Charting the Future of Integrated Behavioral Health: Perspectives from the Field
– I’m happy to welcome you to today’s presentation, today’s webinar, Charting the Future of
Integrated Behavioral Health. As Danielle chatted in, we’re just gonna get started now, let a couple of those regulars come in who had meetings up until this time. We’re really excited today, The AHRQ Academy, as well as AHRQ is really excited to
present this webinar today about Perspectives from the Field with Dr. Unützer and Dr. Little, some seminal researchers in our field, and having the opportunity
to hear from them as well as ask them questions. I’m gonna go over just a little bit of how the webinar’s gonna go, since it’s not a
traditional webinar today, and then we’ll get started. So I’m gonna give you just a
little bit of overview of IBH and the AHRQ Academy. We have a lot of people,
new registrants, today who didn’t know what the AHRQ Academy was, so we wanna give you a
little bit of a overview of who we are and where we come from. And then I’ll introduce
both of our speakers, Dr. Unützer and Dr. Little, and turn it over to them for them to give a couple of remarks, about 10 minutes of remarks each, about the future of integrated
behavioral healthcare. Then we’re gonna turn, and we’ll
have about an hour for this of a moderated panel discussion. So we’re really looking for
your questions in our Q&A boxes. And to facilitate that, we have some of the people
put in as they registered, but the time is for us to ask
the questions to the experts. And so, please submit
the questions you have, or as you think of them
during the remarks, put those in our Q&A box. And we’ll conclude with just
a couple of closing remarks. So my name is Anne Roubal, I’m the Project Director of the AHRQ Academy for integration, and I’ll be the webinar host today. And I’m joined by Garrett Moran, who is the current PI of the project, but also has been on the project since its integration, and
was the PD for several years. And so, he’s gonna join
me a little bit later when we go into the Q&A part, and we’ll sort of take
turns asking your questions to our experts. So we have a large number of
people in the audience today who didn’t know what AHRQ Academy was, so we just wanna sort of
give a little level setting about how we think about
integrated behavioral health, as well as what the
Academy is, and what we do. And so, when we think about
integrated behavioral health, we’re really thinking about
a team of primary care and behavioral health
clinicians working together to improve outcomes. So that could be things like
improving or reducing costs, improving patient outcomes, really providing patient-centered
whole person care for specific populations. And you can see on the
bottom bullet there, the types of conditions that we’re mostly interested in improving and working together with
primary care physicians and clinics to improve. On the left, you see our Academy lexicon, which you can see better on our website, but we have in green and blue there, when those things work together well, we can achieve integrated
behavioral healthcare and be really successful at it, so things like teamwork, or
collecting data efficiently, and alignment of leadership models. So when all these work together, we can do effective integrated
behavioral healthcare. And why is integrated
behavioral healthcare important? I think many of us know this, and these aren’t the only
reasons it’s important, but these are some of the
ones that have been studied. And so, we have improved
patient satisfaction and provider satisfaction, as well as reduced costs,
as I mentioned before, or reduced healthcare utilization, which can also, you
know, reduce ED visits, but really, improved patient
health outcomes in the end is one of the main goals. And what is the Integration Academy? So we’re bringing you this webinar today that we’re really excited about, but we don’t just do webinars, we are an entire website, and you can see our website below there, integrationacademy.ahrq.gov, and you can visit that to find
resources about integration. We have things like our IBH playbook there that can help people wherever they are in their journey for integrated care. We also just recently published
a topic brief on pediatrics, it’s new, within the last couple weeks. So if you’re working on
integrated care with children, that might be a place to start. We also host a ton of, or we share our partners
who are doing integration, some of their events
and resources as well. So we really try to be
a resource for you all, no matter where you are in the journey. And we love to hear from you, so if there’s things or resources that feel like they’re missing, we would love to hear that. If there’s resources that
you find really helpful, we would love to get
that feedback as well. We also provide newsletters
that come out monthly or weekly depending on when we
have things to come out, and so you can definitely
stay in contact with us. So without further ado, I’m gonna introduce our speakers and turn to the interesting
part of the presentation here. So we’re really excited, as I mentioned, to have Dr. Unützer and Dr.
Little here to talk to us today. They are leaders in the
field, as we all know, and I just wanna share a little
bit about their backgrounds. So Dr. Unützer… Sorry. My mouse appears to have stopped working, apologies for that. Okay, so Dr. Unützer
is currently the Chair of Psychiatry and
Behavioral Health Sciences at the University of Washington, and the director of the Garvey Institute
for Brain Health Solutions. And his work focuses on integration of mental health services
in general medical care, and translating research on evidence-based mental
health interventions into effective clinical
and public health practice. He’s published over 300 scientific papers, and has received numerous
federal and foundation grants and awards for his research on integrated behavioral healthcare. And he is one of the founders of Integrated Behavioral Healthcare and has really pushed it forward. And then, after he gives his remarks, Dr. Little will give hers, and she is a Co-Founder of Concert Health and a Co-Founder and COO of Zero Overdose, national expert in integrated care for collaborative care model
and suicide prevention. And she’s gonna draw
on some lessons learned from scaling integrated care
and suicide prevention efforts across diverse healthcare settings. On top of those accomplishments, she also previously worked 22 years as the Senior Vice President for a large federally qualified health center network in New York and oversaw over 300 behavioral
health and community staff. So I’ll turn it over to
Dr. Unützer for his remarks about the future of integrated
behavioral healthcare. – Well, good afternoon, everybody. Thank you for the nice invitation to speak with you all today. Thanks to AHRQ and thanks to Westat and the Integration Academy
for the opportunity. I’m gonna make a few comments
just to help us get started. As you heard, I’m a psychiatrist, I’ve been doing that for
a little over 30 years. My day job is a Chair of
Department of Psychiatry here at the University of Washington. We are a School of Medicine that serves a five state region here in the Pacific Northwest. Some of that region is
urban, much of it is rural, and 27% of the US land
mass are in that region. And access to behavioral healthcare has always been a tremendous challenge. And that’s one of the reasons why we got interested in this
work quite a long time ago. So I was fortunate enough
to work on some teams to conduct some of the early
research on how we do this. And then about 15 years ago, I helped found a center here at the University of Washington
called the AIMS Center. And the AIMS Center, for those of us who are
not familiar with it, really is about helping organizations implement evidence-based care. So my comments are basically
going to reflect my experiences working in this space
for about three decades, and it’s an area that’s
near and dear to my heart, and I have a lot of passion for it. And although we are supposed to talk about charting the future, I’m gonna do a very, very brief recap of I think what is
important for us to remember in terms of how we got here. And from my perspective, and I think maybe from
the perspective of AHRQ, that journey started
about three decades ago. And AHRQ really has
been a big part of this all the way from the get-go. And, you know, in my mind,
that started in 1994, so about 31 years ago when
AHRQ used to be called AHCPR, the Agency for Health
Care Policy and Research. And they published in 1994
a seminal set of guidelines on how we can improve the
treatment for depression in primary care. And that set of guidelines
I think is still a phenomenal piece of work, it’s still highly relevant, it’s been updated since then, but the core principles are still really, really
relevant and important. And it really sort of
generated a blueprint that sort of told all of us
that “Yes, we can do this.” And then some of us have
spent the last 20, 30 years to think about “How do we best do it?” But I really want to call that out. I think what we all
realized about at that time was that, you know, treatments
for depression, for anxiety, for other common mental health problems that work in specialty care actually can also be
delivered in primary care, if there is enough support to do it well. So medications work just as well when they’re prescribed
by a primary care doctor, than when they’re prescribed
by a psychiatrist. Evidence-based psychotherapies
cannot only be delivered in a mental health specialist’s office, they can also be delivered
