Better Behavioral Health Care Through Collaboration and Virtual Care

00;00;01;02 - 00;00;36;01
Tom Haederle
The old sports saying there is no I in team recognizes that collaborative efforts can often attain goals beyond what an individual or even a single department can achieve. Six years ago, Henry Ford Health System put that principle into action in a big way, and today their patients are better off for it. Welcome to Advancing Health, a podcast from the American Hospital Association.

00;00;36;03 - 00;00;58;23
Tom Haederle
I'm Tom Haederle, with AHA Communications. It's not exactly news that the demand for behavioral health care has outstripped available resources for a long time. The pandemic made that well-known problem even worse, as many patients who needed therapy or other behavioral health services were forced to turn to their primary care providers for help, rather than face a long wait for scarce specialists.

00;00;58;25 - 00;01;25;28
Tom Haederle
In response, Detroit-based Henry Ford Health System decided to create a new collaborative care program that for the first time integrated primary care with behavioral health, in essence, "marrying" two departments that had always been separate. How has it worked out? In today's podcast, four clinicians from Henry Ford join the AHA’s Rebecca Chickey, senior director of Behavioral Health Services, Clinical Affairs and Workforce, to answer that question.

00;01;26;00 - 00;01;53;10
Rebecca Chickey
Thank you, Tom. I have the honor today of being joined by four experts from Henry Ford Health System. First of all, Dr. Dizon, who is the physician practice lead at the Henry Ford Medical Center in Dearborn, Michigan, part of the Henry Ford health system. Dr. Doree Ann Espiritu, who is the medical director of behavioral health at the adult outpatient division at Henry Ford Health.

00;01;53;13 - 00;02;26;09
Rebecca Chickey
Amanda May a licensed clinical social worker and the Collaborative Care Operations director at Henry Ford Health. And Dr. Osunfisan who is a consultant psychiatrist, also at Henry Ford. So it is my honor to be joined with these four clinicians who have years of experience in integration even before COVID, but how they put the value of integration in the forefront when COVID hit

00;02;26;11 - 00;02;46;29
Rebecca Chickey
and really were able to scale and improve access to psychiatric services during that time and into the future. So I'm going to kick us off by asking Dr. Espiritu, why do we need integration and what is integration of physical and behavioral health?

00;02;47;01 - 00;03;01;08
Doree Ann Espiritu, M.D.
Hello and thank you so much for giving our team at Henry Ford Health the opportunity to be able to discuss with you a very exciting program that has been in operation since 2017.

00;03;01;11 - 00;03;28;27
Doree Ann Espiritu, M.D.
So we all know how overwhelmed and broken mental health care has been for quite some time. And COVID 19 pandemic has led to even a bigger crisis in the access of mental health services. So we also know that even if we were to hire everyone who works in mental health care, we will never be able to meet the demand.

00;03;29;00 - 00;04;00;09
Doree Ann Espiritu, M.D.
And that's how difficult it was at Henry Ford. Majority of the patients who have mental health conditions were sent through their primary care doctors, and this led to even a more overwhelming affect to the primary care doctors because they are not able to, number one, address their mental health needs appropriately or sometimes their patients fall into a dark spot because they're not followed by a behavioral health professional.

00;04;00;11 - 00;04;34;03
Doree Ann Espiritu, M.D.
So we were hurting. Primary care was hurting. And so we looked into different programs across the country and how we learned about the collaborative care model of University of Washington aims. And so we decided that this was going to be the integrated program that we were going to implement at Henry Ford. So Dr. Dizon was one of the champions in primary care, and he will also, you know, describe how it was prior to the collaborative care model.

00;04;34;05 - 00;05;07;03
Emmanuel Dizon, M.D.
Thanks, Dorian. Yeah. So I'm a primary care physician, internist in Henry Ford, and it was really a great opportunity to participate in my mind. Collaborative care really is an extension of evolution of team-based care. So not only are you having facets of a team in your own clinic, you're involving another department, behavioral health in the primary care setting and actually integrating, as you would say, into the into patient care.

