United Physicians, based in Bingham Farms, Michigan, is always on the hunt for programs that empower its primary care providers to serve as the medical home for patients. United Physicians is an independent physician organization in metropolitan Detroit supporting approximately 2,000 providers.

THE PROBLEM

The mission at United Physicians is to advance physician performance to improve patient health outcomes. With this in mind, in working with its doctors, it noticed that patients' mental health issues increasingly were negatively impacting their health status.

"Most people know we're currently in a mental health crisis; depression and anxiety are the most common mental health challenges facing our society today," said Dr. Kim Coleman, CMO at United Physicians. "In adults, when anxiety and depression set in, patients may lose their motivation to take care of themselves."

For example, someone with depression and diabetes may be less likely to eat healthily, take their insulin and visit the doctor to manage their diabetes. Until physicians can get that patient's depression under control, those physical ailments are not likely to improve. In fact, they'll worsen.

Additionally, unaddressed mental health issues often drive increased utilization of services such as unnecessary ED visits, diagnostic testing and specialist consultations.

"For adolescents, we see some of the same changes when it comes to depression and anxiety, but the effects show up in different areas, such as a lack of interest in social outings, a decline in grades and school performance, personality changes, drug or alcohol use, and engagement in other risk behaviors," Coleman explained.

"Our more than 400 PCPs are fiercely loyal to their patients and vice versa," she continued. "When it came to referrals for behavioral health services, both our PCPs and their patients were extremely frustrated. Accessing available mental health providers in our community is extremely challenging, often consuming large amounts of practice staff time to navigate."

When left to the patient, United Physicians was finding that it was asking too much of them to find a local mental health specialist who was accepting new patients. If they were lucky enough to find one, they often needed to wait several months for their appointment.

"Virtual collaborative care outcomes aren't just better for patients, but for practices, too."

Dr. Kim Coleman, United Physicians

In addition, with a shortage of mental health providers, insurance "carve-outs" and a high penetration of "cash-only" providers posed additional barriers to patients being able to access mental health services.

"For the past several years, we had been looking for a way to integrate behavioral care management into the primary care medical home," Coleman said. "However, the shortage of behavioral health specialists and challenges of co-location in PCP practices, as well as lack of reimbursement, proved challenging.

"Our PCPs already were engaged in team-based care utilizing multidisciplinary care managers to assist patients in overcoming barriers to chronic medical conditions," she continued. 

"Many PCPs were managing depression and anxiety in their practices, but few felt completely at ease with it. They just needed some help. So, we searched for a solution that built on the PCP's existing medical home capabilities and offered consulting support from psychiatrists and other behavioral health team members."

PROPOSAL

Having more than 400 PCPs in our community, United Physicians knew it had to partner with a provider that would eventually be able to service all of the physicians. The IPO turned to Array Behavioral Care, the largest telepsychiatry provider in the nation. 

Array's clinicians have been involved with collaborative care models for more than a decade. Array's proposal was threefold: PCP collaboration, PCP training, and direct provision of behavioral care services via telemedicine.

"The PCP collaboration followed most collaborative care models in which our PCPs would work with Array's behavioral case managers on identifying, assessing, treating and tracking patients with mild to moderate anxiety or depression," Coleman explained. "The difference with Array's model is that it's all done virtually.

"This meant our PCPs didn't have to rely on blocks of in-person availability for one specialist," she continued. "Array's behavioral healthcare manager also could bring in one of Array's 500-plus licensed clinicians based on patient needs, ranging from psychiatric assessment to talk therapy to medication management."

Additionally, the virtual care model eliminated the challenges associated with coordinating on-site care such as provider availability and patient no-shows or cancellations. Appointments can be scheduled at any time with patients across a variety of practices.

"The telepsychiatry was important because, with psychiatry specialists, our PCPs suddenly had access to a wider range of treatment options," Coleman noted. "For example, some depression and anxiety medications only are accessible if prescribed by psychiatry clinicians.

"Beyond working with the PCPs, Array's clinicians really educated them," she continued. "Part of implementation included creating a new workflow in which anxiety and depression screening are done at every well visit. 

"Some PCPs were already doing it, and some weren't. But either way, Array trained our PCPs on handling the PHQ-9 (depression), PHQ-A (depression for adolescents) and GAD-7 (anxiety) assessments."

What United Physicians also likes about Array's model is that it is both scalable and flexible. The program could be deployed by a solo practitioner or a group practice just the same. The IPO saw great results across its PCPs in adults, so it extended the program to the growing need among pediatrics.

