Care Delivery in the Future: The Role of the Health Care Workforce-The Behavioral Health Workforce

SARAH DASH:  We are really, really excited to have this panel here today. The Behavior Health Workforce plays such a significant role in many of the themes that we’ve been talking about:  How to improve the delivery system, how to improve care to people across the life span, and we’re really lucky to have a panel here today that is going to help us understand some of the current issues and forward facing issues that we need to be thinking about, when it comes to behavioral health, which of course has been quite a bit in the news the last few years with the opioid epidemic, with many efforts to improve behavioral health policy. But we are really excited here to talk about the workforce.   I’m going to go ahead and introduce our panel. First, to my left, is Peter Maramaldi, who is a professor and a director of the PHD Program at the Simmons School of Social Work in Boston. He is also an adjunct professor at the Harvard TH Chan School of Public Health in Social and Behavioral Sciences, as well as an instructor at the Harvard School of Dental Medicine and Oral Health Policy and Epidemiology. So, you get both of those important and often neglected body parts, I guess you could say. Thanks for being here.   Next, we have Andrew Sperling, who is the Director of Federal Legislative Advocacy for NAMI, the National Alliance on Mental Illness, where he leads NAMI’s legislative advocacy initiatives in Congress, and before federal agencies.   Finally, I’m very pleased to introduce Mohini Venkatesh, who is Vice President of Business and Strategy at the National Council for Behavioral Health, where she leads the council’s efforts to create new partnerships to support community behavioral health.   So, welcome everybody. I’m just going to ask, I know there were a couple problems hearing in the last panel, so if anyone is having a problem hearing at any point, just kind of raise your hand and we’ll kind of keep an eye out for you so that we can make sure everybody hears the conversation.   Let me dive right into the first question. I will kind of ask a broad question, which is:  How do you see the role of the behavioral health workforce changing, for better or for worse? You can put whatever time span you want on it, but how do you see the behavioral health workforce changing in time?   PETER MARAMALDI: Shall I start? There is a physician in Boston, who was struggling trying to help immigrant populations, and just didn’t know what to do. Spending too much time doing non-medical things with this whole population. So, brought in somebody who would help with the non-medical stuff, and that person was Ida Cannon, and the physician was Richard Cavot, and the year was 1915. Here we are, we haven’t gotten very far. We are really dealing with the same things.   When you said “time frame”, it made me think of that, Sarah. But I think where we are with behavioral health, and I won’t belabor it, because I know my esteemed colleagues here have a lot to say, is that if you look at historically, in 1965, Medicare brought people into the hospitals who had never had access to medical care before, and they came in very ill, and they came in somewhat older than one would expect. It just drove up costs. We saw a real surge in social work. Social work at that time was at a salary level higher than nursing — RN nursing. Then right straight through till 1980, and this is the policy’s driving — always driving — the behavioral health workforce. When nursing took over the discharge planning, which brought the costs down for the hospital stays. Nursing and social work switched salaries, in effect, and it’s remained constant ever since 1980.   I think that we see now an opportunity for the behavioral workforce with the Affordable Care Act, and the emphasis on team. And I think that — I’m working on several studies now. We travel around the country, and everybody is talking about team, and everybody is talking about behavioral health, and people using the term “coach”, “navigator”. I think that we don’t really understand what social work is, and what social work does, but we have been doing it for 100 years, and I think that we are beginning to bring it forward. The way we are doing that is through — and you mentioned the PhD program, is we didn’t used to have our own PhDs. We are developing a new technology in our own field, and we have with us today, Darla Spence Coffey, who is the President of the Council on Social Work Education. I think Darla has done a terrific job and she’s gotten social work recognized in IPEC and we are beginning to bring behavioral change theories — evidence based theories, to an applied practice model, where we can help people change their behaviors. If you think about the patient contributions to illness, and the patient contributions in complications and the strains on the healthcare system, it’s a terrific place to enter. So, the short answer to your question is: It’s a real opportunity right now.   SARAH DASH:   Thanks. Anyone else want to weigh in?   