Mayfair Internal Medicine
(Pictured, left to right: Candi Roller, medical assistant; Amber Ivanova, LCSW,  behavioral health specialist; Dr. Larry Plunkett; Tiffany Martin, office manager; Dr. David Bolshoun; Dr. Edith Lovegren; Abby Hess (sitting), front desk)


A firm foundation in primary care transformation and quality improvement practices has served Mayfair Internal Medicine well in the Colorado State Innovation Model (SIM) program. Three seasoned physicians lead the practice and care for a largely older, Medicare-eligible population.

The established Denver, Colo. practice is a veteran of the Comprehensive Primary Care Plus medical home transformation initiative, and was supported by HealthTeamWorks for practice transformation. Its twice-monthly quality improvement team meetings are well-organized and productive, so when HealthTeamWorks began supporting Mayfair for the SIM program in 2017, the practice was ready to hit the ground running.

HealthTeamWorks provides practice facilitation as well as a clinical health information technology advisor (CHITA) to support the work. As an advanced primary care practice, Mayfair is tracking double the required six measures under the SIM program. HealthTeamWorks practice facilitation supports the quality improvement process so measurement activities fit into the regular flow of a busy practice, e.g., whether to do screenings during an annual wellness visit or when patients come in for an annual physical, and how to seamlessly code for reimbursement and capture the screening results in the patient’s electronic health record. The CHITA advisor offers counsel and technical advice so Mayfair can get to the data needed to assess population health opportunities, identify preventive health targets and report activities and results required for the CPC+ and SIM programs.

SIM focuses on screening for depression and social determinants of health needs, as well as referral to resources when needs are identified. Mayfair has surpassed the requirement to screen more than 50 percent of its adult patients for depression; in 2018 alone, the practice identified 1,814 patients who needed followup care for this chronic condition.

Because few behavioral health providers in the Denver area accept Medicare patients to treat depression, the screenings uncovered a resource gap for Mayfair’s patients with depression. Mayfair responded with a significant practice change to support the spirit of SIM. It contracted with a mental health facility to bring a licensed behavioral health professional into the practice so, when a corresponding need is uncovered during a visit, physicians are able to refer patients with a warm handoff and introduction to the practice’s own provider. Integrated, onsite primary care and behavioral health is a best practice, designed to make followup care for depression and other behavioral health needs easier for the patient—and more likely to happen.

“SIM is helping reduce the stigma associated with behavioral health and is breaking down barriers,” says Tiffany Martin, Mayfair’s office manager. “SIM has given us access to a behavioral health provider and allowed us to take care of the whole patient.”