November 4, 2020: There are more and more patients with mental health issues and the lack of access to quality behavioral health services can be frustrating. Today we explore the intersection between primary care and behavioural health. For a very long time healthcare has separated the two. Christine Brocato of CommonSpirit and Spencer Hutchins of Concert Health share their elegant solution. It’s called the collaborative care model. How do we get patients access to quality care more quickly? How do we lighten the load of the primary care physician? What are the codes? How does this get funded? And what are the projected results?
Bringing Behavioral Health to Primary Care with CommonSpirit
Episode 324: Transcript – November 4, 2020
This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.
[00:00:00] Bill Russell: [00:00:00] Welcome to This Week in Health IT. Today, we have a Solution Showcase for you, and I’m really excited to bring it to you. This is the intersection of behavioral health and primary care, and it’s a great solution that CommonSpirit is rolling out. My name is Bill Russell, former healthcare CIO, CIO, coach consultant, and creator of This Week in Health IT a set a podcast videos and collaboration events dedicated to developing the next generation of health leaders. I want to thank [00:00:30] Sirius healthcare for supporting the mission of our show to develop the next generation of health leaders. their weekly support of the show this year has enabled us to expand and develop our services to the community. So special thanks again to Sirius Healthcare. Now, well, actually one last thing. we, the competition on the referral program is going really well. if you’re not familiar with it, you can, sign up for clip notes and then you can refer your friends to clip notes and what’s happening is, people are referring it [00:01:00] to their friends. They just go out onto the website, they hit subscribe and they put your email address in there. And a bunch of you are amassing referrals, which is great. If you get one referral, you’re entered into a drawing to get a, potentially a work from home kit from this week in health IT. If you get up to 10 referrals, you get this, black mole skin notebook with the embossed logo on it.
[00:01:23] And for one of you, you’re going to get the opportunity, opportunity. I’m not gonna force you, but you’re gonna get the [00:01:30] opportunity to come on the Tuesday new stage show with me. And we’ll talk about the news, the health IT news that is impacting the community. looking forward to that, thanks for your participation. Really appreciate it. We want to get this in as many people’s hands as possible. So yeah. Now, great show. Looking forward to sharing with you. Over the last, couple of months, starting with COVID series, we’ve done a couple of episodes on behavioral health. And I’m excited about this one because I think it just makes so much sense.
[00:01:56] First of all it’s a great health system in CommonSpirit Health, [00:02:00] and it’s also a great solution that concert health, in partnership or bringing it together. we have sped, Spencer Hutchins, Spencer what’s what’s your title? Are you.
[00:02:12] Spencer Hutchins: [00:02:12] Co-founder and CEO
[00:02:14] Bill Russell: [00:02:14] Co-founder and CEO. And we have Christine Brocato the Vice President of Strategic Innovation at CommonSpirit, joining. Welcome to the show. Welcome Christine.
[00:02:24] Christine Brocato: [00:02:24] Thank you. Thanks for having us. It’s exciting to talk to you about this program today.
[00:02:29] Bill Russell: [00:02:29] Yeah. [00:02:30] I’m really looking forward to it. There’s there’s so many exciting aspects of this, but I’m just gonna, I’m going to let you guys tell the story. Sometimes I over. I will talk over, I’ll share the whole story and then say, okay, tell us more. But tell us about the partnership, tell us what you guys are doing and why it’s unique and why it’s exciting. I don’t know who wants to Christine? Why don’t you start and then Spencer you can fill in some of the details.
[00:02:56] Christine Brocato: [00:02:56] Sure, absolutely. So, first of all, [00:03:00] this, this program, the genesis of it, began last year, so pre COVID. We were in our markets, as we usually are talking to our primary care physicians about, some of the challenges that they see, what innovations that we need to bring to market. And a trend started to emerge with them saying that they’re seeing more and more patients in their panel, with mental health issues. And it [00:03:30] was really concerning to them. But they also expressed a lot of frustration with lack of access to quality behavioral health services in their markets. And usually what happens is that there’s, three to four, behavioral health therapists in the market that the PCP knows like skills competent and referring.