00;05;07;05 - 00;05;39;22
Emmanuel Dizon, M.D.
And so we definitely needed that in our primary care setting. As a internist, it is really hard to get care for my patients when it's needed. Some therapy, they needed some medication referrals, etc. So this really allowed us to really improve the access and shorten the time it takes to see someone. I think in the past it was months out to see a therapist and then after that we were able to cut that by a few weeks and I think that's really a great success.

00;05;39;23 - 00;05;54;11
Emmanuel Dizon, M.D.
It's really helped in my practice. It's really helped my colleagues' morale and it's given us a lot of confidence in knowing that we have a another department, another facet of primary care and behavioral health working together.

00;05;54;13 - 00;06;17;19
Rebecca Chickey
So I'm going to ask you to build on that just a little bit. Dr. Dizon and Dr. Espiritu, to please feel free to join. But you talk about having it's an expansion of the team approach, and I love that because it really is. And it's interesting, a lot of behavioral health care, particularly inpatient, has operated as a team for decades.

00;06;17;21 - 00;06;34;05
Rebecca Chickey
And now some of our colleagues are saying, well, things work better when they're done in a team. And we're like, yes, and we can share some of our experiences with you. So can you give me a little bit more on what the team is, what it's comprised of?

00;06;34;07 - 00;06;43;10
Doree Ann Espiritu, M.D.
So we are introducing two members into the primary care team, and that is the behavioral health integration. 00;06;43;10 - 00;07;08;17
Doree Ann Espiritu, M.D.
Psychotherapist in the collaborative care model, they are the behavioral care managers, but because we didn't want to confuse too many care managers, they are too behavioral health information therapists. And then there's the psychiatric consultant, which is me. And Dr. Osunfisan is one who works with the therapists and gives recommendation sessions to the primary care doctors like Dr. John.

00;07;08;22 - 00;07;41;23
Doree Ann Espiritu, M.D.
And the reason why I think it's a true essence of a team is that once we get consulted, we're there for them. You know, we're not prescribing per se, because, you know, we we are not in primary care. Dr. Dizon will do the prescribing if there needs to be an the present. But if they need anything in terms of questions about antidepressants, in terms of how to move forward with the care, in terms of where to send the patient, we're there for them.

00;07;41;25 - 00;08;00;27
Doree Ann Espiritu, M.D.
A lot of mild conditions are being given to primary care to treat. And you know, for behavioral health, we don't leave them on their own. We're there with them. Mild to moderate psychiatric conditions...help them out.

00;08;00;29 - 00;08;29;18
Emmanuel Dizon, M.D.
I think that's really key, just that we have the help. So it's given us primary care physicians a lot of confidence in prescribing medications. We have a very in real-time feedback from the therapists. They will tell us, oh, patient X, we saw for this depression or anxiety. You know, the psychiatric consultant recommends medication A and let us know, you know how it does in a few weeks.

00;08;29;20 - 00;08;50;08
Emmanuel Dizon, M.D.
They even give us information dosage information, what kind of side effects to look out for. So it really helps us in primary care to gain some confidence in treating some of these mild to moderate mental health conditions. And that will in the end, just help us become more effective as primary care physicians with their help.

00;08;50;11 - 00;08;52;06
Rebecca Chickey
And be able to treat the whole person.

00;08;52;06 - 00;08;52;23
Emmanuel Dizon, M.D.
Exactly.

00;08;52;25 - 00;09;05;15
Rebecca Chickey
And not have to wait for periods of time, longer periods of time to actually be treating all of the disorders that an individual patient may have. Is that correct?

00;09;05;18 - 00;09;06;20
Emmanuel Dizon, M.D.
Yes, Yes,

00;09;06;23 - 00;09;07;09
Doree Ann Espiritu, M.D.
yes.

00;09;07;12 - 00;09;35;20
Doree Ann Espiritu, M.D.
And at a place where they feel most comfortable, you know. They don't need to leave primary care and go to a brick and mortar psychiatric clinic where sometimes they fear that they can be stigmatized if seen in that clinic. So it's improving access. It is improving primary care physicians' satisfaction when they are being able to treat individuals with behavioral health and comorbid physical conditions.

00;09;35;24 - 00;10;09;15
Rebecca Chickey
And it's reducing stigma. I think that's kind of a win-win-win trifecta, as they would say. But how did this all come about? Amanda, I hear you might be the individual who really is the operation champion in taking this evidence-based, because I think there have been over 100, if not more, evidence-based studies that have shown that collaborative care management can and does work to improve outcomes and reduce the total cost of care.

