OhioHealth Puts Primary Care on the Suicide Prevention Frontline

The health system has implemented a behavioral health integration program that features mental health screening at primary care clinics.

As part of a $15 million behavioral health initiative launched last year, Columbus-based OhioHealth is striving to screen nearly all of its primary care patients for depression, anxiety, and suicide risk.

As a study released in June by the Centers for Disease Control and Prevention reports, suicide rates have been rising in nearly every state. In 2016, there were 45,000 Americans over the age of 10 who died by suicide, the CDC says.

To help prevent suicide in the communities it serves, OhioHealth is implementing a behavioral health integration program that features screening at primary care clinics, where patients identified with mental health conditions are enrolled in a course of multidisciplinary treatment.

"This can identify patients in distress when they are seeing their primary care physician, giving us an opportunity to intervene before there is a disastrous outcome," says Dallas Erdmann, MD, system chief of behavioral services at OhioHealth.

Every patient over the age of 16 is screened. Patients who score high on the PHQ-9 questionnaire are referred to a behavioral health provider—either a social worker or a counselor—who helps manage anxiety or depression for six to nine months. A psychiatrist helps supervise the caseload in weekly meetings.

Primary care practices are a logical setting to serve as the backbone of OhioHealth's behavioral health integration program, says Amanda Maynard, DO, an OhioHealth primary care doctor and a physician champion for the program.

"We are the first line of defense for all disease processes. Depression and anxiety are prevalent in society today," she says.

The behavioral health integration program is simultaneously increasing access to mental health services and helping OhioHealth cope with a shortage of psychiatrists, Erdmann says.

"This model supports primary care doctors in caring for mild-to-moderate depression and anxiety. Those are bread-and-butter conditions, and this program frees up psychiatrists to attend to the more complicated cases of refractory depression, bipolar disorder, and psychosis that primary care doctors are uncomfortable attending to because they have not had the training," he says.

OhioHealth launched the behavioral health integration program in late 2017. So far, 15 of the OhioHealth Physician Group's 25 practices have joined the program, with a total of 63 physicians participating.

Key metrics of the program include patient enrollment in integrated services and achievement of a 50% reduction in PHQ-9 scores. As of September, 1,000 patients had enrolled in the program, and about 35% of patients enrolled in the program for at least six months had achieved a 50% reduction in PHQ-9 scores.

OhioHealth has taken a systematic approach to implementing the behavioral health integration program at the organizational and primary care practice levels, with expectations that the effort will be sustainable and effective.

Organizational rollout
 

Erdmann says there have been four primary steps to implementing the behavioral health integration program at the health system level:

1. OhioHealth's senior leadership has been actively involved and invested in the effort from its onset.
    
2. Physician champions and other crucial individuals were identified at primary care practices to help the senior leadership team problem solve and operationalize the program.
    
3. Psychiatric providers have been enlisted to participate in the program and support primary care physicians.
    
4. A training program was crafted to prepare clinics to join in the program.
    

The training process for primary care practices takes about a day and a half, with a select handful of staff members present for instruction, including one physician or nurse practitioner, one practice manager, one medical assistant, and one office specialist, Erdmann says.

"We get fairly in-depth defining the process, setting the workflow, looking for nuances to roll the program out in the particular clinic, identifying some of the roles and responsibilities of the various team members, and cross-training staff members to be able to work as a team," Erdmann says.

Social workers receive supplemental training, he says. "For the behavioral health providers—the social workers—we provide them with additional training in documentation and the care model."

The training is conducted with in-house resources and has been led by Heather Esber, system program manager of service lines for OhioHealth.

Practice implementation
 

Maynard's practice was one of the first OhioHealth sites to implement the behavioral health integration program.

"We thought our site would be one of the better sites because not only are we downtown but we also have close proximity to a Level 1 trauma center, and we are very close to women's domestic shelters and suboxone clinics. We thought downtown was a good site because of the prevalence of mental illness," she says.

Implementing the behavioral health integration program has not been a heavy burden on the practice, Maynard says. "There were some growing pains such as working the program into the workflow to be effective. It took a week to figure out the best way to do it."

She considers the PHQ-9 questionnaire as collecting a vital sign.

"It was time management. The patients get the questionnaire when they check in at the front desk. They are either filling it out or have filled it out by the time the medical assistant rooms them. Then that information is either handed to the physician or it is placed in the computer system. The physician looks at the questionnaire and decides where to go from there," she says.

The providers in Maynard's practice are comfortable with their treatment role in the behavioral health integration program, she says.

"We are very capable of getting patients on medication for mood disorders; however, 99% of bipolar and schizophrenic patients are also going to need a psychiatrist onboard with us. That is a benefit of this program: these patients can see me in the primary care office, and I can reach out to our psychiatrists who can direct me on medication adjustments," she says.

Patients who score high on the PHQ-9 question related to suicide are immediately referred to an emergency room for evaluation, Maynard says. If the patient has a family member with them, the family member escorts the patient to the ER, which is a block away. If the patient is alone, the patient is transported via ambulance to the ER. After arriving at the ER, patients are held for evaluation for 72 hours.

Sustainable and effective
 

Erdmann says the behavioral health integration program is expected to be sustainable and cost effective.

The Centers for Medicaid & Medicare Services recently approved billing codes for collaborative care that will help fund the behavioral health integration program. "It's a way to encourage this form of treatment. We are preparing to start using them," he says.

Boosting behavioral health services is also expected to reduce total cost of care, Erdmann says.

"This can help reduce the cost of care and improve overall health and healthcare outcomes as we identify and catch illnesses early in a preventative way and identify comorbid factors that impact the outcomes of other disease states," he says.

He cited diabetes as an example.

"If you look at actuarial data for healthcare and healthcare costs, you could take a group of patients who have diabetes and understand the cost per member per month. If you take those same patients and add in a comorbid depression, the cost of care doubles. It doubles because of the impact of depression on the patients' ability to care for themselves," Erdmann says.

The behavioral health integration program is improving OhioHealth organizationally on several fronts, he says.

"It is helping to prepare OhioHealth in a variety of ways to address some of the ongoing issues in healthcare. It helps us view the whole patient, and adopt team-based care. It is helping us identify health issues before they reach a crisis level. And by addressing comorbidities, it is helping us reduce total cost of care," he says.

Maynard says the behavioral health integration program has improved access to vital services.

"Typically, if you put a patient into psychiatry the waiting list can be four to six months. What I have seen as a primary care doctor is some of these patients need to be seen sooner rather than later. This program has created access to resources including psychiatrists who can help us manage patients. It makes us like a one-stop shop for patients," she says.

Patients are benefiting, Maynard says. "We have made a big difference in a lot of these patients' lives. Some were not coming out of their homes. Some were not active with their children. Some had no jobs or aspiration to do anything. In some of my patients, I have seen drastic changes."