Optimizing Whole Person Care Through Integration

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Tom Haederle
Henry Ford Health operates 46 medical centers, along with more than 250 clinic locations throughout Michigan. That's serving a lot of people, with too many locations to provide integrated physical and behavioral health services at each and every one. Nonetheless, Henry Ford has perfected a system of providing those services to many who may need them, regardless of where they are.

00;00;33;05 - 00;00;59;00
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. A Henry Ford patient who may benefit from the services of a psychiatrist or social worker - in addition to a medical clinician - can usually access them online and interact with an integrated care team. Henry Ford has focused on putting behavioral health resources into many of its clinics, able to serve patients of all ages.

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Tom Haederle
In this podcast hosted by the AHA’s Rebecca Chickey, senior director of Behavioral Health, Dr. Cathy Frank, who chairs psychiatry and behavioral health services with Henry Ford, shares how its virtual team approach and patient tracking registry benefits patients from every corner of Michigan.

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Rebecca Chickey
Thank you Tom. It is indeed an honor to be here today with Dr. Catherine Frank. I call her Cathy. She is as he indicated, the chair of psychiatry and behavioral health services at the Henry Ford Health in Detroit, Michigan. Cathy, thank you so much for being willing to share of your time and expertise as it relates to the many, many years of integrating physical and behavioral health care at and across the Henry Ford Health System.

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Rebecca Chickey
So I want to start and ask you to tell us, the audience, the listeners, about the origins or drivers of Henry Ford's integration work. In other words, the when, the why and the how.

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Catherine Frank, M.D.
Thank you for the invitation, Rebecca. You know, collaborative care and what we call behavioral health integration at Henry Ford, is a very scalable population health intervention. And that's been something that Henry Ford's been invested in for quite some time. The driver when we started this way back when was to improve quality and access and ensure that our population remained healthy.

00;02;27;01 - 00;02;53;19
Catherine Frank, M.D.
We were also very invested in those early years in suicide prevention and knew even at that point in our evolution as the pioneers of zero suicide, that screening and access were really essential to safe care and suicide prevention. So back in 2001, we really had co-pair, meaning that we put some of our behavioral health people in primary care offices.

00;02;53;21 - 00;03;17;15
Catherine Frank, M.D.
Then we got to a different evolution of putting an advanced practice nurse in the primary care, sort of a teaching model that would sit with primary care docs, help with diagnosis, help with treatment. But what we found is, on a scale that was such a slow process, we'd probably be 20 years before we went to all of our clinics.

00;03;17;18 - 00;03;47;06
Catherine Frank, M.D.
So in 2017, we really transformed our model, to similar to what it is today. We are strictly virtual. We have many, many clinics. And the idea from a access point of view, financial point of view, we couldn't possibly put a behavioral health clinician in every one of our clinics. But with virtual, and this was long before I heard the word Covid,

00;03;47;09 - 00;04;15;28
Catherine Frank, M.D.
we could be very, very nimble and be where the patient and the primary care wanted us to be. At current, we have three varieties of behavioral health integration. We have that with adult primary care docs, aligned with about 285 adult primary care docs. We have a pediatric collaborative care model, and we have a collaborative care model for perinatal patients.

00;04;16;00 - 00;04;39;13
Catherine Frank, M.D.
We hope before the end of 2024 to have one that also addresses substance use care, so that we're really hitting the types of problems that not only affect our patients, but stymie primary care docs and really want to be able to help them and help the patients where they're out at that time.

00;04;39;15 - 00;05;07;28
Rebecca Chickey
First of all, congratulations on being such an early adapter or adopter of integrating physical and behavioral health care. It also helped, as you mentioned, I suspect it helped greatly when the Covid pandemic began and you already had in place a very sophisticated virtual telehealth delivery system for mental health needs. And perhaps it, allowed you to respond more quickly.