in a primary care setting. And I think that’s a really
important opportunity. And I think what we’ve learned
over the last three decades is the fact that mental health really is an important part of all health, you cannot really try to
help someone’s overall health if you’re not paying attention
to their behavioral health, to their addiction problems. And I think 30 years ago, we
were coming to grips with that, now, everybody really understands it. So the question now is really “How do we go about
delivering on that promise?” And I think that, you know, that’s what we have spent
the last 20, 30 years doing research on. And I would say, you know, when it comes to evidence-based for things we do in medicine,
not just in behavioral health, but in healthcare, in
medicine, in general, some of the strongest,
most mature evidence-based we really have for what to
do if you wanna help somebody with a common behavioral health problem actually is work that is pointing to the
collaborative care model, which is basically an evidence-based model of delivering mental health, behavioral health services
for common mental health and addiction problems in primary care. And I think that evidence
base is now stronger than much of what we do in
specialty care, frankly. So, as we heard, the core concept
is pretty straightforward. So we are going to say that many patients, if not most patients, especially people in rural or
otherwise underserved areas, are not going to find
their way to a specialist, because, for example, in many of the areas that we work in here in
the Pacific Northwest, there just are no specialists. More than 50% of the counties in this five-state region that we serve don’t have a single psychiatrist, psychologist, social worker, or anybody who’s got formal
training in helping somebody with a mental health problem. So, really, they go to
their primary care doctor, that could be a pediatrician,
that could be a family doctor, that could be a nurse practitioner, that could be a physician’s assistant, that could be a family doctor. And that’s where we have the
opportunity to find them, to meet them, to engage them, and to start them on a course of treatment that if it’s well done, can
make an enormous difference. And that’s really the opportunity. Then the question is,
“How do we best do that?” And if you look back at the evolution of how we’ve gotten to where we are today with the evidence base, it started by the idea of, you know, “Maybe we should just bring
a behavioral health provider into a primary care office, you know? What if we co-located a psychiatrist, or a psychologist, or a
clinical social worker, or a licensed marriage
and family counselor into a primary care doctor’s office?” And I think that beginning of co-locating a mental health professional
and a primary care doctor was very obvious, it was very effective, but it turned out it was
pretty hard to scale that, there just aren’t enough of us to really make that work at scale, and it ends up… And I’ve done a lot of this myself, I spend a lot of time working in primary care doctor’s offices providing mental health care, but if there’s just one of me, you know, I’m never gonna be
able to meet all of the needs that are going to show up. So I think along the way, we learned about the chronic care model, we learned about the fact
that for many health problems, you know, approaching
this as a team care model where we take the roles, you know, and we divide them up across
different team members, and we come together as a team and we deliver the care as a team, it could make a huge difference, it can reach more people, it
can actually be more effective. And I think that’s how we arrived at the current, you know, evidence-base around the collaborative care model. And so, that’s a model where it’s not just one
mental health professional who comes into primary
care and does their thing, it’s really a team approach where we use things like
measurement-based care, we use things like tracking
people on a registry to make sure that people are
not falling through the cracks, and we have consultation
from a specialist available when things are not
improving in primary care. And we have proven in research now, there’s over a hundred studies that, if you do this well, you can help people with a whole range of
behavioral health problems, depression, anxiety. We recently did a very large study where we treated people with
bipolar affective disorder and post-traumatic stress disorder, we have done this for people with a variety of substance use disorders, we have done this in
person, in primary care, but we’ve also done it where we have the
behavioral health component added to primary care
using telehealth approaches and various combinations of those. And I think that the
evidence base is strong. Implementing a model like
this can be a bit complicated, and I think we’ll talk a
little bit more about that as we move on here today. We have developed billing codes that help primary care offices
bill for this kind of care. Obviously, a very important thing, ’cause if you can’t get paid for it, how could you really implement it? And I think before we go into questions, I’ll leave you with one other thought. The evidence for doing
this is really strong. When it’s done well, it’s an
incredibly satisfying thing, Just like we heard from Anne, when it’s done well, patients feel like they’re well cared for, providers love it because
they’re able to do something that they might not be
able to do on their own, clinical outcomes are much better. We’ve shown that if you do this well, you can reduce total healthcare costs, and you could improve a whole
bunch of healthcare outcomes. But to do it well is not that simple. And I’m gonna leave you with kind of maybe a little
bit of a goofy analogy. But if you think about it
from a music perspective, if you’re going to go and listen to somebody play a really
beautiful instrument, so that’s maybe the
person that you’re seeing, you know, who’s going to
be giving you counseling, or prescribing you a medication, it might be really beautiful
to listen to that music. If you are listening to an orchestra where a whole bunch of people
play different instruments and play them really beautifully together, it’s really amazing, it can
make an enormous difference. And a beautiful orchestra is probably going to be nicer to listen to and maybe more engaging
than a single instrument. But on the other hand, if the orchestra doesn’t
play well together, if everybody plays their thing, and it’s not well-coordinated,
and it’s not well-organized, it can also be a really
horrible experience. And so, I think the strength of a good integrated,
collaborative care model is this team approach, but that
could also be its weakness. You can also think about a sports analogy. So if we had, you know, a football team and everybody is a quarterback, we probably wouldn’t win a lot of games. If we have a team where everybody
knows what their role is, they play well together, we could make a huge difference. And I think that’s what the challenge is in building a really good
collaborative care team, and how do you really make that happen. So I think I will leave you
with that analogy for now, and I will turn it over to
my colleague Virna Little. Virna has an enormous amount of experience really taking these kinds of approaches to scale in a whole bunch
of different settings, so I look forward to hearing from her. Thank you. – Well, thank you. I’m gonna stick with the music analogy, and Concert Health, that’s
kind of how we got there, so it’s kind of funny that you say that. And I actually was thinking maybe I would, you know,
start going back a little bit and just sort of talk about
some of, you know, the lessons learned over the past decades. And, you know, when I think back to the first sort of
thoughts around integration when I was working in the FQHC, trying to pull all of
those pieces together, and even for the first time
doing collaborative care, you know, people will often
ask me about that time. And I think it’s sort
of seen as a success, because it was, you know,
replicated for the first time sort of in the real-world, and we got good outcomes,
and providers loved it, and patients loved it. And yet, I took it as a failure, because I never could get it
paid for in the right way, which a lot of people don’t actually know that I sort of consider
that sort of not a success. And I think that sort of brings back to an important sort of grounding where all of the pieces
have to be in place. And I think we’ve learned over the years what those pieces are and how important it is
to try to reinforce them. You know, we’ve done some
learning around teams and what really makes an effective team, and how do you pull
them, you know, together to sort of play that music? And I had the privilege
today of spending some time with behavioral health leaders
from around the country, and we were talking about teams. And some of the lessons learned, and some of the things that came out, were this idea of, you
know, shared accountability and thinking about treat to target and measurement-based outcomes. And still to this day, we talk
about measurement-based care over here for behavioral health, and we have quality measures
and HEDIS measures over here. And yet, you know, we still haven’t sort
of brought them together in some really meaningful ways. And when I think about what you could do on an organizational level, how do you pick some of those measures, how do you prioritize them, and how do you bring them together, and then hold everybody
accountable for them? You know, we sort of know