00;10;09;17 - 00;10;17;05
Rebecca Chickey
But how do you get from Ground zero to implementing this? What are your success factors and what have you seen?

00;10;17;07 - 00;10;33;03
Amanda May
Yeah, so it takes a lot of patience and a lot of teamwork. We have a small but mighty team that's done a lot of work for this. What we did is we started in a very small location. We started at one of Dr. Dizon's clinics and we started just with those providers.

00;10;33;03 - 00;11;03;16
Amanda May
We really embedded ourselves within the team and got to know the primary care providers, but not just them, their staff. They're amazed there's CSRs to help get that buy-in and that trust of our program. We had a very kind of outlined timeline of how we rolled out and all of the trainings that we did. And then when we implemented our program, actually I, myself or some of our other therapists would go and work from that primary care clinic just for a little bit of time until the primary care providers got comfortable.

00;11;03;19 - 00;11;27;26
Amanda May
After we got through our first couple of clinics, word started to spread and we got those early adopters, and that's when it really took off. Once we had some champions like Dr. Dizon to help share the success stories that their patients had. It helped other doctors to see that there were actual measurable change that was happening and that helped them to want to try the program too.

00;11;27;26 - 00;11;44;00
Amanda May
So from there we spread to all 32 of our primary care sites very quickly after that. So from 1 to 32 primary care sites, over what period of time, if I could ask about two years. Wow. We had a very busy few years.

00;11;44;02 - 00;12;09;01
Emmanuel Dizon, M.D.
We had to start slow first. You know, I think that was the key, is start slow to move fast. I think I heard someone mentioned you have to go slow in order to go fast and really ironing out the kinks. Initially, it's a lot of hand-holding and we appreciate Amanda really doing the hard work of doing the hand-holding for our primary care physicians, reassuring them that, you know, it's it really works.

00;12;09;01 - 00;12;28;18
Emmanuel Dizon, M.D.
It's very effective. And once we could share the patient stories and share physician testimonials about the success of the program, it has the snowball effect. And then people really push to get access to this program and really are asking us, oh, we want it in our program, we want it in our clinic, we want it here. When can you come?

00;12;28;20 - 00;12;30;16
Emmanuel Dizon, M.D.
And that's when it really took off.

00;12;30;19 - 00;12;55;14
Doree Ann Espiritu, M.D.
And from primary care was finished. And then when we spread to pediatrics, it was already covered, but we were ready. You know, that wasn't a hindrance to our spread. So it also is very important that the upper C-suite was the big driver, you know, so there were no worries in terms of, wow, how much is it going to cost?

00;12;55;14 - 00;13;08;08
Doree Ann Espiritu, M.D.
You know, everyone knew from top down how important it was to integrate in a big system, not just a big system for, you know, an approach with primary care and behavioral health.

00;13;08;10 - 00;13;16;16
Rebecca Chickey
So, I had two thoughts there before we move on. So what's been the outcomes of this other than the all the positives that we've already mentioned?

00;13;16;18 - 00;13;41;18
Rebecca Chickey
Dr. Dizon, I have a feeling you are being very humble because a word that I've heard a couple of times already is champion. And I do believe that in most projects, particularly when you're trying to transform the delivery of health care, it's just critical to have a champion from the peer group that this transformation is going to impact.

00;13;41;18 - 00;14;07;01
Rebecca Chickey
So I'm looking at your colleagues now. I realize this is a podcast, but we are all on screen with each other and they are smiling broadly. Just to let those of you who are listening know that I'm not off base in saying that having Dr. Dizon as a champion is one of the critical success factors and something I think they would recommend to anyone trying to move into the collaborative care model.

00;14;07;03 - 00;14;32;02
Emmanuel Dizon, M.D.
I think I would agree and I think that it will. All of us are champions actually. You know, it would not be possible without the leadership of Dr. Espiritu to and Amanda and then Dr. O coming in and lending additional perspectives. I think it really is a team effort. You know, you can't have it without someone to really engage everyone and everyone has a piece to play.

