By Melinda Young

EXECUTIVE SUMMARY

The goal of the CHECK team is to address patients’ obstacles and issues that affect their health.

  • These include problems that have not yet yielded a diagnosis, such as mild depression or anxiety.
  • The team used grant funds to provide rideshare transportation to take patients to medical appointments.
  • Also, the team helped people access legal resources to address their housing challenges.

The CHECK program prevents rehospitalizations by employing a team of community health workers and licensed behavioral health professionals to help people with chronic diseases deal with the social determinants of health that hinder their disease management.

“Some people have high levels of social disarray, like housing, social, transportation issues, as well as behavioral health needs,” says Michael Gerges, LCPC, executive director of the CHECK program at the University of Illinois at Chicago and UI Health.

“What we do with CHECK is say, ‘Why does one person have to address all of these things?’” he says. “Community health workers can have expertise in addressing social determinants, and behavioral health workers can address behavioral health needs, and patients get support from all the experts, working in a coordinated way.”

Address, Treat the Whole Person

The goal of the CHECK team is to address all the obstacles and issues that surround a patient.

“If we start looking at individuals and say, ‘As a whole person, you have all these needs,’ and then we split them up to have different people address them, then we can move people through the healthcare process in a better way,” Gerges says.

The needs the team addresses can be problems that have not yet resulted in a diagnosis, including mild depression or anxiety. For instance, a patient might have some health issues that are not yet a medical or behavioral health diagnosis. In traditional, fee-for-service health care, these patients and those types of issues are not addressed until the problems are exacerbated and reach a crisis level.

“We wait for people to get bad enough to diagnose them, and then we wrap services around them,” Gerges says. “If we focus our efforts on those who haven’t crossed that line yet, then there’s a chance we can prevent [the crisis].”

Gerges uses the analogy of water with ice on the surface. Patients with diagnosable conditions are those who have reached the ice level and can be seen and treated. But right below that sheet of ice are a bunch of patients who will reach that top crisis level soon, but are not yet there.

“We provide direct interventions to the folks below that line,” Gerges says. “These can range to up to six skills-building sessions with a licensed clinician.”

The goal of the CHECK team is to focus on the patient’s existing resources and put the patient on a different, healthier path.

When CHECK, through a grant, focused on young people from birth to age 25, the team saw considerable depression among parents of the children, who had chronic conditions, and were enrolled in the program.

The parents’ behavioral health issues could affect the children and entire family. The team helped them through addressing their social determinants of health, including transportation to behavioral health and medical appointments, Gerges says.

“Medicaid had a specific transportation service available to patients, but it was very challenging to use,” he explains. “You would call for a referral and they would give you a company to call, and we’d set up the medical and behavioral health appointment.”

Then, the patient would wait an hour or longer for the ride. By the time the driver arrived, it would be too late to make the appointment.

“We found ways around that,” Gerges says. “Because we had a grant, we would use a rideshare service to pick up the patient and take them to the appointment, and that made for better engagement.”

The CHECK team also worked with medical-legal advocates to help families with applying for educational services that would accommodate the patient’s medical and behavioral health conditions.

“We helped families recognize what legal resources were available to them to address challenges in their housing,” Gerges says. “We found that a lot of our behavioral health interventions were going to the parents.”

The goal was for the team to use its knowledge of the patient’s health issues to help them approve their surroundings and to intervene as a way to prevent worse health problems, he adds.

“We would send out reminders of a national crisis hotline for anyone needing support,” Gerges says. “We’d offer people information or links to websites and resources.”