Cherokee Health Systems – integrating primary care, behavioural health and addiction services

Rob Warriner of Walsh Trust attended the IIMHL Leadership Exchange 2019 and learned about a Tennessee medical centre and primary health service which takes an integrated approach to service provision.

During September I had the privilege to participate in the International Initiative for Mental Health Leadership, which had its week-long Leadership Exchange.

Around 700 people from around the world participated in knowledge/information exchanges. This involved spending three days with a large (by New Zealand standards) medical centre and primary health service – Cherokee Health Systems in Knoxville, Tennessee.

I then joined all the participants of various matches that took place across the United States and North America, at a Network Meeting in Washington DC. 

Serving patients at their point of need in their own communities

The Cherokee website states:

"Cherokee Health Systems is a non-profit organization that provides primary care, behavioural health, and addiction services to over 70,000 people living across the state of Tennessee.  

"We offer sliding-scale fees and no one is ever denied treatment based on an inability to pay.  

"We have a national reputation as a pioneer and leader in integrated care – an approach in which we embed behavioural health providers alongside primary care physicians to provide the full range of patient care".  

Cherokee Health Systems has been in operation since 1978. In spite of the name, it has nothing to do– with Cherokee Indians. It was initially established as solely a medical centre.

In recent years, in response to population needs, it has included behavioural health (ie mental health and wellbeing services), integrating a range of components as core elements of their business. 

Cherokee Health Systems operates clinics in both urban and rural areas of Tennessee and also 23 telemedicine sites. It serves the migrant farm work population, patients with opioid addictions, people with mental health problems, people on the streets and those who live in public housing - among others. 

Cherokee Health Systems’ goal is to serve patients at their point of need in their own communities. 

 

We go where the grass is browner.

 

A phrase they often say is "We go where the grass is browner." 

This simply means that we place our services in areas of need rather than in areas of potential profit. Currently, they operate 24 rural and urban clinics in 13 Tennessee counties, in addition to numerous on-site and telehealth services provided in many area school systems.

Cherokee’s integrated care approach involves a behavioural health consultant (often a psychologist) and a GP working on the same team. 

At the start of an appointment, the patient answers typical questions about vital signs as well as a few behavioural health queries.

Next, the GP sees the patient and conducts the visit. If the patient answered affirmatively to the behavioural health questions, the GP will ask the behavioural health consultant to talk to the patient as well.

The intent of the behavioural intervention at Cherokee is to help the patient with the presenting issue. By the end of the visit, the GP, the behavioural health consultant and the patient will reach a consensus about the patient’s care plan going forward. 

Patients like Cherokee’s model of service because they don’t have to get referred out to see a behavioural health specialist.

Primary care providers, who often don’t have time to attend to behavioural health or substance use disorders, find it comforting to know they have access to a behavioural health consultant. 

The work requires a unique skill set, values and attitude to fit within the workplace culture that is necessary to support the effectiveness of integrated practices. Hiring the appropriate employees can be a challenge.

Cherokee offers various educational opportunities relating to its work, such as a psychology internship and a practicum experience for masters and doctoral students.

The practicum allows social work, clinical psychology and counselling psychology students to work with and learn from Cherokee healthcare professionals. 

Cherokee Health was described by the Agency for Healthcare Research and Quality as part of “a case study for innovative and high quality services".  

It was selected as a case study as:

"Cherokee Health Systems is a Federally Qualified Health Centre (FQHC) and a Community Mental Health Centre, and is a national leader in integrating primary and behavioural/mental health care.

"It has a mature structure for an integrated practice team; is constantly striving to innovate to improve integrated service delivery; and, in response to demand from other systems, has developed training in primary care/behavioural health care integration".

Two standouts – the curriculum and the training institute

Cherokee Health Systems has developed an extensive training curriculum for its own staff and offers a training programme for other health systems and clinics that want to integrate behavioural health and primary care. 

Interviewees said that long-standing employees have sustained the values of the organisation and are the custodian of the model of care.

Cherokee looks for people who endorse the organisation's values first and then trains them with the skills they need. 

Cherokee has developed a training institute to help the next generation of providers have a good experience working with the underserved. 

Cherokee is the Eastern Tennessee Area Health Education Centre. It has:

  • American Psychological Association credentialing
  • a University of Tennessee Family Residency in behavioural health
  • a joint residency with the University of Colorado being set up.

Rob notes that in his conversations with the team at Cherokee consistently revealed the on-going deliberateness of blending behavioural health and primary care.

  • Not just "business as usual" ie primary care with behavioural health added on; the development required a very distinct shift to focus upon wellbeing. 
  • There was a very strong, and distinct values base; culture of practice, their approach to work, and the workplace resonated strongly. "Backroom functions" (eg finance, IT and data analysis) are a part of "the team." 
  • Development was led by a determination to be relevant and responsive to need, rather than prescribing a response to a perceived need. 
  • All the team were passionate, energetic, committed, diverse, proud of their work. 
  • Their approach, culture and values strongly reinforced the message that "there is no health without mental health" through intentionally and clearly integrating the two. 

Rob suggests that these bullet points would be important key messages to inform the development of health and wellbeing services in New Zealand. 

"I would also have to say that approaches emerging in New Zealand will be greatly enhanced through the emphasis of partnering communities in improving health and wellbeing," says Rob.