Tackling the Behavioral Health Challenge

As the healthcare industry moves toward reimbursement models that reward value, providers cannot ignore patients with mental health and substance abuse issues.

This article first appeared in the June 2015 issue of HealthLeaders magazine.

Patients with behavioral health diagnoses present a particular challenge for health systems and hospitals that are trying to rein in the cost of care. Such patients tend to be heavy utilizers of expensive healthcare resources and have higher-than-average rates of emergency department visits, hospitalizations, and readmissions—all of which hospitals are trying to curb as they work to retain their margins under population health and risk-based payment models.

Some provider organizations are embracing this challenge and are implementing strategies to deliver more effective care to this subset of patients. As a result, they are improving care coordination and lowering costs.

'A financial imperative'
It's becoming "a financial imperative" for hospitals to find ways to provide behavioral health services that truly meet patients' needs, says Gregory Pagliuzza Jr., chief financial officer at UnityPoint Health-Trinity, a four-hospital, 584-licensed-bed integrated delivery system based in Rock Island, Illinois. The system is part of UnityPoint Health, headquartered in West Des Moines, Iowa.

"As the cost structure gets tighter, we have to manage patients with behavioral illnesses more effectively. The old model—where we outsource behavioral health patients elsewhere—is not going to work anymore. It's not going to be funded, and it's not going to be financially successful. As reimbursements get tighter and tighter, the reality is the model is going to have to change to be effective," Pagliuzza says.

In 2009 UnityPoint Health-Trinity began working with the state of Illinois on a three-year Donated Funds Initiative to reduce the utilization of services and readmission rates for patients who have both behavioral and medical diagnoses. The results were significant. Over a 10-quarter period, emergency department visits among this group dropped 50%, which reduced Medicaid payments by 65%. Additionally, psychiatric admissions dropped 54% in the same time frame, cutting payments by 73%.

"The final report of those 366 patients in the Donated Funds program showed they had a 54% reduction in psychiatric admissions and a 32% reduction in medical inpatient admissions, which saved $8.1 million, compared with our expenses of $675,000. It was really a profound program, and it speaks to achieving the best outcomes at the least possible expense and improving the quality of patients' lives," says David Deopere, PhD, president of Robert Young Center for Community Mental Health, an established and financially viable behavioral healthcare organization and Comprehensive Community Mental Health Center that is integrated within Trinity Regional Health System.

After that DFI program ended, UnityPoint Health-Trinity continued to fund its efforts to better manage the health of patients with behavioral health issues by becoming a coordinated care entity through Illinois's Medi-caid managed care program. As a CCE, the health system is working to increase the quality of care, lower costs, and improve population health outcomes.

"This focus on population health management is why behavioral health is coming into its own; we see what those comorbidities do to hospital admissions, ER utilization, and primary care office visits," Deopere says. "Health systems around the country are beginning to recognize this. … When you look at the data from anywhere around the U.S., you see the importance of managing behavioral health comorbidities with physical illnesses."

For example, Deopere says 72% of cardiac patients who are more than 65 years of age have depression and visit the emergency department 40%-50% more often than cardiac patients without depression. "Severely mentally ill patients are some of the highest utilizers of healthcare," he says.

Closing care gaps
One of the most effective interventions the system has implemented so far, Deopere says, is to conduct behavioral health screenings in its emergency department and primary care offices. The screening includes two questions each to monitor for depression and anxiety.

"We instituted these screenings in the ER because we were not, in fact, really consistently screening for PTSD, depression, and anxiety. We've known all along that having a behavioral health diagnosis leads to more ER use, but when you start getting into population health and capitation, it becomes even more important to deal with it effectively," he says.

In many of its primary care offices, UnityPoint Health-Trinity has embedded a behavioral therapist so that a patient whose screening indicates the existence of an underlying behavioral health issue can be immediately treated at the clinic. The system plans to expand this strategy as quickly as possible because it helps close the gap that often exists for behavioral health patients in the traditional primary care setting, Deopere says.

"We now have 13 practices that have a behavioral therapist who is colocated, and we need to find more therapists who are qualified to work in that environment. Our goal is to have a behavioral health therapist in every single primary care office. I think 15 years from now that will be the case in primary care offices across the country," Deopere says.

"The primary care docs are glad to have the support, because they aren't always comfortable dealing with behavioral health issues and they don't have the time. You can't deal with a behavioral health problem in five to eight minutes within the context of a primary care office visit."

Focusing on the patient
Vicki Zude, director of care coordination at the Robert Young Center for Community Mental Health, says that one reason the behavioral health therapists are making a big difference is that they are providing patient-centered care.

