention Care Management Unit (PCMU) model, which places empowerment of clients and communities at the core. The goal of this project is to develop a coordinated and integrated health care delivery network to improve the health of the community.

TAMIU and its partners will focus on the health care system in Webb, Zapata and Jim Hogg counties. This model provides a continuum of care for those with obesity, diabetes, and depression, using a prevention focus to increase compliance, traveling teams, and additional personnel to increase health care capacity, a shared system of resources, and improving knowledge of illnesses. Juntos for Better Health is comprised of three different, but interacting intervention prongs.

1. Prong 1 involves a health education activity and a treatment compliance component. The Juntos model will offer health education on obesity, diabetes, and depression to participants in various community settings in an effort to increase prevention of these illnesses by improving knowledge. TAMIU College of Nursing faculty and students will follow a modified version of the Dartmouth Prevention Care Management Model, which involves a PCMU. Patients with diabetes and/or depression at Border Region Behavioral Health Center and the Laredo Health Department, as well as partnering organizations, who miss appointments, will receive phone calls and home visits in an effort to increase treatment plan compliance.

2. Prong 2 involves traveling health care teams. These teams will engage clients of partner organizations and refer them to appropriate services. Clients who are referred for services but are noncompliant will be placed in the PCMU group for follow-up (Prong 1).

3. Prong 3 involves building capacity and sharing resources among and within partner organizations through the addition of staff, development of referral protocols, and developing a shared health information system to improve plans of care and facilitate referrals.

TAMIU and its partners will implement an intervention that combines the Dartmouth PCMU model and the innovative Juntos model, both of which are client/community empowerment models.

To view previous blogs in this series of Sí Texas blog posts, subscribe at www.mhm.org/blog.

By Anne Connor, director of community grants

In 2014, Methodist Healthcare Ministries of South Texas, Inc. launched the Sí Texas Project: Social Innovation for a Healthy South Texas (Sí Texas Project) with support from an unprecedented federal investment of $10 million by the Social Innovation Fund, a program of the Corporation for National and Community Service. Through the Sí Texas Project, Methodist Healthcare Ministries is evaluating nine evidence-based models of Integrated Behavioral Health (IBH) care, with some innovative aspects targeted at 12 counties within Methodist Healthcare Ministries' service area.

This week I'd like to take a closer look at two IBH models as part of the Sí Texas Project:

1. NuCare: Nuestra Clinica del Valle (NCDV) is implementing NuCare based on the collaborative care model at four of their primary care clinics in the Rio Grande Valley. A hallmark of the model is that patients are not referred to services, but the services come to them. NuCare includes a warm hand-off from the primary care provider to a mental health provider for an immediate, brief mental health intervention and warm hand-offs for health education and nutrition services. One of the innovative features of this model is the use of "promotores," or community health workers. In this project, the community health workers will meet patients in the reception area and accompany them through the visit, assist with depression screening, and meet the patient after the physical examination for an invitation to a wellness program. It is quite innovative to give promotores behavioral health responsibilities since they have been traditionally utilized for community outreach and health education. The focus in selecting promotores will be on hiring those who are controlled diabetics (true peers of the diabetic patients), Hispanic, suited to positions of leadership and program facilitation, and eager to accept training. Their involvement in administering the depression-screening tool (PHQ-9) is key because the clinic population is likely to need assistance because of challenges in reading and fear of behavioral healthcare. The physician and care team in further behavioral health assessments will use this information. The NuCare theory of change is that IBH, combined with health education, nutrition, and community-based support services, can improve diabetes control and reduce depressive symptoms. Improvement in physical and mental health will be achieved over several years in measurable impact for depressive symptoms and HbA1c levels among program participants. The warm hand-off from the primary care provider to the mental health provider, plus the presence of the promotor, breaks through the cultural barrier of stigma against behavioral health services and allows the counselor to develop rapport, encouraging patient confidence in the services offered.

