Behavioral Health Programs Critical to Population Health Success

Behavioral health patients have higher-than-average rates of emergency department visits, hospitalizations, and readmissions. To make behavioral health a core part of its population health strategy, one Ohio health system is partnering with a mental health services provider.

As hospitals and health systems work to develop population health strategies to better serve their communities and rein in the overall cost of care, behavioral health patients—who have higher-than-average rates of emergency department visits, hospitalizations, and readmissions—cannot be ignored.

These individuals make up a large subset of the patient population. According to the Substance Abuse and Mental Health Services Administration's 2012 National Survey on Drug Use and Health, 43.7 million (18.6%) U.S. adults experienced some form of mental illness that year. Additionally, 20.7 million adults (8.8%) had a substance use disorder, and of those, 8.4 million people had both a mental disorder and a substance abuse disorder.

"I think behavioral health needs to be a foundational core strategy for any population health program for an integrated delivery system," says Lee Hammerling, MD, chief physician executive and chief medical officer of ProMedica, a Toledo, Ohio-based health system with 2,268 licensed beds and fiscal year 2014 budgeted revenue of $2.6 billion.

"Without it, you will never be as successful as you need to be. Behavioral health is pervasive and impacts so many conditions, like diabetes, cancer, and congestive heart failure, and the increase in ED use and admissions can be as high as 60%."

Behavioral health is part of care coordination

ProMedica's approach begins with in-office screenings for behavioral health issues.

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"Our goal is to screen 100% of patients that present in our offices. We have about 1.6 million encounters per year, and we want all of those patients to be screened at least once annually," Hammerling says. "Everybody is being screened for high blood pressure, weight, and BMI. Why wouldn't we also ask them about things like their sleep patterns, depression, and anxiety? It's not isolated. It's part of your overall health."

Once a physician determines that a patient needs additional care to deal with a mental health or substance abuse problem, there needs to be a referral path in place, he says.

"We are trying to connect the dots so physicians can be more effective in screening and make sure there is a way to quickly and appropriately refer patients for the right service."

To that end, ProMedica has recently formed a joint operating company with Harbor, a mental health and substance abuse services provider in northwest Ohio with several care sites throughout Toledo.

"This is a great opportunity for two not-for-profits to come together to create an efficient, lean, and mean structure that benefits the community," Hammerling says.

New funding rules create opportunity

Harbor CEO John Sheehan says that while behavioral health has long been treated like "an island in healthcare," that is changing now, thanks in large part to healthcare reform.

"It's an interesting dynamic. For the last 30 years, there's been an inequity in required coverage for services. … But with the Affordable Care Act and the introduction of parity, health plans can no longer carve out behavioral health and deny coverage," he says.

"Now, in an environment where risk is the talk of the day, everyone has to think about chronic disease and population health, and behavioral health has to be a part of that conversation. It's creating a lot of discussion about what we are going to do with this population."

Sheehan says the new joint operating company allows healthcare professionals at both organizations to better coordinate and manage care for behavioral health patients across all care sites.

"I would say the main thing we are focusing on is access. It's important to maintain contact with the patient from treatment modality to treatment modality, wherever they touch the system, so we are following their care, actively managing care, and assisting in a treatment plan they participate in and approve of," he says.

"We are really working for this individual to get the best treatment plan in place and to monitor that care going forward so we are not seeing a backslide in their condition."

Care coordination for behavioral health is not a new idea, Sheehan says, but he believes there are big changes occurring in how inpatient, hospital-based care is now being integrated with outpatient, community-based care.

"Previously, there hasn't been a lot of linkage between these modalities of care. … The changes in the funding of healthcare have allowed us to take a different view of how we provide care. We can now look at all the care the patient needs and actively coordinate that wherever we need to and to span the entire system, which is better for patients and providers. It will also produce better outcomes at a better cost. It's amazing to see how high on the radar behavioral health has risen as an issue," he says.

Health systems have historically not done a great job of providing outpatient behavioral health services to patients, Hammerling says, adding that ProMedica's relationship with Harbor will allow the organization to make significant strides in this area.

"We are implementing these core ideas in new ways," he says. "By bringing in experts like John and his team to become part of ProMedica's care team, we are creating a link and helping to provide better care to our patients. … Behavioral health is now part of every service line."

A better system for physicians

In addition to helping patients receive more effective care, the new agreement between ProMedica and Harbor will also benefit primary care physicians, who often lack support in working with behavioral health patients, Sheehan says.

"Primary care has typically been a catch-all for everything. … That is what is changing here, and I think there is a great need for this kind of synergy between primary care and behavioral health resources. Primary care physicians now have a well-linked referral source. I think this is an opportunity-rich environment because there are so many people who are desperate for this care."