MOHINI VENKATESH:  Integration is the name of the game right now. It’s something that comes up in a variety of domains when we are talking about changes happening in healthcare, particularly with the behavioral health workforce, what we are finding is that there are immense opportunities for the behavioral health workforce to participate and engage in conversations about physical health. Both thinking through prevention, certainly early identification, but also treatment. The challenge here however is, is this workforce — does it have the skills and the training to be able to do that? And secondarily, is the system set up to support it? Really, the challenge that we are experiencing state by state, is that the behavioral health workforce, while there is immense amount of commitment to screening physical health issues, assessing people’s blood pressure, and weight, and sugar, et cetera, they often times exist in health organizations and in states and communities that don’t give them the time to be able to do that with each and every patient that they see. Put that down in the electronic record — if they have that — and then make sure that that information is acted upon by the healthcare workforce. Whether that is in the specialty behavioral health organization, whether it’s in a social service organization somewhere in the community, or in more sort of acute or primary care settings.   ANDREW SPERLING:  We still face enormous workforce challenges in the behavioral health world. I’m going to talk about integration in a second, but I also want to note the fact, at least with the Medicare program, we have historic vestiges that are actually — continue to plague that workforce challenge. Let me give you one example. Up until 2014, in the Medicare Part B program, the participation rate of psychiatrists was the lowest of any specialty organizations. The reason for that is because we had a discriminatory 50% co-pay in the Medicare Part B program. So, unlock your primary care doctor, where the co-pay is 20%, I’m looking over at Mark, he was a part of this legislation that passed the finance committee. We had a 50% co-pay for psychiatrists. So, a psychiatrist was left with the responsibility of finding their patient and chasing them down for a 50% co-pay. Part of fixing it, absolutely. We finally got that done in 2014, the legislation passed in 2008, and it was phased in. but the point here is, often times the workforce challenge, we feel as patients, is not being able to find a psychiatrist willing to take Medicare, not being able to find a psychiatrist that is participating in your particular plan. So, we continue to have that significant problem with a number of systems.   On integration, I just wanted to note, we need to move down this road. We are moving down this road, but it needs to be bi-lateral. What I mean by that is, the way we integrate care for someone who has arthritis or heart disease and never had an episode of depression until they got into their mid-50s, is very, very different than someone who had their onset of schizophrenia when they were 18-19 years, and now here they are, 20 years later, and because of pathologies around high consumption rate of tobacco, sedentary lifestyle, poor diet, on and on and on, they suddenly got diabetes and heart disease when they are 45 years old. The strategy for those two individuals are very, very different. That individual who’s never had a behavior health problem till they reached their mid-50s, referring them out to the specialty behavioral health system, is a really bad idea. They don’t want to be told that they’ve got depression or they are “mentally ill”. We need to get those behavioral health services in the setting that they are most comfortable. The primary care doctor, the endocrinologist, et cetera. That’s exactly the opposite for that non-elderly adult with schizophrenia with three co-morbid chronic medical conditions. The primary care system does a pretty poor job of serving them. We need to bring those primary care services into the specialty behavioral health setting. So, it’s a bilateral strategy we have to undertake.   SARAH DASH:  Thank you. I’m hearing this theme of sort of, past is prologue, and it’s hard to talk about the future of behavioral health, unless you talk about the past and the history. I wonder if any of you can comment on that. To what extent — I mean, are we still kind of climbing out of the historical kind of separation and segregation of mental health and behavioral health, which of course includes additions, substance abuse treatment, and physical health, and this notion that they should be separate and now the struggle to integrate them. If you could comment on where are we along that trajectory?   MOHINI VENKATESH:   Absolutely. We have much work to do to break down the siloes. One of my best friends — I grew up in Massachusetts, and one of my best friends still lives there and is a primary care doc at an FQHC near my hometown. Every time I visit with her, she talks to me about her exacerbation. She is very aware of the behavioral health conditions that are going on in her patient population. Very aware of the influence of trauma in her patient’s experience with accessing treatment. She doesn’t know what to do with that awareness. There is a lot of stress and pressure in her FQHC around this idea of, well, let’s go ahead and screen so that we can start to identify, where does this person sit on the depression continuum if they are struggling with depression? Let’s assess what really traumas they have experienced, and think through how do we integrate a sensitivity to that, into this person’s