00;14;32;04 - 00;14;48;02
Doree Ann Espiritu, M.D.
So in the primary care space, I have to really push to change the culture, push to engage people, and then behavioral has to do the same thing. And it just shows how every piece fits with every other and forms a greater whole.

00;14;48;04 - 00;14;51;07
Rebecca Chickey
What do they say? There's no I in team so.

00;14;51;10 - 00;14;51;21
Emmanuel Dizon, M.D.
That's true.

00;14;51;22 - 00;15;12;05
Rebecca Chickey
The second thing before we go into sort of outcomes, because I know that's probably what everyone is anxiously waiting to hear, like what has been the impact? Can you tell us a little bit about the virtualness Amanda, you mentioned that early on in the first couple of clinics, you you actually physically went to the clinic and walked through that.

00;15;12;05 - 00;15;19;26
Rebecca Chickey
But how did you get to 100%? Is this a word, virtuality and sustain it?

00;15;19;28 - 00;15;36;02
Amanda May
Even though I was there physically in the clinic, I was still seeing the patients virtually, which is funny. So we've been 100% virtual since the start. And part of that is because we knew how many clinics we wanted to be able to work with and we knew how limited the resources were.

00;15;36;02 - 00;16;00;24
Amanda May
And so we wanted a team that was able to treat patients in one city at 10 a.m., at a next city at 10:30, and virtual was really the way to do that. We originally did telemedicine appointments, which were clinic to clinic, so the patient was located in a primary care clinic like Dr. Dizon, and the provider was located at a central location, which was one of our behavioral health clinics in Detroit.

00;16;00;26 - 00;16;19;11
Amanda May
But then we were luckily given the opportunity to test out mobile video visits where the patient could be at home and the provider could be at home. And we actually ended up testing that out in late 2018 or early 2019. And I'll say as a provider, I was nervous about this at first. I didn't know how it would go and I love it.

00;16;19;11 - 00;16;43;01
Amanda May
I love it so much. It's something it has an effect on the patients, you know, it reduces cost and time spent for them. It definitely improves satisfaction of my providers on my team. They were very happy and as a provider, I get a really unique look into the patients lives that I don't usually get in therapy. So I'm able to get their families involved, have their kids involved in their therapy.

00;16;43;04 - 00;16;51;25
Amanda May
That doesn't usually happen. Even seeing their home setting, that's not something we often get, but the virtual component gives me that and it's been really helpful.

00;16;51;27 - 00;17;05;16
Rebecca Chickey
So it also allows you a glimpse without doing some sort of sophisticated survey into the social drivers of health that may be impacting the individual by going mobile. Wow, I hadn't thought of that component.

00;17;05;16 - 00;17;21;17
Rebecca Chickey
So thank you for those insights. So what has this meant in terms of outcomes for patients? I've heard a little bit from Dr. Dizon and others that this really has helped physician satisfaction, but what's it meant to the patients?

00;17;21;19 - 00;17;40;26
Amanda May
We have some outcomes that we've been really proud of. So we talked about the virtual component in 2022 Just in our adult behavioral health integration program, we did over 12,500 video visits where patients were located at home, and that means that it saved over 148,000 miles on travel.

00;17;40;26 - 00;18;07;13
Amanda May
And that's money that we're saving for our patients and time that they're getting back. But most importantly, some of those clinical outcomes, though, in our adult program right now, we have over 2000 patients who are in remission and over about 2500 times the patients have been in remission. So some of our patients come back for a second or third episode of care and they reach remission again, or maybe have a new life stressor going on.

00;18;07;13 - 00;18;32;22
Amanda May
But we're able to get them feeling better, faster. Another thing - and this is kind of just a quick sneak peek of some preliminary findings that will be coming out - but we have found that patients who initiated treatment and had a higher remission and response rate on both the Q9, which is the Depression screener and the GAD seven, which is our anxiety screener, than those who didn't initiate treatment.

00;18;32;25 - 00;18;41;24
Amanda May
So we're seeing, even in these initial research findings, that patients are getting better just by initiating treatment in the program.

00;18;41;26 - 00;18;58;07
Rebecca Chickey
So. Dr. O, I'm going to call on you to add to what Dr. Dizon has already said regarding physician satisfaction. As I understand it, the program was robust and growing and scaling when you came on board.

