The current mental health care system unfortunately is not adequately addressing the roughly 50 million Americans who experience a mental illness. In fact, it takes on average 11 years from onset of mental illness symptoms to treatment. Additionally, 55% of US counties do not have a single practicing Psychiatrist and 148 million people live in a designated Mental Health Professional Shortage Area. With these statistics, the current US model for mental health treatment needs to find new ways to address the disconnect between the need for mental health services and the lack of available providers.
Is integrated care the answer?
Integrated care, which is the partial or full blending of behavioral health services with general medical care, is one solution for addressing this problem. We recently hosted a webinar on “How Technology can Support your Journey Towards Integrated Care” with panelists Dr. Frank Webster, the Behavioral Health Chief Medical Officer at Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma, and Texas, Kacie Kelly, Senior Vice President for National Policy Implementation at the Meadows Mental Health Policy Institute, and Dr. Tom Zaubler, Chief Medical Officer at NeuroFlow. On the webinar, we discussed how integrated care overall could solve for several key challenges the behavioral health industry is facing. More specifically, we talked about the benefits of one model of integrated care called collaborative care.
What is collaborative care?
Collaborative care is a specific type of integrated care using a team-based model of treating behavioral health in the primary care setting bringing primary care and behavioral health clinicians together to provide treatment. All patients in a primary care clinic are universally screened for psychiatric illness as part of their visit. Collaborative care has been studied in more than 80 randomized control trials and has been shown to improve patient outcomes, patient and provider satisfaction, and reduce healthcare costs.
Collaborative care in practice may have primary care physicians meeting with patients and prescribing medications, while Psychiatrists are often used as a caseload supervisors. Dr. Zaubler explains that “this allows Psychiatrists to manage a much larger caseload of patients than if they were seeing them individually.”
Offering behavioral health interventions in primary care settings is convenient, can reduce stigma, can deepen the patient-provider relationship, and can improve care for those with co-occurring mental and medical conditions. In our webinar, Dr. Zaubler noted that “95% of all mental health providers are practicing in siloed settings. And yet, when patients present with their psychiatric problems, roughly 80% either present in medical settings for their psychiatric care. There's a huge disconnect here in terms of where people are seeking care and where the care gets delivered.” Collaborative care attempts to bring together where people are already seeking care and the need for greater behavioral health care.
Challenges for implementing collaborative care
While the evidence supporting collaborative care continues to grow, uptick and adoption remains scant when it comes to implementing collaborative care across providers.
We have evidence that collaborative care is beneficial, but what challenges do health systems and providers face when trying to implement collaborative care? To start, some primary care physicians may have anxiety about a new way of doing things and disrupting current workflows. There is particular concern around prescribing psychiatric medications, which is why it's important to create an environment where primary care physicians feel supported by their behavioral health team and clinical decision support tools.
Additionally, creating a sustainable model of collaborative care requires an upfront investment. Health systems may be hesitant to adopt a new way of working that includes upfront costs. That’s where partners such as the Meadows Mental Health Policy Institute can be beneficial and Kacie Kelly remarked that, “we come in and oftentimes leveraged philanthropy to offset transition costs or startup costs and then help the practice with the operational workflow changes that need to happen, help them understand the changes with billing and reimbursement, and overall practice changes.” In fact, Kacie remarks that collaborative care “can be cost neutral around 6-9 months of utilization, and cost savings at the 9 month mark.” Collaborative care ultimately leads to cost savings through decreased medical utilization, emergency department visits, and inpatient stays.
An important component of collaborative care is measuring patient symptoms using validated measures such as the PHQ-9, a questionnaire screening for depression, and GAD-7, a questionnaire for anxiety. However, this can be time consuming and can create more paperwork for the front desk staff members.
Finally, there can be challenges for health plans reimbursing properly for behavioral health. Dr. Webster noted that “behavioral health typically makes up 3-5% of healthcare costs for commercial insurance. However, it's important for people to understand that 3-5% has a huge impact on medical costs.” Additionally, providers need to understand that they can bill and be reimbursed for these behavioral health assessments.
How can technology help?
We’ve seen the reasons why collaborative care is so important and obstacles to pursuing it, but how can technology help us implement this strategy? Digital solutions can plug into various parts of an integrated care model, as shown in this diagram from Raney et al.
One digital solution, NeuroFlow, is a two-sided behavioral health platform that leverages technology to both remotely assess and identify patients appropriate for collaborative care as well as increase the efficiency of the care teams managing the patient panel. NeuroFlow’s engagement platform allows patients to quickly and easily complete assessments such as the PHQ-9 and GAD-7 in the comfort of their home and immediately engage with relevant clinical content based on their scores. At the same time, their providers and supporting BH care team collaborate on their treatment through a tech-powered registry that populates information directly into electronic medical records, allowing providers to track patient progress over time and be alerted to patients who are at risk. Their combined offering of technology and clinical services showcases the exciting road ahead for empowering care teams with technology to help scale proven models of care.
Another example is Valera Health, which acts as a practice extender and telepsychiatry option. Patients access Valera Health through a mobile app and are triaged by health connectors and then routed to therapists and/or psychiatrists as needed for telehealth visits. Patients then access appropriate self-guided programs and exercises to stay engaged.
Finally BCBS utilizes the Learn to Live program. Health plans have unique challenges because they use claims as healthcare information, but they cannot tell what is happening today, or predict future care. Additionally, health plans have billions of clinical data points but as Dr. Webster mentioned, “getting claims organized and sorted is really difficult.” To address some of these issues, BCBS utilizes the Learn to Live program, which is an online platform where individuals can take assessments and then receive web-based CBT lessons and live clinician coaching. Patients receive treatment and health plans can capture their assessment information as clinical data to help them get targeted resources to the people that need them.
Tips for getting started with collaborative care:
1. Work with experts
Look for behavioral health providers who are well versed in collaborative care to help you with your founding team. Having technical expertise will make a huge difference in the success and longevity of your program.
2. Think creatively about startup costs
Ultimately, collaborative care leads to cost savings, but look into philanthropic options if you need help with startup costs.
3. Remember your CPT codes
Have your staff start getting used to billing CPT codes for all behavioral health assessments to ensure proper reimbursement.
4. When integrating technology, focus on measurement
As Kacie Kelly noted in our webinar, “I would encourage you, as you’re trying to figure out how to extend your workforce and how to get people tools between sessions, to really prioritize those tools that are measuring the outcomes and the impact” of your intervention.
To dive deeper, check out the full webinar, review a helpful collaborative care Q&A from NeuroFlow, and please join us for the Going Digital: Behavioral Health Tech conference on June 8-9, 2022. Registration to the conference is free, or consider making an optional donation to our 2022 non-profit partner, the American Foundation for Suicide Prevention.
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