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Linda Rosenberg

Former President and CEO, National Council for Behavioral Health

Building the Amazon Prime Experience in Health Care

November 6, 2014 | National Council Magazine | Comments
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This editorial originally appeared in the latest edition of National Council Magazine.


It’s Sunday afternoon, I have just a couple of hours to run errands and so many things I need to do. I could head to the farmer’s market for fresh produce and milk; go to the drugstore to pick up my mom’s prescription and paper towels; make a quick stop at the bookstore to buy the Wimpy Kid book my granddaughter Ava has been begging for; run to ToysRUs for Legos for Gabriel because he can’t be left out; check out the sale at Kohl’s — Bob needs socks, and I must get a new iPhone case…OR I could just go to Costco and get it all. And even get flowers and dessert for tonight (who has time to bake?) and check out their new outdoor furniture collections. If only there was time to go to the library.


I really wish I’d planned ahead, I could’ve just ordered through Amazon Prime. And when they get the drones, I’d only need to wait for 30 minutes, less time than it takes to drive to Costco! In the time saved, I could catch up on Downton Abbey Season 4 on iTunes or check out the new Anna Quindlen book on my Kindle.


Increasingly, health care preferences are being shaped by consumers’ shopping, entertainment, and lifestyle experiences. We’re driven by the desire — and need — for one-stop care, instant access, informed choices, reasonable prices, good quality, sound advice, and discernible results. And bonuses like a gym membership and a nutrition plan are as good as free instant video or Kindle books.


Integrated care is no longer about whether to offer primary care at behavioral health sites or embed behavioral health in primary care settings. After all, even those with transportation, moderate incomes, and the support of family and friends don’t have the time for multiple visits, follow up on referrals to different specialists, or the ability to take time off work for doctor’s appointments that can take up to half a day with all the driving and waiting.


In fact, Mike Hogan, former New York State Mental Health Commissioner, predicts that in 45 years, distinct public mental health systems with state-operated and state-funded specialty services will no longer exist in anything like their current form. “We should not maintain state systems if the alternative is being part of the mainstream,” he said.


And being part of the mainstream means offering all health care — for mind and body — anywhere and anytime the customer needs it. At urgent care clinics, at the library where they go for Internet access, or even at home with a smartphone and monitoring devices. How often have you wished you could just text or email your doctor for a quick consultation? Imagine the savings, and the convenience for all. The one-stop shopping approach in health care is highlighted in several case studies in the latest issue of National Council Magazine — Integration Road Trip, Montefiore, SSTAR and Gosnold on Cape Cod, Family Services Inc., Cherokee, and many others.


Community behavioral health organizations have long been the best suited to offer integrated care for the vulnerable, indigent populations they typically serve. The National Council for Mental Wellbeing has led the way by helping to shape policy, institute best practices through consulting, and provide platforms for networking and sharing of successes and challenges. The SAMHSA-HRSA Center for Integrated Health Solutions — a federal technical assistance center that the National Council runs, has provided tremendous momentum to an integrated care effort around the nation. Our members have pursued all avenues for integrated care delivery — thoughtful engineering of staff roles, intensive community outreach, exploration of public and private and funding options, and creative collaborations and partnerships.


Today, as integrated care evolves to a broader population health management concept, community behavioral health continues to have the advantage, with its unique approach, experience, and skill sets.


What is population health management? First, we must note that from a population health perspective, health has been defined not simply as a state free from disease but as the “capacity of people to adapt to, respond to, or control life’s challenges and changes.” Population health management is the coordination of care delivery across a population to improve outcomes through disease management, care management, and demand management. The approach focuses on reducing health disparities that occur on account of the social determinants of health — social, environmental, cultural, and physical factors that have a measurable impact on health. The World Health Organization estimates that in the U.S., social determinants account for 70 percent of avoidable mortality.


While population health management is becoming the norm today — as evidenced in the increasing number of Accountable Care Organizations, health homes, and care management organizations — community behavioral health has long practiced the tenets of this approach. In fact, the popular Four Quadrant Model developed by the National Council a decade ago is in essence a population-based planning framework for the clinical integration of primary and behavioral health services.


As Mike Hogan goes on to say, “Almost all the new service models unleashed by the Affordable Care Act  — from Medicaid health homes to ACOs to patient-centered medical homes  — cannot succeed without integrating behavioral and general medical care. The theme of “integration” is popping up everywhere. Yet the mainstream is not prepared. They need our help. On almost every crucial test  — for example people discharged from an emergency room after self harm, or people who commit suicide after seeing a primary care provider — the mainstream still gets it right only about half the time.”


If we consider where “the mainstream needs our help,” behavioral health offers three distinct advantages.