treatment? But if you screen, if someone needs some extra help for an addiction that they are struggling, with alcohol, or with cannabis, et cetera. Or, if they are struggling with depression, what do you do after that? Are there proper referral and connection to a specialty behavioral health, perhaps integrated into the FQHC? Is that actually in place there? Unfortunately, in her situation, it is not. Similarly, she provides services in an ER that is at a hospital near where I grew up. It is a complete mess. The amount of the folks that are coming into the ERs who are struggling with behavioral health issues, sometimes they come in and they say: My heart is racing, my heart is racing! People think that they are having a panic attack. Lo and behold, they have a variety of underlying chronic health issues, and they are really stressed about coming into an ER, because they have had negative experiences of accessing care. It puts the workforce, whether you want to call it specialty behavioral health, or general healthcare workforce, it puts an immense amount of pressure on them to be community problem solvers, when they are not resourced to do so. When we look at undergrad and graduate programs, and think through, what really are the curricula that is being offered? And is it promoting this philosophy of integration? Are there courses that are expressing that philosophy, and then providing tangible examples of how you make this a reality every day? It’s another great example of, we’ve got a long way to go to setting up the workforce to succeed with this mindset.   ANDREW SPERLING:  I don’t know if we will ever totally break down the silos and not have a system of community mental centers, and not have inpatient facilities that only do behavioral health. I don’t think we are ever going to get there, and I think it should be a realistic goal. We talk about our public mental health system as our system, it’s what we have, it’s what we know, and we don’t want to see it go away. That’s a big concern that we would articulate that as a goal, and try to get there, and feel that we failed just because we didn’t get there, when there are so many things in the interim we could be doing to better integrate care, and deal with really, the horrific story for the population I represent, which is early mortality. And not from the underlying psychiatric disorder, it’s poorly managed diabetes, poorly managed heart disease, COPD, and someone — an adult with schizophrenia in the United States, has a life expectancy that hovers right around an adult in Bangladesh. I mean, it’s a national disgrace, we’ve got to deal with it. But the expectation we are going to do away with the specialty behavioral health sector, and we will get complete integration and nirvana someday, is not a realistic goal. We ought to be focusing on early mortality issues, like improving access to primary medical care services for the population, with severe and persistent mental illness.   PETER MARAMALDI:  I’m more hopeful. I think if nothing else, private equity is going to force our hand, the same way they forced our hand in the way we deliver healthcare. They are going to force our hand on being more efficient in the way we deliver healthcare. And those efficiencies who come by having everyone work to the top of their license. For the past 15 years, I have been teaching a course at the Harvard Medical School on interdisciplinary collaboration. It’s very simple. We talk about primary, secondary, and tertiary competencies. I spend a lot of time with students, and they are bright-eyed, and they are excited, and they really want to go out there and do it, and they love what they are doing. On the other side, I spend a lot of time traveling around the country interviewing physicians, nurses and social workers, and it just saddens me every time — every position I interview, I say, what do you love about your job? And there is usually a silence. But if I say, what are the challenges in your job? They attack the electronic health reg, the third-party payers, they go through the list. They can’t do what they want to do. We talk about burnout. But there is hope for the future where now, we see these models, and there is a guy in Boston, Marty Solomon, he’s an early ed doctor, and we have behavioral series about implementing change, that we don’t use in medicine. We use those in industry. I did a patient safety study, and we went to the airline industry and used their technology to see how we could promote patient safety in dental medicine. It’s pretty astounding to see how far behind we were, relative to people who put planes in the air. It’s just the same thing, we are dealing with people’s life and death issues, mortality issues. But I do think that there is hope for the future, and if we want to point the fingers, I mean, you go into the — I’m an academic, I joke at faculty meetings, and I say, we’re trying to change the curriculum. Hey, look out the window, a glacier just zoomed by, relative to the speed with which we are willing to change things. But our hand is being forced. I think that’s the hope.   SARAH DASH:   Thanks. Let’s talk a little bit more about this question of access and where are we with access. I’m almost afraid to ask that question. Andrew, you mentioned a specific example of people who have severe, persistent mental illness, having access to the appropriate primary care, and other kinds of services. What about access to behavior health services for the various populations, who might need those services? And what can we do to improve it?   