Integrating Behavioral Health Services to Reduce ED Visits: Substance Use Disorder and Social Determinants of Health

Join us for the continuation of an engaging two-part series showcasing an expert dedicated to reducing emergency department visits through the integration of behavioral health practices. Dr Zaubler will share invaluable insights into implementing preventive strategies via behavioral health integration, aiding patients dealing with substance use disorders and those affected by social determinants of health. 

Read the full transcript: 

Dr Tom Zaubler: Hi, nice to be with you today. I'm Tom Zaubler. I'm a psychiatrist, chief medical officer at NeuroFlow. NeuroFlow is a company that focuses on creating a technology platform to improve access and treatment for behavioral health problems in medical and other settings. I've been at NeuroFlow for about three years.

Prior to that, I was a chair of the department of psychiatry for 21 years. I've been immersed in the world of integrating psychiatry and behavioral health into a multitude of medical settings since the mid-1990s. I was very fortunate to have as a mentor the person who created what's called the collaborative care model, which is a evidence-based model to integrate psychiatry into primary care and now into a multitude of other clinical settings as well.

I’m a clinical professor of psychiatry at Thomas Jefferson in Philadelphia. Again, nice to be with you today.

From a payer’s perspective, mental health services are scarcely covered. Do you feel that is the case due to improper screening upfront in the primary care setting?

Dr Tom Zaubler: Let me just say this, so yes, but I think it's getting much better.

I actually have great relationships with payers. We at NeuroFlow have great relationships with the payers, and we see them as allies here because the payers recognize the importance of doing measurement-based care, of getting patients to the right care quickly, precisely because it's a win-win. Costs go down. The payers in some ways are farther ahead than the providers here in a funny way. And you see payers really incentivizing providers and primary care practices and health systems to start models like collaborative care.

And they've been really innovative of that. Most payers are now covering treatments. There are CPT codes for collaborative care, and most payers are paying for those CPT codes and do that very willingly.

And now payers are saying, “you know what, we'll not only pay for those CPT codes, we'll incentivize you in other ways to start providing support for patients in primary care and other medical settings” because they recognize, one, it's doing the right thing. And two, it leads to decreased costs; patients get better, they stay out of the emergency room, they stay out of inpatient units.

We know, for example, that patients with co-occurring medical and psychiatric illness, when they get admitted medically—not psychiatrically—their length of stay is substantially longer. The average length of stay for patients in an acute care setting on a medical unit is about 4 days. When you start looking at cohorts of patients with co-occurring medical and psychiatric illness, it's more like 7, 8, 9, 10 days. Helping those medically complex patients with co-occurring medical and psychiatric illness to get better, to stay out of EDs, to stay out of the hospital—the whole health care ecosystem runs much more efficiently and effectively.

It's a win-win for payers, patients, providers, and our economy, quite frankly.

The key words that come to mind are collaboration is key. The behavioral health integrations you’ve discussed can help save the lives of patients and reduce ED visits across the board.

Dr Tom Zaubler: For patients with substance abuse disorders, only 90% receive no care whatsoever. We talk about overdose deaths—140 ,000 deaths from alcohol poisoning alone, well over 111 ,000 deaths from overdoses in general—there's so much work that needs to be done. So we need to look at ways to surface the underlying problems and deliver that treatment integrated in medical settings. So, it's not just about depression and anxiety. It's about substance use disorders. It's making sure that EDs increasingly for patients with opioid use disorders are starting what's called induction with suboxone to initiate treatment that is life-saving.

Because what you see when patients come into an emergency room, most emergency rooms in the country with an overdose from opioids is they'll get some Narcan, they'll get a referral, and then they don't follow up with that referral. And they're at huge risk at that point because if they were in the hospital for a bit, their tolerance level has gone down, they go back to using the same amount that they were using before and that's where people often tragically die.

So, the alternative is let's initiate treatment in ED settings, let's do the induction. The reason a lot of EDs don't do that is where do they send patients? There aren't the resources. There aren't the facilities.

Primary care docs get a little scared when I start talking about this, but some are all over this and say we need to be doing this. It is possible to provide the maintenance treatment for opioid use disorder.

That's in addition to other medication assisted treatments for substance use disorder. So that's just one example. Looking at oncology, for example, we know that psychiatric illness is prevalent among patients with cancer.

We know that it affects not only well-being and psychiatric outcomes, but we know for a fact it affects morbidity and mortality. And yet, even though there's a whole discipline of psycho-oncology that started in 1970s—Jimmy Holland and others were major figures in that field, well-established—very few cancer centers have robust integrated treatment programs. We're talking about with a lot of those cancer centers now to look at ways to address that.

Even in specialty settings like cardiology—we know that when someone's had an MI, a heart attack, if you control for all sorts of risk factors, like body mass index and cholesterol level and a whole bunch of things, and you break patients up into 2 groups. Again, patients who had a heart attack and tracked them for 6 months—those with depression, those without depression, controlling for all sorts of risk factors. Six months out, 17% of those with psychiatric illness are deceased with depression, actually, the study looked at depression.

