It's been a great meeting. We're so happy that you were able to join us on the last day of the APA's annual meeting. We're excited about the session that we're having today. It's actually a hybrid format, which I'm not used to, but it's really interesting. Last I checked, we have 45 in attendance virtually, in addition to the participants we have in this room. So thank you for joining us. My name is Hossam Mahmoud. I am a clinical assistant professor at Tufts in Boston and a consulting psychiatrist at Array Behavioral Care, and I'm joined today by two of my colleagues, Dr. Nicole Christian-Brathwaite, who is the head of medical and clinical strategy at Headway, and Dr. Shane Rao, who is the vice president and medical director for measurement and outcomes for non-acute care at Array Behavioral Care. Our session today is titled A Paradigm Shift, the Evolving Concepts of Innovation and Integration in Telebehavioral Health. And so what we'll do today is discuss the evolution of telebehavioral health from small-scale feasibility and effectiveness to large-scale application and population health, explore how measurement-based care has been incorporated into tele to enhance quality and track outcomes, appreciate the use of technologies that are inherent to the delivery of remote care in order to enhance integration and innovation, and discuss the evolving concepts of innovation and of integration in telebehavioral health from a population health perspective. So I'll jump right in, and then I'll invite my colleagues to share their presentations. Mine is titled The Digital Mental Health Ecosystem, a Population Health Perspective. I have no conflicts of interest to disclose. Now, usually I like to start my presentation with going over some terminology and definitions to make sure we're all on the same page and speaking the same language. So telebehavioral health, which is also known as telemental health and telepsychiatry, is the use of information and communications technologies in order to deliver behavioral health services remotely. And we've actually had telepsychiatry since the 1950s, so it's not a novel concept, nor is the application novel. However, it appeared like in the early 2000s and throughout the period before the pandemic, the discussion on tele seemed to focus almost exclusively on synchronous videoconferencing, that is, synchronous meaning in real time videoconferencing to deliver care. However, increasingly over the past decade or so, and more so over the past three years, the term digital health has been utilized more often, and it is defined as the use of computing platforms, software, devices, connectivity, and sensors for health care and health-related uses. And telehealth or telebehavioral health is considered a subset of digital health, which also includes examples such as mobile health apps, wearable devices, remote monitoring, and other health information technologies. And while we tend to use tele and digital health interchangeably in many settings, typically when I use the term digital health, I'm being very intentional about it not only being synchronous videoconferencing, but rather a modality or an approach to delivering care that incorporates video, audio, text, self-navigated modules, as well as delivering care both in synchronous and asynchronous manner. So as I mentioned, we've had so much evidence and so many studies demonstrating the effectiveness of tele for several decades. Telebehavioral health has been shown to improve access by bypassing the uneven distribution of behavioral health providers across the country. It expands capacity at the local level and decreases wait time. Telebehavioral health also improves the ease of accessing care. So it's not just the access to care, but also decreasing the burden associated with accessing care. This is very important for folks who have to travel long distances in order to get care. There's a burden and cost associated with this travel. Many folks have physical limitations that limit their ability to travel or certain mental health conditions like severe PTSD, social anxiety, or agoraphobia that really impact the ability to travel. And having to take time away from work or school or forego pay in order to seek care really becomes prohibitive. Tele also optimizes efficiency because clinicians don't have to travel to and from a site and don't have to travel in between sites so they have more capacity to work with patients. And it also allows patients to be able to access care from multiple specialists, sometimes that are located in different locations. And last but not least, we have come a long way addressing stigma, but stigma continues to be a significant barrier within mental health, particularly with substance use disorders. And Tele offers a way to bypass stigma as we continue to work on mitigating stigma overall. Now, we had all of this data, all of this evidence for Tele before COVID, but then COVID hit and it created this, I guess, once-in-a-lifetime conditions. On the one hand, what we saw is an increased need and demand for behavioral health services because of stress, isolation, lockdowns, constant changes, the economic downturn, and behavioral health symptoms related to COVID itself. And so there was increased need and demand on the one hand. On the other hand, COVID disrupted healthcare delivery systems. And between stay-at-home orders, folks being too afraid to go to facilities due to the infection or facilities limiting their capacity for contact precautions. That meant that remote care in the form of Tele behavioral health was really the only option for many, many folks seeking behavioral health services. And that led to a rapid, massive adoption of Tele. And that was facilitated by a combination of regulatory measures, be it through executive orders, legislation, or even reimbursement changes that helped with the expansion. And just for context, just to give one example, for Medicare visits, the fee-for-service Medicare visits went up from having 1% Tele in 2019 to 38% in 2020. And towards the end of 2020, so December of 2020, it was 50% of all behavioral health services provided. So this rapid expansion with the public health emergency had advantages and some limitations. The advantage was that folks continued to be able to access care. So it decreased the care barriers during the pandemic. It mitigated exposure to infection and other infection risks. And the expanded reimbursement of Tele behavioral health, including for audio only, meant that Tele became more affordable for patients and it became more cost-efficient for clinicians. Now, on the other hand, there were some limitations. This rapid adoption meant that we replicated many long-standing issues in our healthcare systems, namely fragmentation between different specialties and primary care, as well as a disruption in the continuity of care, which does exist in our systems, and we ended up replicating that. The other limitation was that there was an ongoing shortage of clinicians. Tele does not create more clinicians. That continued to be an issue, and because of that, many clinicians were experienced burned out. They were overextended. They felt work-life balances were really eroded, and that notion that you're constantly available through technology really meant that many folks just exited the workforce. Another limitation to the rapid expansion during COVID is that we exacerbated access disparities, what we call the digital divide, which is disparate access to technology, disenfranchising people further and limiting their ability to access care, and that is common with folks who come from more modest socioeconomic backgrounds, folks living in rural areas, sexual and gender minorities, or folks that identify as belonging to ethnic or racial minorities. And so while if you had access to technology, that was great, if you did not have access to technology, it meant that you could not access health care. So over the past three years, though, we noticed some interesting trends. There was a significant diversification in the delivery of health care using technologies and some convergence as well that we're seeing, especially over the past year. So I'll give you some examples because there are so many trends I could go over, but I've limited to about six examples. So we saw an increase in asynchronous care. We saw an increase in the use and acceptability of asynchronous care, that is store and forward technology, as opposed to synchronous, which is in real time. Asynchronous care is now used to deliver psychotherapy. It's also used to deliver medication management and a hybrid model between synchronous and asynchronous. And there are studies demonstrating its effectiveness, patient satisfaction. It's convenient because it eliminates that scheduling friction associated with having to make an appointment between a clinician and a patient. And it is private. It also is a way to bypass the digital divide at times if you do not have consistent access to high-speed internet because you can record a message and then have it upload more slowly. But it's not for everyone. Not everyone likes asynchronous care. Some people love it, and some people still want synchronous care. The other trend that we noted is the implementation of TELA at higher levels of care. Historically, when we've talked about TELA, it was to a large extent for outpatient and sometimes for inpatient or ED visits. However, what we've seen with the pandemic is implementation at IOPs, partial programs, residential programs, as well as expansion of inpatient programs and that allowed for more studies of TELA at these levels of care, which demonstrated positive outcomes, patient acceptability, and reduction of symptoms, as well as patient satisfaction. Another trend that we notice is the ubiquity of self-navigated platforms and applications. By some estimates, at some point a year and a half ago, there were 50,000 of them. That's five zero, 50,000. These self-navigated modules or