ANDREW SPERLING:   I will just briefly note, it various across the spectrum. If we work with an individual with severe mental illness, they are likely to be able to easily access services from one of 84 organization’s members. A publicly chartered community mental health center that is legally obligated to serve that particular targeted population. I think where we run into other problems, are people on the more mild end of the spectrum, who have that poorly managed depression, and because of that underlying anxiety depression, are not able to effectively manage their arthritis or their heart disease, or their underlying serious medical condition. I don’t think we should have the expectation that the specialty behavioral health centers are going to be able to serve them. It’s about getting behavioral health services in a primary care setting. Recognize that this is already happening. 69% of the prescriptions that are written for antidepressants in this country, are by primary care doctors, endocrinologists, Ob/Gyns. Many of them are doing it already, they are not necessarily doing it well. Right? An Ob/Gyn who’s got that 15-minute visit with their patient, and can see there is something wrong here about the fact that — it was a struggle for his patient to get there, because they can barely get out of bed, the depression is so bad. That underlying medical condition is not going o get better until you deal with that depression. There is more that we can be doing to bring specialty behavioral healthcare into primary care settings.   SPEAKER:  Is there a question of training more healthcare professionals in behavioral health specifically? To specialize in it? Or, you raised the example of the person who’s in the primary care setting, and just doesn’t know what to do once the patient is screened. So, are we completely missing an opportunity to train the larger cadre of the healthcare workforce in basically what to do, and how to help heal people who have behavioral health needs?   MOHINI VENKATESH:   Given the prevalence, particularly if you think of mental health and substance use issues in the broadest form — mild, moderate and severe — given the prevalence of these issues, it’s incumbent upon us to not pick and choose strategies here, and to think really as inclusively as possible. Because we all are connected to people that we love and care about, that have struggles with mental health and substance use. So, thinking through people being trained and sort of general healthcare settings, helping them with the knowledge and the skills that they need to recognize the early signs and symptoms of mental health and substance use issues, would be great. Then also thinking through — when I was in graduate school, and I had a lot of friends who were doctors, and nurses and all of that, I didn’t even know what community behavioral health was. I didn’t know that there was a core of safety net providers that are treating folks who have multiple co-morbidities, have a severe and persist mental illness, and if they were able to get some community based services, access to medications that they need, that they could live in community, and achieve the goals that we all want for our lives. I had no idea. I just thought that you would put them in the hospital somewhere, because there was no other option available. For us to be offering some training and guidance in graduate programs that are specific to behavioral health, that hey, there is this place that you can go work where you can test out your skills and reach some of the folks that need it the most.   PETER MARAMALDI:  I think that it really — if we think about the competencies that we are training students in, do they match the competencies in the practitioners that they are going to go out and work with in their practices? What are the competencies in practice? We do continuing ed, but do we really measure those competencies? How do we really adjust those competencies right through the course of one’s career? I think that the real opportunities in terms of getting access to behavioral health, are again, the efficiencies. How many physicians are really not working the majority of their day? What percentage are they working in their primary competencies? How often are they doing secondary or tertiary competencies? Things that somebody else could be doing. Do they really want to do those things? We talked earlier today about the electronic health record. I interview so many physicians that say: I don’t read it, I just sign off. I’m a proponent of the electronic health records, and they say:  Yeah, it’s wonderful. Who’s got time to read it? Then there is the notion of — I think the other opportunity that we are beginning to see in a lot of innovative programs, is this emergence of team. Now, team means so many different things to so many different people. It’s kind of the same. You walk around in healthcare and you say, a team, it’s like walking through the supermarket and seeing the word “natural” on the food. It means so many different things to so many different people. But there are some — I visited a lot of programs, I read about a lot of programs, and it really comes down to the common core is, this huddle in the morning, whatever you want to call it. Some carved out time of day, billable time of the day, when people sit down and communicate with each other. And there, there is an opportunity to identify those efficiencies through screening instruments, who are we going to refer people to? And that’s where we — I think there is a real opportunity to not only improve the health and the efficiency of the team delivering care, but the recipients of care get a more direct access, a more direct route to what they need, rather than what our organization is able to spit out.   