Forcing the Conversation on Behavioral Health

As the industry turns toward value-based care and population health management, leaders are recognizing that physical healthcare alone is not sufficient.

This article first appeared in the May 2016 issue of HealthLeaders magazine.

Clarence E. Jordan, MBA, has dealt with a diagnosis of co-occurring mental health issues and substance abuse for the past 30 years of his adult life. It may come as a surprise to some that a person with behavioral health issues could be successful as a business and healthcare leader. The stereotype that those with behavioral health problems are violent, unemployable, strange, or erratic still exists. In fact, before he received a behavioral health diagnosis, Jordan had a similar image of those dealing with mental illness.

"Like many people, I probably saw mental illness as a homeless individual with a shopping cart with all their belongings loaded into it, pushing it down the street," says Jordan, the vice president of wellness and recovery for Boston-based Beacon Health Options, a behavioral health management company that serves 48 million people in the United States and the United Kingdom. "When I was given my original diagnosis, it came as a real shock to me because I did not ever feel that I had a mental illness. Life to me was normal."

For many Americans, living with behavioral health issues is the norm. According to the National Institute of Mental Health, in 2014 an estimated 43.6 million—or 18.1% of U.S. adults age 18 or older—experienced any form of mental illness (AMI, which includes mental, behavioral, or emotional disorders, but excludes developmental and substance use disorders). That same year, about 4% of U.S. adults, nearly 10 million, had serious mental illness (SMI, which results in serious functional impairment that substantially interferes with or limits one or more major life activities).

That's a significant portion of the population, and the challenges surrounding delivery of behavioral healthcare—stigma, access to care, utilization of resources, funding, cost, and reimbursement—are significant as well.

These issues have dogged behavioral healthcare for decades, but now, with the Patient Protection and Affordable Care Act's emphasis on population health, quality outcomes, and value-based payment models, industry leaders are recognizing the integral role that behavioral healthcare must have in patient care, and they are developing solutions.

Why now?
"I think CEOs and healthcare leaders across the country are realizing, as they move toward value-based contracting, behavioral health is a unique variable that can help accomplish the Triple Aim," says David Deopere, PhD, corporate vice president for behavioral health development at Des Moines, Iowa-based UnityPoint Health, a system with 3,788 licensed beds, 185 physician clinics, and total operating revenue of $3.8 billion in 2014.

It's hard to deny that behavioral healthcare is a key component to achieving the Institute for Healthcare Improvement's Triple Aim goals of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of healthcare.

"When you start to look at value-based contracting, capitated-type contracting, we know that people with behavioral comorbidity go to their primary care doctor more often with depression—comorbid depression—than if they don't have comorbid depression," Deopere says. "They also go to the emergency rooms more frequently. They get readmitted to the hospital more frequently."

To Deopere's point, according to the Medicaid and CHIP Payment Access Commission, total spending for an enrollee with a behavioral health diagnosis was almost four times greater than for an enrollee without a behavioral health diagnosis. The World Health Organization reports that mental health issues and substance abuse are the leading cause of disability worldwide, and according to a fact sheet from the National Alliance on Mental Illness, some $193 billion per year in workplace earnings is lost due to untreated mental illness. Plus, individuals living with serious mental illness face an increased risk of having chronic medical conditions, and adults living with serious mental illness die, on average, 25 years earlier than other Americans, largely due to treatable medical conditions.

"The real drive around this, and the real conversation around this starting now is because of population health and accountable care organizations," says Martha Whitecotton, MSN, FACHE, senior vice president of behavioral health services at Carolinas HealthCare System in Charlotte, North Carolina, a nonprofit organization with more than 900 locations and 7,395 licensed beds throughout North and South Carolina.

"If you ever hope to see progress in health outcomes for diabetics or patients with congestive heart failure, you have to address both behavioral and physical health. The way people are going to be paid, placing their payment at risk for overall health and overall cost, it's forcing the conversation around what do we do about mental illness."

Treatment works—if you can get it
The way behavioral health needs have been addressed in this country has not been stellar—something Jordan has experienced.

