The New Ideas from Kaufman Hall podcast series investigates emerging and unexpected trends in healthcare and beyond, featuring Kaufman Hall experts and guests from health systems, academia and related disciplines.
Season 1, Episode 8 - Primary Care Welcomes Virtual Behavioral Health to the Doctor’s Office
Primary care physicians have long grappled with the challenge of helping their patients make healthier choices after their appointments are over. But what if they could offer their patients instant access to behavioral health before they head home?
North Carolina-based Atrium Health now offers patients virtual behavioral health services within their primary care practices. Will Behrmann, assistant vice president for Innovation Business Development at Atrium Health, recently joined the New Ideas podcast to discuss how Atrium’s efforts to better understand its patients and their lives inspired the virtual visit initiative.
The episode also explores:
- Tapping the insights of “nudge theory” to improve patient care
- Identifying patients for potential behavioral health needs
- How to develop protocols for virtual visits and referrals
Haydn Bush has two decades of experience as a journalist and communications professional in healthcare and related fields. He currently serves as vice president in Kaufman Hall’s Thought Leadership department.
Prior to Kaufman Hall, Haydn worked in various communications roles at the American Hospital Association and McCabe Message Partners, an award-winning public relations firm focused exclusively on health and healthcare.
During his tenure as a writer and editor for Hospitals & Health Networks magazine, Haydn’s reporting on improving care and reducing costs for the patients with the highest healthcare costs received honors from the National Institute for Health Care Management Foundation and American Business Media.
Will Behrmann is the assistant vice president for Innovation Business Development at Atrium Health, one of the most comprehensive and highly integrated healthcare systems in the US. In this role, he works with internal and external thought leaders to turn ideas into measurable impact to accelerate the transformation of the system. He guides development of new services and products, which are increasingly disruptive to the traditional healthcare clinical and business models. He provides internal expertise in the areas of disruptive innovation, business model innovation and customer discovery methods. Through this role, Will works closely with Harvard Business School and the Clayton Christensen Institute to research and implement the theories of disruptive innovation and Jobs to be Done.
Prior to this role, Will served in a variety of system-level strategic planning, business development and financial budgeting roles within Atrium Health and Texas Health Resources.
Haydn Bush: Welcome to New Ideas from Kaufman Hall. I'm Haydn Bush. Primary care physicians have long grappled with the challenge of helping their patients make healthier choices. But what if they could offer their patients instant access to behavioral health before they head home? North Carolina-based Atrium Health offers patients virtual behavioral health services within their primary care practices. I recently spoke with Will Behrmann, assistant vice president for Innovation at Atrium Health, about how the system's efforts to better understand its patients helped inspire the initiative.
Will Behrmann: We wanted to better understand what they were going through. We had a lot of segmentation: they were a certain age, they were a certain demographic, they had this number of diseases. But what we found is that that didn't define who they were. We looked at it through the lens of “jobs-to-be-done” theory, which is looking at, what’s the progress they were trying to make in their life. And for most of them, it was progress that they didn't want to get an illness. They didn't want to have a chronic condition. If they had one, they wanted to be able to manage it well enough now that it didn't become debilitating in the future. By understanding what the goal was, we could identify the job-to-be-done and develop the resources and processes that we needed to be able to try to achieve that job-to-be-done. A lot of it had to do with, "I'm getting older," and “older” could be 35 to 36 or it could be 65 to 70. But, "I'm getting older, I have some concerns either through family history or through elevated cholesterol, [and in] some of these areas, but I don't want them to become a debilitating disease in my future." It ended up then becoming around behavior change. And once we understood the job-to-be-done, then by applying nudges and understanding some of the behavior change theories, that's how we developed the value-based practice – understanding that we had to change the cost curve by changing behavior, which changed the onset of disease.
Bush: The system's practices began screening patients for potential behavioral health needs and scheduling same-day visits with system counselors.