MEETING THE CHALLENGE

Everything starts with the PCP, Coleman stated.

"The patient population we first targeted was adults with depression and anxiety," she said. "Now we're looking to expand the program to include children and teens between the ages of 12–18. When a patient comes in, the PCP may recognize the signs of possible diagnosis and then assess them using screening tools.

"For the collaborative care program with Array, PCPs specifically are using the PHQ-9 and GAD-7 screens," she added. "If the patient scores 10 or higher on either test, they are eligible for the program. The PCP then discusses with the patient what a positive screen means diagnostically and offers them a referral into the program."

Once a patient has agreed to participate, the PCP will reach out to an Array behavioral-health case manager through United Physicians' athenahealth EHR. The case manager then contacts the patient via phone to confirm participation and schedule their initial assessment with an Array clinician via secure video.

It typically is a one- to two-week process from positive screen identification to initial assessment. By comparison, the IPO often sees three- to six-month waiting lists for adults needing behavioral care. And specialists for children and teens are essentially unicorns, though not with Array, Coleman noted.

"After the initial assessment, Array's psychiatric consultants are brought in by the behavioral case manager when appropriate to clarify, refine diagnosis, assist in determining the appropriate level of care, and provide medication recommendations," she explained. 

"Behavioral health case managers and psychiatrists consult with our physicians over a HIPAA-compliant teleconference discussing multiple patients at once.

"From there, Array and our physicians keep track of patients in a registry that follows their assessment scores, time spent in appointments, frequency of appointments, time spent in case coordination between clinicians, and many other data points that help us track outcomes and support billing collaborative care codes," she added.

RESULTS

United Physicians began the adult collaborative care program in May 2021 in four practice locations. It has since added two more and has another launching this month.

"We launched the child and adolescent program in August and already have it operational in five clinics; our pediatricians were clamoring for it," Coleman noted. "In August alone, we conducted 308 encounters in these nine clinics in which adult and pediatric patients were assessed for anxiety and depression.

"From those encounters, our physicians surfaced 32 new referrals into the program to begin working with Array," she continued. "And that's just new patients in August. For all patients in the program, the Array team conducted 75 visits in August – and September was on track for even higher numbers. 

"As you can see, there's an immense need, and we're now capable of meeting the demand. As we refine our processes for referral, outreach and engagement, we expect significant expansion of our capacity."

Array's work with both the IPO's adult and teen patients has been immediately impactful.

"When patients come into the program, they have to have scores of 10 or above on the PHQ-9, PHQ-A or GAD-7," she explained. "Our patients' average has been a score of 11. Since May, when we launched the models with Array, we've seen patients' overall average scores reduced to near eight.

"Once a patient gets to a score of five, the Array-PCP treatment plan moves them into a relapse prevention program phase, and once that has been completed, they transition out of the program, although they always have the ability to check in or re-engage if symptoms escalate," she continued. "We are thrilled with the fact that in just three months we're already halfway to our treatment goals, and we fully expect the progress to be sustainable."

ADVICE FOR OTHERS

"For any physician organization scratching their head trying to figure out how to address behavioral care challenges, virtual collaborative care is a great solution," Coleman advised. "The integration of telepsychiatry into more practices allows providers to work more upstream with licensed behavioral health clinicians.

"This proactive and collaborative approach toward treatment plans, instead of referring patients out, enables PCPs to have a sharper focus into how a patient's physical health is affected by their mental health," she continued. 

"Plus, the virtual aspect creates faster, more reliable access to behavioral health professionals anywhere in the country and frees PCPs and patients from traditional models of collaborative care that rely on proximity and availability of specialists."

On average, a behavioral care manager and a psychiatric consultant can cover up to 150 patients in a two-hour session, she added.

"The patient benefits are known, too," she said. "They can receive help for their behavioral care within the confines of their already-established, already-trusted PCP relationship. For many patients, this removes the stigma associated with 'getting a therapist' and makes them more likely to accept the help they need.

"Our results speak for themselves," she continued. "We're helping patients feel better mentally, which is essential to helping them feel better physically. Virtual collaborative care outcomes aren't just better for patients, but for practices, too. Our PCPs are relieved to have ready access to high-quality behavioral healthcare for their patients and truly appreciate the input of the psychiatric consultants."

By addressing unmet mental health issues, the IPO's physicians are finding their patients are more available to actively engage and participate in improving their other medical conditions, she concluded.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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