self-navigated solutions are aimed to address milder behavioral health conditions, so milder anxiety, milder depression, maybe adjustment disorders, insomnia, or at enhancing wellness and resilience. They offer different modules, anywhere from psychoeducation or meditation all the way to more formal modules like cognitive behavioral therapy and motivational interviewing. They have many advantages. They're very convenient. They're private, no stigma associated or very little stigma associated with accessing them. You don't need to make an appointment. You can access them 24-7. At the same time, they have the benefit of being able to capture what we call patient-reported outcome measures under measurement-based care. In order to track how someone is doing, there's also applications that are able to collect passively data on someone's well-being and then either reflect them back to the patient or send them to the provider. Now, there are some challenges associated with the self-navigated modules. Some patients just don't like using them. A lot of these applications have challenges in having consistent engagement with them, so folks download them, use them maybe a couple of times, but are not consistently using them. And there is a lot of variation in the research that is supporting some of these applications, so I always urge folks or my colleagues to do research on the evidence that's supporting a particular application or solution before recommending it. We also saw with the pandemic expansion of teleconsultative services, and there's no surprise there. It is absolutely necessary because we're trying to address behavioral health needs in the context of a severe shortage of behavioral health clinicians, and most patients actually get behavioral health services in primary care settings. So what we've seen is expansion of asynchronous consults, that's e-consults typically delivered through electronic health records, as well as curbside consults via video or via audio, and definitely the collaborative care model, which my colleagues will touch on later. But some of the advantages with a collaborative care model is that it has all the evidence supporting its efficacy, it strengthens cross-specialty integration, and supports measurement-based care. So with all of that diversification, the examples that I provided, there's also a convergence that we're seeing over the past year. Now we see a lot more hybridization of care delivery between in-person and tele, synchronous and asynchronous care, virtual direct care, or consultative models together, and a hybridization of the tech that is being used, meaning combinations of video, audio, or text. And there are some approaches to delivering remote care that have been highlighted as helping patients that are encountering that digital divide still access care, like audio sessions or asynchronous care. And the APA actually anticipates that the typical psychiatric practice is one that will likely deliver a hybrid model of in-person video and audio telephone visits. So as you see, within a relatively short period of time, you know, say 2018, 2019 until now, we've really come a long way with a conversation about tele. Because when we were presenting at the APA in 2018, 2019, the conversations were focusing more about whether tele was really feasible or effective, or whether it's scalable. And what we've seen over the past few years is that it's definitely scalable, it's feasible, it is effective. There's been diversification of digital health care delivery. Right now, the conversation's evolving further on how to use the technology that's inherent to the delivery of remote care to collect more data, to analyze this data, look at quality and outcomes, and improve quality and outcomes further, to contain costs, and also to use this data to come up, you know, with more innovative models of care. And we're moving towards a digital ecosystem now with so many solutions out there. But what's clear now is that the virtual replication of in-person care via videoconferencing is no longer synonymous with innovation on its own. Endpoint solutions that don't integrate into that continuum of care and don't provide like an array of services and solutions that feed into each other really have significant limitations. Rather, to make a population health impact, what we need is a cohesive digital ecosystem that offers a wide range of virtual programs that expand both the capacity and the ease of accessing care in a manner that's equitable while improving quality and integration and supporting clinical outcomes and ensuring cost efficiency. Now, I share with you this slide because this slide is like my dream. This is where, you know, that is what ideally a cohesive digital ecosystem would look like. It's one that addresses the behavioral needs of patients across their journey, from promoting wellness to treating mental health and substance use conditions to delivering care at higher levels of care through med management, therapy, consultative services, and use of peer supports and other non-clinician support. One that diversifies for patients their ability to access care, be it synchronous, asynchronous, video, audio, text, or self-navigated solutions. One that emphasizes the importance of, quote, care coordination and referral pathways to try to mitigate the fragmentation in our health care system. And one that supports integration across primary care and behavioral health, between behavioral health and... meaning behavioral health in person and tele, as well as between health care delivery and pharmacy. And one that incorporates data analytics. We absolutely need data in order to assess the quality of the services being provided, to continue to improve these outcomes and enhance cost efficiency as well. And a digital health ecosystem that's dictated by evidence-based policies and regulations, both at the federal level and the local level, and reimbursements that make sense, that make sense for patients to be able to access care in a manner that is more affordable and for clinicians to be able to bill. And be able to provide the services in a manner that's cost efficient. And last but not least, an ecosystem that supports health equity at the population health level. We are serving patients. Our patient populations are extremely diverse. And so it's important for any ecosystem that is cohesive, that is comprehensive, to be able to look at these social determinants of health, mitigate the digital divide, and ensure that folks that need care can access them. So I don't have a clear blueprint on how to access, sorry, on how to deliver or make our way into this ecosystem. However, my two colleagues today are going to give us examples of some amazing work that's being done to bring us closer to such an ecosystem. So thank you so much. I will pass it on to my colleague, Dr. Christian Brathwaite. Excuse me, thank you. Dr. Mockboot made it seem like we'll have answers to all of these big questions. So it's a little bit of pressure. But thank you so much again for joining us. My name is Dr. Nicole Christian Brathwaite. I'm a child and adolescent psychiatrist. And again, the head of medical and clinical strategy at Headway. I do not have any conflicts of interest to disclose. So the focus of our conversation today will really be around measurement-based care and how to incorporate measurement-based care into the digital health ecosystem. But when we think about measurement-based care, we tend to have a narrow view. So if I were to say measurement-based care, what would be some of the questionnaires or measurements that you would think of immediately? You can just yell it out. PHQ-9. PHQ-9, right. GAD-7. Yeah, GAD-7. And those tend to be when you think of measurement-based care, that's often what we tend to think about as psychiatrists, as clinicians. However, what this chart essentially demonstrates is that we're somewhat limiting or limiting ourselves in terms of what's available. Granted, some of these cost money and you have to pay for them. So I realize that that's a limitation and accessibility, certainly length. But I think ultimately what this is showing us is that we have additional tools beyond just the PHQ-9 and GAD-7 that can really help us capture more evidence-based outcomes and information. On average, right now, the most recent studies show that about 20% of behavioral health clinicians regularly use measurement-based care. However, when we think about the population of behavioral health providers, that's very small. And so there are certainly a number of benefits of measurement-based care that are often not communicated or realized, including integrating evidence-based tools into daily practice. And when used appropriately, measurement-based care can really serve as a tool to improve communication and partnership with patients. Certainly when we're utilizing measurement-based care in a longitudinal fashion, we can use that outcome data to adjust our treatment decisions. And studies show that clinicians who consistently utilize measurement-based care actually see significantly improved patient outcomes when compared to their colleagues who don't use any form of measurement-based care. We're also seeing that having this concrete objective data leads to more rapid detection of worsening symptoms and even potentially contributing to relapse prevention. And, you know, again, realistically, if someone were to ask you, how did you feel two weeks ago, it's going to be fuzzy. So the patient report of what the mood experience was, what their symptoms were two weeks ago is not always accurate. And so sometimes what we're treating may be the immediate perception of the patient, not necessarily the historical truth of what the patient is actually experiencing. So these tools can really help even guide medication management decisions by ensuring accurate and more objective patient reporting. But we also have to be honest and acknowledge that there are a number of barriers to effectively