This is an exclusive BHB+ story.

Serious mental illness treatment in the U.S. faces several challenges from care silos, poor consideration of non-clinical elements of recovery and limited public awareness of available services.

Layer on top of that the latent stigma many in need of care face, as well as unique cultural pressures, and you get one of the most unfavorable treatment environments of all health care.

Behavioral health providers have long been pushed to do more with less. But in recent years, investors and regulators alike have seen the value of simplifying the health care journey for vulnerable patients. Amae Health, founded in 2022, announced in November that it had raised $25 million to expand its all-in-one clinic footprint and partnership initiatives for SMI.

The company combines primary care, therapy, psychiatry, coaching and peer services to offer customized treatment plans that evolve with the patients’ recovery paths. In part, the company partners with hospitals, which often act as the proverbial front door to care when people with and SMI are in acute need.

“Once that’s stable, really, the hospital’s not the right care setting for an individual to continue to receive help and services for the mental health side of things,” Sonia Garcia, co-founder and chief growth officer of Amae Health, said during our latest BHB+ TALKS session. “What would happen is — if a patient has undergone psychosis, maybe a suicide attempt, and presents at a hospital — they’ll be medically stabilized, and then we have relationships and operate as the hospital’s outpatient SMI arm.”

Amae Health, in part, was founded based on the lived experience of Garcia and her family. In this session, Garcia breaks down her “why” for founding the company, how it seeks to remake the system that those with SMI have to navigate, details the care model it seeks to scale with the new funding round and highlights the latest research on helping those with the most severe need find recovery.

The following BHB+ TALKS was hosted by Associate Editor Chris Larson. The following transcript has been lightly edited.

Chris Larson: Hello, everybody. Chris Larson here with Behavioral Health Business. I’m the associate editor over there. It’s my pleasure to welcome you to our latest session of BHB+ TALKS. I’m going to be joined by Sonia Garcia, co-founder and chief growth officer, of Amae Health.

BHB+ TALKS is a digital gathering meant to bring together passionate and deeply involved leaders in the behavioral health space to learn from one another. Each month, we select a compelling leader from the field to have a conversation with, and we want to bring every member of our BHB community together and bring them into the conversation too.

So, what does that mean? That means if you have a question you’ve been dying to get answered, share it with us via the chat function here on the Zoom, and we’ll fold it into the conversation as we go along. BHB’s mission is to serve the behavioral health industry through building community, delivering content, and making connections. Hopefully, we’ll be able to bring all of that to bear in this chat. Be sure to tune in. Join us in the conversation. I’ll be giving significant deference and space to the questions that come up during the chat and fold them in real time on top of all the questions that I’m prepared to ask Sonia as we go along. …

Ok, Sonia, let’s go ahead and start by getting to know you a little bit better and your connections to the principles that you practice in your business at Amae. Would you be okay opening up and sharing the personal story and motivation that originally pushed you towards building solutions for people with serious mental illness, as you’ve done with Amae Health?

Sonia Garcia: Thank you, Chris, for the question, happy to. I’ve definitely shared my story before, but it is my motivation and why I’m passionate for what we’re building. I’ll just start off by sharing [that] I grew up in a pretty conservative, traditional Hispanic household. We didn’t talk about our feelings. We didn’t talk about mental health. I grew up in South Texas. Both my parents are Hispanic. My mother is Mexican. My father was Puerto Rican. You had a culture there that was just really about the immigrant dream and putting your head down and working really hard, and we don’t talk about our feelings. By and large, we grew up really happy. I’m the oldest of five, so I have four younger siblings.

The big disservice was that because we didn’t have any vernacular or education on mental health, I think we weren’t able to really be attuned to when one another was struggling. That ultimately culminated really tragically and really unfortunately in the passing of my dad. We did lose him in 2008 to suicide. It was the hardest thing that we’ve had to survive and overcome. There’s a lot within that that was difficult about it — the loss itself, and there was a lot of self-blame. Then also, his family didn’t understand what was going on, and tried to blame us too. We got ostracized by our community. We were really seen as this out-there, not-to-be-talked-to family. We ultimately had to leave our home and spend some time back in Mexico and figure things out while we were grieving and in survival mode. That was really isolating and really terrifying.

It opened my eyes. I was also just 16 years old at the time. It opened my eyes to really say, “Wow, I want my life to have a lot of purpose and meaning to it. I don’t want this to just be for nothing. I’d like to begin to channel some of that purpose.” It started to step me forward on a path toward trying to figure out what suicide was about — mental illness, mental health, education, and figuring out what existed and how many more families like mine were out there, because at the time, it felt really lonely.