"You have to make it meaningful for patients. You have to develop a relationship and make sure it's patient-driven. Instead of saying, 'You are obese, and you need to lose this amount of weight,' you have to ask them what they want to be able to do. You then turn those into healthcare wellness goals," Zude says.

"There are a lot of techniques that go into this behind the scenes. We work on developing trust with the patient and on training staff to approach the patient with a motivational technique. We develop a wellness recovery action plan. None of these are simple things. They all take time, but they do work when they are done right."

These types of patient-focused behavioral health programs will become increasingly important, Pagliuzza adds. "If you start getting into population health and you start taking on more risk, you can't avoid this population. This group is very expensive, and they are high utilizers. What we are building here is a model that is going to work for patients."

Part of the care continuum
At Sandusky, Ohio-based Firelands Regional Medical Center—a 236-staffed-bed institution with more than $500 million in annual gross revenue—behavioral health has been woven into the care delivery network since 1985, when the leadership team at that time decided to provide a full continuum of care for all mentally ill and chemically dependent people. On average, Firelands serves 1,600 inpatients in its 34-bed psychiatric unit and 14,000 behavioral health outpatients annually in seven counties throughout the state.

"As a not-for-profit healthcare organization, we have always had a mission to treat everyone in our community, no matter what their health need is or what their ability to pay is. By having behavioral health as part of our continuum, it allows us to have a very profound impact on the health of this population," says Daniel J. Moncher, Firelands' executive vice president and chief financial officer.

"Behavioral health is another service line that we look at, and we need to be able to afford to provide those services. Fortunately, we've been able to do it with the benefit of grants."

Among those grants are two from the Substance Abuse Mental Health Services Administration, an agency within the U.S. Department of Health and Human Services. The grants are being used to fund screening programs in Firelands' emergency department and its primary care sites. Licensed clinicians screen for depression and substance abuse, provide some basic education on site, and refer the patient for either inpatient or outpatient treatment as appropriate.

Its three largest clinics also offer the Firelands Counseling and Recovery Services Plus program, which integrates primary care and behavioral health within one location. The care team includes a nurse practitioner, a care manager, and a health home specialist, who all work together to meet the needs of patients with serious mental illness and chronic healthcare conditions.

"What we are really doing here is bidirectional integration. We are extending ourselves to go into the hospital setting, and we are integrating behavioral health into our primary care settings. That has helped a great deal because we are constantly educating people. Every policy and procedure has been revised to make sure that at every junction we are talking to folks about issues like drug use, smoking, and controlling their blood pressure and their weight," says Marsha Mruk, vice president of Firelands' behavioral health department.

The program has driven down readmission rates. From 2013 to 2014, there was a 33% drop in medical re-admissions and a 5% drop in psychiatric readmissions within 30 days for patients participating in the integrated primary and behavioral health program.

Emergency department usage has also decreased. "In the first two years, we have decreased the ED use by this population by 28%," Mruk says, adding that reining in the utilization of expensive resources by this patient group is critical for healthcare organizations that are trying to succeed financially within population health payment structures.

"About 30% of our behavioral health outpatients are severely mentally ill, and they are the ones who are so costly. In relation to cost, medical costs for individuals with depression are 54% higher than for those without depression. They are 68% higher for those with anxiety."

Timely response
Firelands also offers emergency services through its 24-hour telephone hotline. This is another way to help people in crisis and to prevent them from using the emergency department unnecessarily, Mruk says. "If we hear from someone who is considering going to the ER, we will call to get them in to see their primary care doctor. We try real hard to steer them away from the ER."

In all of its primary care offices, Firelands has moved to having same-day access so that patients can be seen quickly when they are in need of services. This has helped Firelands cut its no-show rate for its behavioral health patients from nearly 60% to 20%, and has kept people from presenting in the emergency department for nonemergent conditions, Mruk says.

"If you are having an emotional problem, the clinic will have you come in that day. Now better than 75% of individuals we intake throughout the system are getting in the same day. For those who are not, there is generally a specific reason, which is usually that they choose not to come in the same day," she says.

Mruk says that in order to bend the cost curve on treating patients with mental health and substance abuse diagnoses and to thrive in a value-based reimbursement environment, hospitals must first acknowledge that they are in the behavioral health business whether they choose to be or not.

"When you look at incidence of mental illness in the U.S., some of the statistics are staggering: 43 million adults age 18 or older had a mental health issue last year. That is about 18% of all U.S. adults," she says. "Psychiatric care is very much a part of medical care and can't be divorced from it. About 5.5 million people go to the ED every year with mental illness. It represents 4% of all ED visits, so whether or not hospitals want to be in this business, they are."

Reprint HLR0615-4