Finding a well-researched, effective and equitable digital health solution is only one component of building a behavioral health ecosystem. Making it work within an organization is equally essential. How do stakeholders see success? Are the metrics clear and the path to success well outlined? And what are the best referral methods when clinicians have such limited time with patients?
These are just some of the questions that Trina Histon has honed to guide behavioral health implementations during a two-decade career at the forefront of digital mental health. At Kaiser Permanente (KP), Trina shaped the strategic direction of the group’s wellness and prevention activities and scaled its digital mental health ecosystem. Now, Trina is advancing the software transformation of psychiatry, behavioral health and primary care as Vice President of Clinical Product Strategy at Woebot Health.
We spoke to Trina about their previous work at KP, and what they learned about integrating digital tools into care pathways.
To start, by knowing what’s happening in the real world. In primary care, most doctors have 17 minutes with their patients; during this visit, on average five topics are covered. In that small window, patients have the opportunity to share the deeper context of their health so a care plan can be built. It’s important to be deeply respectful of the context of how those 17 minutes are being spent in a primary care setting. We know from a recent Health Affairs paper that primary care doctors have experienced a 50% increase in patients presenting with mental health concerns. While medications and referral to therapy are in their clinical toolbox, more health systems, payors and providers are looking to augment care with digital mental health solutions like Woebot that can offer support to patients as they move through their lives. I’ve been at Woebot Health for a few months now and see this firsthand: 77% of conversations users have with Woebot are outside of clinical office hours.
You must understand how mental health concerns actually surface during a visit. What are the usual referral options? Do clinicians already refer to digital tools? How receptive are they to using this modality of support? Clinicians spend their time with patients doing a variety of things. Doctors may be in the EMR documenting the reason for the patient’s visit, noting symptoms and the impact of ongoing issues. In this dialogue with patients, they are expressing empathy and probing on areas that may inform a plan of care and how that will fit in with a patient’s life and lifestyle. Therapists, depending on their practice, will assess how a patient has been since their last session, review any updated assessments the patient has completed, and probe and reflect on any changes. A lot of the time will be leveraged to hold space for what is happening in the patient’s life; this will likely include some problem identification and checking in on aspects of a patient's life that may support or hinder a path forward.
In my experience, you can have the best evidence-based product and even a compelling user experience, but the product is never used because the work to integrate it into the clinical workflow didn’t happen. For me, integration also includes clinician training. From the literature, we know barriers to adoption include workflow considerations but also low confidence and a belief that apps may not help patients. Clinical enablement must address all these concerns if clinical adoption is going to be achieved.
While clinicians in specialty care may have more time with patients, the opportunity to frame the value of adding digital mental health to a plan of care must be additive to the visit, in terms of referral pathways in the EMR, and the ease of receiving that information as a patient. Being able to text the patient the link to get the app from your organization is the optimal referral path. It’s also good to send it via secure message as a backup. Lastly, printing the instructions on an After Visit Summary (AVS)/patient instructions may also be relevant for health systems that don’t have texting capabilities.
First and foremost, trust is imperative. The trusted patient-clinician relationship is the fulcrum to deploying digital mental health products. Patients are more willing to try a tool if their clinician recommends it, the referral is personalized, and how the product can help them is contextualized to what that patient is experiencing. It’s also important to have a multi-stakeholder partnership that includes senior leadership, IT partners, innovators, change management experts and, critically, front-line teams who can inform workflow design and reflect the optimal patient match.
I’d also say that too often, the rollout phase isn't carefully planned. Some people anchor to their first experience with digital tools; if that hasn’t been positive, there could be more resistance with subsequent efforts. Additionally, if people had a positive experience and the toolbox was then taken away from clinicians, this can also impact efforts. Being clear about the phases of work, from pilot to scale within teams, and communicating clearly at each phase, will increase buy-in and create curiosity for those who may be part of later rollouts.
Last, applying human-centered design and empathy-based problem-solving ensures user needs are what get scaled. For example, in exploring what helps or hinders patients in caring for their mental health, it is possible to probe where digital tools might fit into their day, asking how they already use their phones, if they use apps for day-to-day things, etc. Answers to these questions can provide insight into how to frame a referral to a digital mental health app. Getting to what matters to patients in how their clinician frames the referral can then be codified in the training materials.