It started off with biomedical engineering, and I ended up working in the health care consulting space. When I was just picking up my first career move and working within that with some health systems and health plans, my brother had started off his college journey and had left home for the first time. He’s a few years younger than me. I just think the grieving and the trauma, and going out on his own, and the pressure and the stress — he, all of a sudden, within his first year, had his first psychotic break. I remember law enforcement, police, that came first before medical care. It was really confusing and tumultuous. It led to a series of years and multiple repeat attempts at trying to get him care and get him back on track with his life. It was really hard. It was extraordinarily fragmented. We had a ton of desperation as a family in navigating what’s going on with him and how we can really help, and what do we do from here, because we knew the worst possible scenario if we didn’t act at the right time. We had already lived through the worst-case scenario.

There was tons of action and desperation from wanting to figure it out. Still, we were faced with tons of, I think, roadblocks and obstacles and a really cumbersome health care system that didn’t make any sense. There would be these repeat cycles of hospitalization and maybe ushering into some form of care, but with tons of family support and then no adherence and no follow-through, no engagement. You would end up trying to restart over, but there would be some moments when you’d go missing back on the street and the manias and the psychosis would pick up again.

It taught me a lot about what exists out there, what the patient experiences, what the caregivers experience. Ultimately, we didn’t find good care for him until we left the country again.

We actually felt like we exhausted all possible resources and options, went back to Mexico, and in Mexico found a really great psychiatrist, Dr. Jose Castillo Ruiz, who got him back on track. Not overnight, but I’ll skip ahead from the details there just to state that he had a really integrated holistic program that, yes, had the psychiatry element, but also a team of nurses and coaches. They thought about nutrition, and everything was a home-cooked meal. It was all vegetables, whole grains, and protein. Then he was on a really strict sleep schedule, and they started incorporating exercise and a lot of cultural competency work. They had some spirituality work. They were also working on what are your life goals and how do we start to get you back on track with part-time schooling or your hobbies, because he had practiced martial arts for the majority of his life and gotten back on that. All of a sudden, pieces started coming together, and he began improving.

It was a light bulb, “aha” moment. I’m like, “This is what we needed the whole time. This is what I’ve been searching for. I can’t believe we found it by leaving the U.S.” It was a pivotal moment where I said, “Now I want to go back to the U.S. again. I really want to go at this full force and see what we can do.” That led me to Stanford. I did a graduate thesis on mental health innovation for a few years there as a Knight-Hennessy scholar. Got to work with the best and brightest minds across different research labs, the medical school, policy, business, design, engineering, everything.

Then the pandemic hit.

I had a little interruption in some of that process. Within that time, it led me to find a really interesting pathway toward Brightline. I worked at Brightline, which is a pediatric and adolescent behavioral health provider. Got to scale that for two years. Joined in as employee number five, I believe. In the interim as we were figuring out what’s going to happen in the world, I got to understand what virtual access and solutions could look like and where the younger population was really struggling and needing support. Built some great tracks, tools, processes and solutions. At the end of that experience, I was like, now it’s time to go after the really hard stuff, the really complex, high-acuity populations that I still hadn’t seen any solutions pop up for. It really felt like that need and the demand was growing and growing, particularly after the pandemic. There has been this massive societal shift in folks really recognizing mental health is real. It was addressed on a federal level. Socially, people were finally coming out, talking about it, being much more open, and, I think, willing to receive services. I said, “I think this is a window of opportunity where now is the time. Now we can really make something happen.”

I got connected to my co-founder, Stas Sokolin, through the Stanford network. We found our chief medical officer really through relationships with UCLA. Dr. Scott Fears had been working at the UCLA Depression Grand Challenge and also as the division chief of SMI for the Los Angeles VA. That set of experiences and connection points really brought us to say, can we do something together? Can we really get after this full force? Four years ago, lo and behold, we set out to really become a fully integrated care provider and a center of excellence for individuals and families that are struggling with severe mental illness.

We’ve got five clinics up and running throughout the country now. We have some phenomenal health system partnerships. We’re really working on expanding and building out our tech and AI platform. I know this is just question number one of what led you to this. I’ll definitely pause and let you put forth the rest of the questions there. It was a really deeply personal moment. I think I had to have lived it all firsthand to really understand what changes needed to come into effect and to be able to have that sense of empathy and connection to the problem space and true passion for figuring this out in the best way that we can for the folks that are in most need.

Larson: Thank you for being so willing and open to share the depth and the specificity of your lived experience that has gone into Amae Health. It’s an amazing story, one that I can only imagine. Then understanding and feeling what you shared really pushed your family in some really difficult ways. It seems to be maybe a truism across shared experiences that sometimes in those dark moments, that turns out to be the thing that helps bring about some of the greatest joys and successes later in life.

Before we get into some of the other questions about Amae, I do want to talk about the name “Amae” itself because this connects to, of course, the comment that you made earlier about going to spend some time in Japan. I want to know what the word means and what concepts are connected with that name to the overall approach of Amae Health?

Garcia: Absolutely, Chris. I appreciate that. Interestingly, when Stas and I really came together to say, “How do we dream this up, and what will it become?” The thing that we had, we both had our lived experiences from our family members that really cemented us, and again, had that passion. We were also trying to figure out, what else do we have in common? If we’re really going to come together and partner in this manner and build something together for years and years and years, where’s our common ground?

