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Coalition weathers a storm
In response to a lack of consumer participation in follow-up care in the area, the Gulf Coast Center (GCC)-the regional mental health authority for Galveston and Brazoria Counties in southeast Texas-began collaborating with other local agencies to improve access for mental health services while containing cost. The need for better communication between the mental health authority, the community, and the local hospital was evident, and in 2005, a continuum of care model was created to allow GCC case managers to work in the field at “critical points” identified throughout the community.
Selected “critical point” sites for GCC's continuum of care model were:
The University of Texas Medical Branch at Galveston (UTMB) inpatient psychiatric unit
Two Galveston County Health District clinics (FQHCs)
The Jesse Tree (social services agency)
St. Vincent's House (free clinic)
Luke Society (free weekend street clinic)
Galveston County Jail
Brazoria County Jail
This model also included providing consumers in rural areas with access to services via telepsychiatry. The top priority for this effort-along with providing consumers with continuous, accessible services-was to keep GCC clients from unnecessary use of UTMB's ER or hospital resources by closely monitoring care and compliance in the “critical point” settings.
Little did GCC know when it created this model to better serve the community that these methods would be the organization's salvation after a disaster. Fortunately, the model was able to weather a direct hit from Hurricane Ike in 2008 and proved to be a vital element in the recovery of mental health services following this disaster.
The continuum of care model in action
The continuum of care model sent GCC staff out of their offices and into their assigned community settings, equipped with portable laptops, air cards, and new protocols. The seven organizations in the coalition opened their doors to allow GCC case managers to work part-time onsite. From these sites, the case managers had face-to-face contact with GCC clients and completed case management activities to re-connect the client to GCC services.
In addition to community placements, some case managers were assigned to leased vehicles and formed into mobile response teams (MRTs). Each team included male and female case managers dispatched to clients wherever they were found. Among the reasons to dispatch the MRTs were:
Missed psychiatric evaluations or first after-care appointments following hospital discharge;
General follow-up from the state hospital;
Missed labs, medication appointments, or injections;
Complaints from others;
Crisis intervention; and
Transportation to telepsychiatry or other clinic appointments.
Many of these problems were brought on by a lack of transportation or motivation, and MRTs proved critical to ensuring enrolled clients kept their scheduled clinical appointments and medication checks.
Proven success
The results of the entire outreach initiative were outstanding. Case managers and MRTs recorded nearly 10,000 encounters with more than 4,800 clients over three years, traveling an average of 37,271 miles per year. This effort improved health and social outcomes for clients while containing costs for the healthcare providers.
During this period, the outreach helped thousands of consumers: Hundreds completed applications and were approved for Social Service Income (SSI), while 7,805 applications and approvals were completed for no-cost medications from the state's Pharmacy Assistance Program (PAP), benefitting about 2,000 consumers, most of whom required multiple medications. These steps resulted in $98,000 in savings to GCC in one year-money that could be used for clients without resources but ineligible for entitlement programs. Evidence from the program revealed the case managers were very capable of performing their tasks in alternative sites and became incredibly efficient in assisting each other.
Most impressive among the outcomes was the rate of success in getting UTMB inpatients re-enrolled in GCC services and, therefore, preventing unnecessary hospital visits. The GCC case manager situated in the UTMB psychiatric inpatient unit saw 87 percent of the patients admitted to the hospital that year. An appointment was made at GCC for 91 percent of those clients and, through the collaborative efforts of multiple case management team members, 65 percent completed follow-up appointments at GCC and became more stable.
By avoiding re-admission to the hospital for the clients who kept their appointments with GCC, the savings amounted to $1.5 million. The avoidance of a visit to the ER by those same clients saved another $753,000. Total estimated savings through cost avoidance amounted to $2.3 million. A system was established at GCC to refer qualified clients to the federally qualified health center (FQHC) operated by the Galveston County Health District (GCHD), thereby establishing a medical home for 125 clients through the case manager working part-time at the GCHD clinics.
Disaster hits, coalition acts
In September 2008, Hurricane Ike hit southeast Texas, disrupting all healthcare services in Galveston and leaving the GCC offices damaged for months. But GCC staff was ready to act. The continuum of care model was truly tested, as most social services were displaced and the regional ER and psychiatric hospital were closed indefinitely. Staff adapted to the crisis using their mobile tools and experience with integrated community-based crisis management.
Following the storm, the UTMB hospital case manager moved to a psychiatric hospital 50 miles away. Patients were usually taken to the hospital by ambulance and returned to their homes by the MRTs. Almost all patients from Galveston or Brazoria Counties seen by the hospital case manager were referred to GCC, with nearly 80 percent of referred patients re-connecting with GCC services. Based on the success of the MRTs, GCC had initiated mobile crisis response teams two years prior to the storm, which became an invaluable resource in the hurricane's wake.
Thereafter, new client needs emerged. Many clients in both counties, but especially in Galveston County, were displaced by the storm when two-thirds of Galveston Island flooded. GCC clients needed immediate help from GCC case managers to register with FEMA and become eligible for assistance. Some clients also needed a great deal of support from GCC to register and apply for housing vouchers. The GCC case manager maintained communication with the health district staff as well as staff in emergency tents and crisis resource centers.
St. Vincent's House, a faith-based organization that operates a free clinic, was one of the only members of the continuum of care coalition that was able to re-open its doors to clients within a few weeks of Hurricane Ike. Soon St. Vincent's filled with hundreds of people seeking relief and mental health services from the UTMB clinicians and students who operated the clinic while the university hospitals were closed. When the GCC case manager was restored to that site following the storm, it was possible to reconnect with GCC records and help with client referrals.
Even though the GCC Galveston Island office and clinics were uninhabitable for seven months, GCC staff operated from their mainland clinic, where they opened up space for the UTMB Department of Psychiatry, which was also displaced. The case managers were assigned full-time to the jails and continued to provide screening and referrals for hundreds of clients. This service was not disrupted by the storm. Telepsychiatry was restored and prevented at least 150 ER visits during this time period.
Not every community will face a hurricane, but many are vulnerable to a variety of disasters. By planning and practicing integrated services, many community mental health agencies will be better prepared to weather their own storms.
Praise for GCC and its partners
Due to the success of the coalition and the impact of its work on the community, UTMB won a competitive national award from the Community Campus Partnerships for Health (CCPH) in 2003.
In 2008, GCC received the State of Texas Heroes Award.
In 2008, UTMB was a finalist for the prestigious American Association of Medial Colleges (AAMC) award for the successful community-based approaches it fosters, including the continuum of care model program.
UTMB was honored for its financial support of the continuum of care model and its role in the Galveston County Health Access Program (CHAP) with the 2009 Texas Hospital Association Award for Community Excellence.
In 2009, GCC received the prestigious State of Texas National Alliance for Mental Illness (NAMI) Above and Beyond Award.
G. Michael Winburn is the Executive Director at Gulf Coast Center, while Kathleen Tierman is the Director of Health Outcomes, Office of Health and Policy, and Legislative Affairs at the University of Texas Medical Branch, Galveston, Texas. Ben G. Raimer, MD, is the Senior Vice President of Health Policy and Legislative Affairs at the University of Texas Medical Branch, Galveston, Texas. Behavioral Healthcare 2010 October;30(9):16-18