2. Salud y Vida 2.0: The UT School of Public Health–Brownsville Campus will implement the Salud y Vida 2.0 model. The model incorporates enhanced primary and behavioral care, medication therapy management, community-based lifestyle programs, and teams of promotores or community health workers to conduct home follow-up visits. Medication Therapy Management will be provided for participants with low levels of medication adherence, and behavioral health services will be provided for participants who do not qualify for services with the local mental health authority, but who need behavioral health support. Community-based lifestyle programs will be provided across the Rio Grande Valley for the participants and their loved ones through peer-led support groups, cooking classes to build hands-on skills for patients wishing to prepare healthier foods, a healthy food choice customized smartphone application, and an obesity treatment program. The key to integration is on-going, systematic communication between hospital, clinic, mental health case managers, and the team of promotores who are following up with participants in their homes and at community-based educational sessions. Semimonthly case review meetings and a shared, secured web-based system called Chronicle Diabetes allow for coordination of participant services, advocacy, education and care. This model builds upon their existing Salud y Vida 1.0 program, a comprehensive chronic care management program that includes diabetes self-management education, integrated care planning and case review and outreach by community health workers.

To view all blogs in this series of Sí Texas blog posts, subscribe at www.mhm.org/blog.

By Anne Connor, director of community grants

In 2014, Methodist Healthcare Ministries of South Texas, Inc. launched the Sí Texas Project: Social Innovation for a Healthy South Texas (Sí Texas Project) with support from an unprecedented federal investment of $10 million by the Social Innovation Fund, a program of the Corporation for National and Community Service. Through the Sí Texas Project, Methodist Healthcare Ministries is evaluating nine evidence-based models of Integrated Behavioral Health (IBH) care, with some innovative aspects targeted at 12 counties within Methodist Healthcare Ministries' service area.

This week I'd like to take a closer look at three IBH models as part of the Sí Texas Project:

1. Community Healthcare InveSted in keeping Patients Active (CHISPA): El Milagro Clinic is implementing the Community Healthcare InveSted in keeping Patients Active (CHISPA) model in McAllen, Texas. This model is heavy on community-based chronic disease services, including the use of promotores in both the community and the clinic. The model utilizes monthly group-mediated cognitive behavioral meetings, and community-based services through the Healthy Living Partnerships to Prevent Diabetes (HELP PD). CHISPA will adapt the HELP PD model to account for the unique cultural and geographic needs of the Rio Grande Valley. An integral and innovative component of the CHISPA program, is the use of promotores, or community health workers. This community health worker-led health promotion intervention emphasizes integration and coordination of primary care with behavioral health care services, with community health workers integrated into the clinic team through depression screening and other patient services. A key component is the use of an occupational therapist to work with patients to identify needs early on, set goals and monitor progress. The intervention will include an initial meeting with an occupational therapist and follow-up as needed to coordinate and manage community-based services that meet the individual needs of patients, including referral to behavioral health services. The occupational therapist and the community health workers will also lead the group-mediated cognitive behavioral meetings.

2. Transportation for Rural Integrated health Partnership (TRIP) for Salud y Vida: The Rural Economic Assistance League, Inc. (REAL) is implementing the Transportation for Rural Integrated health Partnership (TRIP) model for Salud y Vida model, based in Alice, Texas, and covering a rural five-county service area. Like the Tropical Texas Behavioral Health model profiled in the previous blog, it focuses on the needs of Severe & Persistent Mental Illness (SPMI) consumers. This model was developed by REAL, in partnership with Coastal Plains Community Center, a local mental health authority serving SPMI patients; Kleberg County Human Services – Paisano Transit; and the South Coastal Area Health Education Center. The model responds to a specific need to expand the reach of current IBH services within the rural community, specifically to address the 22 percent (more than 1 in 5) consumer no-show rate for follow-up care. If patients aren't showing up for their follow-up appointments, there is little hope of advancing their health care outcomes. The key element of the TRIP for Salud y Vida model is the systematic and seamless offering of transportation services and programs to build self-empowerment to SPMI patients in the five-county service area. All TRIP for Salud y Vida consumers have a behavioral health diagnosis including severe depression, bipolar or schizophrenia.