We both had this really strong personal affinity to Japan and the way that they live their life and the way they treat their people and their culture, and everything that they do. They have some fascinating principles and philosophies that govern so much of their tradition and rituals and how they’ve been able to foment just a beautiful culture in many ways. We had both been to Japan individually of our own accord because of that attraction and wow and mystique and admiration for the way that they did some of these things and the philosophies that they uphold.

Amae, it has a couple of different terms. It can also mean “sweet” in different capacities. In psychology, it’s also been a terminology that’s used to say amae is the meaning that you can’t do it alone. You have to have dependency on other people around you in order to build yourself back up. That dependency, that nice dependency on other people that can help me — I can open up and ask for help; I don’t have to go at it alone — is so important and crucial to the work that we’re doing here, and why we also say we’re wrapping a team around you. You’re coming into a community. You’re not alone. We’re reinstilling hope.

It’s impossible to do this on your own to begin with. You need a team, and you need everyone to come around you. That dependency is actually good. It’s not something bad. I know that in American culture we typically just think of everything as independent and on your own as soon as possible, as fast as possible, and self-made. Maybe there’s a time and place for that, of course, but when you are at your sickest, particularly in the mental illness space, you do need people that are coming here and can advocate for you, support you, help you adhere to treatment, help you show up to treatment, and help you engage in all these different facets.

We thought that that was a really encapsulating term and way to think about this, and how we were going to bring a multidisciplinary team in, and how we were going to have all of our clinics be brick and mortar, but with a really zen-like manner and with community at the forefront, and a lot of hospitality and respect and dignity placed within these areas. It’s really been a manifestation of that term that we use in many different methods but that we embody and signal as a means of this is supposed to be a team-wide effort. It’s true even on the business front, on the team that we are assembling in order to be able to grow and place out and partner and establish more clinics and deliver more care.

Larson: Understood. Okay. Let’s understand a couple more basic points and facts about Amae. When was it founded, and is there anybody else that we should note that has been significant to the earliest days of Amae up to this point?

Garcia: It was founded in January of 2022, January 4th. It was Stas, myself, and our chief medical officer at the outset, but there’s been a number of people to our name too. We could not have gotten to the place where we are or even kicked off our first clinic without all the support of our tremendous mentors and advisors that we still uphold and have contact with today. We couldn’t have done it alone. We did not have all the subject matter expertise that was required to stand something like this up. We had to bring a team around us to begin to mentor and coach and support, and connect us, and introduce networks.

Yes, in many different ways. I had the Brightline network, Stanford, Knight-Hennessy Network. Stas had [the Chan Zuckerberg Network], had worked at Zing Health, had worked at Google Health and Google X as well and had done a lot of different initiatives across UCLA and the Depression Grand Challenge. It’s thanks to all of these networks and advisors that we were able to begin to connect the dots, begin to get feedback on these solutions, and begin to get really introduced and in the rooms with the right people who were going to help us bring this to life.

Larson: Understood. Tell us a little bit more about what I generally like to call baseball card information for the company. Where does it operate? How many sites of service? How many employees? Et cetera.

Garcia: Headquarters, I think technically you could call it to be in San Francisco in the Pacific Heights area. We have five clinics currently operating. One in Los Angeles, and that’s in collaboration with Cedars-Sinai. We have two in the Bay Area in San Mateo and Los Altos. We have one in North Carolina in the Raleigh region with Alliance Health. We have one with New York Presbyterian in New York, soon to open a second out there. There are additional expansion plans, but these are the five that are live currently. Sites of service. What else was the question, Chris?

Larson: How many employees today?

Garcia: Over 100 employees, but the majority of that really is in the clinical setting. Again, we have that multidisciplinary team, psychiatrists, therapists, health coaches, primary care doctors, clinical care coordinators, and peers, and nutritionists, and dieticians. You have amassed a huge team of support services that all collaborate together within our clinical center. Each one has its own team. Then we’ve got a couple of folks out on the corporate side in the headquarters that are working across operations, clinical operations, product strategy, technology, business development, revenue cycle management, all that fun stuff that needs to happen in order to get a health care business up and running.

Larson: I got you. The structure of the company and its approach are inspired by the experience that you and your family had with your family member in Mexico. Also, we’ve reported that, at least in small part, the Amae model is also inspired by the Department of Veterans Affairs mental health intensive case management program, MHICM, as well. Can you describe what the Amae model is? What service lines go in there? What are the specific clinicians and other support services that are part of the multidisciplinary team that you’ve talked about so far?

Garcia: Absolutely. Yes, Chris, to your point, with our chief medical officer, Dr. Scott Fears, we said, “You’ve been doing this work for decades and decades. You have amassed all these best practices and know what really plays well. Can we leverage all best practices and begin to incorporate some layers of technology and innovation and thinking through making this accessible for the general population so that we can scale this out to the folks that need it throughout the country, whether they’re veterans or not?”