that this idea of care plans and shared care plans are really helpful, but, you know, how do we
really operationalize them, or put them together in a way where we don’t have behavioral
health doing treatment plans and primary care doing care plans, like sort of what does that
look like on the ground, and even some of the shared training and sort of how that looks like? So, when I think about all
the learning we’ve done, and now that we sort of know
what the ingredients are, like, we know what instruments we need, we know how to play that music, how do we really take it forward
in some meaningful steps? And, you know, in co-founding Concert about eight and a half years ago, and we do collaborative care,
we only do collaborative care, and how do we figure out how
to do collaborative scale, you know, at scale, what
does that really look like, and how do you sort of
overcome all of the barriers? And I think we still do have
a lot of those barriers. And as we go forward, I think it’s gonna be important to really isolate some of them and sort of take them on, because I don’t think we’re gonna be able to give the support and
truly scale integrated care, unless we tackle some of
these individual challenges. And so, as I’m thinking about, you know, what some of those look like, it’s really important to
think about the training, and how we’re training
some of the disciplines that are going into the field. If you were gonna ask me
for my own profession, I’m a Psychologist and a Social Worker, I don’t actually think
we do a fabulous job of training people in my disciplines how to go out and truly
practice an integrated setting. So I think there are pockets of schools or places that do really good work, but I don’t think we do it consistently. And I don’t think we’re
doing it at the volume to which we’re actually gonna meet some of the workforce needs, particularly as we grow and
scale some of these models. And I think we need to think
about some of the technology and working with some of
the technology pieces. I know, you know, oftentimes, it feels like behavioral health is sort of still being a
square peg in a round hole with some of the
electronic health records, and what that looks like in the field. And so, I’m incredibly excited about sort of what the future holds now that we have figured
out some of these pieces, but I also want us to really think about what we’ve learned
over the past decades, and how can we actually take that and move us forward in
some meaningful ways, how can we reinforce it as we move into, you know, thinking about different payment models
and technology and training? And so, I’ll end there off
of some of Jürgen’s thoughts and just sort of summaries. – Well, thank you both for those. I love a good analogy, and I love that we got to be
reminded of where we’ve been, and then sort of thinking
about where we are and where we’re going. And I see questions coming
into the chat, or the Q&A box, so I wanna remind people to continue to put questions in there, because that’s what we’re gonna use the rest of the time today
to do, to pick your brains. And right now, I’m gonna
turn it over to Garrett to ask the first question
and to get us started. But continue to please put
those questions in the chat, because that’s what we get to cover. – Thank you, Anne, and thank you Jürgen and Virna,
great thoughtful comments. So we’ve been working
on this now for 30 years trying to advance this model. Why is this still the right thing to do? And if it is the right thing to do, you know, why is it not more implemented on a more widespread basis? And I’ll just let you
all jump in on that one whenever you like. – Yeah, I’ll get us started. And I’m gonna actually do
that with one more analogy, and that’s a medical analogy. So, if you look at the impact of behavioral health conditions on health-related disabilities, so the kinds of things that make us not be able to do the things
we’d like to do with our lives, the data is now very clear,
very strong, for example, that behavioral health conditions, especially if they’re not treated, cause 10 to 20 times more
health-related disability than things like diabetes,
heart disease, or cancer. Now, if you think about that for a moment, you know, what we have learned about treating those conditions is that they’re either
chronic or recurrent, they’re not short-term acute problems that you can just bat at
once and it’ll go away. So when you treat them,
you have to treat them, you know, in a pretty significant way, and you usually have to
treat them in a team. It’s very rare that, you know, if you’re getting cancer care, there isn’t a whole team of people that are all playing
something very important, very well together, that they’re
actually sticking with you until your cancer is in remission. You know, you’ll not just give somebody a light touch of chemo and say,
“Let’s hope this goes away.” That would not cure anybody. So I think there are a lot of things that, you know, I’ve learned from working alongside my colleagues in other parts of medicine where I’m like, you know, that’s probably
what it takes for us to be really successful too. So I think that, yes, it’s absolutely still
the right thing to do, I think we have learned
that a single provider cannot help that many people. None of us are so good as
behavioral health professionals where we don’t need anybody else’s help to get everybody well, so if we can play as a good team, if we can make it an effort where we not just give
you a little bit of care and hope that it works, but we’re gonna give you
a full course of treatment that really helps you get
well enough where you say, “I can live with this now,
I have this under control,” that’s what it takes. And I think that we need to do that just as well and just as seriously as the way we treat other
serious health problems like cancer, like diabetes,
like heart disease. And so, that’s another little analogy. I think the bottom line is, even more so than I think we
appreciated 20 or 30 years ago, it’s absolutely the right way to go if we want to reach more people
with effective treatment. Now, we could spend a whole bunch of time and we probably will spend a bunch of time thinking about the
challenges, the barriers, Virna mentioned some of them. But maybe I’ll hand off to Virna here before we go on to the barriers to think a little bit
about why do we think this is the right way to go today. – You know, I think we
continue to see outcomes, and we’ve had the opportunity
to really look at outcomes across rural populations,
adolescents, you know, across different payer mixes. And I think we continue
to see good outcomes, we continue to see cost savings. And now, we’re really
fortunate to have health plans putting out cost-saving data, to have states that are
sharing that information. And there is so much
information out there now, not randomized control trials, but just people who are reporting and doing research from the field, “Hey, this is what the
outcome is that we’re seeing in our women’s health population.” You know, a topic that’s near
and dear to me: suicide care. We’ve been really able
to show positive outcomes across multiple organizations
and large populations with suicide care. And so, I think as we
continue to go forward now looking at some of the chronic illnesses and starting to see, not
just the cost savings, but also to see some really good outcomes. And so, I think more and more, we continue to know it’s a good idea, we continue to redo it, right,
or to have it reinforced, that we’re on the right track, you know, we should keep doing what our hearts told us to
do, you know, 30 years ago. And I think that’s just
gonna keep mounting. – Great. Anne? You had a question?
– Yeah, thank you for those comments. So I think you started to allude to it, and I see a couple of questions building off it in the chat. (chuckles) But I’ll ask the big question here, which are what are some
of the biggest challenges? And I see in the chat particularly around
workforce being brought up. So I don’t know, Virna, if
you wanna start with that. But I know that’s not
the only challenge, so… – So I think there’s a couple of pieces, you know, to workforce. One of the, you know, wonderful pieces about collaborative care is that you actually have the ability to have a little bit more
of a diverse workforce that you have. You know, collaborative care really was sort of meant
to be telephonic and remote kind of from day one, because all of the frequent
contacts and the follow up. And that really allows
you to hire individuals that are hybrid, or that are remote to be able, particularly in rural areas, to, you know, fill some of those positions that maybe you wouldn’t
be able to fill otherwise. And I think it also allows us to incorporate trainees
into the service model and have them practice, and then, oftentimes, you know,
become part of those teams. And so, I am pretty
excited about the ability to continue to grow a workforce that specializes in
working in integrated care. I also think that it has allowed us to bring in other, you know, professions, such as addiction medicine, and be able to develop
some expertise there, so that they can actually serve in the role for some populations where we’re working in
MAT programs and that. So I do think that there
are a lot of opportunities, they’re not that… You know, workforce is
certainly a challenge across the board, but I think it allows
us for the flexibility to be able to be a lot more creative about solving some of
the workforce problems than we might have been able to do, particularly before
the dedicated CPT codes were put in place. – Yeah, maybe-
– A lot of… Okay.