3. Sí Texas Hope: Hope Family Health Center is implementing this collaborative care model at its clinic in McAllen, Texas. Hope Family Health Center has already begun integration of services, and the Sí Texas Project will enable them to move further along the integration continuum. The intervention involves moving from Hope Family Health Center's current model, where medical and behavioral providers work with each other episodically, to a more fully integrated model with care coordination, shared treatment plans, shared service provision, and shared record keeping. To achieve this enhanced level of integration, Hope Family Health Center will change its current primary care workflow to include a behavioral health specialist who will conduct assessments, provide initial counseling (individual or group), and coordinate referrals to care management and/or community-based health services. They will also include a care coordinator to manage referrals and follow-up and a transitional nurse to provide health and nutrition coaching and medication management. The new model of care will emphasize more collaboration between primary care and behavioral health care providers, including enhanced communication.

A series of blog articles will be added to the Methodist Healthcare Ministries Blog over the next few weeks to introduce additional models. To stay in the loop, please subscribe to the Blog at www.mhm.org/blog.

By Anne Connor, director of community grants

In 2014, Methodist Healthcare Ministries of South Texas, Inc. launched the Sí Texas Project: Social Innovation for a Healthy South Texas (Sí Texas Project) with support from an unprecedented federal investment of $10 million by the Social Innovation Fund, a program of the Corporation for National and Community Service. Through the Sí Texas Project, Methodist Healthcare Ministries is evaluating nine evidence-based models of Integrated Behavioral Health (IBH) care, with some innovative aspects targeted at 12 counties within Methodist Healthcare Ministries' service area.

This week I'd like to take a closer look at three IBH models as part of the Sí Texas Project:

1. Sí Three: Mercy Ministries of Laredo, a relatively small, faith-based clinic located in Laredo is implementing a model called, Sí Three: Integration of 3-D Health Services. The model's name comes from its three aspects of wellness: mind, body, and spirit. The model moves the clinic from its existing co-located model, in which behavioral and physical health services were offered in the same building, to an integrated model, in which these services are fully coordinated. Core components include:

• Navigators: Nurse practitioners who provide primary care services and develop patients' care plans;
• Referrals to internal and external resources, including telepsychiatry and faith-based counseling;
• Care coordinators to follow up on patient referrals; and
• Warm handoffs to behavioral health coordinators (licensed professional counselors) who patients see at every visit.

Mercy Ministries aims for its staff and providers to have a greater understanding of the roles and culture associated with IBH care. Patients' physical health is addressed through Mercy Ministries' primary care clinic. Mental health is addressed through internal and external referrals for counseling and through the use of telepsychiatry since psychiatrists are scarce in Webb County. Spiritual health is addressed through faith-based counseling. This is the only model in the Sí Texas Project that is evaluating a spiritual component, using a validated instrument that assesses spiritual well-being, and correlating the use of spiritual services with other key health outcomes related to diabetes, blood pressure, and depression.

2. Primary Care Behavioral Health (PCBH): The University of Texas, Rio Grande Valley (UTRGV) is implementing the Mountainview Primary Care Behavioral Health (PCBH) model in McAllen and Edinburg. This model integrates care through a consultant model, in which behavioral health professionals function as consultants to primary care providers and to their patients. At UTRGV, this model is implemented at family practice clinics where UTRGV medical students are placed for their residencies. In addition to the innovative use of medical residents, a key feature of this model is the use of a behavioral health consultant. Trained to function as a generalist consultant for the primary care physician, the behavioral health consultant addresses lifestyle-based somatic complaints, subthreshold syndromes, preventive care, and chronic disease. The behavioral health consultant also develops a clear patient care plan for both the patient and the primary care physician to follow.

3. Reverse Co-location and Wagner: Tropical Texas Behavioral Health is implementing Reverse Co-location in Brownsville, and aims to accomplish the key elements of the Wagner model for effective chronic illness care. Tropical Texas Behavioral Health is a Local Mental Health Authority, an agency that serves patients with Severe & Persistent Mental Illness (SPMI). The approach is called "reverse" co-location, because it is more common to integrate mental health providers into a primary care setting than to integrate primary care providers into a mental health setting. Following the reverse co-location model, Tropical Texas Behavioral Health will embed primary care and preventive services within their behavioral health setting. The Wagner model features an organized delivery system linked with complementary community resources, sustained by productive interactions between multidisciplinary care teams and educated patients and families.