It’s true, the mental health intensive case management model, MHICM, as well as the whole-person care model, were two of the very pivotal and initial central models that were being leveraged for us to really say, “Where do we build up from here?” From our own experiences, we had come to know and been through within our families, team delivery models. We had gone through PHPs, residential, IOPs, traditional outpatient. We’ve explored the full gamut of what exists right now, and so how do we really leverage that to bring it together and make something formidable work for the long term?

I would actually pause on this insight on “long term” because in mental health, in severe mental illness in particular, there’s no cure yet. These conditions, once they’re onset, — typically in the teen years, 16, 17, 18, we’re seeing some earlier onset in recent times — it is something that you then have to manage for life. It doesn’t go away. Somebody has an episode, is diagnosed with schizophrenia, and we know that they have it and they need to continue to manage it. Their symptoms and acuity levels might ebb and flow, might move up and down as life progresses and they have different routines or medical and treatment adherence that they’re undergoing.

It’s not just that you showed up with this episode, we gave you some meds, you got hospitalized, I’m sending you back on your merry way, have a nice life. It is, “I need to educate you because this is something you need to pay attention to for the rest of your life now.” It will be something that you always have in the back of your mind or in the front of your mind but are needing to manage, similar to how you would with something like diabetes, where it is thought of in that chronic care management space.

Mental health for this sort of acuity level, like the services that go into the SMI space, had not ever really been delivered in a long-term setting for the masses, for the general public.

You could enter into these short-term multi-week programs I mentioned, like a partial hospitalization program or the intensive outpatient programs for four, maybe six weeks at a time or so, but after that, you just get told, “Thanks so much for engaging,” whether you’re better or not. Whether you feel ready or not, you’re back to the real world and figure it out. That break in care is what would often, in our own personal case—I’ll say this personally, but from my brother’s experiences — was what would then break down all the structure that we’ve been trying to build up but wasn’t so cemented yet. It would start to fall apart and crumble, and it would get worse and worse and worse. Then behold, another episode would take shape. You had this cycle you couldn’t escape because you’d only have these episodic short-term interventions that would mitigate the issue for a little bit but not actually connect the dots and help you and serve and treat these folks long-term.

For us, one of the main imperatives when we were piecing together the best practices was, how do you make it operate long-term, and what do you offer that meets a patient really where they are and truly understands the needs at any point of their acuity phase but doesn’t let them go and has that continuity of care available to them? In its simplest form, if I had to really, really break it down, it looks like you combine the elements of PHP, IOP, and OP, traditional outpatient, into one brick-and-mortar setting with the integrated nature and layer on top where we said we’re bridging in both the behavioral health and the physical health and the social services all in one ecosystem.

The thing is, we won’t discharge our folks. They will move as safely and efficiently as possible down to that outpatient phase where they can get back to living in their real worlds and abiding by work or school or being active members of their community and coming in once a month. If you need that care, if you get fired from your job, if a loved one passes, if you’re in an accident, if you just can’t adhere to your healthy routines and behaviors for so many days, we would taper you back up to a higher intensity level and just contain and continue to treat you in a really efficacious way so that you can avoid that break, or new plan, or new medication, or new provider, or hospitalization that wasn’t necessary. Instead, you’re maintained and kept in this safe environment, this community that knows you and that you trust and that mutually knows exactly what interventions are needed to get you restabilized and avoid anything from escalating further.

That has really been the unique element. Now that we’ve seen this play out for many years, we still have our first patients that kicked off in LA about three and a half years ago with us continuing in care. Sure, just once a month or seeing their provider and getting a long-acting injectable administered and their therapy check-in or maybe a primary care visit here or there. But it’s been really fruitful for them to have that continuity where it never existed before and where they’re being able to be seen as a whole person and are receiving those psychiatry services or therapy services on a group and individual level.

The health coaching element that goes into nutrition, diet, exercise, sleep. What are all the lifestyle modifications and the diet modifications and behaviors to adhere to? Then there are the social elements and services—do you need to be applying for any sort of disability, or do we need to help you get back into independent living and into stable housing there, or do we need to help you re-enroll in resume prep for work and school. All of that has a place within our clinics. It’s not like you have to go out here and coordinate out there.

The families like to call us this one-stop shop where they’re now finally coming into one set resource. It’s all coordinated, it’s all talked about, and then it’s all acted on in a way that is really serving toward the ultimate goal of getting people back on track with their lives, living really purposeful, meaningful, high-quality lifestyles with their condition under good management.

All the while, I would say separately, there’s a whole ecosystem within the company and some core pillars for trying to navigate and push for technology innovations and ways in which we can begin to really deploy precision medicine tactics and approaches and ultimately figure out, can we get this into remission for long study periods of time? Can we find a cure? Can we call it a cure if you are five years or more in remission from your schizophrenia and your bipolar disorder?