– I’ll just add just a few thoughts to this, since we’re sticking on workforce. So, yes, I think one
of the major challenges is, always has been and is going to be how do we find enough
qualified staff to do this? And if you think about how we train behavioral
health professionals, we haven’t changed things very much since I trained in
psychiatry 30 years ago. We’re teaching psychiatrists
and psychologists who do what we call a 50-minute hour, which is, you know, you sit
down with a client in person and you make a nice relationship,
you engage with them, you ask a bunch of questions, you develop a formulation
for what’s going on, you maybe work on a
treatment plan together, and then you try to wrap that up, you know, with about 10 minutes to go, so you can write a chart note,
maybe go use the restroom, have a cup of coffee, and then
you do another one of those. And that’s a really important core skill that I think we all teach, we all learn as behavioral
health professionals, but it doesn’t scale
terribly well, you know? You can only do a handful
of these 50-minute hours with a handful of clients, and it’s not going to
reach that many people. So I feel like we are still
training people in skills that are important, that are foundational, but they’re not really learning
how to work great in a team. We’re teaching people how to play one instrument really well, I’m sorry, I’m going
back to my music analogy, and they’re becoming virtuoso in playing that one instrument. But then you put a whole
bunch of those people together in a busy primary care practice, and they don’t know how
to make music together. Everybody does their thing and says, “I just need my this,
I just need my that.” And so, I think that’s
the challenge, you know? And I think if we want to change that, we need to actually have
people train in places where they’re seeing good team care, where they’re seeing how
people compliment each other. You know, I think I learned
very early on doing this work that, you know, a well-timed
five minute phone conversation at the right time for the
patient, or even a text message, can be a lot more impactful than having another 50-minute
hour that’s scheduled where the patient has to take
a half a day off from work and come into the office and sit with me, and maybe it’s not the
right time for them. And so, if we are a
little bit more flexible about how we use our time, our skills, if we start using technologies, and early on it was simple technologies, a phone call, a text message, now we have more
sophisticated technologies. I think if we’re willing to say “How do we practice a
little bit differently? How do we teach people how to practice a little bit more flexibly?” And then you might start saying, “Oh my god, you know, what if we do know things that
don’t work terribly well?” That’s why I think it’s important, whatever it is we do,
we still have to say, “Is it actually engaging the patient?”, and most importantly, “Is
the patient getting better?” And, again, I go back to my analogy, in cancer care, the bottom line is, “Is the cancer going away? Is the patient surviving?” We need to do the same
thing in behavioral health. We need to know how do we know
if this is working or not? And if it’s not working,
let’s not beat ourselves up. Let’s just say “We need
something else, someone else. We need a consultation as a team.” And I think those are
all the kinds of things that we don’t really teach yet very much when we teach behavioral
health professionals. – And I think we teach one way, so, you know, that 50-minute hour, but many behavioral health interventions are like six to eight minutes. And so, how do we think about
doses of that treatment? How do I work with you on an intervention? How do I reinforce it, you know, work on an
intervention and reinforce it, so that, you know,
behavioral health treatment is actually better
delivered in those doses and then reinforced? And I think we’re not teaching people that model of delivery. And I think what it does for
the people that we care for is that it’s very restrictive. I always call it the therapy
bus, which is not a great… Like people get on the therapy bus, they don’t know when they’re going, they don’t know when it’s gonna stop, and they’re like, “Oh, the first chance
I get, I’m off,” right? Because we’re kind of just
limiting what their choices are. And so, I love the ability to
really give people options, and for clinicians to be trained
to deliver those options, and sort of what really works best. And what works best oftentimes are these, you know,
doses and reinforcements. – One of the questions
that the audience submitted I think is hitting another key issue, and that is performance measurement. I mean, you know, we all saw that what you measure is what you get. And I tell people about
visiting my primary care doc not long ago, and ask about how they deal with behavioral health issues. And he says, “Well, you
know, I give ’em a pill, but I do what it takes to meet
their performance measures.” So what’s the gap between the
performance we’re measuring, and what we need to measure
if we wanna see the expansion of behavioral health integration? – Yeah, I would say that that’s an area that we have come to very, very
slowly in behavioral health. The idea that what we
do could be measured, that the care we provide is
not going to help everybody. But if it doesn’t help anybody, we shouldn’t beat ourselves up. We should just say, “Let’s
not do a couple more of this, because that’s not helping
this particular client. What else can we do? How do we know?’ And, you know, starting with the patient, how does the patient know, how do we know that they’re
actually getting better? So if you think about it, and, again, I’m going back to
a couple of medical analogies, I’ve got a problem called hypertension, I developed that in my 30s,
you know, I’m now in my 60s. If I hadn’t treated this
high-blood pressure, I might have died from a stroke by now. But every time I go in to see
a healthcare professional, somebody puts a blood pressure cuff on me and says “It’s good, it’s not so good.” People don’t spend a lot of time thinking about “Are
they good, are they bad? Am I good, am I bad?” If it’s not the right number, we make some changes and we get it right. You know, if you’re treating
somebody who’s got diabetes, we’re not saying to them, “How do you feel your
diabetes is going these days?” We measure what their
blood sugars are, you know? But in behavioral health
for the most part, we’re still saying to people, “How do you feel like you’re doing?” And people like you, you’re a nice person, they don’t wanna upset you, so they say “I’m a little bit better.” But if somebody had
said to me 25 years ago, “How do you think your
blood pressure is doing?”, and I said, “I think it’s
doing a little bit better,” I probably would be dead
from a stroke by now. So I think it’s really important for us, just like in every part
of medicine that we say “We are going to find a way to measure if this treatment is working. And if it’s not working, it’s
okay, we just make a change.” And I think that’s something that behavioral health professionals have had a slow time coming to, I think that’s getting better. But we tend to take
that a lot more personal than my colleagues in primary care. If someone’s blood
pressure isn’t doing well, they’re not sort of
fretting about, you know, “Is it my fault, is it his fault?”, they’re just saying, “I think we need to make a
change in your treatment.” But I think in mental healthcare
and behavioral healthcare, we often take that a little bit personal. We sort of think, “Oh, you know, I’m not getting
them all that much better. What’s wrong with me?
What’s wrong with them?” I feel like we should
just say “How do we know?” If we’re treating anxiety,
is the anxiety less? If we’re treating depression,
is the depression less? If we’re treating some other
thing that’s not working, if we’re treating an addiction problem, is the person using less? Those are all things that can be measured, there’s nothing wrong with that. And I think it’s really important that we all get comfortable
and stay comfortable with that concept. – I think we need to think
about the training again, because I wasn’t really trained
to use tools and practice, and I spent a lot of time teaching behavioral health providers, how do you actually do
measurement-based care like day to day? How do you have the
discussions with people about what got better, what got worse? How do you have conversations
that involve the tools, and not just sort of
go through a checklist? How do you use the tools to
arrive at a differential, to come up with a care plan? You know, like as an example, you know, for the PHQ, if I’m a 0 to a 1, well, we’re starting to think about a go-forward plan, right? If I score a 2 or 3, then maybe that’s gonna
be, you know, stuff we’re gonna pay attention to, and then I might ask some questions, and then I’m gonna, you
know, get some information from my psychiatric consultants, and I’m gonna kind of go through and use that as a foundation
for that encounter that day, which can be engaging
and getting information and also really building in that tool and that measurement-based care, and then sharing it with someone, “Hey, you know, you’re here and you wanna be here, you know? And what does that look like, and let’s talk about a way to get there.” And I think that is a skill that we need to start
early on in training, and then it needs to get
role modeled in practice. – Thank you for those answers. I’m gonna stick with the barriers, ’cause there’s a question here about “How do we use emerging
technologies, such as AI, you know, to advance integration
of behavioral health?” – Yeah. So that is definitely looking forward, and I think it’s a great question. I would say, before we go to that, I wanna sort of mention one other thing, and I think it’s not unrelated, but one of the challenges in
a busy primary care clinic is that you always have
competing priorities, you know? So when you’re treating something like an addiction problem, or a serious depression
or anxiety problem, or somebody who’s struggling with post-traumatic stress
disorder or bipolar disorder, these are not things you
can sort of make go away with one or two or three touches. But what’s happening in primary care is, the office is full of people who are coming in with an acute problem, they need that acute problem addressed. And so, there is what I call
the tyranny of the urgent, there’s always going to be something that’s more urgent today, right now, than paying attention to something that’s been there for a while, and that’s probably still
going to be there for a while. And that’s the same thing, and, again, I’m sorry, I’ll
go back to my cancer analogy, if we sort of said we wanna treat cancer, we can’t forget about the
cancer, we gotta keep on that. Because if every time
they come in they say, “Now my right foot hurts, and now I have a cough,
and now I have this,” if we just chase every one of those things every time somebody comes in, we’re going to forget about
the really big important thing that sits in the background. So it’s challenging to remember. So that’s my segue to technology. Human brains are not
very good at remembering “Who are all the people in my practice who I started on something, but they haven’t finished it yet, they’re still not better?” Because the human brain just responds to what shows up and comes into my office, and says “I need some
attention right now.” That’s where a piece of technology can be incredibly helpful. So a technology can say, “Hey, you started these 25
