|Patrick Dombrowski on Collaborative Bridges initiative in Chicago
via Health News Illinois
Last week saw the launch of Collaborative Bridges, a collaboration between community organizations and safety-net providers on Chicago’s west side that aims to transform the way mental and behavioral health services are provided.
The initiative, supported by the Department of Healthcare and Family Services’ healthcare transformation funds, will see community teams help patients transition care as they return to their communities from hospitals and create plans to help prevent individuals from re-hospitalizations.
Hartgrove Hospital, Loretto Hospital and Humboldt Park Health are part of the effort. Its initial community organizations are Community Counseling Centers of Chicago, Bobby E. Wright Comprehensive Behavioral Health Center and Habilitative Systems, Inc.
Each community organization is paired with a hospital-based partner to close the gap in service between inpatient and outpatient services.
Patrick Dombrowski, executive director of Collaborative Bridges, spoke with Health News Illinois this week about the initiative, how it will help address long-standing healthcare disparities on the city’s west side and how policymakers can continue to support the collaborative work.
Edited excerpts below:
HNI: How did this initiative come to be?
PD: We started to explore conversations with west side behavioral health hospitals and safety-net hospitals. And we were the only collaborative that was driven by a community organization. All the other collaborators were largely driven by one of the safety-net hospitals. So I definitely think that our value proposition was incredibly strong because just the reality of what these patients experience. Systemwide, only about 25 percent of individuals coming out of inpatient hospitals were connecting to long-term, community-based providers. So our goal, and our primary indicator of success, is driven by wanting to reduce re-hospitalizations. And that statistic is similar … This is a nationwide thing. Close to 45 percent of all individuals who have an inpatient behavioral health stay end up being readmitted. So for the community organizations, it is really trying to deal with kind of the downriver Band-Aid of just going into crisis event after crisis event, seeing the same people. It’s really integrating with the hospital systems to ensure that we can see people as soon as they’re discharged to make sure they don’t go back into the hospital.
Our model is distinct from other collaboratives because it really focuses just on behavioral health, individuals with substance use and mental health needs. We have evolved as well as an organization as the whole perception of kind of mental health interventions too. We recognize that a lot of times when people present to the emergency room for mental health needs, it’s often because of social determinants of health. It’s often because of issues with housing, stressors in their life and situations that ultimately don’t necessarily have to do with a chronic mental health condition, but just because they have case management and care coordination needs. So our project, it marries those two elements of having care coordination, largely peers and largely from the west side doing kind of the this community-level, intensive linkage services. But we — and this is kind of separate from some of the other funded entities — we also have therapists and (certified alcohol and drug counselors) on staff. So the care plans created in the hospitals are really continued, and then the treatment is continuous throughout until they’re connected to a long-term provider. So that’s kind of the genesis and driving force of wanting to change these fragmented kinds of systems and change these silos.
HNI: How will Collaborative Bridges work for this transition of care for patients?
PD: We really are looking at a fully integrated system of care, whereas the community teams that we have are embedded fully within the hospitals’ treatment models. We have two discharge coordinators who really are focused on transitioning these patients to Collaborate Bridges. One is hired by the hospital and was hired by the community organization. For that stage, those two staff members are tasked with two primary duties. One is to ensure a seamless transition. Two is the day that somebody leaves the hospital, that all of their immediate needs are addressed: filling medication, making sure they have someplace to stay, making sure they clearly understand their discharge recommendations and, ultimately, doing the engagement work to make sure that they’re invested in connecting to our Collaborate Bridges team.
So then they get a hand-up to our larger team, there’s eight staff, the four care coordinators, (certified alcohol and drug counselors) and therapists. Each of the (community-based organization) teams are paired with the hospital, so that’s an additional resource for that hospital to continue the work once they’re discharged. That team, they’re really focused on three primary goals. One is crisis stabilization, so continuously having conversations to return a patient that we’re serving back to equilibrium to ensure that the crisis episode they have is resolved. There are specific kinds of modalities of treatment that they utilize to that end. Their second goal is to do a full evaluation and assessment of all their social determinants of health needs. They’re partnering with different organizations connecting them to identify the services. The third is to really change individuals’ thinking about looking at the hospital as the kind of primary treatment center and really try to facilitate getting them connected to long-term community providers.