I will put that aside. Anyway, that’s all to say that the long-term nature is most important. It is in person. That’s the other thing that folks often are trying to navigate. Like, what’s the role there? People need that in-person time and community to show up and have a safe place and a safe haven to continuously receive these services. We’re asking them to do a lot. It’s not effective to do this over virtual sessions because I need you to come in and engage in exercises, and I’m helping you on the physical health side.

I’m doing actual measurements and data collection on how you’re doing within your physical health and your PMI or trying to take other measurements, and maybe administering actual injections and medication to you, and I need you to come in so that we can do that on a monthly basis. Then you need the people; you need human connection. Oftentimes, when you’re going through those hardest periods in the journey of the mental illness, you are often abandoned by everyone else, or you might be in a period where you can’t return to those places that used to be social support structures, so you’re on your own.

This usually ends up being; this community ends up being the only place where you can feel seen and understood, and you can have conversations and human connection taking place because maybe you have to have a separation from your family, and you no longer have your workplace because you were fired from your job or your school because you were put on leave.

The other healing element is really that human connection that we’re able to foster through in-person nature. Then, like I said, remaining as flexible as possible to really meet patients where they are and uncover their core needs and not stay in these rigid, artificial four-week duration programs or six-week duration programs that may not be of benefit at all from a medical or clinical perspective towards what that patient really needs.

Larson: Absolutely. You’re breaking down the silos that exist within health care. It makes a ton of sense. What we’re finding at BHB, especially in our most recent live events at INVEST and the Autism Investor Summit — East, is that there’s this inherent challenge that’s baked into operating in health care where the innovations that are being discussed and that people are trying to make readily available to a lot of people, they can be impactful, they can do amazing things for the world.

However, you can’t be so innovative that it’s challenging to operate within the constructs that led to some of the siloing of health care to begin with. One of those challenges that we hear about a lot is working with payers. I’m curious about how Amae works with payers. Let’s actually start with, primarily, which category of payers do you usually work with, and then how do you normally work with that main category of payers?

Garcia: Great question, Chris. It is market-by-market dependent, but for us it’s also a core imperative to have this care be as accessible as possible and not let the financial element be a burden. We intentionally work with all insurances, all lines of business with consideration over what’s possible within each state. I’ll highlight that in California, we currently are all commercial, and we work with all major insurers in the state of California on the commercial side while still working toward our aim to be able to treat the Medi-Cal population.

In California, it’s an interesting structure with Medi-Cal. When it comes to mental illness, it gets carved to the county level. If the county does not have certain openings or is in a state of contracting with new providers, there’s no way to get in and become a Medicaid provider or Medi-Cal provider, and so you’re willing and on standby to say, where is the county within its resources, within its opportunities to engage? What are we willing and able to do with that?

So far, it’s not been a really open space. I think we’re still continuing to form relationships and understand where we can come in from now on with our Northern California clinics as well, but we’ve been working steadily with Los Angeles County and forming some great relationships in the meantime to say, whenever you’re able to, and whenever the opportunity presents itself, we’re here. We know that there’s still a lot of need where we can serve your Medi-Cal populations and the folks that could really stand to benefit from this kind of comprehensive long-term care.

In North Carolina and in New York, we are predominantly Medicaid, and we were able to start with Medicaid within those regions. I mentioned Alliance Health in North Carolina’s managed Medicaid plan that we work with, and then we’re expanding out services from there. We’re also a network, for example, with Blue Cross Blue Shield of North Carolina, so the commercial plans are coming in. In New York, we also kicked off with, I would say it’s maybe 80% Medicaid or so, working with Health First and Fidelis and some of the great plans out there, and then also coming into play with the commercial folks as well.

Our job is really to say, no barriers, no blockers. How do we make this as accessible and eliminate all the burden from families and individuals that are needing to seek care on the insurance front and finance front and where and how? We really have an enrollment team, an insurance team, and our CM team that are fantastic at navigating all those elements. On really helping folks adhere to the deployment of their insurance and using that in order to cover services within an Amae. We would love to work with everybody all at the same time. I think it is a lengthy process, as you know, and there are a lot of different requirements to get into networks.

We are pushing forward and ahead, but our goal is to have full coverage. I’d eliminate that even from the conversation of just insurance should be covering these services. I don’t want you to think about that. I don’t want you to not try to pursue care in fear of that or in consideration of that whatsoever. Let’s look at what’s clinically needed for you and just act on that as best we can. Did I answer your question?

Larson: Yes, it definitely does. We’re going to talk about value-based care in just a second to get to these bigger concepts of what actually makes all of this work together as a whole thing, as opposed to just discrete separate services being offered all at once. I do want to ID what specific types of services there are. If I recall off the top of my head, at these clinics, you’re offering, I believe, psychiatry, primary care, coaching, and peer services. Is that correct? Are any of those wrong? Then what other services are available through an Amae clinic?