Before receiving a behavioral health diagnosis, Jordan found that mental illness and substance abuse can strain productivity. Though he did well during his naval career, becoming a commander and attaining a master's degree, after retirement from the military, he found it difficult to maintain a job as a civilian.

"After leaving the service, I had one of those experiences that took me from job to job, town to town, in search of some stability, in search of something to root myself to," Jordan recalls. "It never happened for me, at least during the course of the first 10 years out of the Navy, which I would classify as the period of my darkest time."

"The way people are going to be paid, placing their payment at risk for overall health and overall cost, it's forcing the conversation around what do we do about mental illness."

Jordan says he had many problems maintaining healthy relationships and had significant conflict with authority. It wasn't until he landed in front of Judge Seth Norman in a Davidson County, Tennessee, drug court that things began to change for him and he received a behavioral health diagnosis.

"It was through the courts, as a matter of fact, that I received mandated treatment," Jordan says. "I was given the option of going to jail or getting treatment. That was not a hard decision to make."

Unlike Jordan, many people in need of behavioral healthcare never receive necessary services.

"Because our system is so broken, only 40% of people who actively have mental health issues are getting treatment," says John Santopietro, MD, FAPA, DFAPA, chief clinical officer of behavioral health at Carolinas HealthCare System. However, with proper diagnosis and treatment, he says, 60%–80% of those with behavioral health issues can experience recovery. "Success rates are very high with the treatment we have today, but people have no clue about that. They don't know it because what they see day to day is people not getting treatment."

Over the years, a major barrier to treatment has been reimbursement for and funding of services. Medicaid is the single largest payer source for behavioral health in the United States, but it has typically had low reimbursement rates.

"It's heavily Medicaid and lower socioeconomic populations that we serve," says Greg Pagliuzza, vice president of finance and CFO at UnityPoint Health-Trinity, a 584-licensed-bed integrated delivery system based in Rock Island, Illinois. "We are dependent so heavily on grants from the state, and the Medicaid payment rates, which have not been increased, I believe, in at least 20 years. Our reimbursement rate is the same as it was 20 years ago, and we've had a reduction in grants."

"Success rates are very high with the treatment we have today, but people have no clue about that. They don't know it because what they see day to day is people not getting treatment."

Funding for behavioral health services varies from state to state, and in many areas of the country, dollars for behavioral health have been subjected to the chopping block.

"Basically, there are 50 different departments of mental health. There's no real federal driver for quality and consistency and programming in mental healthcare in the country," Santopietro says. "There's SAMSHA [the Substance Abuse and Mental Health Services Administration within the U.S. Department of Health and Human Services], but they have a tiny budget compared to the Centers for Medicare & Medicaid Services, so it's state by state."

For example, according to 2013 data from the National Association of State Mental Health Program Directors Research Institute, the U.S. average mental health spending per capita was $119.62, with a high of $345.36 in Maine, and a low of $32.77 in Idaho. But there has been some movement toward improving behavioral health benefit coverage through parity laws and the PPACA.

"Policy change is often a combination of philosophy and money," says Linda Rosenberg, MSW, president and CEO of the National Council for Behavioral Health in Washington, D.C., a nonprofit association representing 2,700 mental health and addiction treatment member organizations. "The end of the state hospitals was philosophy. People could live well in the community, but Medicaid also drove it. I think we're having the same thing now—a combination of philosophy but also money. I think parity and the ACA introduced more money into behavioral health."

Prior to the passage of parity laws, behavioral health benefits were often not covered by insurance plans, or if they were, the number of treatments or provider visits a patient could receive were limited and hefty copayments were attached. The Mental Health Parity and Addiction Equity Act of 2008 attempted to break down those barriers to care by requiring health plans to provide mental health and substance abuse benefits that are on par with medical/surgical health benefits.

For example, if a patient has a $30 copayment for an orthopedist, then the copayment for a behavioral health specialist cannot exceed $30. In addition, there are stipulations in the PPACA that require all new small-group and individual plans to cover mental health and substance abuse benefits. And, while it holds much promise, the logistics of parity are still a work in progress.