delivering, but not just delivering, incorporating, interpreting measurement-based care. So you'll often see measurement-based care, patient-reported outcomes available, but the clinician's not looking at them, the patient doesn't understand them, and it's not actually being utilized to support care in any way. And so when we look at the barriers and challenges, there's certainly clinician and patient barriers, which I'll focus on, but also thinking about the more systemic barriers or at the organizational level, what are some of those functional barriers that are getting in the way? And ultimately, if measurement-based care or patient-reported outcomes are not truly seamlessly integrated into the visit, patients may see it as being burdensome. Even asynchronous questionnaires could be burdensome and time-consuming. And as I mentioned on that first slide, there are a number of excellent questionnaires, but if it takes 15 or 20 minutes, most patients aren't going to use them. Although the information is useful and quality, the patient effort or willingness to complete them because of the time requirements may actually be a significant barrier. So other potential patient barriers include patient lack of understanding, or how is this relevant to their treatment or their disease? Again, if you just say a PHQ-9, what does that mean to someone? What does a score of 15 actually mean to that patient, and why should they invest the five or 10 minutes to actually complete it? And then certainly lack of clinician engagement or involvement. If the clinician isn't bought in, or the patient asks the clinician why, and the clinician is like, well, don't worry about it. You have to complete it, but it's not that serious. Of course then, at that 90-day mark when you need a follow-up, the likelihood of the patient actually completing it is very low. And then certainly looking at technology limitations, lack of culturally appropriate questionnaires, poor feedback loops. So if a patient says, this format, the way that this is presented is difficult for me to complete, but we're not listening, that can certainly be frustrating, obviously, for the patient experience. And then we'll talk a little bit more about clinician barriers or frustrations, but just to quickly go over a quick summary. So research has shown that the most common clinician barriers include, again, lack of education and understanding of the actual purpose of measurement-based care, what measurements to use and when, or diagnostic correlation. So if every single patient that comes into your office is taking a PHQ-9 or GAD-7, what about those with personality disorders? What about the bipolar patients? What about ADHD, schizophrenia, right? So if we're only using GAD-7 and PHQ-9, we're not actually capturing the majority of our patient populations, and even those with comorbid or dual-diagnosis illnesses. Certainly difficulty incorporating the measurement-based care into clinical workflows. If it adds more time or administrative burden, it's not happening. Consistently, when we look at the top three reasons for clinician burnout, administrative burden is always top three. And so anything that adds to that administrative burden, it potentially not only contributing to burnout, but it could negatively affect the care that the clinician is trying to deliver. And then, lastly, understanding how to actually interpret the results. It's surprising, or maybe not, but when we've, and I'll talk about this in a little bit, but when we've polled clinicians, many of them have no idea how to interpret a PHQ-9 or GAD-7. And so if a patient goes from a score of 20 to 15, what does that actually mean? What is a statistically significant change for a patient in terms of a score? And then how is it clinically relevant to their actual practice? So as I mentioned, I'm the head of medical and clinical strategy at Headway. And just quickly, Headway is the largest network of outpatient or private practice therapists, psychiatrists, nurse practitioners who are in network, who accept insurance. So right now we have about 25, 26,000 clinicians who at some point use the platform to see patients in private practice and take insurance. Some people use it an hour a week, some people use it 40 plus hours a week. So we have a pretty diverse and captive audience, and we wanted to ask this question. What about measurement-based care? Do people, do clinicians in private practice utilize measurement-based care? And there's actually some data that says about 80% of outpatient behavioral health providers have some level of a private practice. So most of us have, even if it's a small private practice or a very large private practice, engage in some level of private practice, and increasingly more providers, more clinicians are accepting insurance. And we do know that a lot of insurance companies are looking for measurement-based care. They're expecting this specific outcome data. So we polled about 300 clinicians, and this was a mix between therapists, psychologists, psychiatrists, and nurse practitioners. I don't have the specific breakdown of the type of provider, but just to kind of let you know, it was all over the country in a broad group of clinicians. So the first baseline question, do you use patient-reported outcomes or PROMs? And if yes, when do you utilize PROMs? And surprisingly, over 40% of the clinicians that we polled reported using some form of measurement-based care at some point in their practice. Now this doesn't mean every patient every time. It just means that at some point during their practice they may incorporate questionnaires or measurement-based care. And so I'll highlight just a few of the more interesting responses that we received from our study and some of the themes that we were able to pull out. But so again, about 40, 45% of our clinicians said they do use patient-reported outcomes and they use it to track treatment. However, about an equal amount, 40% said, nope, no interest, no desire, don't use it, don't plan on using it. And so of those who endorsed even occasionally using patient-reported outcomes, we asked them, okay, so when? When do you bring this into your clinical practice or what are you using it for? And so about 90% of the clinicians who reported using PROMs indicated that they tend to administer it at intake. So they use it to establish a baseline of patient symptoms and getting a better understanding of the initial presentation. Slightly fewer people use the PROMs for longitudinal guidance or as a safety screener. So of that 45% that use it, it seems like for most of them it may be a one-time baseline evaluation but not something that they're continuing to use consistently throughout their practice. So now moving to the more interesting group, that 40% that report never using PROMs. And I would love to hear at the end during our questions and answers if any of these themes or responses are surprising to you or if these resonate based on your personal experiences or experiences with your colleagues. So in addition to answering multiple-choice questions, we did ask our clinicians to elaborate on their answers. That's where the good stuff comes out is when people can kind of just free text what their thoughts are. So about 80% of those clinicians who reported that they don't use patient-reported outcomes, about 80% of them said it's because they can get the information through traditional methods. It's not providing any additional data for them. Others indicated that they see these instruments as being forced. Many expressed concern that measurement-based care would, again, add that additional burden not only on themselves but also on their patients. So this quote, the client reports that they are annoying and feel like an extra task when they are overwhelmed. As we discussed in the beginning, often our understanding of measurement-based care or utilizing PROMs are limited to the most common basic tools. And so the second quote is kind of a perfect example of that. They're usually screening tools. I am not in primary care screening for depression like a PHQ-9. I'm going much deeper. GAD-7 and these other scales were not intended to be used to guide treatment. I could never use a survey to guide my decisions. And so let's look at a few of the themes of those individuals who did not feel comfortable using PROMs. So we all recognize that psychiatry, behavioral health is both an art and a science. We need both to be a good psychiatrist. However, sometimes we tend to lean much more heavily on the art side and are more resistant to the data and science side. And in general, behavioral health clinicians have been more resistant to adopting more measurement-based care strategies and integrating these standardized measurements into their practice. And frankly, many clinicians just don't trust or believe in the data, specifically patient-reported outcomes. So another quote, I don't use PROMs because I don't believe in them. I don't believe in standardized measures. No treatment is standard. But again, this is medicine, right? We have to have standards. And so these are some of the challenges and perceptions of behavioral health clinicians. And some clinicians don't believe not only in them in general, but don't believe in the evidence that they're valid. But others do make valid points. These questionnaires and measurements were never created to support or accurately capture the experiences of marginalized populations. The majority of people who have taken these and who the measurements were used to validate the outcomes were often not people of color. They were not people who were bilingual. They were not immigrants. And so when we're thinking about using these measurements, we do have to admit that the diverse population of patients that we may be seeing don't accurately reflect the experience or even the way that the questions are presented. For example, for African-Americans and Latinos who often express depression physically through