Garcia: That’s correct, as well as therapy. I would say the frequency of each is dependent on patient need and their clinical presentation. Let me overview a little bit of the journey for a patient and how that’s really recognized and established. Where the health system partnerships come in is that typically when folks are in an emergency state, high-acuity state, or in a place of seeking support, they show up to hospitals. Whether there’s a medical necessity for that or not, it’s just the automatic front door entry, I’m showing up to an ED, or I’m just presenting at a hospital if I don’t know anywhere else to go and I don’t feel in control of my well-being and my health.

In hospitals, they at times do have a medical portion of things, of, “Hey, this individual maybe through their psychosis, for example, endured a car crash or got hit by a car and now has a broken elbow, and we need to address that from the ortho side.” Once that’s stable, really, the hospital’s not the right care setting for an individual to continue to receive help and services for the mental health side of things.

What would happen is — if a patient has undergone psychosis, maybe a suicide attempt, and presents at a hospital — they’ll be medically stabilized, and then we have relationships and operate as the hospital’s outpatient SMI arm.

We’ll partner with them to then say, “you can refer anyone from your team across the ED, the inpatient, outpatient ambulatory, collaborative care, anywhere within your hospital setting,” and they can then refer patients over to an SMI where they would begin their care journey with us.

In that relationship, we will also deploy what we call a transition planner, which comes in and connects with the social worker a few days before discharge, begins to do a little bit of relationship building and education, often also engages in what we call a warm handoff. That means the transition planner will have to show up into, let’s say, Cedars-Sinai, present at the hospital bed. Greet someone with perhaps a nice card or some baked goods and say, “Hi, I’m (for example) Tiffany from Amae Health. I’m here to help.” Often family will also be around, and we can educate them as well. You begin little by little to just explain and educate on what’s next and what’s going to happen within the journey.

We do receive folks that maybe are dealing with this for the first time in their life, or maybe it’s their 20th time being hospitalized for their mental illness. You have to tailor the messaging and the education and what you’re explaining to these folks and what we’re delivering and here to do with them in very different ways to meet them where they are as a result. That trust building and relationship often is that human element that goes a really long way for folks to then say, I’m with it. I’m going to try this. I’m going to do what’s difficult, but still try to connect into your care.

They’ll be ushered, accompanied by Tiffany, into our clinics. The first appointment that they engage with is an intake appointment by a psychiatrist. That psychiatrist goes in and has maybe an hour, family is also present, can be an hour and a half, but a dedicated period of time where they are running through, who are you as a person? How can I really support you? What’s been your journey up to now? What do you need from the medical side, the mental health side, the social services side? Let’s really uncover what’s happening to you as a whole person.

They begin to develop a curated and personalized treatment plan for that patient based on everything that they need and based on their presentation. It goes so much further to uncover as well what’s happening in your day-to-day life. Are you in school? Are you back at work? Do you have responsibilities in the home? Are you a parent? How do we structure a program that’s going to be able to work for you and that you can show up to again and again and start making some strides toward getting better while still understanding that you have a life to live and lots of responsibilities at hand?

Within that intake, the treatment plan is developed. We call them our members. Our member would walk away with that whole comprehensive plan in hand, an introduction to the rest of the team. We have clinic directors that help deploy all of that treatment plan real time. They would begin their journey, most often probably coming in five days a week for five hours a day or so, really in a more structured manner. That’s often the case where somebody has definitely lost a job or is no longer in school, or cannot cope with the day-to-day and needs that rigor to come in.

What happens within those days is a mix of individual sessions and group sessions. There’s group programming happening in the core of the milieu and within the clinics. Then folks receive either once-a-week or twice-a-week ongoing psychiatry sessions, their individual therapy sessions, individual health coaching, or dietician services. That comes into, also, like I said, stabilizing on what you are doing for your physical health. Do we have any comorbidities that we need to manage? How are you eating, sleeping, thinking about exercise at all to begin with? Can we put in some behavior changes there?

Also, is there anything on the primary care side? They’ll be seen by a primary care doctor. We conduct a liaison with your existing primary care doctor if they have one. Then you get into the clinic care coordinator or peer support services or the social services side of what do you need in order to be more stable in the real world? What do you need in order to go home at night into a safe place and begin to work towards some life goals to get you back on track and recovering in your work or school or whatever that core aim is?

They’ll engage in some of those individual sessions as well with these folks. Then there’s those group sessions across all of it, CBT for psychosis, CBT groups, coping skills. We’re doing a lot on the nutritional landscape as well. They’ll do some yoga, exercise, movement, therapy, and skills. We’ll do creative skills as well. Oftentimes, our members are extraordinarily creative and use art as a therapeutic element, whether it’s music, whether it’s hands-on and more crafty. That becomes a really healing mechanism when words only go so far or you’re engaging in so much talk therapy per day.

You have this really holistic healing center where people are paying attention to what’s happening to you on an individual level. Let’s get you on this plan and think about the medication portion as well throughout that. Then as you start to get better, we’ll taper that down. We will say, now that you’ve been adhering for this long, we’ve checked against your goals, here’s where you’re progressing. We’re doing these measures on a weekly basis as well. We utilize computerized adaptive testing for mental health, CAT-MH, digital assessment that really gets in on all the symptom severity outputs from psychosis, mania, depression, anxiety, suicide.