[00:03:55] And when those folks are at capacity they’re at a [00:04:00] loss for where to send their patients and end up. Spending more time with those patients in a visit, managing them more closely calling, following up. And so they’re doing this work today, not getting paid for a lot of it. And just frustrated with the lack of ability to send their patients somewhere competently. And so we realized that there was a need to find a solution that would work for them. [00:04:30] And they made one request of us as they were like, listen, I’m dealing with a very diverse patient population. So don’t get fancy. Don’t give me anything. That’s super complicated that the majority of our patients really can’t use. And so our team started to do research and that’s when we started to, research different models and, came across the collaborative care approach [00:05:00] in the thought that it solved two things.
[00:05:04] One is just the access problem. How do we get patients access to quality care more quickly? And then the second is a recognition of integrating behavioral health care with medical care. And that’s exactly what, collaborative care does. I would say that for a very long time healthcare really separated the two [00:05:30] but what the research shows is that when you integrate behavioral healthcare into medical care, not only do you get better outcomes in terms of decreasing depression and anxiety, but you also have, better outcomes in clinical care as well. so for all that reasons, this part, this partnership made sense.
[00:05:54] Bill Russell: [00:05:54] Yeah absolutely. I remember at the health conference a year ago, Bernard [00:06:00] Tyson saying, we’ve one of the things that we’ve done in healthcare. We separated the head from the rest of, of the body and we just care for the rest of the body. And he was really passionate about it. He was talking about mental health. So Spencer talk about this. This is really integrating primary care and behavioral health services. So give us an idea of what Concert Health does and what you guys brought to the partnership.
[00:06:24] Spencer Hutchins: [00:06:24] Yeah. So Concert Health is aiming to build America’s largest and best behavioral [00:06:30] health medical group. So we’re now over a hundred team members. The vast majority of whom are counselors and psychiatrists that work from home. and what we do is team up with medical groups and health systems that have a passion for integrating, but. Don’t want to figure it all out themselves, right. Or looking for a partner, dedicated group of, our team, often bilingual, to support each of those primary care practices, and really are there [00:07:00] to provide same day and next day access.
[00:07:02] So Christine mentioned, we use a model called collaborative care management, which, might not be familiar to a lot of your listeners. Although I think the logic behind it will be for those engineers or technologists, I think in many ways it’s a more engineering mindset to the problem. So the beginning is to start with recognizing that probably 50 to 60% of people with depression and anxiety.
[00:07:23] Don’t tell you the habit. either because they don’t realize it or, or they’re embarrassed about it, [00:07:30] or they’re just hesitant to bring it up, but we’ve known for years that there’s a series of pretty easy screening tools, really just quick surveys that you can give people, at least on an annual basis or around any major health event, like a new diagnosis or hospitalization.
[00:07:44] And it picks up a lot more, not to diagnose people, but to screen them for higher risks. Right. So it should be flagged for their primary care physician. So one thing we’re doing is working with CommonSpirit to do that. How do you implement and scale that? So really everybody’s being asked and you pick up that 50, 60% of the [00:08:00] people that maybe never were going to get we’re going to be missed by care. and then you provide a warm hand off. So now when a patient shows up in the, in Bakersfield, clinics with, they’re able to say, let’s say on the patient, instead of saying, hey Spencer, you have depression, here’s an anti-depressant you should think about seeing a therapist.
[00:08:18] Yeah, you could say, Hey, Spencer looks like you’re struggling with your nerves, with your sleep, with your mood. I’ve I see that a lot of people in our, what I’d love is for a member of my team, Dani, to call you [00:08:30] today or tomorrow. And what Dani does with a lot of my patients is checks and in between our visits and what she does is is, gives you the same tool we gave you this morning, so we can really quantify how you’re doing. Just check in on how things are going. If this medication I’m giving you is working. And she’s got some coping techniques, that she teaches a lot of my patients that they find helpful. So some people will recognize that as, oh, Dani’s a therapist that’s in house.
