This is an exclusive BHB+ story
For a concept that by definition means connecting a patient to care, “fragmented” is how most behavioral health providers describe the state of triage for their patients.
Reinventing the process would improve outcomes and may even help address the mental health staffing crisis, experts told Behavioral Health Business.
Triaging a patient with a physical health condition is generally straightforward: Clinicians assess the level of need and urgency, then coordinate where they should be sent for care. The frameworks for navigating it in behavioral health, however, are almost nonexistent and often lead to issues such as emergency department boarding, care delays and overcrowding.
“If someone says they have chest pain, the emergency department knows just what to do to help them,” Dr. Sara Gotheridge, chief medical officer at Array Behavioral Care, told BHB. “They take some vitals, they do an EKG, they might give them some oxygen and some aspirin, and then they figure out if they’re having a heart attack or not. It’s very prescribed. It is not prescribed in behavioral health in a way that’s attached to outcomes.”
Array Behavioral Care is a virtual psychiatry and therapy provider that connects patients with integrated care for high-acuity interventions, outpatient clinic support and at-home care. While Array is virtual, the company has partnerships with hospitals and health systems to provide real-time psychiatric support in EDs, inpatient units and crisis stabilization spaces.
Existing tools to assess behavioral health patients, like the PHQ-9 and GAD-7, are not sufficient for evaluating or understanding the complexity of mental health conditions presenting in patients, Gotheridge told BHB.
“Current methods are just so limited,” Gotheridge said. “It’s not enough. … We are not winning. There are more folks with behavioral health challenges every day. Their acuity is worse, the prevalence is worse, the incidence is worse. We’re not winning. So that’s why we need to do something.”
Lack of integrated care between physical health and mental health is, in large part, to blame for the existing gaps in the triage process for behavioral health patients – and in many cases, funding structures and reimbursement pathways also contribute.
“Behavioral health care is really delivered separately from medical care, and that’s one of the reasons it’s so tough to connect the dots,” Faith Tarver, vice president of behavioral health at AbsoluteCare, told BHB.
AbsoluteCare is a value-based provider of integrated health care that operates across five states.
Because basic mental health care is delivered by separate providers in separate buildings with individual practices, the system itself “naturally fragments the care,” Tarver said.
Improper or delayed triage for mental health patients can also result in physical health ramifications and worsen long-term outcomes. Mental health patients in general are at a higher risk of being exposed to diagnostic errors for physical health conditions as well. The lack of behavioral health training among ED clinicians presents another major barrier to timely and appropriate triaging.
“The way that states and health plans carve in or carve out behavioral health services and benefits, the different funding sources, and the stigma that follows behavioral health care all contribute,” Tarver said. “In those ways, our system and our policies have forced mental health care and physical health care to be on separate planes. The separate delivery structures really promote fragmentation.”
Smarter triage models
The need for stronger triage pathways for mental health patients isn’t limited to those who show up in the ED.
Primary care is the first line of treatment patients generally rely on for both physical health and some mental health services, but depending on a patient’s needs, not all physicians are comfortable handling the range of complexities mental health presents. They may make a referral, but that’s generally where the overlap stops.
“There’s not a lot of incentive for, from a policy or payer perspective, that really incentivizes a PCP to talk to a psychiatrist,” Tarver said. “There’s not much that incentivizes a conversation or shared decision-making between the different provider types. So that’s a barrier.”
Triaging mental health patients to the right level of care at the right time outside the ED can help prevent them from ending up there at all. That is what led two longtime mental health physicians, Dr. Tom Insel and Dr. David Mou, to build a new system from the ground up.
Earlier this year, Insel and Mou co-founded Benchmark Health, a company focused on mental health triage to more effectively guide patients through care systems.
The company works directly with PCPs who can hand off a patient to Benchmark’s licensed mental health professionals. While the company is not a therapy provider, the mental health professional serves as a patient advocate. They conduct a wellness exam and can more effectively evaluate what level of care and resources the patient might need and connect the care “dots” for them by scheduling the appointments and making the phone calls for them.
“We figure out what is actually best for the patient to maximize the chance for a good clinical outcome, and we have that flexibility to triage them to resources accordingly,” Mou told BHB.