HNI: What demand are you seeing for behavioral health services in Chicago?
PD: The demand on the west side has always been huge … The populations that have substance use and mental health needs, often the waitlist for treatment — particularly with Medicaid populations — is incredibly long. So that has always been one component, either having to wait for care or just having care that is not integrated with the full needs of the individual. And then secondly, particularly as ideas around what causes mental health needs evolve to really understand that poverty, poor health, physical health, economic drivers and community drivers really are impacting outcomes, that would apply to a lot higher degree for individuals that live on the west side. We look at the life expectancy gap. West Garfield Park, it’s 68 (years old). Downtown, it’s 86. That’s pretty stark. An individual that has chronic mental health conditions often will have comorbid physical conditions, and it is all interrelated. So what we aim to do is really improve access to care, and improve the capacities of not only hospital partners, but community partners as well.
HNI: What are some of the main challenges you still see delivering care in these historically underserved Chicago neighborhoods?
PD: The fact that the different providers are really coming together with a solution-focused lens is huge in itself. Ultimately, our scope of work is very focused on individuals coming out of crisis or having over-reliance on hospital systems to resolve their needs. It’s an honor to be part of a larger change and really look at what are the drivers that are contributing to poor outcomes. For us, it’s coordinating and having a cross-agency focus.
To speak to integration, it’s tracking individuals, it is joining together with governing bodies, policymakers, community organizations, hospitals and managed care companies as well, to really look at this fragmented system and come up with solutions to do things in a different way. Collaborative Bridges in itself is designed to evolve. Next year, we’ll be bringing out three additional hospital partners. We feel scalable. I think that, ideally, this model is something that can be replicated as we show successes in reducing hospitalization, successes in shortening hospital stays, because that is often a real problem with this population, as well for these west side hospitals. There’s a lot of individuals where their immediate crisis has been resolved, but they still remain in the hospital because there’s no adequate discharge plan. And there’s a clear indication that when they return to the community, the crisis will re-present.
HNI: What’s next for Collaborative Bridges now that it’s launched?
PD: With the core clinical work, the other elements of our project are developing an integrated (electronic health record) and (health impact assessment) that will ensure that there’s bi-directional communication and the ability to track all individuals. We also are looking to open a community wellness center on the west side, where not only our Collaborative Bridges hospital teams will operate, but we’ll also have ancillary services as well. With the angle in mind of presenting over-reliance on hospital admissions, we will have staff there who will be able to receive individuals … ensuring that if there’s no need to go to the emergency room, they can have a full kind of triaging of their crisis needs … We would like to really continue to show the value of our work … Ideally, with relationships with managed care organizations, we transition more to a capitated payment system that is more value-based, and it’s more about outcomes rather than simple count of services — value, not volume, as they say. And MCOs definitely get it.
HNI: What more can policymakers do to help this sort of work?
PD: It is just really owning the fact that we didn’t get to where we are now overnight. There have been decades of disinvestment on the west side that really led to these disproportionate rates of chronic disease, disproportionate rates of substance use and huge issues with poverty. Fundamentally, I do think there has been an evolution with a lot of policymakers understanding the importance of equity — everyone is always jarred by the huge gap in life expectancy. I also think that the pandemic really gave policymakers a deeper understanding of trauma and acceptance of mental health and understanding that mental health needs are not only something that everyone experiences, but that they ultimately lead to more adverse health outcomes. So to that end, it’s just continued investment in funding collaboratives such as ours. The beauty of healthcare transformation, and really a lot of the collaborative work that is going on, is that there is a bit of a latitude to evolve and to listen to their community and to really understand their needs. Data can only tell you so much. It’s really fully integrating within the community and ensuring services are designed in ways that are impactful.