Why Behavioral Health Is Driving Population Health Strategies at Cityblock, Boston Medical Center, Eleanor Health

Following the pandemic, there has been a renewed interest in behavioral health from public health agencies and the medical community at large.

Historically, behavioral health has been a side note in population health strategies. But a new emphasis on integrated, holistic care, coupled with advancing data collection capabilities, could drive behavioral health to be a larger part of population health strategies in the future.

Population health differs from traditional care because it focuses on large groups of people instead of one-on-one patient interactions.

“In substance use disorder (SUD), … we think about somebody getting clean or abstinent,” Corbin Petro, CEO of Eleanor Health, told Behavioral Health Business. “When really we should just be thinking about how we make this whole population better than they were last year. How do we move them along the continuum? Because otherwise you’ll run into cherry-picking.”

Eleanor Health is an addiction and mental health care provider built around deploying population health and value-based payment models. It has roughly $82 million in funding.

Integrating behavioral health into a population health strategy could also make financial sense. Although behavioral health only accounts for about 5% of the total health care spend in the U.S., 45% of costs are driven from behavioral health, Petro noted.

“A population health strategy needs to include addressing behavioral health because you’ll see the impacts across populations in other areas where you’re sort of right-sizing the spend,” Petro said. “So I think it has to be a part – and for many populations, it should be the leading intervention and the leading relationship.”

Powering a behavioral health strategy

The “data revolution” of the 21st century has brought new insights into health care. Analytics now allow stakeholders to pull out health and outcomes data of specific populations.

These insights can help providers identify pain points of a certain population.

“I am forever grateful for our really smart analytics team who pull those really big-picture views into a place,” Deborah R. Goldfarb, director of behavioral health at Boston Medical Center (BMC), told BHB. “It [helps] someone like myself, who at the end of the day is clinician, drive strategy.  We look at psychiatric inpatient readmission rates, and [if] we have a subset of people who have rapid readmissions. What resources can we provide to that subgroup?”

Boston Medical Center is an academic medical center with 514 beds. The health system reports that about 75% of its patients come from underserved populations. It is part of the Boston Accountable Care Organizations and provides care to MassHealth patients.

These resources also help providers better understand the needs and preferences of a specific patient population.

“If we’re managing a population, which we do in our work, or we’re assigned to population by payers, we first get all the data we can to really understand who it is that we’re managing and how they’re engaging with the health care system,” Petro said.

BMC has used its analytics to pinpoint at-risk populations. After doing so, it then connects individuals in that population to relevant services.

“We’re able to measure risks and then provide more targeted resources to people who have higher risk,” Goldfarb said. “Our patients that have the highest risk are offered an intensive care management program. There, we pair behavioral health specialists, typically a social worker, with nurses in the community, health workers, all working together on a team.”

Analytics has come a long way in the last decade, but behavioral health providers are notoriously behind physical health providers in implementing electronic health records (EHRs). In fact, only 6% of behavioral health providers have EHRs.

At times, this can be a roadblock to behavioral health playing a leading role in population health management strategies.

“It’s been a major issue – and remains … a major issue – especially from the quality-improvement and kind of quality-monitoring stance,” Jonathan Purtle, associate professor and director of policy research at New York University’s School of Global Public Health, told BHB.

Populations’ physical, mental and societal needs

Many providers and agencies are beginning to look at population health through a holistic lens.

This means addressing a populations’ physical health, behavioral health and social determinants of health (SDoH) all at once.

“I think there is a desire to bring behavioral health [into population health], but because our system is historically so fragmented – medical is different from behavioral, behavior is often different from substance use disorder – it’s very hard to get them all together,” Dr. Michael Tang, head of behavioral health at Cityblock, told BHB. “At Cityblock, we have combined medical, behavioral and substance use contracts. So we have all of it together from a finance perspective, so that we can think about the individual as a whole person.”

Social determinants of health, which include economic stability, housing, education, food security and other factors, can also impact a population’s behavioral wellness.

“What are those non-clinical things that really impact individuals’ behavioral health? To us, that’s focusing on social determinants of health,” Goldfarb said. “I call it more social factors of behavioral health. We spent a lot of time and resources at BMC on that piece, and understanding things like housing and transportation, food insecurity, maybe involvement in the criminal legal system, education and employment. That really impacts behavioral health outcomes.”

BMC has both internal and external resources to help patients address SDoH.

For example, the health system has its own food pantry and community garden. It also made partnerships with community resource centers where it can then direct its patients.

The ‘right’ front door

Oftentimes, the primary care physicians serve as the front door to health care. This means that in the future, primary care could be tasked with administering screenings and gauging the mental health, as well as physical health, of a population.

“If we are going to hang our hat on primary care in this country as the mechanism for which to drive health outcomes, primary care needs to be held to screenings, management, getting people to the right places,” Petro said. “Some folks are not going to get that at primary care. And so that then begs the question of, ‘Is that the right relationship for every type of patient?’”

Although primary care can be an entry point to behavioral health services, it may not be the right path for all patient populations. BMC is looking to treat patients with SUD in the community.

For example, the provider has co-located some of its lowest barrier addiction treatment centers close to the shelter system. It also provides behavioral health services in community health centers.

“The idea is to create endless doors to be able to access services. For some people, going through primary care makes a lot of sense,” Goldfarb said. “But some people aren’t engaged with primary care or don’t want to be engaged in primary care.”

Regardless of the front door, relationships are key.

“I think it’s really important to think about different cohorts and different segments of the population and who they have a relationship with within the health care ecosystem,” Petro said. “And then drive the value from that relationship. A lower-income Medicaid member that is unhoused may derive the most value from a community health worker.”

Schools provide many of those relationships for the pediatric population.

In July, the Biden administration pledged nearly $300 million to expand mental health services into schools. Specifically, the funding will go towards bolstering the school mental health provider pipeline and providing more in-school behavioral health services.

“Schools are the primary source of mental health services for kids,” Purtle said. “Schools are often mentioned as the de facto mental health system for kids, but that makes it a peak mental health system for kids. I think we need to make sure that schools have the resources to handle this appropriately. It’s serious stuff, and schools have a lot on their plate. I think if there’s going to be policy action around getting schools to address behavioral health more head on, we need to make sure that there’s resources, training, support and people dedicated to it so that it can be done well.”

Public health agencies’ role

Traditionally, federal and local public health agencies have had a large role in caring for the health of a population. But the bulk of these efforts have fallen under physical health.

“Within government at the state [and] local level, often not always, there is some other public entity that’s charged with behavioral health,” Purtle said. “But these behavioral health agencies are generally really focused on providing clinical services, and typically clinical services for people with really severe needs, which is super important, and their work is critical. But there’s not really someone thinking that much about prevention, or really having the bandwidth to think about prevention in a population-based way.”

Partnerships between public health agencies and behavioral health stakeholders could be a key to making behavioral health part of population health.

“I also think that public health departments who are used to thinking … about populations instead of individuals could help behavioral health agencies who are more used to thinking in terms of individual clinical encounters, because that’s how they’re typically funded, through Medicaid and reimbursement-based systems. I think there’s a lot of room for partnership there.”

The federal government is beginning to make moves integrating behavioral health into public health.

For example, the federal government has rolled out the 988 crisis response line. Additionally, the Biden administration has pledged $700 million in FY 2023 to staffing local crisis centers.

“988, I think, is kind of indicative of a paradigm shift more towards parity and of elevating up behavioral health as something that’s really addressed as a focal point being primary as opposed to secondary,” Purtle noted.