Engaging People in Care to Make Treatment “The Path of Least Resistance”
I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel. – Maya Angelou
Ensuring that people with mental illnesses and substance use disorders have access to treatment and recovery services at parity with those offered for physical illnesses is a laudable goal and one that we are making strides in achieving. National Council members offer same-day access and just-in-time scheduling, and we have fought long and hard to ensure parity between physical and behavioral health.
But access and parity are just two legs of a three-legged stool, and we may only pay lip service to the third leg – engagement. We do so at our peril. Fewer than half of Americans with mental disorders initiate treatment, and only a third of those who seek services engage in minimally adequate care. The data is even more alarming for addictions.
This is a problem we can no longer ignore, because treatment engagement predicts positive outcomes, such as increased employment and decreased criminal justice involvement. Conversely, lack of engagement leads to negative outcomes, including relapse, rehospitalization and incarceration.
“We need to make treatment the path of least resistance,” says NatCon18 thought leader Dr. Omar Manejwala, senior vice president and chief medical officer of Catasys. We spoke about engagement with Dr. Manejwala and with Anthony Salerno, Ph.D., practice and policy scholar at New York University’s McSilver Institute and a senior consultant to the National Council. They were generous in sharing their insights with us.
The first thing we must do is understand what engagement is and isn’t.
Access is about an organization’s policies and procedures. How soon after a person calls can she be seen? Are your clinic hours convenient for her? Do you accept her insurance? Once she has cleared those hurdles, the real work of engagement begins.
On the face of it, engagement is simple. “Engagement is about the relationship between the people providing services and the people receiving them,” Tony says. Engagement is about respecting the patient and actively listening to him. It’s about making his concerns our top priority. It’s about recognizing his strengths and treating him as a person.
Of course, simple is not necessarily easy. “To engage patients effectively takes skills, knowledge and intentionality,” Tony notes. “It begins with as empathic response that communicates to the person that understanding their personal perspective is our top priority.” It also requires recognizing and responding to the differences in the way we engage people who have physical and behavioral health conditions. “If someone with diabetes is not checking their blood sugar regularly, we offer them telehealth services or maybe even an implantable device,” Dr. Manejwala says. “In behavioral health, we say, ‘That’s on them’; we gave them access and coverage.” We blame the person for the system’s shortcomings.
Not only that, but we too often put the treatment ahead of the person, deciding upfront what the intervention should be. We make assumptions about what constitutes effective treatment in both physical and behavioral health, but we’ve begun testing those assumptions in physical health. “That’s why we’re delivering interventions for high blood pressure for African Americans in barbershops,” Dr. Manejwala points out.
This is the Amazon Prime generation. We want to engage when we need something and come back again, weeks or months later, when we need something more. In behavioral health, if we haven’t seen a patient in 90 days, we may close their case. But physical health doesn’t work this way. If I return to see my primary care physician or cardiologist after 90 days, my file is still open. In behavioral health, we talk about “no shows,” but we never look at whether people want something different and how we should respond. We can no longer afford to operate this way.
A Shifting Paradigm
So how do we make it easier to engage with our patients, given the realities of limited resources, overworked and underpaid staff and a technological revolution on our doorstep? Dr. Manejwala offers a four-step prescription for success:
- First, we must understand the problem by sharing and analyzing data to determine the impact of untreated behavioral health disorders. We must understand who these patients are and how their avoidance of care is impacting the system.
- Second, we must shift the paradigm in how we provide treatment. We must remember that our job is to help people solve problems in their lives. We must start with the person, not the intervention.
- Third, we must offer integrated care, not just the same coverage and benefits, but treatment offered in the same systems by a cross-trained workforce with the same supportive services. This is why the National Council advocates for and supports Certified Community Behavioral Health Clinics (CCBHCs). By being paid a Medicaid rate for the delivery of integrated care for patients with complex conditions, CCBHCs can transform care around the country.
- Finally, we need a wholesale culture shift to address the discrimination experienced by people with mental illnesses and substance use disorders and the providers who serve them. Because of negative attitudes and beliefs, “People are not getting help, they are getting sicker and families are being torn apart,” Dr. Manejwala says.
Starting the Conversation
Longstanding ways of doing business don’t change overnight. And community behavioral health organizations too often starved for funds have all they can do to keep their heads above water. But in today’s value-based environment, we must prove we can get results, and we can’t do that if we aren’t engaging the patients who need our help.
Let’s start the conversation. How are you engaging patients and their families in mental health and substance use treatment? You can respond to this post or write to me at LindaR@TheNationalCouncil.org. I’d love to hear from you!