How to leverage population health strategies

As the healthcare landscape moves to patient-centered models, it is imperative that whole-person care—which includes creating strategies for large populations of patients—be an integral part of behavioral health. However, creating population health strategies for the specialty has its challenges.

“Behavioral health organizations have traditionally operated as silos in specialty care,” says Cara English, director of the Doctor of Behavioral Health program for the Cummings Institute in Phoenix. “Behavioral health clinicians and clinician leaders will need to learn to speak the language of primary care and have a better understanding of chronic and acute medical conditions that can cause or exacerbate mental health conditions.”

Continuity of care between primary care providers and behavioral health providers continues to be a struggle, though technological advances aim to cure some of those issues.

“Care coordination is particularly difficult when patients need a referral outside the practice. The burden of coordinating follow-up and communicating treatment and discharge summaries is entirely placed upon the patient and the family for the most part,” English says. “Due to the stigma of seeking care, patients are unlikely to follow up on a behavioral health referral outside the primary care practice.”

Though challenges arise, it is essential that behavioral health providers create population health strategies to increase patient engagement and eventually cut healthcare costs.

“Population health models that address both clinical issues and barriers to self-care are showing success in lowering costs and improving the health of patients,” says Jordan Asher, MD, MS, chief clinical officer for Nashville, Tenn.-based MissionPoint Health Partners. “The true challenge is enabling the paradigm shift of how the present healthcare environment thinks about working with patients.”

Partnerships that increase engagement

Population health is viewed by many as a strategy for primary care providers, but behavioral healthcare plays an intricate part. Often chronic health conditions co-occur or can lead to substance abuse or mental health issues, and working with primary care is important to create a complete picture of patients, says Asher.

“We find that we have to address a patient’s anxiety and depression before we can expect them to actively engage in activities to better manage a chronic disease like diabetes or congestive heart failure,” Asher says. “Unless a patient is in a medical crisis, we think about the behavioral dynamics as first order and clinical issues as a very close second order, which is often 180 degrees different than a traditional disease-based model.”

Partnering with primary care providers to develop screenings and tests for a more integrated health experience is one way to destigmatize behavioral health, English says.

“Due to the stigma of seeking care, patients are unlikely to follow up on a behavioral health referral outside the primary care practice,” English says. “They are much more likely to present to their primary care provider with behavioral health symptoms and want to have care for that condition delivered by that same doctor that they trust. Unfortunately, primary care providers lack the training, tools and expertise necessary to address these issues, and few primary care practices hire behavioral health providers to consult with patients. Initiating new relationships with providers can be difficult for patients with depression, anxiety or serious mental illness.”

Creating partnerships with organizations outside of healthcare is essential to affecting change across populations, says Beth Lonergan, director of behavioral health services for the University of Wisconsin Hospitals and Clinics (UW Health) in Madison, Wisc. She adds that building relationships with schools, community-based organizations and faith-based organizations are ways to meet patients in a comfortable environment and explain how behavioral health services integrate into overall health.

“World Mental Health Day, on October 10, is a great opportunity to build capacity and awareness of behavioral health services in a community. Anti-stigma campaigns can normalize behavioral health issues, which helps get patients through the doors,” Lonergan says. “It is also important in building relationships with teachers, clergy and those on the ground level who can learn how to identify issues and get people help.”

Outreach can also extend beyond community organizations. With the rise of opioid misuse and other substance abuse crises, it is important to partner with local government agencies to be a part of strategies that include law enforcement and the judicial system.

“At UW, we have efforts to create county health ratings and develop strategies to improve health. We also evaluate how our organization can support existing efforts in law enforcement, social services and schools,” Lonergan says.

Technology barriers and solutions

Interoperability issues between clinical and behavioral healthcare systems limit the care coordination that is necessary to make effective changes to population health, English says.

“The electronic health record is something new to many providers, and navigating interoperability issues, ensuring HIPAA and 42 CFR Part 2 compliance and determining how to roll out new patient portals can be overwhelming for many experienced providers,” English says. “For a primary care physician to be able to access hospital or emergency department visit summaries, including behavioral health visits, it is up to the patient to get and bring those summaries back to the primary care provider. Having an integrated electronic health record is critical to patient engagement.”

Many behavioral health providers are finding a boost in patient engagement when using adjunctive online portals, assessments and tools that can also connect patients who have similar health issues. Reimbursement for telehealth is increasing for Medicare, Medicaid and private payers, so the possibilities to reach more patients remotely also is growing, Lonergan says.

“There’s a real shortage of geriatric and pediatric behavioral health providers, so telehealth is a real solution to reach and engage patients in rural areas,” Lonergan says.

She believes that low-cost solutions can assist with improving population health, such as the many free app choices available to patients today. Plus, some apps can link directly to providers.

“Texting patients to remind them of appointments is very effective, especially with young people,” Lonergan says. “Programs that help patients set smartphone alarms to commit to certain behavior changes, like exercising or taking medications, is another great way to use technology.”

Reimbursement options

Finding ways to pay for innovative programming is often the barrier that stops a lot of progress in population health. Reimbursements can vary from state to state, though grants are often available for pilot programs that test value-based reimbursement models.

“The good news is that as our nation shifts to alternative payment models and value-based payments, the door for innovations around how we work with patients—and how that work is reimbursed—is completely opened,” Asher says. “Under some of the new payment arrangements that enable providers to take risks, patient engagement services will become extremely valuable to both to the patient and to whomever is holding the financial risk.”

English says that federal Meaningful Use incentives have not been available for independent behavioral healthcare providers or behavioral health organizations without a physician. However, grant funds that incentivize electronic health records initiatives are available.

“We need to redesign care systems to be more patient-centered and tap into the opportunities presented by new funding streams, capitated fee arrangements and value-based contracts,” English says.

Lonergan adds that grants are just not enough to assist with real population health change. In the next few years, Lonergan hopes to see real value-based change in both public and private payers, she says.

“Frankly, a lot of organizations are able to get seed money or grants to see if these programs are effective. But we need more ways to sustain innovation,” Lonergan says. “Clinical advancement moves quicker than the payer landscape. We not a lot of programs and tools that are effective, but many of them aren’t reimbursed.”

Donna Marbury is a freelance writer based in Ohio.