"It's a complex law to implement, and I think it's still a process. It's so complex that case law will actually, I think, clarify it, because some of it is simple and other parts of it are not so simple," Rosenberg says. "The copay is simple. It becomes more complex when you're talking about services where there isn't necessarily an equivalent on the medical side and it becomes an issue of utilization management, or it becomes an issue of medical necessity. That's often subjective and harder to sort out."

The emergency department safety net
What's not hard to sort out is where behavioral health patients end up seeking care when they lack community and outpatient resources—the emergency department.

"Acute care emergency rooms are being overrun with patients that have psychiatric illnesses because they have nowhere else to go."

According to data from the CDC, 5% of ED visits were made by patients with a primary mental health diagnosis during 2007–2008. During the period 2008–2010, the CDC reported, nearly 10% of ED visits had one or more MHD-DCs assigned to the visit and the rate of MHD-DC-related ED visits increased seven times as much as the overall rate of ED visits in North Carolina during the study period.

"Acute care emergency rooms are being overrun with patients that have psychiatric illnesses because they have nowhere else to go," Whitecotton says. "There are no resources. There's no place for them to seek care so they show up in emergency rooms."

There are many reasons an ED is not the optimal place to seek behavioral healthcare, expense being one. A 2012 study titled "The Impact of Psychiatric Patient Boarding in the Emergency Department" and published in Emergency Medicine International found that from 2007 to 2008, psychiatric patient boarding cost the department $2,250 per patient in lost payments due to slower turnover.

With two- and three-day wait times for placement, a behavioral health patient occupying an emergency room bed can be an obstacle to ED flow and throughput for patients with medical issues.

"Their focus in the ED is get the patient through the system so you can get the next patient in," Whitecotton says. "Even if we were still in the volume world, in an emergency room, a patient that occupies a bed for 40 hours—think of the lost revenue opportunity from having that bed tied up."

Plus, being trapped in the limbo of a chaotic ED is not conducive to good mental hygiene.

One organization that witnessed what can happen when state and local funding for behavioral healthcare gets cut is Swedish Covenant Hospital in Chicago, a 279-bed nonprofit teaching hospital with a total patient revenue of nearly $1.4 billion. Between 2009 and 2012, Illinois cut $113.7 million in general funds from the state's mental health budget. In April 2012, Chicago closed six of its 12 city-run mental health clinics. It was around that time that Ajimol Lukose, DNP, RN-BC, nursing director at the hospital, noticed more patients with behavioral health issues seeking treatment in the ED.

"There was a reduction in mental health clinics, so the follow-up or outpatient programs were limited. That resulted in patients showing up in the emergency department," Lukose says.

On any given day, there could be as many as six or seven behavioral health patients in the ED. "Our emergency department was struggling with patients with mental health issues staying there for three and four days and waiting for state transfer, especially unfunded patients," she says.

To address this problem, Lukose launched a safe care delivery model to improve patient outcomes among behavioral health patients in the ED. Long term, she wants to see a decrease in several metrics, including ED length of stay, the use of sitters and behavioral restraints, elopement events, and labor costs.

To accomplish these goals, Lukose hired a nurse practitioner to round on behavioral health patients in the ED, established a dedicated area for behavioral health patients in the department, and created new policies, procedures, and timelines regarding assessment of behavioral health patients and implementation of interventions. A walk-in "bridge" program for patients waiting to connect with community resources was also created.

Designating the nurse practitioner as the ED behavioral health liaison helps meet the new expectation that an initial behavioral health assessment in the ED will occur within one hour of its order time with a member of the crisis team and that behavioral health interventions will be initiated with the nurse practitioner within two hours of the consultation order time being set. The NP works eight-hour shifts, Monday through Friday, rounding on behavioral health patients in the ED, completing psychiatric evaluations, initiating appropriate interventions, and coordinating discharge planning.

Lukose and the ED director developed policies, procedures, and guidelines using the Four S Model, which calls for focus on safety, support, structure, and symptom management. For example, giving behavioral health patients a different color gown so they can be easily identified if they are trying to elope, placing all patient belongings into a locked cabinet, and ensuring that metal objects such as soda cans or silverware are not brought into the room.

In addition to training to boost the staff's comfort and compliance with the new policies, a checklist—similar to a preoperative checklist—was created.