First, we know more about person-centered care and patient engagement than the mainstream. A primary care appointment lasts 10 minutes or less, leaving little time for engagement. In contrast, behavioral health providers spend considerably more time with each patient, building relationships, nurturing trust, and helping them navigate life in the community. Customized, long-term treatment plans are developed for patients based on their preferences and with the involvement of family and caregivers. We’ve modeled care that extends beyond clinic walls, into the community and into people’s lives. That’s really what Assertive Community Treatment is all about. Dom Scotto, who directed an ACT program in New Jersey describes ACT as “community mental health at its raw, basic level.” He explains, “Staff have conducted psychiatric intakes at Burger King and on the boardwalk.  They don’t think twice about teaching someone to fry an egg or clean a dirty house.”


Second, we know that partnerships and collaborations are crucial to the success of a population health approach. As Abby Cofsky, program officer at the Robert Wood Johnson Foundation says, building healthy communities requires “leadership that focuses on authentic and meaningful engagement with the people that live in the community. National Council members are ‘community problem solvers.’ That’s exactly the kind of leadership we need.” Behavioral health has always collaborated with a range of community institutions and systems — criminal justice, hospitals, schools, faith communities, homeless shelters, supported housing and employment, veterans services, child welfare, and many more. We’ve always factored in the social determinants of health.


Third, the roles and responsibilities of community behavioral health staff have primed them for population health management. As Joan King notes in her article on new roles for case managers, “It’s important to bring access, understanding, and knowledge of the community and the resources to support management of chronic illness. Case managers in behavioral health have the skills to provide this level of service.” She points out that while care managers are in demand in the world of population health, they’re really just taking on existing case management skills and integrating them with healthcare. They’re becoming experts in health behavior change and building relationships, because positive change happens only in the context of good relationships.


MacArthur Genius and primary care physician Jeffrey Brenner sums it up well when he says “Actually, our behavioral health colleagues are about 30 years ahead of us. I hope primary care can learn from behavioral health. When psychiatric care was deinstitutionalized, behavioral health did heroic work to figure out how to deliver better care at lower cost and evolved some creative models. The different tiered interventions provided in behavioral health and ways to engage patients are really remarkable.”


However, we are not lacking in areas for improvement. If behavioral health organizations want to be effective in population health management, we must focus on building strengths that have traditionally not been high on our priority list. Let’s talk about three areas where we can do better.


First, we need to focus on public education and on prevention/early intervention. It’s been heartening to see how behavioral health organizations have embraced Mental Health First Aid. We’ve trained more than 250,000 people, but so much remains to be done. We need literacy and early intervention programs like Mental Health First Aid to touch every community, every home, every school, and every corporation in America.  Behavioral health organizations can help make this happen.


And we need the spread of initiatives like the Felton Institute’s Prevention and Recovery in Early Psychosis program, where early intervention and targeted treatment for schizophrenia are achieving dramatic results — 75 percent of people in are employed or in school by the sixth month of treatment. Within five years of entering treatment, most cases of psychosis are in remission. PREP provides early intervention and diagnosis for psychosis and translates evidence-based practices from academic to community settings.


Second, we must measure outcomes. Henry Chung, the chief medical officer at Montefiore notes, “There’s too much treatment inertia in all of healthcare. We keep doing the same thing over and over again. When we don’t measure, how can we tell if we’re really helping the patient or not? Population health is about looking for outcomes. We must have goals, and when we don’t meet them, we must look at what else we can do for our population.”


Third, we must capitalize on the power of technology to extend the reach of staff. Consider for instance, the Health Buddy — a simple clock radio-sized device designed to help individuals manage their physical and mental health needs on a daily basis in the comfort of their homes. Vinfen in Massachusetts is using Health Buddy to transmit patients health status daily to an internet site for review by the nurse practitioner and action to ensure proper disease management and overall improved health.


Of course, we know that electronic health record systems can decrease the fragmentation of care by improving care coordination. Only EHRs can integrate and organize patient health information and facilitate instant distribution among all who are involved in a patient’s care. As Steve Ronik, CEO of Henderson Behavioral Health in Florida says (page # for article 26), “We don’t have a choice — nobody does — you can go kicking and screaming, but you have to have an EHR.”


Chris Murphy, in an article in Information Week, argues that providers should benchmark their online engagement against other industries. He points out that some of most innovative changes that have been made in healthcare over the years are the result of thinking from the outside in, rather than the inside out. He quipped, “How come a retailer such as Amazon or Apple can remember I bought an Ace of Base recording the last time I visited, but the people who help keep me alive or healthy have to ask about my allergies every time I show up at the doctor’s office? Why can I book a flight, hotel and car from three different companies on one website but not schedule doctor appointments online and see all of my upcoming medical visits in one place?”


Behavioral health can lead the way in population health management if we think from the outside in. If we commit to building the Amazon Prime experience for the millions of people who depend on us for better health and better lives.