somatic symptoms, many of those symptoms are not accurately captured through some of the measurement-based care questionnaires that we currently utilize. So this quote, I don't use PROMs because they lack validity. Many standardized measures are still inherently lacking when it comes to their validity for various demographic groups, which is an additional factor for me and my clients. And there were some clinicians who felt strongly that PROMs were a form of corporate oversight or control. As you can see, those who were opposed felt quite strongly about not implementing these measures in their day-to-day practice. So I don't want to utilize PROMs because PROMs equal corporate malevolence. PROMs equal the corporatization of medicine and mental health. Don't do it. Having to use a form for something so basic is an insult to the profession. If I can't tell how my client is doing through my regular sessions with them, then what the heck am I doing this for? It is redundant, unnecessary, and a total, complete waste of time. This kind of thing is nothing more than collecting evaluation information on employees. I have never gotten one of these in my entire life as a patient from any doctor, hospital, or other healthcare service. And again, there's a lot of passion in many of these quotes, but often I think sometimes the perspective is skewed because of the overall frustration around administrative burden because of some of the other corporate expectations in medicine in a hospital setting, and it kind of bleeds over into these other areas. We know that PROMs are consistently used in primary care. Most of us, when we go to our PCP, we receive some kind of prescreening before the appointment. And then increasingly, many practices in hospitals are requiring measurement-based care be a part of treatment. Certainly a lot of the larger hospital systems but we found an overwhelming negative response to mandating the use of patient-reported outcomes or measurement-based care. I don't want my employer or practice to require PROMs because it feels forced and not necessary. I feel that it should be tailored to each specific client and never required as it can be detrimental to the therapeutic relationship in some instances. And again, I'm not dismissing these concerns because if it feels forced on both the patient and the clinician, that does negatively impact the relationship. It does negatively impact the patient's perception of their care. And so I'm certainly not in any way implying that these comments are wholly inaccurate because there certainly is truth in many of them. And I find that I am able to obtain information more effectively by talking to my patients directly and naturally. I do not use them. In my experience, patients find them tedious and it makes them feel like a research subject. So ultimately, now, you know, what do we do? I always feel like I deliver, like, really, really bad news and then I try to bring the rainbow in at the end. Like, there are some things we can do to improve this. So, but one thing is that we have to address both clinicians and patient reluctance directly. And when we're building the systems, both the clinicians and the patients need to have a say. I love the phrase, not for us, without us, right? A lot of these systems that are being built, both the EHRs and using technology to integrate measurement-based care are built by people who are not going to use them, who are not going to be the recipient. And so when we have really, really brilliant, amazing people building these systems without input from clinicians and patients, it often then makes it a more difficult experience. And so I realize I'm preaching to the choir here, but making sure that from the beginning of building these digital systems, incorporating measurement-based care, that there are clinician voices in the room to help build even something as simple as the workflow. And so there are numerous ways that we can work to improve acceptance and utilization. There are a number of studies, particularly over the last five or so years, that detail successful strategies for integrating measurement-based care into real-world settings. But consistently, for both parties, it starts with education. There has to be an understanding of the why and the what for both groups, again, for both clinicians and patients. And then being informed of the benefits for those clinicians that don't understand the purpose or understanding the outcomes, not just sending them 20-page papers and saying, you know, review this to understand, but actually sitting down and having a conversation, ensuring that the information is translated in a way that's easy to understand and the value is clear for both clinicians and patients. Other important factors for patients include ensuring patient voice and choice. So, again, involving them in the assessment, helping them, helping the patients to interpret and understand the results, but is also thinking about how to minimize the overall burden. Choosing tools that are relatively easy to complete and understand. And then, again, being open to feedback, so asking for feedback but actually acting on it. The worst thing we can do is ask someone for their opinion and then dismiss it. And then clinician interventions can certainly involve recruiting a few champions, so having clinical members of the staff who can really help build that interest and engagement with the overall clinical population. And then similar to the patient experience, the clinician experience really has to minimize disruption of the day-to-day workflow. And ideally, in a perfect world, be fully integrated into the EHR or telehealth platform, so it's reducing, again, that experience of administrative burden. They don't need to go anywhere else to find the PHQ-9 score, GAD-7, or mood disorders questionnaire, and the trend is clear and present. Whereas, I know it may seem minor, but one or two extra clicks for some people is just too much. You know, if you have 15 or 20 patients, those two extra clicks can really add up and become overwhelming. But again, any approach has to both directly address the patients and the clinicians simultaneously and prioritizing both groups. Full engagement from both parties are essential for successful adoption. This is just, and I apologize if this is a little fuzzy, so this is kind of just a sample form that a patient may see. So when we're talking about ensuring that patients understand what they're doing, it's helpful to show the patient and the clinician what the trends are. Explain to the patient and the clinician what the score means, and so the last time that they took the PHQ-9 or GAD-7, or, you know, the GAD-7, they were in the severe anxiety category. And so, 60 days later, and they're taking it, what does that reveal? And for patients, even that can be very insightful because if they're only focusing on one specific symptom, and that symptom hasn't improved, their perception is, I'm not getting better. And so, even having these measurements and revealing the evidence can also be helpful for patients to realize you are actually getting better. It's just sometimes not as evident. And this is an example of, so Hedway is in the process of building a platform that will allow our clinicians who are in private practice to still integrate measurement-based care into their practice. So we're working on encouraging the use of measurement-based care, again, by incorporating the results into the technology platform and providing the data-driven information to help inform treatment decisions prior to the appointment. So, again, showing trends, letting, you know, showing exactly the last dates. Often, when we look at some of the PROMs or measurement-based care, you see that one data point, but that's not helpful if you don't have the full trend. And so, ensuring that when you're providing this data to clinicians that they're able, excuse me, they're able to see the full picture. And this is just a list of apps or web-based options or tools for measurement-based care collection that were really created to improve the ease of use for patients and clinicians and encourage asynchronous adoption. I am not endorsing any of these. These just happen to be a number of the tools that during the research that I found or that other clinicians have used or recommended. So, the image on the right is an image from the MoodFX, which basically allows users to screen and track their symptoms, set reminders, share their results with their clinicians. And then providers can also send patients educational resources through the app based on the outcome data. And so, lastly, again, just kind of summarizing what the evidence shows around clinician engagement and adoption of measurement-based care. So, this chart is from a study called Setting Measurement-Based Care in Motion, Practical Lessons, and the Implementation and Integration of Measurement-Based Care in Psychiatry Clinical Practice. So, basically, in this study, pulled a number of clinicians and looked at aggregate data, and they developed a list of about eight key takeaways from their research. And again, many of which are consistent with prior studies as well as what we discovered at Hedway. So, those eight takeaways are, one, select measures that are clinically relevant and appropriate. Two, make measurement-based care data easy to use. Measurement-based care data easily accessible within the EMR. Three, collect data at every visit, although this is where you'll see some studies vary. Some people do it 30, 60, 90. Other studies recommend every single appointment. So, that's the kind of one area where we see some difference. And then, four, ensure measures can be completed prior to the appointment so that you're not using the face-to-face appointment time completing these measurements. Five, prioritize patient engagement and education. Six, seek feedback from both parties. Seven, incorporate collection efforts into telehealth. And then, eight, optimize