ANDREW SPERLING:   We are going to get there. If bundle payments work the way they are supposed to, we are going to start paying for value, rather than volume. The system’s got to get there. The cardiologist is going to get dinged, because the bad outcome on the cardiac side, because that patient is not motivated to engage in treatment and do all of the things they are supposed to be doing to deal with their heart disease, because they’ve got underlying depression. If we realign the incentives right, it’s going to happen.   SARAH DASH:  We talked a lot in the last panel about burnout, and this idea of burnout and overwhelm. Talk about the role the behavior health professional, in a team, and can that help to reduce burnout on both ends? I assume burnout is also a problem in the behavioral health workforce, just as much as the workforce we were talking about on the last panel. Are there some good examples of models that have been used that can help to improve not just teamwork and information exchange, but also morale and joy in work, if you will?   MOHINI VENKATESH:  I would love to know what those things are. I’m going to offer a slight twist in my response, and talk a little bit about the role of technology in all of this, and the potential that it creates. There are some incredible apps and tools that are being piloted around the country, helping to think through patient activation, sharing of information from the patient to the provider, in-between visits, helping mobile outreach teams stay connected to their patient population, wherever they are in the community. Helping teams to communicate with each other so much more. The stuff is really difficult to make it sort of align with the workflow in different kinds of settings. We have a long way to go with that. But on a more positive note, offers some incredible potential. All of us in our jobs, we don’t want to have to — if we’ve just spent eight hours in my car, driving around, connecting with my patients in the community, I don’t want to have to go back to the office to type up notes. I want to be able to do that in my car quickly, and then go home at night to spend time with my family. Or, if my patient misses an appointment several times, I want to know what’s going on with them. Not know that, challenges my aspirations and my hope that I have, that I’m having an impact on the patients that I work with. So, opportunities to help provides stay connected to patients, to stay connected to their colleagues, can help to reduce fatigue and exhaustion and a sense that you are trying, trying, trying, but not having an impact. These things can really help to shed a light and help us to understand the impact we are having day-to-day on patients, which I think, for all of us, would be something that we would want. To know that we are making a difference.   PETER MARAMALDI:  We are going to stay now, with Karen Dunlin at MGH, on frail elders living in the community health delivery of services. Every place we go, and it’s a national study, every place we go, people say, I wish I had a social worker in my practice. I’m not sure they know what they mean when they say “social worker”, but if they knew what they meant — and we see a lot of these teams that they are really stressed, and I think that social workers are unique prepared — and we talk about coaches and navigators — they are uniquely prepared to bring evidence-based approaches and teach those to the teams at all levels, from the top of the food chain to the entry level volunteer people, to the receptionist at the front desk. Those behavior change models, and the self-awareness models, in fairness, there is a lot of movement now toward mindfulness. This is anecdotal, but I was interviewing somebody, and they said, I don’t want or deep relaxation exercise, I want 15 extra minutes. I think we have to be aware of that as well. Those things won’t change, but I do think that huddles are a way to address that. With the Dunlin study, we were in Colorado, and first thing in the morning we flew out there, we got there to a team, and they sat around and spent 20 minutes talking about what they did over the weekend — it’s that relationship building. How many people have that luxury to do that? And they recreate with each other outside of work, which is pretty extraordinary as well. Maybe it’s a Denver thing. I don’t know. Is anyone from Denver?   SARAH DASH:   Denver is a pretty fun place. Let’s move on. The last few minutes before we open it up for audience Q&A, to the question of policy. We are, after all, here in Washington D.C. Andrew, you talked about one particular issue in the Medicare payment model. It’s kind of amazing that you mentioned that it was finally implemented in 2014. That was three years ago. What are some of the policy options to improve upon some of the issues that we have been talking about? Whether it be access, training, integrated care, delivery system — let’s talk about the policy options and some of the different programs that are in place to do that.   