Integrating Behavioral Health Services to Reduce ED Visits: Suicide Prevention and Preemptive Primary Care

Come join us for the first installment of a captivating two-part series featuring an expert committed to minimizing emergency department visits through the implementation of behavioral health integrations. Dr Zaubler will offer valuable insights on providing patients with essential support within a primary care environment, fostering proactive care in suicide prevention and ideation, all while alleviating the strain on emergency department physicians.

Read the full transcript:

Dr Tom Zaubler: Hi, nice to be with you today. I'm Tom Zaubler. I'm a psychiatrist and 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. 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.

In your experience, how has the integration of behavioral health services impacted the identification and management of mental health issues before they escalate to a level requiring ED intervention?

Dr Tom Zaubler: So, I think that the barriers often have to do with change management and working through different workflows, whether it's a primary care doctor or a specialist, an oncologist or others, to manage patient flow differently than what they're accustomed to.

So, that's what we're going to talk about today. That requires some time spent with the physicians. It requires time spent with the staff—the front desk staff and medical assistants in the practices—to understand what this looks like and what can be done to manage patients much more efficiently and effectively.

So, there are some change workflows. And what you find is that once you provide some education once the workflows are put into place, which is a modification for the practices, that everyone winds up being a lot happier. The physicians feel unburdened because patients who—particularly in primary care, but other medical settings as well—who can take up a lot of time, patients with underlying depression and anxiety, often that manifests with physical symptoms like low back pain, pain and ringing in the ears, tinnitus and headache and a whole range of symptoms and they can take up a lot of time in a primary care practice or in a specialty practice as well. And so what you see is when you start surfacing the underlying psychiatric illness, when you start identifying it and when you get patients to the right level of care at the right time, the calls become less frequent, the ED visits go down. Everything works more efficiently and effectively.

You have patients who are doing better. You have physicians who are feeling unburdened because patients are actually staying out of the emergency room because they're not calling as much because they're getting better, not only psychiatrically but medically. So, it does lead to greater efficiencies in care, economies of scale and improve patient and provider satisfaction.

But I would say the biggest barrier is helping people to manage the change workflows, and often that involves incorporating certain technologies to facilitate that. Over the past 10, 15 years, pretty much every physician is working through an electronic health record, and many view that as a necessary evil. There’s often a reluctant reluctance to embrace technology.

The reality is the way I see technology is that when it's used well and it's used effectively, it actually helps to build the relationship between a patient and a physician because more time can be spent directly with the patient because the technology makes things much more efficient and reduces administrative time. But it's convincing people that this technology which is going to help to implement these workflows and scale them, will actually help to facilitate improved relationships with patients and decrease administrative burden on physicians.

As society progresses, the once-prevailing stigma surrounding mental health and illness is gradually diminishing. However, do you believe that the challenges we encounter today stem primarily from lingering societal attitudes toward mental health.

Dr Tom Zaubler: Well, I think that over the past 30 years, there's been a greater recognition that mental illness is a biological reality. There's a psychological reality and there's a social reality to it.

But it's really no different than other types of medical problems. Psychiatry has been isolated for decades from the rest of medicine, and there's a movement to really integrate psychiatry into medical care. And I think that has done a lot to address the stigma, because if one can view psychiatric illness in the same way that you think about diabetes or cancer—although often cancer had a stigma attached to it, and we've come a long ways there as well—and we view it as an illness that can be treated that is not a moral failing and that it's not something where someone can just pull themselves up by their bootstraps. You have lots of people, including celebrities and public figures, talking about their own mental illness. And so I think that the stigma has gone down.

And then, of course, with COVID-19, I think that actually has also helped one of the most important issues in the world of the silver linings, perhaps, if we can put a silver lining on COVID-19, but people are much more open to talking about mental illness because it became so prominent and apparent, especially in our youth. And the third point is, when I think about our youth—you go to a college campus and young adults, or even kids are much more comfortable talking about their mental illness than in my generation. And I was at a college campus the other day talking with a dean, and there's a kid across the quad that the dean said hello to, and then they said, "We need to get together. Let's figure out a time for us to meet." And the kid said, "Well, I have my therapy appointment right now,” and he was screaming across the quad to the dean, “but as soon as I'm done, I'll give you a call and we'll set up a time to meet." And it was a beautiful thing to see because it was just part of his routine, and there clearly was not a pause or a stigma. And I think we have a lot more work to do, but we're getting there. And I think that recognition that this is just part of the human condition—it's something we have to embrace.

And it does have negative consequences if we don't embrace it. Negative consequences are quality of life. And we know now, there's a lot of literature that shows that if you have diabetes, if you have a whole range of medical problems, that you don't get better medically without getting better psychiatrically.

There is no health without behavioral health.

Can you share specific examples of behavioral health initiatives that have resulted in a noticeable reduction in ED visits?