measurement-based care by utilizing it to recognize suicide risks specifically and implement suicide risk alert based on those responses. So, ultimately, again, we recognize the importance of measurement-based care, but also have to acknowledge that many clinicians have significant reluctance to incorporating measurement-based care to their traditional practice. And administering patient-reported outcomes or measurement-based care has to be easy, and it has to integrate seamlessly into the EHR. The why has to be obvious and relevant. The clinical application has to be obvious and relevant. How this can ultimately support and impact the practice of the clinician. How they can interpret the results to impact their treatment plans. And then, just the overall value-add has to be effectively communicated. Thank you, and I will now pass this over to Dr. Rao. Thank you, Nicole and Hassam. As stated before, my name is Shane Rao. I'm really honored to be speaking in this setting today and following up for my amazing colleagues. A little bit of pressure coming after these two guys, but I will do my best. You know, so far in our discussions today, we've talked about how telebehavioral health has moved from small-scale feasibility and effectiveness to really a demonstrated scalability and a proven positive impact on population health. We've explored the massive potential of patient-based care for enhancing care quality and for tracking outcomes. And so, what I'd like to focus on now is the concept of enhancing population health management in the virtual space. So, what I'll be trying to do is describe one version of population health management by way of an initiative in a nationwide virtual practice. So, the company that I work for, Ray Behavioral Care, I'll tell you a little bit about what our early experience is and also provide a description of an experience with a well-studied collaborative care model of integration, also by way of a virtual platform. Oops, too fast. I do not have any conflicts of interest to disclose. Let me just start with kind of the overarching question that I think is on the minds of all clinicians, clinical administrators, payers, stakeholders. What's the best treatment for my patients, for our consumers, for my clients? In medical school, we focused on learning about evidence-based treatment, right? So, I was instructed that evidence-based treatment carries the promise of allowing us to deliver the correct treatment for the correct individual at the correct time. But we all understand that, and myself especially as a former aspiring clinical researcher, I know a little bit about how the sausage is made, right? I know a little bit about how the evidence base is created, and because of that, I know that that evidence base can really be flawed. It doesn't necessarily apply evenly across individuals or across populations, and I think in generating the evidence base, we really struggle to account for the uneven allocation and availability of treatment resources. So, evidence base is there, and we definitely need to pay attention to it, but there are some flaws in that, so what do we do? In residency, and in my initial work as an academic psychiatrist, I learned a lot about measurement-based care, and so Nicole has very clearly demonstrated the benefits of measurement-based care. Once you learn that good evidence base, as a good clinician, we're obliged to see if that evidence base applies to our particular patients, to our particular caseload of people, but what if our measurements tell us that, no, we're not seeing the outcomes that are predicted by that evidence base? What if we can't provide that evidence-based treatment to all of our population of patients? So, getting those measurements is really important to know if we're doing well, but then what do we do with that data? What do we do with that information? So, for myself, where this leads me is to think about population health management. As I've personally taken on administrative roles and started to interact with the larger field of psychiatry, public health, other mental health professionals, it's pretty apparent that there are a lot of constraints on what we can offer to patients and to our populations. So, we really do have to think about that population health management process. Population health management has been defined as the process of studying and facilitating healthcare and its delivery in order to create improvement for a population of individuals. Using data analytics to define patient cohorts, to stratify members of a population, and report on both individual and group outcomes. And then we need to feed that data back into the healthcare system for continuous quality improvement. So, the critical components really here of population health management are utilizing measurement-based care, having a system of stratification for the patient population, and integrating what we are doing for and with our patients into the larger healthcare system. So, one example of this, well actually let me say first that payers, non-profit organizations, even the CDC have initiated and championed initiatives over the last few years to enhance and spread population health management. So, this is a high priority for the field at this point. So, what I want to do is provide an example of how we're thinking about it at the company that I work for at Array Behavioral Care. Sort of the initiation of a process that we're trying to get into that we hope is going to address this. And by providing this example, hopefully help you understand sort of population health management more as a whole. Please do not try to read this slide. It is crazy busy, and I recognize that, but it is here just for illustrative purposes. The goal of the initiatives that we're looking at at Array through our virtual direct-to-consumer platform is a paths of treatment process. So, our goal for this is to utilize population health management principles across our virtual care platform. Very briefly, the concept is basically as follows. Patient gets referred in, and they go through an initial intake. During that initial assessment, which in our initial case is going to be through a licensed clinical social worker, he will do a basic mental health diagnostic assessment, utilizing measurement-based care tools at that initiation of treatment. But we've added a little bit of a twist to this. We've designed an acuity stratification tool that we will utilize to look at about 14 different factors for our patients to figure out are they high-need, low-need, medium-need, what is their basic treatment necessity. So, based on that initial assessment, utilizing, again, measurement-based tools, our acuity stratification tool, sort of looking at where they are in age group, what their comorbidities are, they'll be assigned to a treatment path. If they're relatively low acuity, they've got lots of good family support. We feel that they're pretty well functioning out there. They're going to go into path one. They may just get one clinician, relatively low cadence of visits, not going to be high utilizers of treatment necessarily. But if maybe they don't have a lot of support, or they don't have a primary care clinician, or their severity of illness is higher, they might be routed toward path three, where immediately they would be assigned a clinician, a therapist, perhaps a case manager. So, the whole goal is to try to push resources to those patients who really need it right from the start, not wait for a little bit slower clinical decision-making to kind of refer folks in for the resources that they need, but hopefully offer that up front for them. Additionally, we're hoping to add into this process decision-support tools. So, some of the tools that Nicole was mentioning for asynchronous measurement of a patient's symptoms, utilizing tools that can push rating scales out on a scheduled basis, so our clinicians aren't having to think too much about getting those scales out there, but they can just take a look at the results when they come in. All of that will be connected into the passive treatment program. So, in other words, what we're really hoping is to get to this ideal of the right treatment, or the correct treatment, for the correct patient at the correct time, but in the context of variations that occur in the evidence base, and with an optimal allocation of limited resources. So, this is conceptual. This has not been rolled out. We are hoping to start this process, actually, relatively soon, and my hope is that by this time next year, we're going to have some lessons to share and some data to share. But what about integration? So, let's say this works beautifully, and we get all our patients under the right pathways, and everybody's getting the right treatment, but they also have medical comorbidities. We may be treating folks with dual diagnosis, and so these are clinical treatments that we are not expert in, and we need to integrate into the larger healthcare system to get the services for them that they need. Oops. Why am I not moving forward? Let's try that again. Hmm. I'm seeing it move forward here, but not. There we go. Okay. So, integrated care, again, if we're thinking about population health, we do need to move beyond just that measurement-based care process and stratification, but also figure out how are we going to integrate into the larger healthcare system. And this slide demonstrates a few of the reasons why I think it's so important. Lifetime prevalence of mental illness and substance abuse in the U.S. is about 50 percent. That's about half of us. At some point in our lives, we'll have a mental health symptom or syndrome or may struggle a little bit with a substance. Only 50 percent of those receiving mental healthcare in the U.S. receive it from mental health providers. Half of those folks are actually getting that treatment from general medical providers. So, these folks are really not even coming into the system, right? So, they're elsewhere. We