00;18;58;10 - 00;19;14;04
Rebecca Chickey
So you had the benefit of coming in with an almost baked cake, I guess I would say ready to put the icing on. And so what's been your experience in terms of being able to benefit from this and also think about the future?

00;19;14;07 - 00;19;39;24
Tiwalola Osunfisan, M.D.
So it's been a great experience for me just coming from another system and joining Henry Ford and the great champions, the work they've done already and just been able to be part of this has been rewarding to be able to collaborate with other primary care physicians. So even just like what Dr. Dizon was saying, I mean, you know, one of the primary care physician and they just they're excited.

00;19;39;24 - 00;20;07;27
Tiwalola Osunfisan, M.D.
They're happy. They're grateful for what we've done, how we help them, the real time recommendation, the expert on recommendation, and then, you know, they feel more comfortable being able to manage the mild to moderate anxiety and depression that, you know, they don't have to wait three months before they have to see psychiatry, but their patients are happy. The patients feel, you know, supportive that their primary care physician is involved in their care.

00;20;08;04 - 00;20;52;17
Tiwalola Osunfisan, M.D.
So it's not just go to behavioral health and, you know, don't come back. But Dr. Dizon is involved. Doctor Dizon knows, okay: doctor should be sent up to speed to meet his recommendation. Does Dr. Dizon support this recommendation, the side effect, what is going on? So just having that collaboration of all the providers with the therapist, it's been received with great satisfaction, even to the patients, even to the physicians, even to me. You know, even the the consultant is enabled to be there to be able to support the all collaboration has been really great and really, you know, looking forward to even expanding even beyond primary care, which Amanda will probably talk a little bit

00;20;52;17 - 00;21;09;08
Tiwalola Osunfisan, M.D.
more about. But one of the things that physicians say is, you know, they don't feel burnt out. They don't, you know, the stigma of their patients. The patient is not just going to say, I'm just going to see a shrink. No, I feel like I'm still just going for my primary care visit. But my my mental health is being managed.

00;21;09;10 - 00;21;34;07
Tiwalola Osunfisan, M.D.
You know what Dr. Dizon said that before about the access. This has improved access. And overall, the burnout for me, you can tell from my excitement, I really enjoy what I do and this has reduced the burnout even for me, just being able to put things into context. If a patient was coming to see me in the clinic or a new visit is an hour and a follow up is 30 minutes.

00;21;34;09 - 00;21;55;23
Tiwalola Osunfisan, M.D.
For this one, I get to touch at least ten lives in an hour and meet with the therapist every week. And we reviewed their cases, and you know, the patient registry who is not doing well. You know, our target. The target is to remission or at least five points down of the PHQ and the and the GP seven.

00;21;55;23 - 00;22;17;16
Tiwalola Osunfisan, M.D.
So being able to touch ten lives at least in an hour compared to maybe two is very, very rewarding to to me. And I excitedly looking forward to opportunities as we expand beyond primary care and just really grateful for the team.

00;22;17;19 - 00;22;55;23
Doree Ann Espiritu, M.D.
From the mental health, the psychiatry side. We're not proud if we're not able to see our patients come back when they are really in need of our care. But with having a registry, we know exactly how many patients are served. We know how many patients need to be seen. Again, we know how many patients are in remission. So that is the rewarding piece of being a psychiatrist as part of a collaborative care model, is is knowing exactly where those 2,000 patients are, you know, who is still in treatment and who is in remission.

00;22;55;26 - 00;22;58;15
Doree Ann Espiritu, M.D.
So that that's the other reward.

00;22;58;18 - 00;23;25;14
Rebecca Chickey
That's phenomenal. And I'll just say for the listeners, Dr. Espiritu mentioned the registry. If you Google collaborative care model, which is what we're talking about here, there are some key components of this integration model that were developed. It was mentioned earlier at the University of Washington State. Dr. Utser was one of the key drivers of the creation of this model.

00;23;25;14 - 00;23;44;06
Rebecca Chickey
So if you want to learn more about the individual components of collaborative care, which is reimbursed by Medicare now, please feel free to give it a Google. But Amanda closes out here a little bit. Give me a couple of things. That is, what are the next steps for this integration model at Henry Ford?