[00:08:54] Others would have say, no, she’s part of my team. You don’t need to make that. You don’t need to have that same division [00:09:00] of this is somebody different. It’s just part of a comprehensive primary care experience. But Dani would be one of our licensed mental health providers to just do that. Patient would experience us as a phone call or a video visit, whichever they like, and often touching base two to five times over the course of that each month and what we do is every month we give them that same assessment tool. In depression, it’s one commonly used as a PHQ nine, or there’s different ones for anxiety, suicide risk, bipolar in each of those cases, whenever possible, [00:09:30] really measuring whether or not I’m getting better as a patient and then doing brief psychotherapy interventions, each of our Dani’s each of our care managers, then each have a weekly check-in. With one of our psychiatrists, using that data registry to talk through those patients that aren’t getting better. So let’s say again, using myself as an example, let’s say I am doing great with my morning meditation but I stopped taking my antidepressant because I have erectile dysfunction. Eight weeks later my [00:10:00] PHQ nine has dropped from 18 to 12. That’s great. That’s an improvement lower better on that score, but that’s still pretty symptomatic. That’d be a classic person. It’s a, Hey, I’m feeling better so I’m going to not bring it up or I’m embarrassed about the side effect I have so I’m never going to talk to my doctor about it again. By having that collaborative care team around by having Dani with me she’ll know that, bring it up to the psychiatrist. Doesn’t even have to be an hour long visit in that case, they’d say let’s drop a quick note to the primary care physician. Remind her that, [00:10:30] congratulate Spencer on the meditation is doing think about changing it to a different SSRI. That’s less likely to create that side effect cause it looks like we’re going to need both the therapy intervention, add a medication to make Spencer asymptomatic. So my primary care physician looks like a hero.
[00:10:42] She knows what’s happening in my life. And she has an actual recommendation that she can act on. And Dani’s is really making sure that I don’t slip through the cracks and that patients may manage and it might get I’m being managed until we’re really declare success which is when I’m asymptomatic. Right.
[00:10:56] When I’m over at, when I had in remission, I can move on. So [00:11:00] that’s what we’ve been doing. We’ve been doing it for four years now, across 40 medical groups and health systems, and incredibly excited to be kicking off in Bakersfield with CommonSpirit and obviously taking the relationship hopefully to many other locations around the state and around the country.
[00:11:17] Bill Russell: [00:11:17] So I’m going to, I’m going to come back to some really pragmatic questions, but I want to start in Bakersfield and Christine, give us an idea of what you’re looking for out of the pilot and what you’re learning and what you hope to learn.
[00:11:29] Christine Brocato: [00:11:29] Yeah, [00:11:30] absolutely. We were fortunate to receive a grant from the state of California to implement integrated behavioral health care in Bakersfield and in inland empire. So that’s where we’re starting first. And for folks who aren’t familiar with Central Valley, California, it’s a very diverse population. It’s isolated in the middle, between Southern California [00:12:00] and the Bay area. and there’s a little of a, we call it a little of everything. We have folks who, a lot of agricultural workers, we have, a huge rural population. And when we think about the diversity in that population it’s pretty enormous. And so what we’re looking to do. Is to implement this program with our primary care providers [00:12:30] and really demonstrate that we could, prove out the results in this real world setting that we’ve seen in their research.
[00:12:39] And so we’d expect to see three major pieces, which is one, a reduction in mild to moderate depression and anxiety 90 days out, to a reduction in clinical or an improvement in clinical outcomes. And so that would mean for chronic care patients improvements in [00:13:00] A1C, a reduction in ED and inpatient visits, and all of that contributing to a reduction in cost of care. And we also want to demonstrate that these results, could be meaningful to the Medicaid population which is, has always been a challenge in terms of meeting their behavioral health needs. And so I think this is, we have a pretty [00:13:30] aggressive, goal ahead of us but we’re really excited and excited by, not only the collaboration from our PCPs but also in working with the payers in that market as well.