need to find ways to reach out to them. There's very significant comorbidity that exists between physical and mental illness, and there's a bilateral negative influence of one upon the other. An example of that is amongst patients being treated for diabetes, those that have comorbid depression are much more likely to have incident disability at five years than those without depression. One influences the other. So, again, we have to integrate our treatment to include our physical health colleagues. In addition to contributing to solutions for the need to treat the whole person, integrated care also hits the triple aim in healthcare. So, utilizing integrated care models have been proven to improve outcomes, have demonstrated high patient satisfaction, and are cost effective, sort of the trifecta of what we're looking for in our organizations. So, the rest of my discussion today is going to focus in on an experience that I've been involved with, with Array Behavioral Care, and the MCCIST, the Michigan Collaborative Care Implementation Support Team, that's a mouthful, as well as United Physicians. So, the MCCIST partners with health systems across the state of Michigan and beyond to provide individualized consultation and specialized training for the implementation of the collaborative care model. That collaborative care model is highly evidence based as a model of integrated behavioral care, helps patients with mental health conditions receive access to high quality mental health care within the primary care setting. I'll talk a little bit more about the model as we go. Array Behavioral Care is the nation's leading clinician-centric virtual psychiatry and therapy practice, and we have partnered with United Physicians, which is one of Michigan's largest physician organizations. They represent about 1,700 physicians in southeast Michigan, and their mission is to deliver efficient and integrated care through a network of physicians. So, we felt like this partnership could come together, utilizing really high quality training to create a collaborative care model of treatment for adults and children. In our partnership with United Physicians, the United Physicians team identified 11 clinics that had a strong interest in participating in our program. These are independent practices, so they have different workflows, different clinical policies, different EMRs. So, it's a loose confederation, I would say, of practices that we were able to participate with. So, the collaborative care model that we utilized in partnership is illustrated to some degree here. It's a model that was developed at the University of Washington, and it is now researched and implemented through the Advancing Integrated Mental Health Solution Center, or AIMS Center, at University of Washington. If you go to the AIMS Center website, there is a fantastic collection of evidence base that proves how well this model has worked. Also, it helps to show some of the pitfalls that we have to be careful of. But the goal of the model is to supply much needed psychiatric care in the medical care home, to provide care options that are faster and more affordable than traditional channels of mental health care. The wait time to get in to see a therapist in many communities, obviously, can be quite long. The wait time to get to a psychiatrist can be quite long. This helps to bypass some of that. Also, to help improve the overall health by supporting patients with depression and anxiety in a primary care clinic. You know, we have that reciprocal connection between physical and mental health. If we help to improve somebody's mental health, hopefully we're also helping to improve their physical health. There are various individuals that are part of a collaborative care treatment team as part of this model. We have our primary care provider and practice staff. The patient, obviously, is kept at the center of this process. There's a behavioral health care manager, as well as a psychiatric consultant. And you can see, based on the arrows here, that the behavioral health care manager and the primary care practice are going to have a lot of very frequent interactions. The behavioral health care manager is also directly seeing and providing treatment for the patient. The behavioral health care manager and the psychiatric consultant are linked together with a systematic case review tool. And the psychiatrist themselves really is interacting with the care manager and the assessment tool, not interacting all that often with the patient or almost never with the patient themselves, and somewhat rarely with the primary care provider. So, the psychiatric consultant is really free to utilize the time that they have for the program, providing solid recommendations and dealing with the data that's coming in. Just a little bit more on the roles for each of these different individuals in the program. The primary care physician and staff are tasked with, excuse me, recognizing the signs of possible depression or anxiety in their patient population by performing and reviewing screening tools. So, in this particular project, we did utilize the PHQ-9 and the GAD-7 for screening here. They educate the patient regarding possible diagnoses. Training is provided at the initiation of this process for the primary care folks to make sure they've got a good, solid understanding of the diagnoses they may be seeing. And then the practice coordinates with the behavioral health care manager, as appropriate. Then the behavioral health care manager, which is really the meat, I would say, of this collaborative care team. They're doing lots of the hard work. They make contact with the referred patient, and if that patient consents to join the program, they perform an initial diagnostic assessment to diagnose, confirm appropriateness for the treatment program, and develop some initial treatment goals. Follow-ups then occur weekly for the first few weeks, every other week for four to six weeks, and then at least monthly for three months, sometimes quite a bit longer. Those follow-ups are 15- to 30-minute visits, typically done by telehealth, and typically done direct to consumers, so a patient is usually in their home. They provide skill-based interventions, like motivational interviewing, behavioral activation, and problem-solving. And then the behavioral health care manager also meets very regularly with the primary care physician or their practice staff, or both, to discuss the process, how things are going, and also to discuss patient's progress. The behavioral health care manager is also responsible for deactivation from the program, if and when that occurs. So if the assessments indicate sufficient improvement, or the behavioral health care manager and the patient agree that sufficient progress has been made, they can make a decision to terminate the process. Also, if further treatment is determined to either be not necessary or not appropriate, so if one of the patients in the program needs a higher level of care, they need to get in to see a psychiatrist more urgently, that's another reason they may be terminated from the system. The cadence and overall duration of the program can be adjusted based on the level of acuity, and also if a patient graduates from the program, per se, and sometime later they have a relapse, they may be re-referred into the program, as long as they're meeting criteria for re-referral. And then the psychiatric consultant is going to be sort of looking at the case profiles, and will help to confirm diagnoses. They serve as a behavioral health subject expert, subject matter expert, excuse me, for the practices. They do meet with the behavioral health care managers on a weekly basis to review cases that have been referred, provide written recommendations for medication options, and evaluate the need for referral, if necessary, to a higher level of care. They're available on a regular basis to the primary care physicians for curbside consultations if there are questions about recommendations being made. Very rarely, there may be a situation where they would see one of the patients. That's very rare and purposely kept to a minimum, because the PCP is still the prescribing clinician. So, since a psychiatrist is not seeing the patients regularly, they are not providing prescriptions, they're simply providing recommendations. So, the way this process works, once a clinic has identified itself as interested in participating, they were provided an orientation to collaborative care, training that was provided by the MCCIST. A physician champion was selected in each clinic. Staffing level and staff readiness were reviewed by array staff to ensure the clinic had appropriate resources. Training included, in addition to training on the collaborative care model, a suicide protocol development and implementation for safety purpose. A little bit into this program, we realized that some of the clinics that were self-identifying were having a hard time finding enough referrals or sort of making sure that they had enough folks to send in. So, we began to require that they identify 50 or more qualified patients at the beginning of the process to ensure a good referral source. And then, read-only access to the electronic medical record was provided for the psychiatrist and the behavioral health care manager. Over the course of the program, there were several things that were tracked, but probably the most predominant data that we looked at on a regular basis were the number of referrals per clinic site. So, we looked at this over a trailing 12 weeks. The number of sessions being provided by the behavioral health care managers per site. And with this information, we were able to identify clinics that were maybe struggling to get referrals in and also identify some superstar clinics, the clinics that were really doing a great job of referring patients in and appropriately. Then, we had weekly or bi-weekly discussions between Array medical leadership and coordination