Sg2 Strategic Countdown: Reconsidering Behavioral Health

Many health systems have neglected behavioral health care for decades, for reasons ranging from poor reimbursement to the safety concerns and stigma associated with these patients. Behavioral health—defined as mental illness and substance abuse/chemical dependency—is a challenging arena. But with the evolution toward value-based purchasing, accountable care and population health management, behavioral health care is no longer optional. Better behavioral health care can be one of the linchpins for managing under risk contracts, avoiding penalties, taking costs out of the system and de-stressing the clinical workforce, while addressing huge unmet needs in our communities. It’s clearly time to reconsider behavioral health.

Too often, behavioral health conditions go undiagnosed and untreated. When individuals do first seek treatment, they may be in crisis and their entry point may be the ED. And if the only service offering for crisis management is inpatient care, a costly inpatient stay may be the next step. A well-built behavioral health System of CARE preempts the utilization of high-cost, high-acuity services with behavioral health screening and treatment integrated into primary care settings and protocols and robust outpatient and community care options. The System of CARE is especially important in behavioral health, where care has often been disjointed and where integration pays high benefits in improved outcomes and reduced costs.

Sg2 recommends the following strategies to strengthen the behavioral health System of CARE:

  1. Build Access Points to Guide Patients to the Right Level and Setting of Care. Quickly funneling patients to appropriate care is a critical aspect of keeping a behavioral health System of CARE operating efficiently. Many provider systems have adopted the concept of “no wrong door,” developing a variety of portals to ensure timely access to appropriate behavioral health care. Centralized call centers, access clinics that offer walk-in or next-day appointments and ED-based triage are some examples. But the key is a unified triage system to get patients the care they need promptly.
  2. Optimally Manage the Influx of Behavioral Health Patients Into the ED. Sg2 expects behavioral health ED volumes to climb 15% over the next 5 years, boosted by expansion of insurance coverage under the Affordable Care Act. Therefore, reducing unnecessary ED visits for behavioral health conditions is a high priority. Doing so requires early screening, diagnosis and intervention to keep problems from turning into crises requiring emergency care. It also requires alternative, lower-acuity care sites. Behavioral health patients who do show up in the ED must be managed as quickly and efficiently as possible.
  3. Evaluate Virtual Visits for Access and Cost Control. In response to shortages of behavioral health providers—especially psychiatrists—in both urban and rural areas, many organizations have adopted telemedicine to improve patient access to timely assessments. Telemedicine also extends providers’ reach, allowing them to treat patients over a large geography. Telepsychiatry services reduce costs significantly and decrease “no-shows” compared with in-person visits. Some organizations are also considering another type of virtual visit, online therapy, for lower-acuity behavioral health conditions.
  4. Weigh Inpatient Options. Inpatient behavioral health strategy poses tough questions. Is an inpatient unit necessary to meet community needs? If so, can it be self-sustaining financially? If not, how can the organization provide high-acuity behavioral health care? The answers to these “build vs partner” questions will depend on the organization’s history and current characteristics, other behavioral health assets in the community, and market specifics such as labor costs and payer profile.
  5. Strengthen Outpatient Offerings to Free Inpatient Beds. Outpatient behavioral health care comprises a broad range of options, from partial hospitalization programs (PHPs) and intensive outpatient programs (IOPs) to services provided in community mental health centers, physician/provider offices, federally qualified behavioral health centers and federally qualified health centers. PHPs and IOPs are especially important because they provide an alternative to inpatient stays.
  6. Integrate Behavioral Health and Primary Care. Approximately 50% of all behavioral health disorders are treated in primary care. Behavioral health treatment provided within primary care improves both behavioral health and general health outcomes and reduces costs. Integrated care is patient-centered care delivered by a team of primary care and behavioral health providers. The makeup of the care team and care protocols vary, and strategies must be matched to the resources available in the organization and community.
  7. Consider Niche Programs Across the Life Span. Organizations with particular strengths in behavioral health care may want to consider creating programs to meet specialized needs in the community, the region or even the state. Such niche programs may focus on specific conditions (eg, eating disorders, self-injury), the behavioral health issues of various age groups (adolescents, older adults), or even a combination of these (eg, addiction in older adults). When planning a niche program, organizations must evaluate resources and programs available from other providers to determine program feasibility or partnership potential.
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