people in the last month on a treatment for anxiety,
for depression, for whatever, and they’re coming in for
other things right now, but that’s still going on. Can you remember to try to
do something about that?” So I think that’s one way in
which we can use technology to kind of scaffold what we as humans aren’t all that good at. We are really good at,
hopefully, we’re good at, you know, have the emotional intelligence to respond to another human
being who comes in front of us to hear what they need
right now, to address that. And a piece of technology
can sit in the background and say to us, “Hey, don’t
forget about this other thing that’s really, really important.” So that’s one way of using technology. I think more broadly, and I’d be interested to see
what Virna thinks about this, but I think that if we think
about collaborative care, it’s a set of functions that
somebody on a team needs to do, so there is engaging the
patient, making a diagnosis, making a treatment plan,
somebody starts a treatment, somebody carries out the treatment, somebody goes back to the patient and makes sure they’re
actually taking the treatment, somebody checks to see is
the treatment really working? Those are all functions that in the original
collaborative care model, we had human beings do. And we might have had a
simple piece of technology like a registry tool, to
sort of sit behind that to make sure things don’t
fall through the cracks. But I do think that with
artificial intelligence, many of these functions, you could have an AI copilot who’s part of a collaborative care team who does a lot of these functions, and that would help me
make sure it’s robust, it doesn’t fall through the cracks, and I might be able to help
five or six times more people than if I’m just one human being on the collaborative care team. For example, you know, they’re
now, you know, AI tools that are good enough at engaging people and doing symptom checks and, you know, reaching out
to the patient at a time that’s super convenient to them, and in a way that’s
super convenient to them, just to make sure, you know, their symptoms are getting better, and if they’re not, to flag it to me. if I have to schedule an
appointment to bring you in and to read you a bunch of questions, that’s a lot more cumbersome. I think, you know, an
AI tool could do that very, very nicely. There are now really nice AI tools that can do the basics of something like cognitive behavioral therapy. I might learn how to do
that working with somebody, with a human being in
a primary care office, but if that person can say, “Hey, you’re getting pretty good at this, I have a tool here where
you can practice that skill, that cognitive reframing skill, or that behavioral activation skill that we were working on. You can practice that
however times you want, whenever you want it, you can do it in the middle of the night, and all I’m gonna get from that tool is a little update that
you’re working with it, that you’re practicing.” Then I have a copilot
that could really leverage what I can do as a therapist. So I think there are lots
of potential uses now of AI technology. And the way I would think about it is not replacing a human, but bringing an AI copilot onto the collaborative care team to help me be more effective
and reach more people. I don’t know what you
think about this, Virna. – Yeah, I’ve actually been some of what you’ve been thinking, and also fascinated by the ability of AI to predict engagement. And so, the first time I’m
having that conversation, if someone could sort of real-time, if there was AI that
could predict engagement, then that’s someone that I
might, you know, engage with every day or every other day, maybe someone that I could, you know, put forward for a week, it
would really be helpful. And I think, you know, using AI for sort of functions like
that are pretty incredible. And so, that’s something
recently that I’ve been like, “Hmm, gotta think about
how to bring that in and figure that out.” – Very interesting, and
it’s exciting prospect. And I see all the work underway
on addressing workforce, and I think we’re never
gonna get enough workforce unless we change the care models and start integrating technologies, I think that’s just key. So a good audience question here is on the per member per
month capitation rates and the codes that are being used to pay for behavioral
health integration now, and they’re saying that
they’re not really adequate, particularly to cover the
initial startup costs. What do you see that’s
being done to address those, and make those more adequate, overcome that hump that’s needed to deal with the initial
integration process? – Yeah, I can actually
start off on that one. So, a couple of thoughts. You know, really passing
the dedicated CPT codes, you know, some years back
was incredibly helpful to collaborative care. I think past that, what happened is that implementation and adoption on the Medicaid fee
schedules by the states was all over the map. I mean, even to date, we’re
just recently at 35 states that have put the codes on
the Medicaid fee schedule. And how they’ve done it, at what percentage of
Medicare they reimburse, literally goes from like half all the way up to 120%, what they’ve done around
some of the minutes, some states recognize minutes, others like New York do not, what they’ve done for their federally
qualified health centers, and whether they’ve included them or not? And so, that has actually
really made it difficult for a lot of organizations based on whether your state has the codes, and sort of based on what some of the other, you
know, guidance has been. I do wanna say though and sort of put out, I am pretty hopeful about some
of the CMS proposed rules, getting rid of the G0512 for the federally qualified
and rural health centers, I think is huge, adding collaborative care codes to the advanced primary care I think is also another huge, and the complete Care Act I think is gonna be, you know, certainly
helpful and a game changer. I do think there’s some
advocacy for states that have not yet passed
the code certainly, but also to get everybody
so that there is a floor, so that we’re gonna say at
least Medicare is the floor for the state, for commercial,
you know, for Medicaid, and that’s gonna be sort of
a standard across the board. I do think, however, what I have seen, and this may not be an
incredibly popular opinion, but that, oftentimes, one of the ways that we don’t have
successful implementations or sustainable implementations is because we’re not doing
the implementation well. Like at the end of the day, if you don’t have enough patients engaged in your collaborative care model, it’s not gonna be self-sustaining, it doesn’t matter what the rates are. And I think we have learned so much about how to successfully
launch collaborative care, like, if you were gonna ask me, I do it so differently now
than I did even two years ago, and certainly how I did it 10 years ago. And so, that we can really
look for that sustainability sort of on the front end that we’re actually doing proformas, we’re really talking about the financing and building models out, so that practices can be successful. You know, some of you might have heard me, oftentimes when I’m speaking, I show a picture of the desert, and it’s a place I call the
land of perpetual launch. It’s a dry place, once you’re there, it’s
very hard to get out of it. And I think that is actually,
you know, part of the problem, is we’ve learned to launch
a little bit better. So not that there aren’t
payment or reimbursement, and I do think we need to get to a place where we’re not getting rid
of the administrative burden, you know, of some of the time tracking, and some of those pieces, so I do think it’s a combination. So that was probably a
pretty long explanation, or some thought.
– Yeah. I think it’s super helpful. I have a couple of other thoughts, and you’re really much more in the middle of all of the payment stuff than I am, but I guess somebody mentioned the notion of per member per month. So that assumes that, you know, you’re looking at total healthcare as some kind of a capitated thing. And I would say that’s
another one of these things that’s been coming in my
career for the last 30 years, and we still haven’t
probably found our way to it. So, 95% of us are living
in a fee-for-service world. – Yeah.
– I think in a capitated world, this thing does make all
the sense in the world. The research we did and published, you know, two decades ago is that when we were doing
this in organizations like the VA or a Kaiser Permanente that really are capitated, they were seeing tremendous cost savings. And those organizations
then have figured out, “We gotta do this on a
pretty robust scale,” because it just makes all
the sense in the world. Not only do patients like
it, and providers like it, and people get better, it’s actually saving us money. So I think that, in that environment, I think there is a pretty
strong argument to be made. And the organizations
that are fully capitated I think have, you know,
pretty robustly gone that way. You know, the interesting thing about the fee-for-service
billing for this, as Virna mentioned, you
know, it’s interesting. It took us probably about 20 years to figure out how to do this well, to do the work well, how to build models that
are not just efficacious but they’re effective, they’re robust enough so
they don’t break easily. It seems to be taking another 20 years to get people comfortable
with figuring out how to use a set of new billing codes. You know, our billing people have to get comfortable with it, our providers have to
get comfortable with it, the idea that a primary care provider has to get an informed
consent from a patient, you know, to have these charges submitted. You know, there’s lots of little things that can make things complicated, and I think it’s sort of a slow process, you know, I see that
in my own organization. The only other thought I have is, and it goes back to the
comment on technology and AI, I do think that if we can deploy
AI technology more broadly, we can probably get more scale, we might be able to reduce the cost of doing this a little bit, because, you know, if I can have a copilot that doesn’t cost very
much but is very effective, you know, the humans are the
part that’s very expensive about collaborative care, right? So the cost might become a
little bit more attractive. The whole notion of “How
do we capture the work of a team member? How do we track the minutes?” I bet you there’s technology
solutions to that as well that’ll evolve over time. So I think that, yes, it’s challenging, but I do think that
things are getting better with regards to that, and then we will probably
have some technology solutions that’ll help us do that even better. – Fingers crossed. Thank you. – Fingers crossed. I second Garrett’s notion. That was like exactly what
my brain was thinking. So I’m gonna ask the last
question we had prepared before, or, well, that people submitted before. We’ve been sprinkling in
the audience questions, ’cause they’re obviously
related to the questions that people submitted before, but we’re gonna turn completely
to the audience questions after this one. So, again, just a reminder
to put them in the chat, I know we have quite a few in there, but I’m pulling them out. So this is kind of a big picture question, Jürgen (chuckles) and Virna, but, “What cultural shifts
or structural shifts might be needed in healthcare settings, or among providers, for integrated care to become the standard of care
rather than in exceptions?” – You know-
– Uh… – Go ahead.