staff and the United Physicians leadership and coordination staff to assist those struggling clinics to come up with problem solving and to export the techniques from the superstar clinics to the rest. And then, regular re-education and training occurred throughout the program, again, for those clinics that were struggling. So, how did we do? The partnership, in my personal experience, was more challenging than I expected. And I think that was contributed to by the fact that United Physicians has these somewhat disparate, very unique personalities, I think, across those different clinics. It was hard to standardize, I think, our approach with that group. This graph that you're seeing here looks at the number of sessions and the number of unique patients and active status month by month over the first year of the program. And you can see in those initial months, June, July, August, you know, referrals were kind of trickling in. Somewhere around September, October, we began to implement that primer list of those 50-plus qualified patients, and you can see the referrals jumped up at that point. If you look at number of sessions compared to the number of patients involved, they were having a cadence of about two and a half to three sessions with our care managers per month on average. Over the full course of the program, there were about 796 unique patients referred and enrolled. However, only about 244 of those had qualifying initial scale scores. So, we had a lot of referral from folks, referrals of individuals, that didn't quite meet the criteria. And it indicated to us that there was a little bit of misunderstanding at the level of the primary care clinic staff about exactly who to refer. And also, given that there was a little bit of lag time between referral and initial assessment, some patients just got a little better by knowing that they had someone to go to. So, our actual data set is that 244 folks that came in with the appropriate initial scores. As you can see, the start date of the program was May of 2021. It ran through to September of 2022. So, what were the rating outcomes that we saw? So, our PHQ-9 and GAD scores were primary outcomes that we measured over the course of the program. Symptom severity drops did occur and were clinically significant for the patient population. There were 338 patients that had at least one completed PHQ-9 scale. 186 of those had those PHQ-9 scores in the appropriate range, above 10 at the beginning. If you look at the average first PHQ-9 versus the average last PHQ-9 for the whole patient population, there was a drop of about 3.1 points, or a 29% drop in that score, which led the average population from a moderate level of depression to a mild level of depression. So that's some improvement, which was nice to see. But then we took a look at the individual scores and individual change over the course of the treatment and found that about 25% of patients reached remission over the course of the program. About 17 or so percent didn't quite remit, but they did reach clinically significant improvement. About a third of patients did not have any change. And about five, six-ish percent of folks actually had a worsening over the course of the program, likely related to external stressors. So in my mind, I felt pretty good about those numbers. We were seeing some improvement in a lot of folks. Patient satisfaction with the program was very high, so that was excellent. We had very few dropouts or losses to follow up, so those were wonderful things. I did want to take a look at how that compares to the literature. And so I took a look at this meta-analysis by Bauer et al., looking at implementation for depression management in community-based primary care clinics. So very closely aligned with the kind of program that we had. With that group, they found that over a number of different studies and programs, about 60% of patients showed at least clinically significant improvement. So we underperformed a little bit along those lines. We did well for remission, though. About 25% of folks remitted, if you look at the literature as a whole, and that was the same for our program. We did also look at GAD-7 scores to look at anxiety symptoms. We had 339 folks that had at least one completed GAD scale. There was one person that did a GAD who didn't do a PHQ. About 193 of those folks started with a GAD greater than 10, so met the criteria for inclusion. Graph on the left demonstrates, just like the last graph, the average first GAD versus the last GAD score across the population. And we saw about an average 3.5 drop, about 33% drop. Again, moving our average population from moderate anxiety to mild anxiety. Looking at individual consumer change scores. For the GAD-7, the literature suggests looking at percentage drop as opposed to necessarily looking at point drop. So clinically significant improvement is any drop of 50% or more on the GAD-7. We had about 41-ish percent of folks that had clinically significant improvement. Just like with the PHQ, about a third of folks did not show change. And just like the PHQ in that five to 6% range, we had some folks that had a little worsening. So, after demonstrating that data, some lessons that we learned, and that we definitely want to think about if we attempt this again. Primer lists were actually not a part of the initial onboarding process, and we found that those were extremely helpful for driving referral sources. Adoption of rating scales was often a rate-limiting factor for some of the clinics. Nicole pointed out a lot of the resistance that we can see with clinicians to initiating PROMs or initiating those scales. That was true in our population of clinics as well. And so, additional education or additional training around that at the beginning of the process we think would have been helpful. Behavioral health care managers, excuse me, involvement in the referral push was found to be a lot more effective than relying on the clinic's administrative staff. So we really had to get our care managers in there, pushing the story, pushing this line. The administrative staff in the clinic had an awful lot to do already, so we needed to really insert ourselves and add that piece. And there was a lack of true integration in the clinic's EMR. That was one of the biggest challenges from my standpoint. So it made it difficult for us to try to make any assessment of correlation between improvement in mental health and improvement in physical health. So that is another piece that we would want to negotiate probably differently if we try again. The lessons that we learned are the lessons that have already been learned in some of the literature that I was able to take a look at in preparing for this discussion today. Effective implementation of collaborative care for depression in studies has been shown to require nine significant or specific factors. These are the things that lead to a highly successful program. Number one, the operating costs need to be seen as not a barrier. So the clinic that you are working with needs to have adequate coverage or other financial resources for patients to be able to afford the extra operational costs. So you don't want to have to make your patients pay more to get into this program. There were financial incentives involved in the contract that we had with United Physicians that worked out quite nicely. There needs to be an engaged psychiatrist. That psychiatric consultant needs to be engaged. Showing up every week, doing those case reviews, reaching out to the primary care physicians to do the curbside consults. That's critical. The primary care physicians need to buy into the process. Most clinicians in the clinic support, need to support the program and refer patients in. The clinics that were the real superstars were the ones that had primary care clinicians that really bought into the program, really bought into the process. Some of the clinics that struggled, the primary care physicians struggled a little bit to understand exactly what we were trying to accomplish. And I think just had a little bit more difficulty finding patients for us. Needs to be a strong care manager. That person needs to be perceived as the right person for the job and work well with the other staff members in the clinic. Warm handoffs are very important. So face-to-face meetings are very important. And we've had a lot of those in the past. We've had a lot of those in the past. Warm handoffs are very important. So face-to-face or at least real-time referrals are a major benefit. Strong top leadership support. If you don't have good support from the top down that can damage your ability to have a strong program. Primary care physicians need to be strong champions, really push and actively promote the project. The care manager role needs to be very well-defined and implemented. Everyone should know exactly what that person's job is and exactly what types of interactions they need to have. And then the care manager should be onsite or at least visible by televideo and available for referrals and to answer questions if there are issues or problems in the process. So on future iterations of this model of care, we are still doing some collaborative care work. And if we do initiate another project of this scale, my hope would be that we can add in some measures of quality of life and general functioning in addition to the census scores, add in some measures of metabolic parameters. So metabolic syndrome is something that's common in our patient population that we want to track. And suicide safer care measures or safety measures should be added in and analyzed in more detail. So just to try to wrap up our whole morning here in a few words, I think what we've been able to demonstrate is telebehavioral health is here to stay. It's effective. It's scalable. Implementing population health strategies across virtual practices and by way of integrated care has really profound potential for a rapid spread of optimized care across