ANDREW SPERLING: Behavioral health is behind. We were behind on electronic medical records. Our providers, including were left out of the high-tech act and the meaningful use payments that began in 2009 and 2010. It was an error of the staff. The Democratic staff, Mark, not the — it was in the stimulus package and they referenced a section of the Public Health Service Act that excluded community mental health centers and psychiatric hospitals. So, that left us behind with the development of electronic medical records. In addition, we have an obscure federal regulation that was promulgated during the Nixon Administration called 42 CFR Part 2. I could spend another hour explaining what this is, but it’s basically — again, long before HIPAA, there was a scheme for consent for sharing medical records that apply only to substance abuse treatment records. It is a major barrier to getting an integrated electronic medical record, because behavioral health records ended up getting excluded from that, because you don’t have that separate and higher level of consent. It’s a big problem. We have legislation in Congress to fix it, and we are hoping it will advance this year.   MOHINI VENKATESH:  When you specifically talk about the behavioral health workforce and the safety net, one of the huge inhibitors right now is pay. These organizations are not able to pay the behavioral health workforce very well. This is deeply connected to the reimbursement that the organizations receive for billable services. One of the ways in which we are trying to sort of shift that dynamic is by establishing a new kind of entity in the safety net called Certified Community Behavioral Health Clinics. And these organizations, the idea is that similar to FQHC’s, receive perspective payment. So, they are paid for actual costs of services provided. Right now, this program is a demonstration program, via Medicaid, that exists in eight states, and there are about 70 organizations that are participating. So, imagine the idea — you know, we estimate that in traditional form of payment, for every dollar our members spend on someone that is a Medicaid beneficiary, they are only paid 70 cents. So, day after day, if you are underpaid again and again, if that means a lot of scary things for you as a non-profit organization. So, then suddenly under Certified Community Behavior Health Clinics, when you are asked to define what the costs of the services are that you are providing, not to make a profit, but simply to cover the cost of the front desk staff person, confirming the appointment, having the patient come in, the cost of the rent of the space and the cost of the electronic health record, and all of the wrap-around supports that help make a behavioral health person a professional, successful with their patient. If those costs are covered, that suddenly means that maybe these organizations can pay their staff a little bit better. We are already starting to see some anecdotal evidence of this making a difference. This program just started. They received their first new kind of payment this summer. We heard a story of one of these entities that is located in a rural — a very rural community that’s had an open child psychiatry position for six and a half years, and was finally able to hire a child psychiatrist. And there is no child psychiatrist for 150 miles around this agency. So, all of a sudden, if we can shift and remember that these organizations are a critical component of the safety net, and use policy to drive resources in a way that represents their costs, we can start to shift some things about the quality of care that the patients are receiving, and connected to the focus of this panel, make it so that this is an inviting employer of choice for the Behavioral Health Workforce.   PETER MARAMALDI:  Ironically, the people with the most touch, get the least pay. That’s always been the way. We’ve got to look at that. If Robin Stone was here, she would be screaming about that, I’m sure. And she’s right, in my opinion. The other thing is that we will follow the money, and in addition to that, we also have — and I think we’ve learned from industry, we can change organizations. There are technologies by which organizations can be changed, and that includes healthcare organizations. We can do it.   SARAH DASH:   Great, thank you. I would like at this point to open it up to audience questions. I have — your hand went up first in the back. So, we will bring the mic to the two of you, and then I think I saw some —   AUDIENCE MEMBER:  Thank you. Andrew Kessler, representing the ICAC, the International Substance Abuse Counselors. Question for whoever wants to field it. Behavioral health in and of itself is a tricky phrase. It’s kind of all-encompassing. It includes a lot of different areas. Just like other areas of healthcare, there are specialties. For example, an oncologist may do cancer, but there are those oncologists who may specialize in breast cancer or colon cancer, or brain cancer. Also, within behavioral health, there might be professionals who specialize in mental health or substance