We get a percentage severity score and can then track that over time on how each patient is doing and engaging within their care, and what’s working and what’s not. Then the whole team comes in and rounds up and can diagnose and assess the situation, putting some interventions in place. Anyway, as people get better, they then come down. We’ll say, now, you have your part-time work happening two days a week, then three days a week you’re coming to the clinic for just a shorter span of time. Let’s try three hours or so of treatment. Ultimately, we want to get you into that coming once a month. Maybe you do have your long-acting injectable that we’ll administer for you or that therapy relationship, or the primary care side.

That’s a really nice element of it is that it works in concert with your life, and we’re all aligned on the same goals. We want to get you back to quality. We don’t just want to babysit, and we don’t just want to keep you in here because that way we can render services. The idea is how can I swiftly, safely, efficiently move you through the treatment paradigm, flow through that, and get you into the outpatient state where you are your healthiest?

You have in play all of your toolkit and resources and behavior changes and new routines and new medication with the most minimal side effects. That’s all working in tandem for you, and we’ll continue to use that digital assessment on a weekly basis to see how you’re doing in between your monthly check-ins and monthly care sessions.

Larson: Within all of that, there is going to probably — I’m going to assume and all the chance, but I will assume, at least with some trying to understand what’s going on here, that there has to be some consideration with your partnerships with payers to be able to do all of this in one spot. Maybe something that if it’s not the textbook health policy version of value-based care, something that looks akin to a lot of those principles that we talk about in value-based care, which is aligning incentives, making sure that providers are being reimbursed for things that one might not consider billable under a fee-for-service hierarchy, but nonetheless contribute to the actual recovery of people with SMI.

What do these value-based care conversations or value-based-like payment innovation conversations look like with your payers? What are you trying to get them to when you approach them about partnership?

Garcia: It’s very insurer-by-insurer dependent. Everyone, I think, is at different levels of, I don’t know if it’s maturity or willingness to engage in PPC. There’s a lot of changing and dynamic landscape unfolding right now. I think some of this will also evolve even more over the next few years. In these conversations, the alignment of incentives that really happens is that for health systems, they don’t want these patients really to be stuck inside of their systems because they’re not able to render services beyond any medical intervention.

It might be someone that does need some supervision or does need some psychiatric support, but by and large is just sitting in a bed in a place where it’s really hectic and ER lights are going off and on, and it’s just chaos. There’s no healing out. They don’t want these folks in their hospital if they can avoid it. Often, they’re stuck with saying, if I don’t have a place to send them, I’m transitioning them from maybe ED to inpatient, inpatient with pretty long lengths of stay. I’m trying to find providers and find ways to not have them continue to show up into the hospital. I’m trying to connect them into care.

By and large, if it’s struggled and then said, this is where the Amae partnership really shines, if you’re actually that connection point. I can safely and in a timely manner usher these folks into the right care setting and avoid them from having these long lengths of stay or staying in the hospital for too long, which also for the insurance side is costing the insurance a lot.

They’re saying this is the highest cost care setting without the right outcomes and without necessarily good value for the dollar, because it’s not that there’s a lot of services being rendered here. It’s just more so like a holding place at times, or maybe they are going through their inpatient, but after they’ve completed what the inpatient needs to do, and as far as it can go from a care delivery point of view, what’s next? Let’s get you into a lower cost care setting where it’s really oriented towards getting the right outcomes and the right care in place.

For the insurers, they care about, am I actually having this person get better, get stable, but in the lowest cost possible manner so that I can continue to treat my population at large and really manage that? Some of the conversations orient toward the avoidance of rehospitalizations. He just measures and tracks toward that and really being diligent on the outputs and aligning toward how we ensure these folks get better from their 7-day follow-ups, their 30-day follow-ups, their medication adherence, their metabolic lab screenings. It’s all things that we’re already doing at its core anyway because it’s what’s right for the patient.

That’s where you do have that nice alignment of incentives where they’re saying, we don’t want them in the hospital. We say, we don’t either. The more that they can stay connected into our care and stabilize and adhere into our treatment, the better. We have that continuity and we have that coordination, and you can affect change much more efficaciously in that way. I think that that’s been the nice way. Putting this against what’s existing in the fee-for-service world and behavioral health is the hard part where you’re coming into a world with a set of codes and services and not all the things that we do in our clinic are reversible at times.

Sometimes we are identifying that a patient could benefit from maybe two individual sessions that day and one group. Or you have multiple services taking hold throughout that day, and in a traditional fee-for-service setting, they might say, oh, I’m not approving that. You build accidentally too many services here and there’s a requirement to not. It’s like, no, that was 100% intentional. This is what the clinician is saying is most apt to keep somebody away from the hospital, which is the ultimate goal.

