Many patients with chronic pain also have mental health diagnoses. Yet pain management and behavioral healthcare specialists often are siloed, and the hand-offs can fail. Sudhir Rao, M.D., of Pain and Spine Specialists (PASS) has led an effort to integrate behavioral health providers into PASS, which has offices in Pennsylvania, Virginia and Maryland. A tech platform called NeuroFlow is linking patients with both sets of providers.
In a recent interview, Rao explained his realization that his practice could do a better job of getting its patients help with their mental/behavioral health.
“As chronic pain specialists, we traditionally focused on treating the patient's physical pain. We treat patients with medications, which would be anti-inflammatory medications, topical pain medications, muscle relaxants, nerve pain medications, and opioids, as well as interventional treatments, such as different types of procedures or injections to get patients feeling better improving their quality of life and functionality,” he explained. “I'm an anesthesiologist, and I did a pain medicine fellowship. Back then, we didn't really focus on behavioral and mental health concerns much. So for three-quarters of my career, I was focusing just on treating patients’ pain, and I thought we were doing a good job. We found patients who had mental health issues, such as depression, anxiety and PTSD. They all go hand in hand with chronic pain, as well as more complicated mental health concerns.”
PASS also deals with the behavioral health concerns of chronic opioid therapy, including potential opiate dependency addiction. “For a long while, we felt there is a psychiatrist or psychologist out there, and those are different scopes of medicine, outside of our training, and so we refer patients out,” Rao said. “When we come up with treatment plans, it sounds reasonable. However, practically speaking, we found that 90 percent of the people we referred out never went to see someone — mostly because they can't afford it. Most of our psychologists and psychiatrists were out of network or they're fee-for-service cash practices. And I'd say 50 percent of my clientele is on Medicare or Medicaid, so they don't have disposable income, so they wouldn't go.”
Rao realized that they were not making a lot of progress with some patients. “Sure, we're able to help people manage their pain, but their behavioral or mental health concern is being neglected, so we started looking into how we could expand our services,” he added. “As a practice, we decided to get trained in Suboxone, so we're able to provide opiate dependency treatments with buprenorphine products. A part of that is providing counseling. So once again, we thought we were taking a step forward. We got licensed to be able to prescribe and manage patients with Suboxone or buprenorphine. However, the states requires counseling, and rightfully so. So when we refer patients to counseling, we found ourselves back in the same boat. We decided we really needed to bring in social workers and behavioral health specialists into our practice to be able to provide that service through insurance, and have the continuity of care and the providers can speak to one another.”
In 2019 PASS started working with a company called NeuroFlow, which has a platform that allows the practice to be able to integrate service between mental health and pain management in a seamless format where all the providers on the team have access to the information.
Outside of a large healthcare system, the biggest complaint Rao gets is that patients are confused that clinicians don't know about their other providers and outcomes. “I would love for there to be a national universal electronic medical record where every provider gets to see this information. Unfortunately, that's not the case. And we often have to rely on notes being faxed to us.”
NeuroFlow allows the patient to enter real-time information on how they're feeling, and what their concerns are. There are assessments that patients can do as frequently as they want. There are also training resources to help patients deal with their mental and behavioral health concerns.
“With NeuroFlow, we realized that not only can we have this data readily accessible, but then we can risk-stratify and see what types of patients we have and what the acuity is, and that led us to realize we have enough patients who probably would benefit from a behavioral health integration approach,” Rao said.
The behavioral health integration approach uses case managers and psychiatrists to collaborate on each patient's care. “It provides the prescribing provider, in our scenario, the pain physician, information on what's going happening on the behavioral/mental health side, and then allows that person to know what's going on from a physical pain standpoint,” Rao explained.
CMS and most commercial payers are reimbursing for behavioral health integration. One challenge, Rao added, has been finding behavioral health specialists, even prior to COVID. “There are a lot of licensure requirements that each state has, and there's just not been a surplus of these clinical social workers or psychologists. The practice has made a big investment, but I think it was the right thing to do, because we saw the clinical benefits right away. But from a financial standpoint, from a business side point, it did take a while to get caught up.”
Rao cites some impressive results from the implementation so far:
• 71 percent of collaborative care patients have reached a treatment response (defined as a 50 percent decrease in assessment scores).
• 37 percent have reached depression remission within 4-8 months of usage (no longer experiencing symptoms) vs. 20 percent in treatment as usual.
One of the only benefits of the pandemic, Rao said, is the accelerating adoption of telehealth and providers being able to get reimbursed and bill for those services.
“When the shutdown happened last March, we immediately pivoted toward telehealth, and that allowed us to use the NeuroFlow platform even more, because it was one of the easier ways for the patients to be able to interact with us,” Rao said. “What we found was that although the patients weren’t able to come into the office, they were still very happy to be able to communicate with us via NeuroFlow. Telehealth became a big part of our practice over the course of the last year. We have subsequently segued back into in-person visits as much as possible. But I think telehealth is here to stay. it provides a lot of value, especially for patients who otherwise are in remote areas or just can't get in because of sickness or illness. From a behavioral/mental health standpoint, during the pandemic, we saw a big spike in anxiety and depression. But we're also able to quantify how our efforts have been able to reduce some of those initial spike numbers. And I think that's a testament to what our program is doing and what the NeuroFlow platform allows us to do.”