An important aspect of this model is the use of a collaborative, interdisciplinary provider team, which functions with the help of a care coordinator. The clinical team will deliver coordinated, preventive primary care to Tropical Texas Behavioral Health clients with SPMI and chronic disease (i.e., obesity, diabetes, hypertension, or hypercholesterolemia). At its core, the proposed intervention features a team of medical professionals consisting of a primary care physician, physician assistant or nurse practitioner; a licensed vocational nurse; a registered dietician; a care coordinator; and other medical support staff. Together, this team will deliver coordinated, preventive primary care to Tropical Texas Behavioral Health clients with co-morbid SPMI and chronic disease (specifically obesity, diabetes, hypertension, or asthma) within a community-based outpatient behavioral health setting. SPMI includes individuals with major depressive disorder, bipolar disorder, schizophrenia, and other related disorders. Additionally, this model will actively link patients with various community resources beyond the clinic setting. Because of barriers created by SPMI, it is difficult for this target population to seek (on their own) services they need to help their lives be more stable and healthy.

A series of blog articles will be added to the Methodist Healthcare Ministries Blog over the next few weeks to introduce additional Sí Texas Project IBH models. To stay in the loop, please subscribe to the Blog at www.mhm.org/blog.

By Anne N. Connor, director of community grants

In 2014, Methodist Healthcare Ministries of South Texas, Inc. launched the Sí Texas Project: Social Innovation for a Healthy South Texas (Sí Texas Project) with support from an unprecedented federal investment of $10 million by the Social Innovation Fund, a program of the Corporation for National and Community Service. Through the Sí Texas Project, Methodist Healthcare Ministries is evaluating nine evidence-based models of Integrated Behavioral Health (IBH) care, with some innovative aspects targeted at 12 counties within Methodist Healthcare Ministries' service area.

Q: Why Integrated Behavioral Health?
A: Methodist Healthcare Ministries' mission is to improve the health of those least served, in mind, body, and spirit. This holistic approach is reflected in IBH models, which bring collaborative teams of providers together to care for the whole person, addressing behavioral health and primary care not just under the same roof, but in a coordinated manner. Research has shown that an integrated approach leads to better health outcomes for patients, and there is a large incidence of comorbidities (co-occurring health issues that cross between mental and physical) in South Texas, so the need is there. Methodist Healthcare Ministries is also developing its own IBH team at its owned and operated clinics, a reflection of our commitment to this approach.

Q: How do you balance "evidence-based" with "innovative"?
A: Sí Texas Project subgrantees started with models that had been proven effective, and modified them to be more appropriate for their local needs (such as for Hispanic border populations or rural populations). We are interested to see if these modifications help the models to be more effective here. It is part of the Social Innovation Fund's purpose to "support innovations that have advanced beyond the beginning stages, are showing signs of effectiveness, and have the potential for greater scale."

Q: How are you evaluating the models?
A: Methodist Healthcare Ministries has engaged Health Resources in Action (HRiA) to evaluate each model. Each model is being evaluated using either a Quasi-Experimental Design (with control groups) or a Randomized Controlled Trial (with random assignment), with robust research methodology and statistical analysis to back it up. Methodist Healthcare Ministries also built its own capacity by forming an internal evaluation team to interface between Methodist Healthcare Ministries and the subgrantees.

Q: What will you do when you find out which models work best?
A: The first phase of the Sí Texas Project is building evidence for the models. In the second phase, scaling what works, we will fund expansion of the most effective models, whether through the agencies already employing them, or by offering other subgrantees the chance to apply them.

Q: What are the nine models?
A: The nine IBH models will be showcased individually through a series of articles to be added to the Methodist Healthcare Ministries Blog over the next few weeks to introduce each model. To stay in the loop, please subscribe to the Blog at www.mhm.org/blog.