00;23;44;08 - 00;23;52;21
Amanda May
One thing Dr. Espiritu and I were just talking about this morning is that in order to continue to expand, we also have to sustain what we already have.

00;23;52;21 - 00;24;12;01
Amanda May
And so one of the most important parts to us is making sure that we have annual clinic restrictions with our clinics that we already work with. We want to make sure that they're comfortable. Any new providers know about our program and that we're keeping that collaboration strong. So we're putting just as much effort into those clinics as to our future.

00;24;12;04 - 00;24;35;12
Amanda May
But as Dr. Espiritu mentioned earlier, we have now expanded into all 15 of our pediatric clinics. Our pediatric behavioral health integration program is now expanding into our family medicine clinics. We have started a women's health or perinatal behavioral health integration that as of today actually is live at five of our clinics. And we'll be expanding through the rest.

00;24;35;14 - 00;24;58;07
Amanda May
And we're going to look in the upcoming years of how we can partner even in the areas of substance use. There's more research coming out showing that this program can be effective in many different areas, not just in primary care. And we want to make sure that we have every opportunity to help our patients and our providers throughout the system who need access to this type of care.

00;24;58;09 - 00;25;21;17
Rebecca Chickey
Well, this is phenomenal. It is such an honor to be able to share the work that you're doing with a broader field who weren't able to attend the AHA’s 2023 Leadership Summit, where they gave a much more in-depth presentation on this topic. As I close out our podcast today, I want to for the listeners point them to a website at AHA.

00;25;21;18 - 00;25;56;08
Rebecca Chickey
It is aha.org/behavioral health. And when you scroll down on that page, you will see that one of the strategic priorities of the American Hospital Association is to advance the integration of physical and behavioral health. So the recording of this podcast will be accessible there along with a number of other resources, one of which is a just released in August of 2023, a four page brief on the value of integrating physical and behavioral health.

00;25;56;08 - 00;26;27;22
Rebecca Chickey
We've mentioned a number of those key topics today: reducing stigma, improving patient outcomes, reducing burnout of both psychiatrist and primary care physicians. In addition to those, it can reduce health disparities. You can actually have a positive return on investment through integration, which is something I want to emphasize for those listening. And that issue brief provides the research that backs up all the statements that have been made here today.

00;26;27;24 - 00;26;48;17
Rebecca Chickey
So as we close out any I'm going to start with Dr. Espiritu: what do you want the listeners to remember the most? Give me one thing, each of you. So Dr. Espiritu, you get to go first that behavioral integration with primary care is the way to go, and that it is not as hard as others think it is.

00;26;48;19 - 00;26;58;09
Doree Ann Espiritu, M.D.
It's a fun project. Everyone, not just the patients. They're still all smiling. Yes, we're still smiling. Yeah, thank you for this opportunity,

00;26;58;11 - 00;27;01;11
Rebecca Chickey
Dr. Dizon, any message? Last message for you.

00;27;01;13 - 00;27;05;15
Emmanuel Dizon, M.D.
I think the teamwork is really the key and it is the future for health care.

00;27;05;17 - 00;27;07;15
Rebecca Chickey
And Amanda?

00;27;07;18 - 00;27;18;20
Amanda May
Yeah, I have to agree that teamwork really makes all of the difference here. This is something that can have a huge impact on your patients and your systems. And I encourage you so much to look into this.

00;27;18;22 - 00;27;20;23
Rebecca Chickey
And finally, Dr. O, bring it home.

00;27;20;25 - 00;27;45;29
Tiwalola Osunfisan, M.D.
So I'm going to agree with everyone, but really emphasize what Dr. Dizon said. It is indeed the future. And if you're listening to us and you are not sure, we say go for it, try it out. If you have questions, reach out. But this is the future of medicine. Because of the access, because of stigma, just do it, go for it and do it.

00;27;45;29 - 00;28;08;00
Tiwalola Osunfisan, M.D.
And it is rewarding to the psychiatrist, rewarding to the primary care physician, rewarding to the behavioral health therapist. And it brings satisfaction to the patient. Because of the convenience, they can see their providers from anywhere in Michigan. So if you're thinking about this and you're not sure, do it.

00;28;08;02 - 00;28;10;21
Rebecca Chickey
The time is now. Thank you so much.