June 04, 2020

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On May 21, Dr. John Findley, Caravan Health, Medical Director ACO Programs hosted a COVID-19 educational webinar on virtual behavioral health. The presentation focused on behavioral health and the importance of bolstering preparations in anticipation of an uptick in behavioral health related issues as a result of COVID-19. Dr. Findley also addressed the importance of reducing the stigma of mental illness and recognized that May was National Mental Health Awareness month.

Currently, the mental health system in the U.S. is compromised, under-funded and doesn’t have the resources it needs to meet a surge in demand. This requires primary care providers to help offset the imbalance and the webinar provided insight into how to accomplish that task.

Primary care is the front door to behavioral health for the vast majority of people
and typically the first place patients present with what could become a pending behavioral health issue or mental health crisis.

 
One common concern expressed by primary care providers teams is the notion that behavioral health patients are difficult to manage or that they are uncomfortable providing in-between visit support. However, it is important to remember that the majority of patients with behavioral health issues suffer from anxiety and depression and have a well-established relationship with their primary care provider. Trust has already been established thus facilitating a meaningful, and oftentimes quicker, impact.

CMS encourages primary care providers to screen patients for depression – including substance use – and conduct brief interventions and refer to specialists and treatment when indicated. A Care Manager can provide a bridge between the patient’s primary care physician and a specialist and by conducting repeat assessments can effectively quantify patient improvement or need for further treatment by their provider.
 









 


Behavioral Health Integration has proven to be successful when led by nurses operating in population health environments and has shown to lower overall costs of patient care. It is important to recognize that the effects of the pandemic, and related behavioral health concerns, are not simply going to go away. CMS has recognized this by demonstrating their continued support of ACOs and the importance of BHI by placing a value on nurse-led programs that reduce costs. A new diagnosis of anxiety or depression is a relatively common scenario in primary care that is easy to follow through with telehealth, including sessions by a licensed therapist. Caravan Health studies demonstrate consistent decreases in ER utilization rates by 24% in patients who have had three or more months of BHI when compared to patients without BHI. Adding between visit nurse-led support greatly improves patient care.  



During the COVID-19 Public Health Emergency it is important for providers and their teams to routinely screen patients for depression during Annual Wellness Visits, Chronic Care Management or telephone E/M. While specific screening is impactful, consider asking your patients open-ended questions which may help to initiate the conversation such as:
                Have you experienced any loss related to COVID-19?
                How have COVID-19 stay-at-home orders impacted your ability to function?
 
Ultimately, everyone has been impacted by COVID-19 and experienced life changes on some level. Behavioral health needs will increase, and your staff must recognize the importance of overcoming the stigma of mental illness and help patients accept care. Caravan health provides population health nurse training that helps with this process and with the expansion of telehealth and CCM, providers are well positioned to proactively reach out to patients during periods of social isolation, which can help to identify potential concerns, particularly for those who are high-risk.
Q&A

Are there any suggestions for families with children who are at home having to do school online?
One thing to remember is the importance of having conversations. Work to reduce any stigma around feeling of sadness or frustration and provide a safe place where you can ask, ‘Are you doing ok?’, ‘What can I do to help?’
 
Do you plan to present anything on same-day access for Behavioral Health?
In the event that someone has a positive PHQ-9 you should have an escalation path in place where you could either schedule them with a provider at some point that day with a telehealth audio or audio/video appointment and from that appointment you could also enroll them in BHI. The day you know you have a positive is the day you want to move to action.
 
How do you handle monthly care plan meetings with a physician when there are multiple involved, or do you only do so by clinic note and signature?
There are some, as per CCM, time assumptions as to how much time is spent by that provider in any given month, so the best approach is to document the care plan and document what was discussed and prepared with the provider. That time could easily be accomplished in a 10-minute huddle a couple of times a week with that provider going over a list of patients and notes. Best practice is to routinely review care plans with billing providers as per CMS’ guidance.
 
What are some basic BHI resources for Care Managers who do not have BHI experience or skillset?
Our population health nurse curriculum has some remarkable sections devoted to Motivational Interviewing and other behavioral coaching interventions intended to help nursing become more comfortable with these patient level interactions. If you’re interested, and you are a Caravan client who hasn’t completed the pop health curriculum, it is a valuable resource. Outside of that, the AIMS program through the University of Washington has led the charge in terms of putting some great resources together and making some trainings available that you could consider for your team.
 
What is the percentage of people with undiagnosed or untreated anxiety or depression?
I don’t know the answer to that off the top of my head however, I can look at this and respond by saying, if we don’t ask that question (via screening), we’re never going to know the answer and it is up to us to start the conversation with our patients – to find out.
 
What are some examples of patient-centered goals for BHI?
This is something that would be part of your core care plan. Individuals need to set readily identifiable goals. In some of the work I’ve done I had the triple A plan. First is to bring Awareness to the condition, second in terms of the work of Care Managers is to take Action with behaviors that need to be modified or changed, and the third is Accountability – to find someone who can hold you accountable to those stated goals and this is all about specificity. Patient-centered goals need to be specific and small enough that they feel obtainable and they need to be actionable.
 
I believe peer support also further reduces care cost when combined with therapy and nutrition.
Absolutely, on par with my prior comments, peer-to-peer support is critical and isolation right now is a risk factor, so as part of those conversations about actionable steps – encouraging folks to walk down that path of asking, who, when, and how are you connecting with loved ones? Is it a phone call, Facetime? This is something that generally needs to be scheduled and looked at as a daily action for health and well-being. I also encourage you to look at the list of qualifying telehealth visit.

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