In the fee-for-service world, it gets really complex, and you have some denials and back and forth, and then you’re appealing, and you’re working through all those motions because you’re trying to say, no, I’m correct. The clinician governed that this is the best course of action. It doesn’t look standard, but we’re not doing standard things, and that’s why it’s working.

Then you’re getting into the value-based side of things, which allows for some more creativity, but putting that against their existing systems and putting that into change is a little bit tricky. That’s really what I’ll say. It’s just harder to put into practice. On paper, it might look really well to align against the outcomes, the metrics, and the measures, no problem, but then how you are continuously evaluating that that’s operating in an efficacious way and in the scoped-out way, and measuring against that for end-of-year reconciliation or if it’s a bundled payment. That’s where it just gets really tricky. It’s great that some folks are willing to try it.

There are insurance out there that are saying, I’m raising my hand, I’m willing to engage in value-based care with you. We’ll say, great, we’ll engage in so much learning as a result of it, and we can start to use this as really strong case studies for why we should do more of this, particularly for this population segment where you do have that full alignment of incentives taking hold. It’s not always playing out this way in health care and other specialty domains or in other areas of care, but for SMI, it really is. It’s not the hospital, and keeping them out of there is what they want. Insurers are also happy with that. We’re all happy with that because it’s right for the patients, and everybody can operate in unison with that plan.

Larson: I understand. We’re starting to wind down here. I want to ask you at least one more very forward-looking question. I want you to cast your mind to the future. Look ahead 5 to 10 years. What is your boldest prediction for how SMI care will evolve, and what role do you hope Amae will play in that transformation?

Garcia: Five to 10 years. My hope is that we have a much deeper understanding over root cause and the role of genetics and genomics in playing a role in determining treatment, and that precision medicine is the standard, and that we’re looking at that way beyond just what the medication intervention needs to be. I say that because when we are internally discussing, we’re working toward a cure, we’re wanting to get the right treatment in place the first time around that a patient comes through our doors, and we owe it to them.

It’s not just thinking about what’s the most accurate meant to prescribe, but it is, who is this individual, and what have they been through, and what are all the elements culturally, genetically, socially, and emotionally, that are going to play a role in what we’re going to do with this patient? Socially, sociodemographically, from their past history, what are all these different elements of this human that’s presenting, and where can we really stand to benefit and impact change? When we talk cure, we also think about what are the most efficacious lifestyle interventions, or even in the diet realm.

We’ve deployed a lot of ketogenic studies. We did an IRB study earlier this year and presented at the Schizophrenia International Research Symposium, where we had ketogenic interventions for the SMI population and saw phenomenal outcomes in the way that it was, one, able to give them cognitive clarity, two, weight loss, three, enable them to be much more adherent on medication, but at a much lower dosage. You weren’t combining lots of different meds to, one, treat the symptom at its core for the schizophrenia element, but then also manage the side effect here, and then another side effect popped up and added another med over here.

You had a really low dosage of medication with a really focused diet plan and with additional lifestyle interventions, and we were looking at that from a whole human lens rather than just, I’m prescribing you something, hope it sticks. If you have some issues, let me know so I can prescribe you more medicine. It had just remarkable output and benefit, and folks are continuing to be adherent to some of these changes in a way that makes them feel good as well as is good for them.

I think that we, in 5 or 10 years, would have accurate assessments and ways to measure out all these different elements where we can have outputs and readings in the genomics phase. Some of that is happening, but right now we don’t know. It’s inconclusive. We just can’t make determinations from it. Then also, can we do some of those metabolic labs and then inference what’s the right and most optimal diet and exercise intervention plan?

Can we also think through the therapeutic intake and what is happening on that side of things from your mental health and begin to deploy the most efficacious interventions and understand that from a whole human lens, and I think, be able to have this really robust method of prescribing the intervention, the medical treatment from all these different domains from a whole person lens that actually gets somebody better and in true remission over their symptoms for good, hopefully.

We are a ways out, but we’re beginning to use technology, AI research, data collection, plus the care delivery element to begin extracting insights. We’re up to some interesting, really awesome work on even going beyond diagnosis and into symptomatology and thinking more so about what are symptoms that people are experiencing, and what patterns can we begin to decipher from that and infer about care intervention from there.

I really hope that we’ve evolved in our understanding of root cause and the whole-person interventions that have to take place to get somebody living a really healthy lifestyle and, in a way, cured. I know it’s a weighted and heated term right now for this space — but cured from the most debilitating symptoms and ailments that this illness often brings about.

Larson: I got you. We’re going to have to leave the conversation there. Sonia, thank you so much for making time for us here to join us for BHB+ TALKS. Just a quick reminder to everybody that if you’re interested in telling us what you really think about the technology services that are out there, both in the behavioral health and in the aging health spaces, go ahead and head to that survey that’s in the chat and also get your chance to be entered in for a drawing for that gift card. We’re going to have to leave it there. Thank you guys so much for joining us for BHB+TALKS. We’ll catch you next time.

Garcia: Thank you, Chris.

Larson: Bye.