– I was gonna jump in, Jürgen. You know, I had the
opportunity to spend today, I mentioned with some
behavioral health leaders, you know, from around the country in integrated care settings. And one of the things that
they continue to voice is, “I am still asking for
a seat at the table. And there are still
organizational decisions, the organization puts out a quality plan, there is no behavioral health piece, nobody asked me to participate in it.” And so, you know, I think
one of the pieces is for integrated care organizations to say “I have a behavioral health business line, I need to understand the finances of it, it needs to be built into all of the parts of my organization, into quality, into
compliance, into the board, into all of those pieces.” And I think, for some, that is a fairly large cultural shift, and I think for a lot of very large organizations and systems, they’re like “Oh, that’s
behavioral health, and we lose money on there, but, you know, it is what it is.” And I think, you know, really trying to change some of that is actually where we need
to really think about it and to be intentional. – Yeah. And I would say that that culture shift, you know, to some extent,
it can come from those of us who are behavioral health specialists, continuing to make the argument that we have value to add in
a busy primary care setting, but it also needs to come
from inside of primary care. And I would say the best advocates in our healthcare system, for example, we have a large academic
healthcare system, 20 plus primary care practices, they all have fully integrated
behavioral health teams now, they didn’t 15, 20 years ago. And it’s not so much me
making the argument for it, it’s really our primary care doctors, especially our younger
primary care doctors, working in a clinic where when somebody is really
struggling in their office with a behavioral health problem, they know “I got somebody down the hall who I can pull in, who’s going to help me. I’m gonna get out in time today, my schedule isn’t gonna
be totally overburdened. And working together with this colleague in behavioral health is gonna help me make a huge difference.” And doctors will always argue for something that helps
their patient get better, they know when they
can help their patient. And I think the best advocates I’ve seen is primary care providers who have experienced
good collaborative care. And then all of a sudden it goes away, and they start saying, you know, “If these people don’t come back, and if I don’t have this help, I’m gonna go work in another clinic.’ And that gets people’s attention. So I feel like, you
know, we have to do more than just those of us who
are behavioral health experts continuing to say, “How can
we get a seat on your table?” I totally agree with you, Virna, that’s probably what I spent
most of my career doing, that’s what I do in my day job here, you know, I convince people that behavioral health is a real thing, and it’s a part of healthcare, and we should be everywhere else, whether it’s healthcare delivered. But I think if we can give our colleagues in primary care, in a
busy primary care setting, the experience of having this, making a difference for their patient, and then they become very,
very strong advocates for it, I think it’s also something
that’s super, super helpful. – Following on just exactly that point, one of the other questions
we wanted to ask was about, you know, we’ve got over a
hundred people here listening to you all today, what can we do, what can each of us do in the healthcare systems we face? I was seeing this in a large
healthcare organization, that it’s a strong reputation, and that I’m involved as a patient, and they’re not doing squawk. (chuckles) What can we do? What can these hundred
people listening today do to start to make a difference? – Yeah, I would say, we tend to think a lot on the supply side as those of us who generate
new solutions in healthcare. If we thought a bit
more on the demand side, what if patients start saying, “Why don’t we have somebody here who can help me with this?” You know, in our cancer
center, patients said, “Why do I have to go see somebody else? I’m here for my cancer care, I’m depressed, I’m anxious,
I’m afraid of needles. Do I really have to go
somewhere else in the clinic where they don’t know
anything about my cancer? I want good behavioral healthcare right here in the cancer center.” And our cancer center said, “Whoa, we don’t wanna lose our patients.” We now have a really
great psycho-oncology team in our cancer center, right? So I think that every one of
us is a consumer of healthcare. And if we start saying, “Why
don’t I have this here?”, people will pay attention. I think if you take it one level up, who’s buying our healthcare? Most of our healthcare
is employer purchased. So if the employers will start saying, “I’m not gonna contract with a health plan that doesn’t have a really robust way of addressing behavioral health needs,” so that’s going to make everybody who needs behavioral healthcare go to, you know, a completely separate setting, where there is very poor
access to specialist providers. If the employer starts saying, you know, “If you don’t have good,
working, and reachable, and effective integrated care, I’m not gonna contract with you,” health plans will start thinking a little bit different, right? So I feel like we could do a lot of work, all of us could do a lot
of work on the demand side, not so much just on pushing
an idea on the supply side. – Mm-hmm. Yeah, I would agree. And I would think, you
know, also as employers, you know, are we asking about
the collaborative care codes? Are we asking what the reimbursement is? Are we asking sort of
what’s, you know, available, and what that looks like? And I think that would be
a really important piece to be able to reinforce, and doing some of that education for sure. – Very good. I’ll see what I can do. – Yeah. (laughs) – Yeah, you need to educate them when you’re there, Garrett, you know?
– Yeah. – My primary care provider,
I told him, I said, “I do trainings on how to do the PHQ-9,” and I said, “I’m gonna
use what just happened as an example of what not to do.” – Right. (chuckles)
– I said, “That was the worst PHQ-9 delivery,” and I said, “You better
not bill for that either.” Like, I had a whole… And now he blocks a
little extra time for me, because I always give him feedback. He’s like, “Did we get it
right this time, Virna?” And I’m like, “Not yet, not yet. (Garrett laughing)
You’re working on it.” Yeah.
– Right. – Quality improvement, right? (laughs) – There you go.
– What you did. – Mm-hmm. – So one question in the chat is, I’m just gonna read it, ’cause
I don’t wanna misspeak on it, but “Is the collaborative care model considered better than
the primary care model? And have these models been compared, or is the choice between
the two mostly dependent on workforce availability
and the business model?” So just wondering if you both might wanna comment-
– Yeah. – [Anne] on the two models? – Collaborative care versus
primary care behavioral health. Yeah. – Yeah.
– Yeah, primary care. – I think this whole idea
of sort of choosing a model, I don’t actually get it, to be honest, because, you know, to
me, collaborative care is incredibly effective
for populations of patients where you’re able to think about measure, outcomes, treat to target, but not every patient goes
into collaborative care. And I think for, you know, when I think about a
behavioral health population in an organization, you have patients that need
health and behavior change, you have collaborative
care where you can measure, you have people that fall out, you have some, you know, folks that maybe have more serious, that maybe are doing groups
or some specialized care. And so, to me, you
wanna come up with a way to care for your entire population. And also how you do that and design that depends on the state and
depends on your payer mix, so “How am I gonna get reimbursed?” So I always tell people, “Stop talking about PCBH
and collaborative care, but actually think about
what your population is, what services you need to
provide to meet those needs, what evidence-based practices, and then who do you have on your team, and how are you gonna bill,
and code, and pay for it?” And I think when you start to answer some of those questions, you can put a service model together that meets the needs of your organization and your population. – Yeah, just a couple
of additions to that. So my sense is that, first of all, there aren’t clean versions of PCBH, Primary Care Behavioral
Health, and collaborative care that are truly distinct. I think all of these models, when you see them implemented
in the real-world, they have components of each other, and they’re on a spectrum. You know, the spectrum is
from a co-located provider who’s readily available to you when you have a patient in the office who is struggling with something, to fully implemented
collaborative care model where you have that provider, but you also have a registry you can track on a chronic illness, you can pull in more expertise if needed. And I think it’s a little bit like saying, “Are treatments for cancer better than treatments for heart disease?” They really are targeting
different things. So, you know, the PCBH
model, in my experience, is very good at the acute thing
that shows up in the office, that if I sit on it for too long, it could become a chronic problem. It’s a person who is struggling with a relationship problem
with, you know, a problem, and it’s a young person who’s struggling with going to school, you know, who is maybe saying, you know, “My tummy hurts, I can’t go to school.” And if you let that go on
for on and on and on and on, it becomes a really serious, you know, a sort of well-entrenched
behavioral health problem, that kind of thing. A couple of, you know, really
good brief interventions from a skilled mental health professional using the PCBH model can make a huge difference, you know? That’s different from somebody who’s living with a chronic
or recurrent mental illness, like bipolar disorder, or
post-traumatic stress disorder, or recurrent major depression. Those things are more like cancer, you know, or like diabetes, they really need ongoing care, they don’t benefit from a
couple of light touches. So it’s a little bit like saying, I think they just have different targets and if I was in a primary
care organization, I’ll need all of these things, right? I’ll need somebody who can make
a brief skilled intervention with one of my patients, you know, who’s struggling
with an acute problem, with a relationship problem, with an acute anxiety about a situation that could be about their healthcare with somebody who needs to learn how to, you know, work with
their diabetes more effectively. But then I have patients,
you know, who have developed full on chronic, recurrent
mental health conditions, “I’ll need more. I’ll probably need a
collaborative care model.” So I think they’re not the same thing, they’re not chasing the same thing, they’re not trying to help the same thing. I think they all have value, but I don’t think it makes a lot of sense. And as far as the evidence
base is concerned, they have not been really tested robustly, in a sense, compared one to the other, because they’re treating different things, so it wouldn’t make sense really. But as far as the evidence goes, there is a ton of high-quality randomized
controlled trial evidence for collaborative care. There is not a lot of randomized
control trial evidence for the PCBH model. That’s not to say that it doesn’t work, it just hasn’t been tested in
a randomized control trial. – So there’s an audience
question here which interests me as a former state mental
health commissioner, “What structural systems
would a state need to ensure that integrated
behavioral health had a seat at the same level that the Department of Health or the Department of Behavioral
Health typically have? Most IBH falls between these
types of state departments, but often there’s disagreement
about where it belongs, and then how to fund it, and
launch it across a state. Are there models, states, that
have done this really well?” – How about starting? Virna probably has a lot
more specifics on this. What I would say is the
big problem there is, why do we even have a separate
agency for behavioral health? It’s health, it should all be health. If we have all of medical health, you know, handled by one agency, and then one little
slice, behavioral health, by a completely different group of people with a different culture,
with different metrics, with different payment systems, it’s never gonna come together, right? So, you know, I would say- – Silos, yeah.
