About Marillac Clinic - Grand Junction, Colorado Clinic Eligibility • 200% of federal poverty level • Mesa County residents • Medical program serves uninsured ages 18-64 • Dental program serves uninsured, CHP+, and Medicaid.

1. Where Two Great Rivers Meet:
Evolution of Integrated Care
Steve Hurd, Ph.D.
steve.hurd@stmarygj.org
970.244.2235

2. Marillac
Clinic
Bridging the healthcare gap

3. Clinic Eligibility
• 200% of federal poverty level
• Mesa County residents
About • Medical program serves
Marillac uninsured ages 18-64
Clinic • Dental program serves uninsured,
CHP+, and Medicaid. No age
limitation.

4. Prevalence Comparisons
Marillac Clinic vs. PHQ 3000
Major Depression
Anxiety
Panic Disorder
About
Alcohol
Marillac Binge Eating
Clinic Any Diagnosis
0% 15% 30% 45% 60%

5. Integrated
Care

6. Guiding Philosophy:
Meeting several patient needs in
one visit results in greater
efficiency for both patient and
Integrated provider.
Care

7. 5. Close Collaboration in a
fully integrated system
4. Close Collaboration in a
partly integrated system
3. Basic on-site
Collaboration
2. Collaboration
Integrated at a distance
Care 1. Minimal
collaboration
McDaniel, Hepworth, and Doherty (1992)

8. Integrated
Care

9. $
• Financial investment at start-up.
$
$
$
• Incentives to participate in
$ $ office visit
collaborative care services:
$
• Single fee for entire
• Reduced group fees
Integrated • “Carving-in” diverse funding sources
Care removes barriers to care.
$

10. •1 Medical Director—Physician
• 3 Physician Assistants
• 2 Nurse Practitioners
• 3+ FTE counselor positions
• Family Therapist
• 2 Licensed Social Workers
Our • Case Manager
• Psychiatric Nurse
Staff • Psychiatrist - 8 Hours Weekly

11. Location Location Location
Lessons
Learned

12. Location Location Location
Having mental heath and
medical providers in adjacent
Lessons offices is essential.
Learned

13. Family Therapist Addictions Case
Psychologist & Psychiatrist Counselor Manager
Medical Medical
Exam Exam
Rooms Rooms
Medical
Provider
Medical Medical
Exam Stations Exam
Rooms Rooms
Bathroom
Lessons
Medical Medical
The Exam
Rooms
Medical
Assistant
Exam
Rooms
Bathroom
Learned Stations
Medical Medical
Rule Exam
Rooms
Exam
Rooms
Reception Front Office

14. Enhanced Record
Keeping
Lessons
Learned

15. Enhanced Record
Keeping
All providers work from the
same medical record
Lessons Crucial for Integrated Care:
Learned • Face-sheet
• Mental health flowsheet
• Health history questionnaire

16. Case Management
Lessons
Learned

17. Essential for helping
Case Management
patients access
community resources
Assists providers
Lessons to stay on schedule
Learned

18. Shared Success
Fosters Trust
Lessons
Learned

19. Shared Success
Fosters Trust
Improved patient outcome
becomes the single most
important source of
Lessons encouragement for functioning
Learned as a single team.

20. Collegiality rather
than Hierarchy

21. Collegiality rather
than Hierarchy
Lessons
Learned

22. Collegiality rather
than Hierarchy
Medical and mental health
providers have equal status
Lessons within the team.
Learned

23. Community Collaboration:
Inter-agency referral agreements
Marillac
Clinic
Colorado
Local
Lessons West Mental
Health
Hospital
Learned
Community Violence &
Medical Addictions
Clinics Agencies

24. Usage of St. Mary’s Services by
Marillac’s Integrated Care Patients
Hospitalization E.R. Visit
30.0%
22.5%
Outcomes 15.0%
9.00% 8.00% 8.00%
7.5%
6.00%
4.00%
0%
Year 1 Year 2 Year 3 Year 4 Year 4.5

25. Usage of St. Mary’s Services by
Marillac’s Integrated Care Patients
Hospitalization E.R. Visit
30.0%
22.5%
Outcomes 15.0%
9.00% 8.00% 8.00%
7.5%
6.00%
4.00%
0%
Year 1 Year 2 Year 3 Year 4 Year 4.5

26. Usage of St. Mary’s Services by
Marillac’s Integrated Care Patients
Hospitalization E.R. Visit
During year 4, only 17% of
hospital admissions were for
30.0%
mental health or substance
22.5% abuse conditions
Outcomes 15.0%
9.00% 8.00% 8.00%
7.5%
6.00%
4.00%
0%
Year 1 Year 2 Year 3 Year 4 Year 4.5

27. Change in Hospitalization Rate (per 1,000)
for All Marillac Integrated Care Patients
Jan-April 2003
Jan-April 2004

28. Psychiatry Length of Stay
January - April 2003 versus 2004

29. Psychiatry Charges:
Jan – Apr 2003 versus Jan – Apr 2004

30. Stepped
Care

31. Stepped
Care
Step 1
Screening, diagnostic, and preventative
services; parental education

32. Stepped
Care

33. Stepped
Care
Step 2
Active treatment in primary care, involvement of care-
giver and allied health professional to prevent relapse

34. Stepped
Care

35. Stepped
Care
Step 3
Psychiatric consultation at the primary-care setting
when emotional or behavioral problems persists or
complications occur

36. Stepped
Care

37. Stepped
Care Step 4
Referral to specialty setting for highly complex
presentations or poor outcomes occur at Step 3

38. Stepped
Care Step 4
Referral to specialty setting for highly complex
presentations or poor outcomes occur at Step 3
More complex
presentations may
begin at Step 3 or 4

39. Marillac Papers to date
• Mauksch, L., Reitz, R. Tucker, S., Hurd, S., Russo, J., and Katon, W. Improving quality of
care for mental illness in an uninsured, low-income primary care population. General
Hospital Psychiatry, 2007, 29, (4), 302-309.
• Mauksch, LB. Katon, W., Russo, J., Tucker, S., Walker, E Cameron, J. The content of a low
income, uninsured primary care population: Including the patient perspective. Journal of the
American Board of Family Practice, 2003, (16) 278-289.
• Cameron, J. and Mauksch, L. Collaborative Family Health Care in an Uninsured Primary
Care Population: Stages of integration. Families, Systems and Health, 2002, 20(4)
343-363.
• Mauksch, L. B., Tucker, S. M., Katon, W. J., Russo, J., Cameron, J., Walker, E., & Spitzer,
R. Mental illness, functional impairment, and patient preferences for collaborative care in an
uninsured, primary care population. Journal of American Board of Family Practice 2001,
50(1), 41-47.

40. Marillac
Clinic
Bridging the healthcare gap