Integrated Care for People with Disabilities: Lessons from an Accountable Care Organization

DASH Project Spotlight: Altair Accountable Care for People with Disabilities


Lead agency: Lutheran Social Services of Minnesota

Partners/collaborators: Altair Accountable Care Organization, four behavioral health specialists, six disability service providers, one primary care provider, and two local public health departments

The challenge

One out of every three people with intellectual and developmental disabilities may also have behavioral health issues. However, very little has been done to standardize the process for assessing this population for depression, anxiety, isolation, and other behavioral health conditions. The Altair Accountable Care Organization (ACO), the first social service-led ACO in Minnesota, is working to identify and address these unmet needs for over 6,500 people with disabilities in the Twin Cities, Minneapolis and St. Paul.

If left untreated, behavioral health conditions can prevent developmentally disabled people from securing employment and actively participating in their communities. Currently, when a person with disabilities in the Twin Cities experiences a critical behavioral health event, it can take anywhere from a few weeks to a year to get placed into proper treatment. This is due to a lack of communication between primary care and behavioral health providers. Clearly, the status quo of fragmented data systems is inefficient and affects patients’ quality of life. Improving continuity of care will require better data exchange across sectors so that care teams can respond to urgent behavioral health needs proactively.

The opportunity

Altair ACO, with Lutheran Social Service of Minnesota as fiscal sponsor and lead member, envisions an e-Health infrastructure that fully integrates primary care, behavioral health, and social services to improve the quality of life of people with disabilities in the Twin Cities. Through Data Across Sectors for Health (DASH), they are pioneering a new delivery model that includes “disability-competent” behavioral health providers in a Health Information Exchange (Eldermark Exchange) to allow access to critical information from different providers and systems when delivering care.

Through this effort, behavioral health providers will be able to measure and track events in the HIE in real time so that the care team can intervene in a timely and appropriate manner. When behavioral health events are submitted, all care team members will be notified according to their particular role in responding to the situation, providing clearly defined expectations for everyone involved. A process will also be implemented to assess patients’ behavioral health needs before placing them into services rather than waiting until a mental health crisis occurs. Nate Tyler, Principal Consultant on the DASH project, explained:

“When someone providing services notices a change in a person’s condition, medication, or anything that could impact their mental state, we want to make sure that we have a plan in place to manage that…We also need to identify patients’ needs before they are enrolled so we do not realize 7-9 months down the road that their placement was not right and that person’s quality of life probably has not been as high as it could have been.”

Altair’s e-Health implementation project currently provides connectivity across six disability service providers, a primary care provider, and the HIE. The DASH project will allow them to extend data sharing to the behavioral health sector. Project Director George Klauser commented:

“We really strive for an integrated flow of information that can provide better care outcomes for people with disabilities. This opportunity has allowed us to build on that foundation and expand it to include behavioral health.”

Engaging sectors to work together

The Altair ACO serves as the coordinating mechanism that manages collaboration across multiple sectors to improve services for people with disabilities. A steering committee of ACO member organizations meets regularly to report on progress and coordinate efforts for rapid results. Each quarter, the committee is joined by people with disabilities and their guardians or trusted advisors, who provide crucial input on decisions that affect their care.

Behavioral health providers have been engaged with the collaborative since it was first established in 2013. Through a State Innovation Model testing grant from the Center for Medicare and Medicaid Innovation, Altair was able to conduct an in-depth assessment to determine how to effectively identify behavioral health partners that can help provide more holistic care for people with disabilities.

Only a limited number of behavioral health providers are able to support people who are intellectually disabled, so it was important to select the right partners and provide proper training to ensure proficient care that meets patients’ needs. Klauser explained:

“We have defined a set of partners, referral process, assessments, and education for both the provider as well as the caregiver and the parent or guardian to ensure that they have an understanding of what is required for disability-competent care.”

Education and training have been crucial to maintaining buy-in from care providers as Altair works to integrate behavioral health partners into the HIE. Altair is gathering their feedback and providing continued education and reinforcement to ensure they have the information they need to properly access and use the data system. Klauser noted:

“You anticipate that people will understand and adopt and follow, but that is more difficult than it appears to be because you are dealing with a lot of competing priorities, especially with the amount of regulation that this sector is challenged with. So we are constantly validating and gaining understanding to ensure that we provide that education as a part of a continuous roll-out process.”

Looking to the future

By notifying care teams about the behavioral health needs of people with disabilities in real time, Altair ACO can ensure that they are providing the right services at the right time. Ultimately, the project aims to improve the quality of life for people with intellectual and developmental disabilities while simultaneously reducing costs. The team hopes that screening patients for behavioral health factors and openly communicating with families will help reduce stigma and better support patients who have mental health diagnoses. Klauser emphasized:

“This is all about changing the outcomes for people’s lives. It is not an academic exercise. It is not a research exercise. It is not an exercise in designing systems. While all those things are important, we are really looking for impactful change that will lead to a person with disabilities living a healthy, happy life in the community.”

Altair ACO will analyze overall trends in the data in coordination with county and state public health agencies to inform population health improvement initiatives for the developmentally disabled in Minnesota. As Altair continues to expand on their integrated delivery model, the findings and lessons for ACOs, expansion of health information exchanges, and treatment of people with disabilities can be applied throughout Minnesota and nationally.

Learn more