00;05;08;01 - 00;05;38;12
Rebecca Chickey
That's an a value of integrating physical and behavioral health at a virtual level that many people probably hadn't even addressed or thought of. We hadn't experienced such a pandemic and hopefully never will again. We will see. But I have a couple of questions to dig a little deeper into what you shared. You mentioned now that it's virtual, and obviously with the workforce shortages, you couldn't possibly have a behavioral health clinician be available in the multitude of clinics that comprise Henry Ford.

00;05;38;14 - 00;05;49;26
Rebecca Chickey
Can you define for the listeners, what do you mean when you say a behavioral health clinician? Is it a licensed clinical social worker? Is it a psychologist? Give a little more detail there if you could.

00;05;49;28 - 00;06;20;13
Catherine Frank, M.D.
So in the classic collaborative care model is really a team approach. So we have the patient. We have the primary care physician. We have some type of clinician. For us it's usually a social worker. And that's paired with a psychiatrist who's a consultant. So in real terms, primary care doc says gee, my patient has some mental health concerns.

00;06;20;16 - 00;06;56;10
Catherine Frank, M.D.
We gear, as most people do, our interventions to people with mild to moderate illnesses and usually the type of illnesses that primary care docs often see, particularly depression and anxiety. So once a primary care doc makes a referral, the social worker in our case, although some systems use nurses or a psychologist, sees the patient virtually and then the cool part for mental health is then that social worker presents the case to a psychiatrist.

00;06;56;13 - 00;07;24;18
Catherine Frank, M.D.
They consult, they talk about it on diagnostic and treatment recommendations, and then that goes in writing. Or if it's urgent by phone call to the primary care doc. And when medication is indicated, the primary care doctor and is coached then becomes the prescriber of choice. The other key to the success of behavioral health integration is that there's a registry.

00;07;24;20 - 00;07;57;15
Catherine Frank, M.D.
So often in a traditional medical or psychiatric clinic, patients may get lost to follow up. But there is a registry that we track patients over time. We also use very well established scales like Patient Health Questionnaire 9 or GAD 7. So we track them. We may talk to them weekly. We may see them x number of times for further evaluation.

00;07;57;17 - 00;08;24;18
Catherine Frank, M.D.
So we never lose track of our patients. we know where they're doing and we know how they're doing. I think one of the things that is a little bit different about Henry Ford, some collaborative care models do that consultation only. We do that. Plus allow up to eight visits of virtual psychotherapy if it's indicated. So in that initial evaluation, we're helping with the diagnosis and treatment plan.

00;08;24;20 - 00;08;37;18
Catherine Frank, M.D.
We're also deciding if that patient needs to be triaged and seen in a more specific psychiatric clinic, or whether they're appropriate for that mild to moderate model with their primary care doc.

00;08;37;20 - 00;09;06;11
Rebecca Chickey
Thank you. That makes it much clearer. And it also highlights the full continuum of integrated care since you offer up to eight visits and never lose track of the patient. That's great. Can you also share for the listeners what have been the impact of this? Obviously I think through having access to virtual mental health and substance use disorder care, you have improved the access to care.

00;09;06;14 - 00;09;26;08
Rebecca Chickey
But can you speak to what's the impact been in terms of on patient outcomes or staff satisfaction, or the return on the investment that you had to make in order to hire the additional clinicians and set up the virtual technology and maintain it? Would love to hear how this has played out in real time.

00;09;26;11 - 00;09;53;22
Catherine Frank, M.D.
Since it started, we've seen about 9200 patients in this specific program. All of them that were referred had a PHQ-9 of greater than five, meaning that they had some illness of some sort. If we look at the statistics, we look at full remission. Again, a lot of these patients start in this model and then go on to longer care.

00;09;53;23 - 00;10;25;01
Catherine Frank, M.D.
But if we look at their treatment time in this model, about 60% reach full remission meaning the PHQ was less than five. And if we look at response defined as their PHQ-9 went down at least by 50% at the minimum, it's more than 50%. So again, some of these patients start here and then are transferred. Some complete care in the model and so forth.