I'm not suggesting that once you start treating the psychiatric illness that we can change that differential entirely, but it starts to whittle away at the morbidity and the mortality. It's huge, and we've got to address that. We also need to look at social drivers of health, the social determinants, because they account for health outcomes much more than the actual health care itself. Probably 70, maybe even 80% of the variance in terms of how patients do with morbidity and a whole bunch of factors has to do with social determinants, environmental factors, socioeconomic factors, structural racism, a whole range of things that that come into the equation that we need to be addressing and we need to tie those in to assessments done routinely and we need to tie them into psychiatric care as well because those are also very closely interrelated, health behaviors, and so on. So, there's a lot of work to do.

Technology can help to facilitate those screenings and the linkages and making sure that patients get to the right care at the right time in a very efficient way.

Opioid use disorder and alcohol use disorder persist as significant challenges across the country. Do you think that proactively addressing behavioral health integration could potentially empower patients to manage their emotions more effectively, reducing the likelihood of substance abuse and frequent visits to the emergency room due to inadequate education and therapeutic support?

Dr Tom Zaubler: 100%. Yes, absolutely. You look at the statistics of follow-through from an ED setting, including patients who have attempted suicide, and they're pretty scary, actually. The majority of people don't follow through with referrals. They're lost to care. Twenty-five percent of patients who present with suicidal ideation wind up coming back to the emergency room within, I think it's a month, but a relatively short period of time.

So, we need to do better than that. We need to make sure that people get to the right level of care. And for substance use, 100%. I mean, the risks are huge. And we see it way too often that someone comes in, they're crying for help. The risk is huge. And they're seen, they're stable, they're given a referral, and they're sent out and they're lost to follow -up. And then they come back to the emergency room.

And sadly, any number of those individuals will wind up overdosing and dying. So, this is literally a matter of life and death for many individuals. We have a very fragmented health care system. Transitions of care from ED, to inpatient, to ambulatory are high risk times. For example, when someone's on a psych unit, the risk of death by suicide in that first week or 2 is 300 times the risk of the general population. And, while hopefully in every psych unit in the country, there are clear discharge plans, whether for substance use treatment or psychiatric care in general, we know that ultimately patients often or certainly sometimes don't follow up with those plans, and we can do better. There are ways to measure how patients are doing in between the inpatient stay and their ambulatory site.

There are ways to use a combination of technology and care navigators to make sure that we're not only getting patients the right level of care with some coaching, but we're tracking how they're doing and if they've had concerns that raise issues around safety and other things that they can be addressed and prevent them from coming back to the emergency room and prevent them from coming back to the psych unit and making sure, again, they get the right level of care in a timely fashion.

What is one key takeaway you hope our audience gains from this interview?

Dr Tom Zaubler: I’ll give one statistic and share my thoughts. Almost 80% of those who die by suicide have seen a health professional in the past year. Over 40% have seen a health professional in the past month, and most of those are not mental health professionals. What it speaks to is that people are seeking care and we're failing them. We’re not identifying who those individuals are. We need to do a much better job in putting patients at the center of care. We need to do a much better job in providing holistic care. I know that's a term that's used a lot, but it's true. We need to do a much better job of that.

We need to unburden the primaries. It's this quintuple aim, right? It's not only unburdening the docs, it's also establishing equity and dealing with structural racism, making sure there's parity in terms of democratizing access to treatment for underlying mental illness. Just reading an article this morning about how women are often undiagnosed with ADD until their late 20s. There are a whole host of reasons for that. We know that in the black community, you're more likely to be diagnosed with severe mental illness and less likely to be diagnosed with depression.

There are a whole range of things that speak to implicit and sometimes explained in the way we do things. So, if we can democratize this, if we can look at ways to screen and do this as objectively as possible and do it in the comfort of patients' homes and make sure we're surfacing on this and make sure we have evidence-based care that is also utilizing measurement-based treatment-to-target interventions, we will start to address these inequities. We will start to universalize protocols and making sure that we surface the underlying illness.

And where people get frightened, "Well, we don't have enough psychiatry, we don't have enough behavioral credit," we don't. But we have models of care that are population-focused. And when we start utilizing those models and we start doing these integrations, utilizing technology, it's critical because you automate workflows, you make it simpler, you get patients' digital interventions, they get better through those digital interventions, it extends the work that goes on in practices. But what you see is a health care system that works better. And we see it from a provider perspective, we see it from a patient perspective, we see it from a payer perspective.

It's a win-win for everyone. And it's getting back to the first question. So, if it's a win-win, why aren't we doing this everywhere? And I sometimes ask myself that all the time, and I don't know that I have a good answer for that, but it's a win-win for everyone.

We're all on this treadmill, and in health care, we're all running at this ridiculous pace, and it's very hard sometimes to slow that down, take a step back and say, "We can actually slow this down. We can make this work much better. We can make everyone happy. We can do this at lower cost." For every dollar you invest in an integrated care program, it's a $6.50 return on investment. When you look at downstream savings and so on, it's over with over $6.50 over a period of years sometimes, so that's one of the challenges, but it's incumbent upon us to do this because people are suffering, people are dying, and from a purely financial perspective, it's not sustainable in our health care ecosystem. And we know how psychiatric illness drives those medical costs exponentially.