Behrmann: The behavioral health practice (and what we did there with our integrated behavioral health) is that we embedded it in the primary care physician's practice. By doing that, [we’re noticing that] if you hadn't been to see your primary care doctor within a certain amount – we started with six months, and we pretty well kept it that way, [minus] a few exceptions – then you received a PHQ-9 score. It's a standardized, validated test. That score became part of your primary care screening. And based on that score, instead of saying, "Hey, I think you might need to go see a psychiatrist or a social worker or somebody," we would set you up that moment, while you're in the primary care office with a virtual visit to a licensed practical counselor. And then if needed, in their same bunker, they had psychologists and psychiatrists, so we could elevate the case as needed. Now, in the case where people were actively suicidal or homicidal, then we immediately called 911 and had care brought to them. It would initiate the behavioral health intervention right away. What we found was, as expected, if we asked somebody to go follow up with a psychiatrist, the utilization rate and the follow-through was really low. But if we initiated care, and they developed a relationship around behavioral health right there in the primary care practice where they were used to receiving care – without any barrier, without any shame, with just a one-on-one conversation with a counselor – then follow-through was around 78 percent. What we found over time, through this intervention, is that we had [a] relationship established with the patient, and it could progress as needed. In some cases, we just referred them and helped them get started on cognitive behavioral therapy. But in [other] cases, it took extensive counseling and medication management, depending on what the diagnosis was.
Bush: Atrium Health used an existing call center to connect primary care and behavioral health staff and developed protocols for guiding each patient's journey.
Behrmann: We already had a call center for behavioral health, and it was being used for institutional to institutional [purposes]. [They served as] specialty referrals [for] when psychiatrists and psychologists needed some coverage. Patients could call into them, [order] prescription refills, [manage their appointments], that sort of thing. We took this resource that was already there that would have been expensive to build from scratch. We set up the virtual integration so that a patient or the physician could call from the primary care office and receive a virtual visit from a counselor first. And then, it could be upgraded if needed to a psychologist or a psychiatrist. We had the resources available. We had the technology available. We started by having one practice work with the behavioral health team, because they were located in the same building. And any time we had a problem, the behavioral health team could go downstairs to the primary care practice and resolve the problem. And through that interaction, we developed the protocols that we then said, "Okay, I think these are standard enough. Let's take them to an off-site location." Then they worked with a primary care practice in a different location that they couldn't just go run downstairs to take care of the patient if needed. And we continued to refine that process and the protocols. It was very important to get that standard protocol that provided comfort for the primary care doctors.
Bush: The initiative has already led to significant improvements in behavioral health outcomes.
Behrmann: Since its inception, we've seen about 40,000 patients treated through this behavioral health integration. Within three months of initiation, 66 percent of patients who had depression had a reduction in their depression. Sixty-eight percent with anxiety had a reduction in anxiety. We're really pleased with these numbers, and it's showing numbers that are equal to or better than what traditional face-to-face care has been. And again, this is just a way to get people started into care and reduce those initial barriers. We were able to meet the patient's job-to-be-done about getting behavioral care in a non-threatening setting, and the physician's job-to-be-done, which was to take care of [their] patient and not leave them hanging with a diagnosis but no cure or no solution.
Bush: Behrmann has two key pieces of advice for health systems considering integrating primary care and behavioral health: stay focused on the barriers patients are facing to adopt healthier behaviors, and start slow.
Behrmann: Start with understanding, what is the job to be done? What are the users', the consumers' view of the world? What keeps them from making progress in their life, and what could help them? In everybody's life, there are things that they're trying to move forward toward, and there are things, usually habits – sometimes bad habits – that are keeping them from moving forward. [Start with] understanding from the patient's perspective of what the job is to be done and how you can design around that. And then also understanding that there has to be some separation for these new ideas to grow and breathe and not have to worry about an ROI in the first year. Quite honestly, virtual behavioral health does not bring in additional revenue for our system. Some of the services that we do now are being paid because mechanisms have caught up to the service we were providing. But our system said, "You know what? This is so critical, and behavioral health issues get in the way of care progress so often, we're going to go ahead and make this investment." And we weren't held to ROI standards. We were given the chance to learn and grow. It's different now. Now that it's evolved, we're held to different standards. But to get this off the ground and to understand, we were given different standards. Those are two of the key issues that helped us to grow and understand, and to be able to segment what we were doing and to provide something that was good enough. It didn't have to be over-engineered. It just had to be good enough to get started, and then we could build on it and take that journey.
Bush: Thanks for listening to this edition of New Ideas from Kaufman Hall.