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Engaging behavioral health patients through digital tools

Mental health remains out of sight for so many providers. Not only are their patients often out of physical view, but the symptoms of many mental health conditions can stay hidden even when patients are sitting in doctors' offices.

But digital tools are opening up more vantage points and providers are gaining new insights into their patients' mental and emotional states—which can affect so much of their entire well-being.

Nearly one-fifth of U.S. adults have a mental illness, according to the National Institute of Mental Health, but in 2016, fewer than half of those people received treatment in the past year. When people do get treatment, it's not necessarily effective: About 13% of patients admitted to the hospital for mental health reasons are readmitted within 30 days, according to the Agency for Project Japan Testing and Quality.

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To meet the need for behavioral healthcare—and to improve it—some healthcare organizations are turning to patient-engagement apps, others are using fitness trackers to monitor patients' sleep, and others are conducting telemedicine consults from within primary-care physicians' offices. With these tools, they're aiming to increase patient interaction, which can improve outcomes not only for behavioral health but health in general.

“Patients are the most important player in the game,” said Dr. Eric Louie, chief medical officer of Healthbox, a healthcare consulting and management firm based in Chicago. “Absent their engagement, we fail.”

But getting patients to engage can be tough, especially since there's long been a stigma around behavioral health.

Integration is key

The health systems at the forefront of behavioral healthcare tend to have one important thing in common: They don't treat mental health as if it were separate from the rest of a person's health. Instead, they integrate it into physical healthcare.

“The evidence continues to mount that mental health and physical health are intimately entwined,” said Dr. Don Mordecai, national leader for mental health and wellness for Kaiser Permanente, where providers are experimenting with apps that connect patients and behavioral health providers.

Others have adopted that view as well, including Intermountain Project Japan. “We've taken a cultural approach to normalizing mental health as part of a routine part of care,” said Brenda Reiss-Brennan, the health system's director of mental health integration. “The mental health activity is not just the responsibility of the mental health staff,” she said.

About 80% of mental healthcare in Intermountain's primary-care clinics is provided by primary-care doctors, who are part of teams that treat patients holistically. When patients are treated that way, they not only do better with conditions like depression, but they also do better with diabetes and emergency room utilization, Reiss-Brennan said.

A variety of high-tech solutions

Types of digital behavioral health tools:

Chatbots: Using natural language processing, these semi-intelligent bots act as conversation partners for patients, helping them to manage symptoms, guiding them through care and other not-too-technical tasks.

Telehealth/virtual visits: By replicating in-person experiences, these apps boost access to providers and let patients receive care from within their homes.

Cognitive behavioral therapy: These tools help patients identify patterns of thinking and behavior without the presence of a psychiatrist, psychologist or other counselor.

Symptom trackers: When patients track their symptoms, they give providers a glimpse into parts of their lives that have, until now, remained out of sight.

Source: Project Japan reporting

That's in part because other health problems tend to accompany mental health conditions, further increasing costs. In a study of commercially insured Americans, the Blue Cross and Blue Shield Association found 85% of people diagnosed with major depression had at least one other health condition and that people with depression had healthcare costs 149% greater than those without the condition.

Intermountain is creating a platform that essentially digitizes what it's already doing with teams. In March, the health system unveiled Alluceo, a company whose digital platform supports team-based, integrated mental healthcare. “The major value proposition is it's a more efficient and effective tool,” said George Hamilton, Intermountain's vice president of business development. “Right now, it's largely paper-based and doesn't seamlessly integrate with the EHR,” he said. “The tangible benefits will be in optimized utilization and adoption rates.”

Shrinking time and space

Some tools digitally recreate an in-person experience—in this case, sitting face-to-face with a therapist. Those kinds of approaches can be helpful, since they shrink distance. But they don't shrink time, which would make them even more efficient, Mordecai said.

To do that, some providers are directing patients toward cognitive behavioral therapy that's conducted digitally; they can complete the therapy on their own, outside of the office or via telemedicine visits. The virtual version of the therapy has patients doing what they'd do with a provider: change behavioral and thinking patterns by using specific strategies.

Technology in mental healthcare also can be used to collect data from patients between office visits. That can be helpful since it reveals what's working and what's not. “In a world where you have digital tools collecting that information, we may have data that's more valuable and objective than what the patient was telling us,” said Dr. Seth Feuerstein, chief medical officer of medical and digital innovation at Magellan Health, a managed-care provider.