– Let’s do that as a start, right? I don’t know what your
thoughts are on this, Virna? – I’m gonna echo that times 10 for sure. And I would say, yeah, and, you know, in our current state where, you know, we’re not
gonna sort of have that vision, I would say, I’ve seen
it be owned successfully, it’s just someone has to own it. You know, like if you take New York State, the Office of Mental Health owns it, they’ve owned collaborative
care for years, they’ve done a really
good job implementing it, I think there’s certainly
a national model. But I do think it wouldn’t
have been such a tough road had it come under the Department of Health and sort of through some
of the primary care, you know, services and that piece. But I think it’s a question of ownership and somebody actually owning it and making sure it gets
delivered and implemented at rates that are sustainable, and with policies, you
know, that make sense. We don’t want attestation, we
don’t want some age limits, we don’t want some of those pieces, you know, that fall in, we don’t have to, you
know, wanna recertify every three months, or some of those state policies that we know just don’t
support implementation and adoption at a broader level. – Thank you. Yeah, I think that one’s
definitely a big challenge. We talked about this a little bit, but I think it’s an
interesting question here. So they’re asking “How
we would measure success of integrated behavioral healthcare? Are there specific domains or measurements that would support that?” And I know Garrett brought
it up a little bit before, but I guess if you guys wanna speak to… Maybe there’s like a short-term and a long-term measurement of success, but curious what your
thoughts are on that. – Maybe at the systems level, not just at the individual patient level. – Right. Yeah, thanks, Garrett,
for clarifying that. – I would say there’s sort of a numerator, sorry, this gets a little geeky, there’s a numerator component
and a denominator component. So, the denominator are all the people in your health plan, in your clinic, in your healthcare organization that have, you know, an identifiable
behavioral health problem, you know, a mental illness, a diagnosable substance use disorder. And, you know, the
first question to me is, what proportion of the
people who meet that criteria have been recognized
and engaged in something that looks like evidence-based care? So that’s at the population level. Then the next question is, of those people… And most people couldn’t
answer that question to be quite honest, but that’s important. Think about it. If we could say, “We have no idea how many people in our organization have cancer.” We would say, “That’s horrible. That’s totally unacceptable,” right? If we said, “We have no idea how many people in our organization have a high blood pressure.” That’s not okay. But we’re okay with saying, “We really have no idea how many people, you know, are living with a serious addiction problem.” So that’s the first thing. So what’s the proportion of people who could benefit from treatment who’ve been identified
and have gotten engaged in some kind of meaningful treatment? That’s where I would start. Then I would say, of those people who started in treatment, how many of them get a good
enough course of treatment that it actually looks like
they should benefit from that? So that’s not just “We
touched them once or twice,” we are actually giving
them a level of care that should ideally help them. And then the big one for me
is, are people getting better? And so, there are a lot
of ways we could do that. If I’m treating an addiction problem, I need to know is the person using, how much are they using, and how much does the use interfere with their ability to do what
they wanna do in their life? Those are all things that can be measured. You know, if I’m treating depression, I wanna see how severe is the depression, how much does it interfere with
your ability to go to work, to go to school? You know, are they having
thoughts of harming themselves? Those are all things that can be measured, you know, and so on, just like
anything else in healthcare. So I do think there is a
kind of population component, and then there is, for the
person, you know, who is in care, I wanna know, “Is this
getting better or not?” And sometimes we might have a target and it turns out it’s not
quite the right target, that’s not the most important
thing to the patient. We can reframe that with them, we can say, “How do you and I know that if we’re gonna make this treatment, this treatment is really helping you?” And I might focus on a symptom, the patient might focus on
something related to functioning, those are all things that can be tracked, that can be measured. So that’s how I think about that. – Yeah, I would think absolutely from a, you know, population thoughts. When I think about, you know,
a practice or an organization, thinking about provider adoption, and so, what percentage of the providers are actively engaged
with collaborative care? What percentage of their patients are referred and actively
getting evidence-based treatment? And, you know, sort of
what does that look like? What percentage of them, and then what percentage
of their patients, or how many, you know,
people do they have engaged in collaborative care? And oftentimes, when you
look across an organization, you see such variation in providers. You don’t see variations
in the populations that they care for, they’re
in the same practice, but you see huge variations in the levels to which
they refer and engage, you know, with collaborative care and sort of the evidence-based treatment. And I think when I think about success, it’s really defining what
you want that to look like and really thinking about
adoption and implementation across the organization, I think of as like a marker of success. – Very good. There’s a question on school-based here-
– Quick thought on- – That are compulsory.
– Just one more. Quick thought on this. So if you ask most organizations today, “Do you provide some version of integrated behavioral healthcare?” You get a socially desirable answer, they’re gonna say “Yes.” But what does that really mean? So what I really wanna know is, if I’m the next patient
that walks in your door and, you know, I’m
struggling with an addiction, I’m struggling with serious depression, I’m struggling with severe anxiety that keeps me from going
to work on a typical day, what’s the likelihood
that the next patient who walks in the door actually gets a good course of integrated behavioral healthcare? That’s very different from
just saying, “Do you do it?” There’s a whole bunch of
questionnaires out there. If you send them to the leaders
in an organization and say, “Do you guys have integrated
behavioral healthcare?” You’ll get a bunch of yeses, you’ll get a bunch of
socially desirable answers, but that’s not the same
as, if I’m showing up here and I’m your next patient, would I actually get it, right? – Yeah. And there’s a question
on school-based care that I definitely wanna get to. But directly following
on that point, Jürgen, somebody says, “What is your
best estimate of the portion of the nation’s 294,000
primary care practices that have a recognizable, evidence-based integrated
care service line? And kind of you’ve already said, you know, “They’re all
gonna say ‘Yes.'” (chuckles) – Well, not all, you know?
– Yeah. – I would say maybe about
a half of them would say, “We got something.” – Yeah.
– What that something is, you know, that’s the challenge, you know? – Yeah.