Benchmark also uses AI tools to collect and review clinical outcomes on a regular basis, which improves the system’s algorithm in matching patients and recommending resources. The advocates assigned to a patient’s case use that information to build a treatment pathway plan. The advocate stays assigned to the case even after connecting a patient to the mental health resources and patients can check back in with them as often as they’d like. Some patients, Mou said, ask to speak with their advocate regularly and prefer that over traditional therapy and may be all they need depending on acuity.
“In a sense, what we’re providing is a kind of concierge service for mental health patients and families,” Insel told BHB. “It’s not that difficult to do. It’s just nobody’s done it because everybody’s either in the payer bucket, the provider bucket, or doing something else in the nonprofit sector. So to have somebody there who’s got your back and who’s helping to guide you through all of this, … it really matters to them. When you’re in the middle of a mental health crisis, this is not the time you want to be navigating a very complicated landscape.”
As providers, Array and AbsoluteCare have undertaken their own efforts to reconfigure triage systems for mental health patients, too.
Array’s triage system incorporates a pipeline of data into one place from assessment tools, including the PHQ-9 and GAD-7, while also incorporating social determinants of health, indicators of substance misuse, adverse childhood event scores (ACES), stress levels and any co-morbidities that may be present.
“We look at the whole picture of someone in the most focused way to say, ‘Okay, this is what we need to address right now.’ That’s the first element of smart triage,” Gotheridge said. “What it then allows us to do is drive our next step, which is: What is the right treatment? What is the treatment cadence? Who are the right providers? The third step is measuring what’s happened as we’re treating, how a patient has progressed, and the fourth step is looking at all that data and fine-tuning.”
While making triage more effective can be a cost-saving effort in the long run for the patient and the provider, the payer side makes reimbursement challenging.
“We know sometimes a person gets better with more touchpoints,” Gotheridge said. “In a commercial payer environment, which is primarily where we work, we also do Medicare Advantage work – the challenge is, how do we get that paid for if we have a lot of touchpoints for that patient?”
Array has met this challenge by creating care pathways in which, when necessary, they invoke all resources for a patient and begin care coordination on a finite level by reaching out to their PCP or connecting them to one, doing medication management – even for physical conditions like asthma, and connecting them to intensive outpatient care. The process has been cost-effective and helps patients stay in more comfortable environments, Gotheridge said.
AbsoluteCare’s triage approach is a highly integrated care model. As a value-based provider of primary care services and behavioral health its therapists and psychiatrists work alongside the medical team every day. If a PCP has a behavioral health question, the therapists and psychiatrists are able to be on-demand subject matter experts and directly consult with the patient’s medical team.
“Our psych providers are also leading the way in helping our PCPs prescribe medications that may be a little bit less common than a typical PCP would prescribe, like an antipsychotic,” Tarver said. “But now they have the backstop of a psych provider and psychiatrist who can really support them in starting or reviewing medications and answering questions. We scale the access both through consultation in our collaborative care model and through face-to-face visits with our behavioral health team.”
Co-location of these medical specialties is where the triage “magic” happens, she said, and is a starting point that other systems could model to begin addressing the gaps that exist in mental health triage.
“We take it further than just being co-located, because we share in the care decision-making of our members. They don’t just sit next to each other, our clinicians talk and really communicate about what’s happening and how a patient’s physical symptoms are impacting their mental health and vice versa. … We can do a lot in one place. That really accelerates the care a person can receive.”
Solutions like those from Benchmark, Array and AbsoluteCare, which focus on patching the gaps in mental health triage, may also serve as a solution to help the shortage of mental health professionals across the U.S., too, Insel told BHB.
“I actually don’t think we need to 10x the number of providers or the number of services,” Insel said. “What we need to do is to solve the supply demand problem through really smart triage. There’s a lot of capacity that’s not being used. There are excellent providers looking for patients, and there also are patients who are waiting in line at clinics that have a nine-month waiting list. There’s a solution for that.”
Further incorporating AI into triage processes could streamline solutions on a national scale, too, he said. With AI and other technologies rapidly advancing in capabilities, in five years, Insel said it is reasonable to expect more improvements in this vein.
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