Dr Tom Zaubler: Absolutely. So let me just give you a little bit of a preamble to answer that question. We have a crisis—a mental health crisis right now in this country. It's been brewing for years, COVID-19 accelerated that. The reality is that 60% of people with psychiatric illness receive no care in any given year.

Imagine if that were diabetes, imagine if that were cancer or heart disease. It's really unimaginable. We know that that about 70% of people with psychiatric illness present for care in medical settings, not psychiatric settings.

And yet, 95% of all behavioral professionals work in either primarily or exclusively siloed behavioral settings: psychiatric clinics, inpatient units, intensive outpatient programs.

There's just a complete misalignment. Part of what we need to do is think about ways to integrate psychiatry into medical settings to provide seamless, holistic, integrated care where patients are at the center of that care, looking at it from a population perspective, and measuring outcomes.

This notion of measuring based-care treatment to target is something that unfortunately, has not really been sufficiently adopted in behavioral health. Only about 20% of people receiving behavioral health care actually have measuring based care. Imagine if you had asthma and you didn't get pulmonary function tests. Imagine if you had some heart disease or had a history of an MI heart attack and you didn't get an EKG. How do we treat depression and anxiety without measuring it, without surfacing it to identify who has it, and then measuring if people are getting better or not? I mean, the idea that we can just tell impressionistically is a questionable proposition and particularly challenging in medical settings. Primary care docs don't have the time to really assess this. So that's the preamble. Here's what we find when we integrate. I mean, I can speak to what we do at NeuroFlow, but just we being physicians, psychiatrists, and, health services researchers, when we integrate behavioral psychiatry into medical settings, great things happen. There are the challenges.

There's a change management piece, different workflows, adoption of technologies. But here's how it looks, once it's done. Let's say you have a primary care practice. And we approach that primary care practice and say, well, we'd like to do screening of your entire population of patients in the primary care practice. And we're going to provide some technology to do that so that we can, in the comfort of patients' homes, either through a telephone, text messaging, desktop or a laptop through the internet, or an app or a whole range of ways of doing that, we can do screens.

You don't have to have your people at your front desk give pen and paper screens and then have someone insert them into the medical record and so on. We can actually do that in a seamless way. When I say we, I mean, this is what technology does now.

It's what we at NeuroFlow do, but technology in general has come a long way. It's automating the screens, looking at an entire population and seeing where there's risk, identifying the psychiatric illness, because 50% of the time in primary care, depression and anxiety are just overlooked. They're not ever diagnosed. So, we can surface it, we can identify who's at risk, we can do this in a pretty seamless way. In addition, we now have the technology to provide support for patients. digitally.

So, when patients are screening positive for depression and anxiety, one, they can get to the right level of care. It could be an integrated model where we have a clinician integrated with the primary care practice and getting treatment right there. It could be that they're getting referred out, although it can be challenging to do that because of the dearth of providers, the workforce challenge issues.

But the reality is that one makes sure that patients get to the right care in a timely fashion, two, that they will get digital interventions. They can get digital cognitive able therapy for anxiety, for depression, for insomnia, and for other things, for pain, for ADD, for a whole range of conditions. So, when patients screen positively, there's this idea of extending the work that goes on in the practice, in the comfort of patients' homes.

So, you're getting a digital intervention. And even when patients are not screening positively, they may have rising levels of risk. The digital interventions may focus on resilience, positive psychology, and can take that rising level of risk and prevent patients from becoming more acutely ill.

And then on the other end of the spectrum, when patients trigger concerns about safety, we capture that. We can capture that, right? So, we know that when patients are suicidal, the time between the onset of suicidal ideation and a potential suicide attempt can be as little as 10 minutes. It can be fleeting. So it's really important to be able to capture people when they're really at risk. And the technology allows for that.

It allows for interventions in the moment. It can be caring context and digitally to patients with local and national resources. It can be a person following up with a phone call to assess how that individual is doing and what needs to happen at that moment in time or down the line. So, all of those things happen when you do the integration. Again, some patients may be seen for psychiatric care within the primary care practice.

The collaborative care model that I mentioned earlier is one of the most well-studied and really effective model. But what you see is when it's done well, more patients are identified and primary care docs get frightened because, well, I don't have time to see all the patients now, but the reality is that things start working more efficiently, and those patients with underlying psychiatric illness that weren't identified get better medically.

So, there are just better outcomes. And what we see is that there's decreased utilization, particularly in ED settings. So for example, Jefferson Medical School in Philadelphia is a client of ours at NeuroFlow. And we have worked with them for years. And what we found—and we published this data—is that when we integrated psychiatry into primary care and OBGYN practices as well we saw 34% reduction in ED visits compared to a treatment as usual group.

That's huge. And we see that in multiple settings in multiple places.