Healthcare advisory firm Chartis recently published a report highlighting several keys to success in launching a digital behavioral health program. In December, Chartis principals Jon Freedman and Mark Wenneker, M.D., M.P.H., spoke with Healthcare Innovation about some of their report’s findings.
HCI: Chartis has described some opportunities around integrating digital behavioral health solutions into primary care, based on lessons learned with health system clients. Are we talking about working with private-sector behavioral health startups or are health systems creating their own solutions internally?
Wenneker: It is both. Some of the larger health systems that have made significant investment in digital are leveraging that investment to include support of a virtual connection across many different specialties, including behavioral health. Some smaller health systems that have not made that investment are utilizing external options.
Freedman: A lot of startups come with new approaches and new technologies, and they're not encumbered by the legacy systems and all that that goes with them.
One of the things your paper recommends when launching a digital behavioral health program is to start with a with a solid use case that's well-defined. Your paper mentioned the Collaborative Care Model as a good example. Could you talk a little about that model and why it's a good example here?
Wenneker: In essence, the model is how bringing the behavioral health clinician to the primary care setting was initially developed. This model is important because a significant percentage of patients who have behavioral health conditions, particularly anxiety and depression, present themselves in primary care settings. Those patients are more likely to be willing to be treated in the primary care setting. There's a lot of evidence to support the effectiveness of that approach, both from a clinical quality standpoint as well as in terms of cost-effectiveness. We are very bullish on that with our health system clients.
Is another point about establishing effective use cases that it is almost like running a research project in the sense that you want to make the case to the rest of the health system that this is worth investing in, so you're going to measure the results and report on what you've accomplished and then also use that for making adjustments?
Freedman: Yes, the Collaborative Care Model lends itself to testing and learning in each of five distinct areas and the dimensions that they represent in ways that are quantifiable, sometimes qualitatively, sometimes quantitatively, but you have that mix of both, which is important. It definitely involves patient experience and the collaboration part is key. That manifests itself with the data that a technology platform is clearly positioned to lend itself well to, so it is a great use case in building that muscle memory, if you will, around how to do this and to build that sort of organizational and cultural alignment around this as a worthwhile endeavor, as your use cases may expand over time.
One core area you identify is patient engagement and patient experience. What kind of digital engagement has proven important to keep people focused and involved with the process since digital might be new to people in terms of how they're engaging with the health system?
Freedman: Start with how many of us experience digital in our own lives and have certain expectations about how we use digital on our phone or computer. It has to feel familiar, look familiar, act familiar. You don't want your patients to have to learn a whole bunch of new tools. They need to be intuitive, so design is a significant part of it. Then there is real-time and near real-time feedback of ‘is this doing something for me and is this worth my time?’ Digital is a great platform for that ongoing communication, both manual and automated, to have a health system or providers facilitate that feedback loop. Another big component involves educational resources, especially for patients who are just starting off on their behavioral health journey. What does it mean to have anxiety or depression? What is this treatment plan? Who are my providers? What's the difference between a psychiatrist, a psychologist and a licensed clinical social worker?
Another area your paper mentions is care team engagement. Are there some reasons that these solutions should appeal to the primary care clinicians? Is it helping them with patients who show up in a primary care setting with behavioral health issues?
Freedman: Yes, that's the advantage of having these resources brought to the primary care office. The question from a care team perspective is how do you create the buy-in of the care team, which is critically important for this, and how do the digital tools help that? From the standpoint of creating the buy-in, as with any technology, you need to think about the framework of early adopters, late adopters, and laggards. It applies here, too, right? You need to find those clinicians who are willing to make necessary changes to the workflow. Because the digital tools enable measurement, they help support the care team in knowing which patients they need to focus on and how they are doing.
The primary care physicians often see a patient for 15 to 20 minutes at a time and the patient is coming in for something else. The ability to push out to the patient digitally an anxiety survey, GAD-7 or a PHQ-9 for depression, and then get those results ahead of time allows that to be flagged for primary care physicians without wasting valuable time for the patients in the waiting room, or for the patient and physician in the exam room. It also enables a primary care clinician to know better when they should refer to a specialist. There will be a cohort of patients who really need to get treated by a psychiatrist directly.
It sounds like making sure the workflow makes sense and is easy for clinicians is important, especially if you're working with an external group on the digital aspect.
Freedman: Without the workflow, nothing works. It's as simple as that. If it's not integrated into your EHR, that's a significant limiting factor. That is not to say that it can't work, but anytime a physician or a care team member goes into two different screens, that's extra work. It's also a pain in the neck, frankly, for patients to have to understand where to go as opposed to a single unified experience. If anything, we should be simplifying workflows, reducing steps, and there's significant opportunity with digital to do that, but it has to be thoughtful and deliberate. If vendors aren't willing to engage in that way with a health system, that is something to look at very critically.
Another key you identified is changing culture around measurement-based care. You mentioned that the field has historically lagged in the development of rigorous quantitative measures of performance. Is that changing and if so, how does that apply to this?
Wenneker: The behavioral health world is really accelerating its use of more objective measures. For the Collaborative Care Model, Jon mentioned the PHQ-9 and GAD-7 are the most common measures that are used. An integral part of the model is to use those measures to identify who needs to be seen, how they're doing and when they need referrals.
Freedman: The biggest advantage of the digital component is that it makes measurement that much easier, and because it's often automated, you have a better view for your organization about the patients you're seeing, which helps you balance resources and understand where your gaps and opportunities are more strategically as an organization.
In addition to improved clinical outcomes, is there a potential financial ROI, too?
Freedman: If you are able to intervene with somebody at a lower acuity, you are going to expand access and get people treatment. There's revenue to the health system coming in, even at lower acuity levels. Also, you are saving a spot, as it were, for somebody who requires higher acuity care because that person is not decompensating into that higher acuity zone. Capacity is a huge challenge for a health system, so you really have to give care to who needs it most when you have limited slots to fill. You get care to people at varying levels of acuity and you allow providers to serve patients at the right level of their license. There still are capacity issues, but this is another tool in the overall toolkit.
Wenneker: All of us who work with behavioral health understand the impact on costs for patients who have other health conditions and comorbidities. The evidence is really undeniable of the relationship. The question is, how do you create interventions that reduce cost and then capture the value of those interventions, right? And that's where value-based care comes in. In a fee-for-service world, you may not actually be able to accrue the value of those interventions, right? That's really the next piece of work that needs to get done is to create more of the value equation for investment in these interventions to reduce the costs and the impact of behavioral health conditions, and have the entities that are investing in these interventions actually be able to realize the value of that.