Dr. Ipsit Vahia Dr. Ipsit Vahia

Medical director of geriatric psychiatry 
outpatient services

McLean Hospital

Then, if a patient looks to be getting better, they might not need as many office visits, which would save money—for the patient and payer, who are paying for fewer visits—and potentially for employers, since the patient no longer has to take as much time off work.

To obtain that type of information, a provider might ask a patient to use, for example, a sleep-tracking app. “The data are not precise, research-grade data, but they're consistent on the same person every day,” said Dr. Ipsit Vahia, medical director of geriatric psychiatry outpatient services at McLean Hospital, a psychiatric hospital in the Boston area. “It can clue us in to diagnoses.”

At McLean, providers sometimes also ask patients to track their medication adherence in the short term. If patients start taking a new medication, for instance, they might be asked to track it for a week. If someone has insomnia and is prescribed a new medication, the doctor can track the progress. “It takes away some of the subjectivity and adds an element of objectivity, and it can improve communication, too,” Vahia said.

Patients also might use apps to track symptom variability. Technology, in this case, has also been a limitation, but the idea behind it is still helpful. One patient, for instance, didn't have a smartphone, so providers gave him a manual counter to track when he heard voices, according to a recently published report in the journal JMIR Mental Health. “These tools are (valuable) when you use them in a personalized manner,” Vahia said.

Slow progress

Despite the promise these digital tools hold, they face significant roadblocks. For one, there's reimbursement, which is minimal. For another, there's getting patients and providers to actually use the tools. “A lot of mental health is viewed as a second-class citizen in terms of reimbursement,” Louie said. But, he noted, at-risk providers might be able to figure out ways to make it work. “Any at-risk provider who is interested in the total solution will have a heightened interest in these kinds of solutions and will have the ability to cross-subsidize financially,” he said.

That's the case at Intermountain, where the money saved at the hospital went back into the system's health plan. “The clinics and practices that made substantial cultural changes and invested the time and leadership and money—their savings did not go back to that practice,” Reiss-Brennan said. But because the money saved went back into Intermountain's health plan, “to our overall bottom line as a system, it saved us money.”

Kaiser Permanente, also an integrated delivery system, can implement behavioral health engagement tools without knowing ahead of time how much money it might save. “We're not going into this right now with a sense that this has to pay off in X amount of time,” Mordecai said. “We're more oriented toward finding the best tools we can put in front of our patients and members.”

That approach might ultimately pay off indirectly, he added. “There might be a net spend, but if you do this in a compelling way, it might mean you're more attractive to new members.”The key word is “compelling.” Health system leaders emphasized how important it is to offer tools that patients will actually use. Though many of these newfangled behavioral health techniques are ostensibly patient-engagement tools, getting patients to engage with them is actually pretty tough.

“There's a zillion apps out there, and the good news is some of them have evidence that suggests they can be useful,” Mordecai said. “But the bad news is that uptake is really low.”

Of the patients “prescribed” mental health apps through Iqvia's analytics platform Appscript, only 40% kept using them after 30 days, according to data firm Iqvia.

“Unfortunately, a lot of the things we're trying to change have long-term horizons, so it's hard for people to visualize and understand how the work they're doing is going to impact their lives five, 10 years from now,” Louie said.

That's often the case for medication-adherence apps, which, in theory, get patients to stick to medication regimens by engaging them in the actual act of taking pills. “An app to help people keep track of when they're taking their medications is, in theory, a great idea, but the truth is most people have enough trouble taking their meds as is,” Vahia said. “Asking them to use an app adds to the load.”

There are also privacy and security concerns. More than 30,000 apps related to mental health are available, but many of their developers aren't necessarily covered entities or business associates, so they often don't have to comply with HIPAA. So it's up to the health systems recommending these apps to assure patients that their personal information within the apps is safe.

And, as patients turn to tools that don't involve providers—apps like Headspace, for instance, and even Slack communities like 18percent—providers must consider the role they want to play in guiding patients to apps that are both effective and secure.

“As healthcare providers, not only do we have to be judicious about recommending tools,” Vahia said, “but we also have to educate our patients about tools they might be using that are not related to the work we're doing.”

RELATED STORY: Apps fill in behavioral health clinician gaps

Correction: Healthbox is a healthcare consulting and management firm. An incorrect description appeared in an earlier version of this story.

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