"If you give a nurse a three-page or four-page policy, they're not going to sit down and read the policy all the time," Lukose says. "So we made a one-page checklist, which is a summary of the entire policy, so the nurse can make sure everything is done."

The results of the project? Lukose says initial behavioral health assessments were completed in one hour 93% of the time and sitter use decreased by 46%. There was also a drop in ED length of stay.

For all uninsured behavioral health patients in the ED, the length of stay dropped to 29.1 hours in fiscal year 2014 from 48.5 hours in 2013—a 40% reduction. For uninsured patients waiting to be transferred to a different facility, the average length of stay was 37.2 hours in fiscal year 2014, down from 74.7 hours in fiscal year 2013.

"The interesting thing that we found was many of them did not need to be in an inpatient psych unit," says Lukose.

Integration improves outcomes
Though the Swedish Covenant program yielded good results, often the best way to improve outcomes and decrease healthcare costs is to keep behavioral health patients out of the ED entirely. Integrating behavioral healthcare into the primary care settings, which SAMSHA describes as "the systematic coordination of behavioral and general healthcare," is one proven way to do this.

"We know behavioral health integration in primary care works," Whitecotton says. "We've had 90 randomized controlled trials that have proven it."

One of the most well-known assessments of behavioral health integration into primary care is the IMPACT trial out of the University of Washington, which refers to Improving Mood Promoting Access to Collaborative Care Treatment. Over two years, researchers tracked about 1,800 depressed adults in 18 primary care clinics across the country. Half the patients received typical care from their primary healthcare providers (including medication regimes and referral to specialty mental health services), and half the patients received care based on a collaborative care model that includes training primary care providers and their embedded behavioral health colleagues in evidence-based medication or psychosocial treatments.

"We know behavioral health integration in primary care works. We've had 90 randomized controlled trials that have proven it."

After 12 months, about half of the patients in the collaborative care cohort reported a 50% or greater decrease in depressive symptoms. Only 19% of the patients in the standard care cohort reported a reduction in symptoms. There were major cost savings when behavioral healthcare was integrated with primary care. For each dollar spent on its collaborative care model, $6 in healthcare costs were saved.

For these reasons—better patient outcomes, cost savings, and improved use of healthcare resources—in 2012, leadership at Carolinas HealthCare System decided to "expand behavioral health, make some significant system investments, and build out an integrated system of care across our system," says Whitecotton. Included in this was integration of behavioral healthcare into the primary care setting.

She says behavioral health integration has taken place in upwards of 40 primary care practices across CHS.

In 2015, primary care providers began using a patient health questionnaire depression tool, PHQ-9, to screen patients on antidepressants, antipsychotics, or for those who had a new problem relative to psychiatric illness. If patients scored above 10, or if they said they had thoughts of harming themselves or others, the primary care provider contacted the call center to connect with a behavioral health specialist.

"Our call center gets a behavioral health specialist on video with the patient right there in real time, while they're in the physician's office," says Whitecotton. Specialists are either licensed professional counselors or master's-prepared social workers who can do diagnostic interviewing and recommend a course of action for the patient. A psychiatrist is also available to assist the primary care provider in developing a medication regimen using evidence-based drug algorithms in the EMR.

Once the primary care providers become more skilled in managing behavioral healthcare treatments, Whitecotton says, they may not need to contact the psychiatrist for as much guidance. Patients are also connected with a health coach.

"Our team reaches out to the patient and establishes a telephonic relationship with them, and keeps them in telephonic health coaching until their score is below a 10," says Whitecotton.

According to the literature, she says, it takes about two years to show overall health improvement, but CHS does have some promising preliminary outcomes data gathered on 442 patients for whom they have data for six months before and six months after integration.

"About 75% of the patients that we've seen have had an elevated depression score, 62% of the patients had anxiety symptoms, and then about 83% of the patients ended up on medication," she says. "We've seen a 49% decrease in the PHQ-9 score, a 38% decrease in anxiety symptoms, and a 67% decrease in suicidal ideation."