[00:13:43] I think all of us recognize that we need more tools, to serve populations, with their behavioral health needs. And yeah. And so the ability to really, track the data and learn together I think is going to be great.
[00:14:00] [00:14:00] Bill Russell: [00:14:00] So I’m going to come back to you and talk about the physicians and how they’re responding to it, how they, how they’re looking at it. I’m also going to go in the direction of the financials. We, our listeners are primarily healthcare providers and whatnot, and right now they’re sitting back going, okay, this is an interesting pilot. And you’re not kidding. When you say Bakersfield is diverse. It’s rural, it is industrial. It is people commuting into LA making [00:14:30] half a million dollars a year. It’s everything, everything in between. So it’s, it really is a microcosm of a lot of different populations. But you know some people might be asking you about the financials. What are the codes? How does this get funded? How does it get paid for. Which one of you wants to take that and talk about that.
[00:14:54] Christine Brocato: [00:14:54] I’ll take a, Oh yeah, I’ll take a look, overview crack, and then I’ll pass it on [00:15:00] to Spencer. Given all the robust research, about collaborative care, about two years ago, Medicare, released collaborative care codes and these are CPT codes, and then many major payers followed suit.And so that was I think, a wonderful win, healthcare, because it’s a recognition [00:15:30] that this type of model, in integrating care with primary care , is that it produces results. And I think some Medicaid, payers reimburse it. Some do not. Currently in the state of California. It’s not. So the challenge is, working with our Medicaid payers in the state and looking to be creative and [00:16:00] prove out their results to establish, establish those codes of the near future. Spencer, what would you add?
[00:16:07] Spencer Hutchins: [00:16:07] Yeah, I think that’s a great overview. Medicare was the leader in 2017 on a pilot created essentially three new codes for those that really want to geek out it’s 99492, 99493 and 99494. It’s a monthly case rate that covers this, but to do it, you have to prove you have assembled this three person team. Primary care, [00:16:30] Behavioral Care Manager and site consultant. You’re using a registry to track outcomes, and you’re doing treat to target meaning you’re, testing and learning based on whether or not you’re generating results and changing the approach in psychotherapy and their approach and medication. And really frankly, faster than we expected the commercial health plans followed essentially every major national plan and almost all the regional blues have covered this, added this to their fee schedule. The evidence is so robust and everybody recognizes they need better access and better [00:17:00] quality on the behavioral health side. and Medicaid has covered it now in 18 States, across all sorts of different markets, Arizona, Washington, New York, Massachusetts, lots of places, red and blue left and right, coastal and inland California in some ways has been a little bit of a laggard frankly. They’re talking a lot about this. They haven’t added it to the fee schedule. One thing that’s inspired us from the beginning of the conversations with common spirit and Christine [00:17:30] is, they said, listen, we’re not going to solve this in an easy place. We’re going to go to a place where the need is the greatest, and we’re going to solve it for the communities that matter. Matter most about us. I remember when they said, we really want to bring this to the inland empire said well it’s not Medicaid in California is not paying for it yet so that’s going to be complicated. There’s a lot of managed care out there. So on the commercial and Medicare side, it’s a little bit more complex and they just put their foot down and said, this is the right thing for the market. And we’re going to use our resources, our brand, our people to bring [00:18:00] everyone to the table.