– And, you know, they all don’t need to
have the same something, If you’re a small… You need to have something
that works for who you are, where you are, who your patients are. You need to build, you know, an integrated behavioral health capacity that serves you and your patients, right? And that’s not gonna be the same thing, you know, for 284,000 or
294,000 primary care practices. You know, I would say 30 years ago, 1% of them would’ve said, “We got this,” You know, even 30 years ago, there were community health clinics, there were federally
qualified health centers that had figured out, if we don’t do some
behavioral health here, you know, we’re not helping anybody. That’s what our patients really need. I think Virna, you were in
one of those organizations early on in your career. I think today, maybe, I don’t
know the number actually, maybe half of them would
say, “We got something.” The question is, what is
that something, right? How good is it, and does it help, you
know, most of the patients who would walk in the door there? – Then I’ll just go ahead, unless Anne’s jumping. (chuckles) – No, go ahead and ask
your question, Garrett. I don’t wanna interrupt you. – Well, the other audience question is about integration of these models into school-based settings, and what’s your experience and thoughts around how that works, and… – I’ve done so many implementations
of collaborative care in school-based health centers. I ran them and did collaborative care in school-based health centers. I actually think it is fabulous for lots of different reasons. One, of course, bringing in
evidence-based treatment, but the ability to do
those short interventions and follow up, the ability to engage in some of the telephonic,
you know, follow ups, the ability to teach skills
and then reinforce them, the flexibility that you get
through the monthly case rate. I think it’s actually a
perfect model for school-based, and I’ve seen it be so
incredibly successful. And when you think of a lot
of, you know, conditions that our adolescents are
struggling with, you know, and DBT being so helpful, and how you can teach a
DBT skill and follow it up, or anxiety, anxiety is so prevalent, and the ability to teach box breathing, or to teach some of those
skills and then reinforce it, tweak it, reinforce it, I’ve just seen it be so
incredibly helpful and flexible around their schedules and the hours and the snippets of time
that they might have, or that you can engage with them on. So I would be a total fan. – Yeah, I totally agree with all of that. I would say, you know, the
first thing I would say, is go where the patient is. So if the patient is in primary care, go do it in primary care. Most kids aren’t in primary care, they go to the primary care doctor, they go to see their
pediatrician once a year, maybe for a school physical, maybe for a broken wrist, whatever, but they’re not hanging out in a primary care doctor’s
office most of the time. So if you can help them in school where they spend most of their time, so, first of all, I think that’s huge. The second thing I would say is, we gotta go in behavioral health upstream, we are waiting way too long. And I’m gonna go one more time
back to my cancer analogy. I think that 30 years ago when I was training in medicine, I was in the South, we were seeing a lot of people come into a regional medical center with very advanced stage cancer, you know, stage 4 colon
cancer, late stage lung cancer, you know, late stage breast cancer, and it was really horrible. And then we basically started saying, you know, “That’s not gonna work. You can’t help these
people all that much.” So people started screening for cancer, people started trying to prevent cancer. People started saying, “How
do we catch it at stage 1?” So, if you think about
what’s the mental health, what’s the behavioral
health equivalent of that, I think by the time somebody gets admitted to our inpatient unit in their 30s or 40s in a psychotic state or, you
know, in substance withdrawal, we have missed a lot of
opportunities to help somebody, and that person was in
school at some point. And I feel like, you
know, mental disorders are much more malleable
with a young person. So a severe depression in an adolescent usually has a reason it started, you can do something and
it might look a lot better a couple months from now. An older person who’s had a stroke, who’s got severe depression, that’s gonna be a lot more chronic. So we should put all of our effort, a lot of our effort upfront, upstream. You know, most of the people who are living with a mental
health or addiction problem, half of them are
diagnosable by the age 14. 75% of them are diagnosable by the time they’re 24 years old. That means we miss a lot of opportunity if we don’t take the chance to say, “Is there something we can do when we see somebody
struggling in school?” And I think schools, you know,
they’re full of teachers, teachers are not healthcare professionals, they might recognize
somebody, but they need help. So I think if you can give school a really good collaborative care program that’s adapted to the
setting of the school, to the population they treat, it can make a huge difference. And I think you’re right Virna, when you do that, that’s
probably a great investment. – Thank you. And thank you for asking
that question, Garrett, to address other populations. I think I’m gonna ask the last question depending on how long your responses are, so we have a little
bit of time to wrap up. But there was a question
about another barrier to care, so, not to end on a bad note, (laughs) they brought up stigma associated with behavioral
health conditions. And the question is, “How do you successfully
navigate the stigma with care teams and
individuals on those teams?” – I think, you know, being all
together as part of a team, then, you know, you’re actually saying, you know, “You are a whole
person, we’re caring for you, these are all of the
experience you’re having on a daily basis that
you’re struggling with, maybe it’s your diabetes,
maybe it’s your sleep, maybe it’s how anxious you’re feeling. And that we’re gonna put
them all on a problem list, we’re gonna come up with a care plan, we’re really gonna work with you,” and I think having some
of those conversations. And I have a lot of
conversations with folks about putting behavioral health conditions on the problem list, and I think when we sort
of have those discussions, we’re actually perpetuating stigma by not actually including them and having shared conversations, and bringing them in
with shared care plans. And so, I think one of the
best things we can do is, as we move forward and really
develop integrated care models is that we sort of move some
of those pieces forward, because I think that is incredibly helpful in sort of decreasing some of that stigma. – Yeah, just to echo that, I think the most important thing we can do is frankly to say it’s something that we could
start with in primary care. You might need specialty care, but that’s the single most
important thing we can do to say “You don’t need
to go to a weird place where only mentally ill and
highly stigmatized populations get their care. You can actually get started in a school-based health center, or in your primary care clinic.” That’s already a huge step. And then, if the providers
in that clinic say, “Hey, depression, I know about depression, I got a team here that
can help me help you with your depression, I
feel good about that,” that’s gonna send me a
very different message than if the provider says, “Oh, wow. Oh, you want mental healthcare? Well, I’m not so sure I’m
so comfortable with that, I don’t know if we have access to that, I don’t really know much about that.” That’s a very, very different message. The only other thing I
will say about stigma, I think one of the most important things I’ve seen in my career in
terms of combating stigma is effective treatment. So, I trained in medicine during the time when we had HIV, AIDS, and we didn’t have
effective treatments yet. It was a horribly scary thing, everybody was afraid, people were dying, providers were getting, you
know, stung with needles, they were afraid of dying, and it was a terribly stigmatized problem. And all of a sudden medicines came along that made it possible to turn
HIV into a chronic illness, you might be working in a
cubicle next to somebody who’s got a family who’s living with HIV. And I think that, all of a sudden, I’m not saying there’s no
stigma attached to HIV, but it’s a heck of a lot better
than it was a long time ago. So I feel like if we can say
“We got treatments for this, it can be treated, you can
have a good life with this, that’s probably one of the
single most important things we can do. And if we have good
integrated behavioral health in primary care, where a doctor can say to you, “Hey, that’s okay, I got this. I can help you with this. This is easier for me to treat than some other things, and I have a team here
that’s good at this. And if the first thing we
try isn’t going to help, we got three or four other things we can try to do for this.” That’s gonna send me a really
different message, you know, in terms of how much
stigma should I be feeling? How much should I be
self-conscious about this, right? – Yeah. Thank you guys so much. Thank you for turning my negative question into a positive answer at
the end as we wrap up here. So I wanna thank both of
you for joining us today and sharing your perspective. This was really fun for
me to do this afternoon. And I wanna thank Garrett
for asking questions with me and managing those audience questions. And then I’ll just share my screen. And thank you for the
audience for sticking with us. Most of you have stayed on, and I know it’s an hour
and a half of your day, so thank you so much for that. So, finally, here, just quickly, we do these webinars and we have other resources
as we mentioned before. So please feel free to visit our website, again, it’s integrationacademy.ahrq.gov. And then you can also sign
up for our newsletters, so the same thing, but a newsletters, where we share our new
resources as we develop them, or update them, or other things that might be of interest
to people interested in working in Integration. So thank you all so much
for joining us today, and apologies if we didn’t
get to your questions. We had a lot of good ones in the chat, but this was really a great experience, and I’m so glad we got to have it, and answer so many
audience questions today. So thank you, y’all.
This was an August 6, 2025, webinar with Dr. Jürgen Unützer, M.D., M.P.H., M.A., Chair of Psychiatry and Behavioral Sciences at the University of Washington and Director of the Garvey Institute for Brain Health Solutions. and Dr. Virna Little, Psy. D, LCSW-r, M.B.A., CCM, SAP, co-founder of Concert Health and co-founder and Chief Operating Officer of Zero Overdose sharing insights from his decades of clinical, research, and policy leadership experience.
Dr. Little, co-founder of Concert Health and co-founder and Chief Operating Officer of Zero Overdose, is a national expert in integrated care, the Collaborative Care model, and suicide prevention. She will draw on lessons learned from implementing and scaling integrated care and suicide prevention efforts across diverse healthcare settings.
For more information, visit https://integrationacademy.ahrq.gov/video/23732.