As for clinical outcomes, Whitecotton says there was no change in patients' weight, but there was a significant decrease in A1C levels. Patients' total cholesterol levels went down, but triglyceride levels increased while HDL levels dropped. Inpatient hospital stays also decreased.

"What we're measuring is not only the patients' response within the context of their mental illness but also the improvement of their physical health," she says. "If we can keep them out of the hospital, out of the emergency room, out of the doctor's office other than for things they really need to be there for, and if we can improve their cholesterol, improve their blood pressure, and decrease their weight, then our overall spend on each patient will go down. Patients will be healthier, so that will be where the return on investment is."

Early intervention
Behavioral healthcare can also be integrated in the pediatric setting, as Montefiore Medical Group in the Bronx, New York, has done since 2006 with the Healthy Steps for Young Children program, a national initiative focusing on early childhood growth and development. In addition to a pediatrician, children from birth to age 5 are seen by a Healthy Steps specialist who is trained in child development and behavior to focus on "the parent-child relationship, the attachment between the two, and developmental and behavioral outcomes for the child," says Rahil Briggs, PsyD, director of the Healthy Steps program and the director of pediatric behavioral health services at Montefiore Medical Group, which provides primary pediatric care to 90,000 children each year across 19 practices.

Briggs says one characteristic unique to Montefiore's Healthy Steps program is its emphasis on parental mental health. "While there's no health without mental health, there's probably not a whole lot of child mental health without parent mental health. And if we're really trying to do preventive work and ensure better outcomes for the next generation, [then] we have to treat the parents' mental health."

The program has had positive, measurable outcomes, says Briggs.

"With our behavior and development consults, the short-term consults, we're able to take a child from screening at-risk to screening not at-risk in an average of 1.4 consults," she says.

The program also appears to disrupt the development of poor outcomes in a child's social and emotional development at age 3 if the mother had experienced abuse or neglect in her own childhood.

In summer 2014, the medical group expanded behavioral health integration to school-aged and adolescent patients. Briggs says thus far the feasibility of the program looks promising, noting that "26% of children who came for well child visits were referred to our program, which is fantastic, and, of those 26%, if they had a warm handoff, 63% of the 26% came for the next visit. If they did not have a warm handoff, 53% came for the next visit." The warm handoff is when the primary care provider introduces the patient to the behavioral health provider during the medical visit.

Looking back on his life, Jordan says he may have been the type of child to benefit from such screening and early intervention. "I was one of those very energetic children, both intellectually and cognitively, and I had a lot of anxiety or anxious moments growing up," he says. "My stepfather was in the Air Force, so we tended to move around the country, so I grew up without what many people would refer to as childhood friends. I think it's safe to say there's a lot of loner behavior in my life, and that combined with this extraordinary amount of energy, without places to channel it, more times than not, is where some of my issues stem from."

What's old is new again
With the recent interest in behavioral healthcare, integration may seem like a new concept in care delivery when it has, in fact, been around for decades. Since 1985, The Robert Young Center for Community Mental Health in Rock Island, Illinois, has been integrated within UnityPoint Health-Trinity, and has managed to stay financially viable despite the state's budget woes.

"The Robert Young Center was the first comprehensive community mental health center in Illinois. It was one of the few that, nationwide, developed within a healthcare system," Deopere says. "It has had a positive contribution margin after overhead allocated expenses; it's been on a positive bottom line for 30 consecutive years."

Dennis Duke, who succeeded Deopere and became president of the Robert Young Center last year, attributes this success not just to integration of behavioral healthcare into the clinical setting but also to integration of behavioral healthcare into organization's leadership. The position of president of the Robert Young Center has had a seat on Unity Point-Trinity's leadership team since the two organizations were integrated in the 1980s.

"There's very few that are configured like we are, as a comprehensive community mental health center that's actually part of a health system, so we have vertical integration in the sense of our leadership and horizontal integration in terms of all the services that we provide," Duke says.

This leadership structure has enabled the organization to be proactive, thoughtful, and flexible about how it operates, Pagliuzza says.

"RYC succeeds because it's creative and is paying attention to how it spends, where it brings monies in, where it needs to expand services, and where it needs to take services away," he says. "It reads the financial reimbursement world well and works within it, besides having a very good model that's very effective at delivery of care."