00;10;25;04 - 00;11;03;04
Catherine Frank, M.D.
And about 82% of those patients had some form of psychotherapy, usually up to eight sessions. So we found that patients truly felt that was a value added to our model. We certainly seen as we follow these cases over the years, a decrease in frequency, certainly of emergency room visits of inpatient psychiatry and actually inpatient medical and fewer primary care visits. Because often these patients are not coming with, you know, I just have malaise,
00;11;03;04 - 00;11;31;05
Catherine Frank, M.D.
I'm tired, I'm not sleeping. And when there is a mental illness that's diagnosed and treated, a lot of those visits are no longer needed for that. So it's been a very positive experience. In terms of the financial angle of things there have been a number of studies showing that it least breaks even or usually makes money for most systems.

00;11;31;07 - 00;12;04;26
Catherine Frank, M.D.
And again, I think you have to look at the financial in a very broad term. So there is how much we get back from CPT codes or from copays and how that is against the salaries we pay people to provide this care. But there's also the fact that, again, if you're looking at population health and management, you're saving on fewer ER visits, fewer unnecessary hospitalizations or visits.

00;12;04;28 - 00;12;41;01
Catherine Frank, M.D.
One of the things that was a big boom shortly after we switched to virtual, is that CMS created billing codes for collaborative care. Now, I will say that not all insurers reimburse for them, and that's a real need nationally, but it certainly allowed us to collect appropriate reimbursement for that. Our social worker for example, bills for an evaluation, bills for psychotherapy, if it's appropriate. In our state

00;12;41;02 - 00;13;15;15
Catherine Frank, M.D.
Blue Cross Blue Shield has been a huge proponent of collaborative care in the state of Michigan. They have probably about 27-28 quality improvement projects in Blue Cross, and one of them is promoting collaborative care. And so we get also as a system value-based reimbursement from Blue Cross, because they're supporting us as better care. And if you add up all those things, we certainly profit from this

00;13;15;18 - 00;13;26;04
Catherine Frank, M.D.
financially. But the main profit is our patients stay well, get better faster, have less morbidity and mortality from their illness.

00;13;26;06 - 00;13;52;19
Rebecca Chickey
Phenomenal. So as we wrap up today's podcast, if you had to say three things to the listeners, why should you go on this journey to either begin your organization's own first steps to integrate physical and behavioral health, or to go to the next level, much as you mentioned at the beginning. Expand that integration as you hope to do with substance use disorder care.

00;13;52;22 - 00;14;00;02
Rebecca Chickey
What are those three points that you want to hammer home so that before we know it this has expanded across the country?

00;14;00;04 - 00;14;45;03
Catherine Frank, M.D.
Well, it's hard to keep it to three, but I would say that one of the things we knew before Covid, and we certainly know after Covid that mental illness has increased dramatically. You know, 2023 was the highest rate of suicide ever in the United States, more than 50,000. So with the increased prevalence of mental illness paired with a shrinking workforce in terms of psychiatrists and psychologists and psychotherapists, collaborative care provides a model that not only improves access, but also interventions that lead to decreased morbidity and mortality.

00;14;45;05 - 00;15;13;11
Catherine Frank, M.D.
Secondly, it sort of explains the obvious. And by that I mean primary care physicians have always been the main providers of mental health care in the United States. But prior to collaborative care, we really weren't helping them in that respect. There was a disincentive, really, to ask people about their symptoms because there was nobody to really help them manage those symptoms.

00;15;13;13 - 00;15;43;04
Catherine Frank, M.D.
And the partnership of psychiatry and primary care helps correct that and provides that support. I think that behavioral health integration lastly, is a treatment option that decreases stigma and really helps reduce health care disparities. It allows us to do that in a way that traditional psychiatric clinics may not do.

00;15;43;04 - 00;16;21;05
Rebecca Chickey
To all the listeners out there, I think she just made the case quite clearly and passionately as to the value of integrating physical and behavioral health. So thank you, Dr. Frank, for sharing of your time and expertise today. For the listeners, if you go to www.org/behavioralhealth, on that landing page, you'll see a section dedicated to resources for the field on other systems, other resources on how to take that first step to integrate care.

00;16;21;07 - 00;16;23;05
Rebecca Chickey
Please check it out.

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Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.