[00:18:01] And as you imagine, it’s a little bit easier to go hand in, with, along with Christine, we’re gonna go talk to the plans and other stuff and say, listen, this is the right thing to do. Let’s figure it out and a little bit, if we can figure it out clinically, and if we can figure it out financially, they are, there’s nowhere in California we won’t be able to do this. And there’s nowhere in other common spirit markets. that’s been inspiring and it’s been exciting to do that. Because we know to be useful at the point of care for that primary care provider. [00:18:30] It needs to work for everybody. Those those physicians are doing so much. They’re seeing 35 people a day. They know three, four or five of them every day are going to have depression, anxiety. If we can find a way to support all of them, it’s a life changer for them clinically and operationally. Oh, I have this person that they’re my partner, anytime I identify these problems, I know someone’s going to be reaching out to the patient, checking in. Documented so that I can see the record giving me useful recommendations. if you’re just, if you take a plan centric view, and you say, well, for my Cigna [00:19:00] patients, I got this, from my Aetna, ACO patients. I can do that. Yeah. If that doesn’t work right. It doesn’t work in the day in the life of the doctor.
[00:19:07] And I think that’s something we’ve been passionate about. We’re so excited for Christine’s leadership and on the ground to say, we’re going to make this work at point of care, which means we have to make it work cross panel for them quite all payer. And that’s where it unlocks the behavior change that drives the clinical outcomes that we all want to see.
[00:19:24] Bill Russell: [00:19:24] Spencer, I’m going to go to Christine here, but I’m going to come back to you on a question around the technology and [00:19:30] how I integrate it into the rest of the tools that I have for sort of an integrated digital experience. Christine, let’s talk about the physician and the physician experience. Is Concert Health sort of white box in the background? Does it appear as just part of the common spirit team? How does, and how, how do the physicians. how do you get the physicians on board? Are they just naturally on board because it’s the right thing to do?
[00:19:55] Christine Brocato: [00:19:55] Yeah so I’m a, I’m an innovation person. And so I’m usually doing, [00:20:00] the big sell on a variety of innovations. And I have to tell you that that is not the case with this. this is a situation where PCPs acutely feel the results of the lack of access to behavioral health in the market. And so when we were presenting this to the PCPs, they got it immediately. They appreciated just how much, [00:20:30] evidence was baked into the model. They put their hand up and said, when are you coming to my clinic? And I think it’s for all the reasons that Spencer talked about. This is a model where they are staying at the center of the care, that they can follow their patient’s progress. The therapist is documenting directly into the EMR and then the physician is able to do, any med rec [00:21:00] that they can. And so for them, this is helping them with their schedule. This is a way to to easily do a warm handoff to the therapist and feel confident that they know where their patients going. and so for all those reasons, I think this is a program where, we feel that there’s PCPs putting their hand up and saying, okay, what about me? Let me get me into the Q and A, and I think that’s, really speaks to the need, [00:21:30] that we feel not only in Bakersfield, but I’d say in a majority of our markets.
[00:21:35] Bill Russell: [00:21:35] Yeah, that makes sense. Spencer, This week in Health IT so we got to talk about the technology aspects of it. I realize phone is some of it. And Christine’s stole some of your thunder. So you’re documenting directly into the EHR. That’s pretty exciting. You have a digital tool. Can I integrate it into the other tools that I have? Give us an idea of some of the lay of the land on the technology side?
[00:21:56] Spencer Hutchins: [00:21:56] Yeah. Our view has always been that [00:22:00] we need to be more than an app, right? We need to build this organization as the medical group itself. Because the magic is the people, the protocol empowered by the right technology. And when we canvas independent practices and large health systems, it wasn’t, they were saying, Hey, the only problem we have in behavioral health integration is I need to do SAS platform that I can license. It said, no, we need to figure out how to find these people, how to train them, how to get paid for this service, how to do the work. Right. And so we said, okay, we need to be [00:22:30] that. Full service solution. not just that now that said we’re proud of the technology we’ve been able to build. And we really focused on is anything that makes the life easier for the patient most importantly and second most importantly, the primary care physician and RGM our care managers and our psychiatric consultants. And so as Christine started, that started in the beginning. We always said, we want to treat all patients, no matter their technological literacy.