Part of the beauty of an integrated system is that it allows for what Deopere describes as "deflection," where only the acutely mentally ill—those in true need of inpatient services—are admitted, while other patients are connected with outpatient or community services.

"Our continuum is a full continuum, and it includes inpatient and outpatient services," says Duke. "We understand that there's a need for inpatient, but in this model we're looking to assess the patient appropriately and get them into a disposition that's the right level of care—and it might be inpatient, but it might be connecting them back with their community provider system."

This type of flexibility is essential to remaining viable in an ever-changing healthcare system, says Kurt Barwis, FACHE, president and CEO of Bristol (Connecticut) Hospital, a 115-staffed-bed facility.

"Ultimately, that business could be switched off in a second if somebody comes up and advances the way that you take care of these patients," he says. "You're here today but gone tomorrow if you don't really pay attention to new models."

"My job as a hospital CEO is to pay attention—not just to one aspect of the outcome but all of the outcomes."

In September 2013, the organization did a community health needs assessment and the results were somewhat surprising, says Barwis, considering the wide variety of behavioral health services the organization was already providing.

"The No. 1 identified need was mental health, substance, and alcohol abuse," he says. "We have expansive behavioral health services. So you get this community health needs report that is in your face, and you have to do something different. You need to try to rethink and reimagine this."

This new vision includes improving care coordination among community services, inpatient services, and outpatient services as well as reassessing the counseling center's fee-for-service business model. After making the decision to outsource some of the organization's crisis workers, Barwis challenged the counseling center's staff to think about how the program should evolve to meet the community's needs.

"The models around us that are emerging are much more value-based and much more home-based," Barwis says. "So I said the thing that I would like to see you do is develop a strategy for yourself, and for everyone to start to ask themselves: 'What do we need to do to morph our program so we adapt it and become better?' "

And though it's often tempting, cost of readmissions should not be the only influencing factor when redesigning care. Patient outcomes beyond the hospital walls need to be considered as well.

"If I've detoxed the same patient 17 times in 12 months, then I'm really not getting it done. I've really failed the community if I can't create a system that helps somebody achieve that continuum and not end up coming back 17 times. There's a huge cost to the system, but there's also a cost to the community," Barwis says. "My job as a hospital CEO is to pay attention—not just to one aspect of the outcome but all of the outcomes. In the old days, the outcome would be within my four walls. Not anymore. Now, the outcome is the whole experience for that person who lives in the community."

One organization that changed its care model to better meet the needs of patients in the community is Durango, Colorado–based Axis Health System (formerly Southwest Colorado Mental Health Center), a nonprofit provider of mental health services, substance abuse treatment, and primary care services with seven locations that include an emergency behavioral health site and two school-based health centers.

Once strictly a behavioral health provider, the organization flipped integration on its head and now also provides primary healthcare. "The early model was one of colocation," says Bern Heath, PhD, CEO at Axis Health System. "So we started out by screening only those folks who the medical staff suggested might have a behavioral health issue, but we began to realize that this wasn't the right approach and what we should be doing is population-based screening."

"You cannot have a separate physical healthcare and separate mental healthcare...and have them be equal. The only way we're going to have equal care is with one system that makes no distinction between the care."

Once they began screening all patients at clinics where their staff was embedded, it became apparent that depression was more prevalent than they initially thought.

"What we found was rather than 8% to 9% of folks with depression, we were getting into 23% to 24% of folks who had depression," he says. "We learned a lot of things in those settings that helped us refine our practice. We began to see the limitation of bringing one or two people into a primary care practice. It didn't lead to a higher level of integration; it just enhanced the referral. That led us to say, 'We need to establish a practice on our own.' "

And that is exactly what they have done by establishing two fully integrated healthcare clinics and two school-based health clinics where they provide primary care and behavioral healthcare.

"You cannot have a separate physical healthcare and separate mental healthcare and separate substance use care systems and have them be equal. The only way we're going to have equal care is with one system that makes no distinction between the care," says Heath. "We have pulled all that into one setting. Somebody walks into our door, they walk into one facility, and it's an integrated health clinic."