[00:22:55] So from the beginning, we said, this is a model that can be done incredibly effectively over the phone. And that’ll always be an [00:23:00] option. Right. and so that is, but if a patient has a preference to do or wants to do video visits, they can do that. it’s a secure link, texted or sent to them. Boom creates a video, connection with their therapist. They can do that every visit or just the first couple to get to know them. Right. And that can be really powerful too. Face-to-face can be great. Sometimes actually the phone can be a great way to access someone from a technology limitation or they’re there. We’re calling [00:23:30] them on their lunch break or on they’re at home, or maybe, they’re so agoraphobic or so depressed that they don’t want it. They don’t feel like they can be up for a video session and get dressed and get, but they will take a call and start talking to us. And that can be a great entree.
[00:23:45] From the primary care physician perspective, our view was, there needs to be a single source of truth. Right. The first time that we make a recommendation based on a med list or broadened list that seven months old is the last time they read a one of our [00:24:00] recommendations. And so that is, we really need to work with, with the medical groups and health systems. Say, we need to have the ability to access the medical record and document directly there. Now what we’re doing more and more as we scale is also doing backend integration. Right, which says, okay, let’s make sure we’re not wreaking medical record numbers, patient names, other things, PHQ nine is being able to pass them back and forth increasingly digitally.
[00:24:24] But I think really always having that direct interface connectivity to the EMR will be important too, because a lot [00:24:30] of people use that phrase, Oh, I’m integrated with an EHR. You say, what does that mean? There’s well, there’s a PA there’s a PDF somewhere buried in someplace. The physician doesn’t even know where to look.
[00:24:39] So yes, it could survive an audit. Yes. The information is there, but it’s not part of their day to day operations. Right. And our view is our team needs to be an extension of theirs and they need to see our messages come through just like we were a nurse or another physician on their team so that they can really interact with us and those sorts of things.
[00:24:57] And so we’ve really built our technology [00:25:00] infrastructure around that, around how to enable that, how to make sure we can bill for it as well, and these new time-based codes, and then be as light touch, from the primary care perspective as possible. And just make it look like it’s, automagically populating even if at times that means our team is doing double data entry or something like that.
[00:25:17] Bill Russell: [00:25:17] Yeah, absolutely. It’s, I’m really glad to do this show. I love doing the show cause we know there’s such a huge need. This is such an elegant solution and a great partnership. I continue [00:25:30] to be impressed with the things that, common spirits rolling out and, it really exciting to, hopefully hear more about this, in the coming year. I’d like to hear how the pilot goes and, I’m looking forward to reading the, the press release as you expand this into other markets. I know I’m, I know I’m putting my expectations out there, but that’s my hope.
[00:25:52] Christine Brocato: [00:25:52] We’re excited about it too. And one of the things that we’re almost like piloting within a [00:26:00] pilot. And I think it’s worth mentioning, to folks who are thinking about behavioral health is that we’re using this as a way to learn about how social needs are surfaced when you’re having behavioral health conversations. So when you are talking to your therapist, you may disclose that you have anxiety because you cannot pay for your utility bill. That you are food insecure. [00:26:30] And what do we do when we hear about those things? And so we’re working out workflows to be able to surface those social needs and get them to our care coordinators who can make those referrals into the community. And so I’m starting to really connect, a variety of programs that I have so that we’re overall just treating the patient holistically. They’re going to surface medical care issues, behavioral health issues, [00:27:00] social needs issues. How do we start to really, connect with those pipes? so that those aren’t separate issues. It’s manifesting altogether in the patient and we’re looking to address those needs. So I’m really excited about that aspect as well.
[00:27:18] Bill Russell: [00:27:18] Yeah. That’s the foundation of Catholic healthcare right there, mind, body and soul. It’s the whole person. And, I want to thank you guys for taking the time to come on the show. And, again, it’s just, [00:27:30] I appreciate the things that you guys are doing. I’m looking forward to, to hearing from you next year on how this progresses.
[00:27:37] Christine Brocato: [00:27:37] Thanks so much. Thanks for, thanks for having us on.
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