geographic boundaries, across patient populations, across treatment settings. If we're able to implement some of the tools that we've discussed today, I think what you're gonna find is that the care that's being provided in this manner is higher quality care than is seen really anywhere else because we have access to this data if we can create the systems to make it work. Integrated care such as the collaborative care model of treatment allows for expansion of best practices and sharing knowledge across the full spectrum of healthcare settings, impacting lives across all levels of society. And we believe that telehealth practices are really uniquely positioned to accomplish this population health management ideal because of the capacity that we've mentioned for broad accessibility, the combination of synchronous and asynchronous treatment, natural drive for adoption of technology to enhance efficiency, lower cost to the consumer, both financially and in terms of activation energy, just getting people into clinics, et cetera, and a lower activation energy for the clinicians to be able to provide treatment across geographic locations and across time limitations. That is it for me. I think that is it for us, and we will be happy to start taking some questions. Thank you all. Thank you. Thank you, Dr. Rao. Thank you, Dr. Christian Brathwaite. Happy to take questions. Yes, thank you for the presentation. I really enjoyed it. It was really helpful. I find when I bring something to a place, it could be a company, it could be a clinic, it's the buy-in. And I find the thing about the buy-in is understanding where they're coming from. But that buy-in is so important. What things do you do to get the buy-in from the clinic or from the company? So I can say I think where the system worked really well, our behavioral health care managers, I think, did a beautiful job of providing training up front to the clinician staff directly, right? So in some of the clinics, I think that initial training, maybe the physician wasn't really gonna be involved in the project moving forward, or some of the clinic staff were turning over. So that led to some disruptions, I think, in obtaining that buy-in. So the folks that were there from the start weren't necessarily there to continue that energy. But it's really the interpersonal interaction, I think, that's most important. You can sell them on slides and help them understand the process as much as you'd like, but unless there's that sort of personal responsibility between those two people, I think it's hard to really get that buy-in established. So that interpersonal interaction, lots of meetings, lots of frequent face-to-face time, I think is what was most important. Yeah. I may kind of flip the situation a bit. Part of my role is to evaluate different digital health solutions to assess whether we wanna partner with them. And when they request a meeting, my first question is, is your medical director going to be on that call? More often than not, they don't have a medical director, which is something that Nicole mentioned. And that really affects my buy-in and biases me before I even meet with them, because I'm already concerned. Now this, of course, I'm happy to be proven wrong, but there's a lot of value to having that relationship with the medical director, being able to speak that clinical language, especially when we're talking about digital health and at the population health level. I would just say kind of similar to what we did at collecting data. I'm sure we've all experienced the frustration of things being implemented and we were never asked. So I would say one, like asking the right questions, doing the research to articulate, to help articulate what the pain points are so that when you are looking to solve a problem, you're actually solving the right problem. And then so collecting the data, getting the feedback from clinicians, patients, staff, but then actually formulating a plan to address those specific problems. Because then when people feel heard, they're willing to invest time and resources. Too late. Good morning. Excellent talk. I really appreciated all the presentations and all the visuals. I'm Dr. Mary Langley. I'm a psychiatrist in the Veterans Health Administration, which is the land of big data. And so we use a lot of integrated care and we have enough data to make it very obvious what our gaps are. So I love the idea of the digital health ecosystem and the promise that integrated care might even help us serve the underserved. And so this is my question. Does the panel have thoughts about how to apply integrated care tools to those, that part of our population, which is very large, that won't even go to a primary care provider? Like our homeless population, for example, we're struggling to figure out how to even do basic things like suicide screening with them. So I'm very interested in hearing what you think about using those tools and applying them. So I can comment. One, I think it's challenging because many of the interventions that are helpful are not reimbursed. And so ultimately going to the community. So I live in Boston and we have a great program called Healthcare for the Homeless where clinicians, psychiatrists, physically go and meet patients where they're at. And they've even started adding tablets. And so if, for example, there's a child, they're able to connect with a child psychiatrist. And so still utilizing that digital technology to bring treatment, but that means like on the ground. And that means you need the funding because you're not going to be able to get reimbursed for that time. So I think that's the most challenging part is who's paying for it. But ultimately we're going to have to make the sacrifice and meet people, literally meet them in the community to provide that care. But then bringing in the digital components to help improve and obtain data. I would add there are some interesting companies out there. They're doing some very interesting work in really utilizing access to mental health or substance use treatment as the entry point for the healthcare system. To some degree, and they take risk on physical health as well. So some degree they're kind of maybe flipping what we would expect of having a primary care physician be the gatekeeper to having the behavioral health clinician be the gatekeeper. Just as I think about this for our online programs that I've had experience with are very much along the lines of what Nicole is describing. Kind of homeless mental health access programs where you are getting out into the community, taking some of that digital technology with you. But also that reversal of integration, utilizing mental health clinics as the gateway, I think is extremely important. There are folks, I think in that sort of sector of society that interact more with mental health than they do with primary care. So we really do have to do a good job of pushing that group toward the primary care practices and integrate solidly with them. But I also think it means as psychiatrists, as mental health providers, developing some of our own expertise in managing basic physical health issues is important. So just like primary care physicians do manage a little bit of depression, do manage a little bit of anxiety, I think we should be able to manage some diabetes, a little bit of heart condition. So I remember a couple of years ago, the APA had a training program for psychiatrists, kind of a primary care for dummies sort of program that I attended. And it's something that I still utilize in my practice where I can manage some basic physical health issues when those patients just can't get to or can't make it to the primary care position. We are often the only physician that someone sees and creating those collaborations, but also taking on some of that responsibility, I think is very important. So we have about four minutes left, so we're happy to take your question. Then we're gonna take a question from our online audience as well. Yeah, great. Hi, my name is Paul. I'm with Sensible Care. It's outpatient clinic down in Orange County. So actually kind of a follow up to what you had just spoken about with the mental health clinic being the first point of contact. Has there been any consideration of potentially having even like a primary care physician be a part of the mental health clinic and therefore providing quick access kind of in the opposite type of model? And then the second question I had was with Dr. Rao, with your program, it didn't really have as much of the psychiatric input as much as the BHCM, but was there a specific concern that was related to why there wasn't more of like the quick access to the psychiatrist? And was it related to just access to enough psychiatrists or something like that? So to address the first question, first, you know, reverse colocalization, colocalization is definitely a part of the field. And I think there's a decent amount of research on seeing primary care clinicians co-located into mental health practices. I'm not aware of that being done in a virtual space as of yet, but it may just be that I haven't looked hard enough. But I definitely think that's highly valuable. So when I worked for the UNC Center for Excellence in Community Mental Health, we had a nurse practitioner, internal medicine nurse practitioner that came into the clinic about once a week, spent about six hours, I think, with us and did provide that kind of treatment for the physical health issues of our patients. And it was highly successful. The patients loved it. Everybody's health got better. It was a good thing. So developing more of those kinds of programs is, I think, critical. You know, in terms of direct access to the psychiatrist and the collaborative care model, my understanding of the model is that you wanna try not to go there. And the reason for that is psychiatrists are very few and far between. The number of hours that are able to be provided by the psychiatrist are very few and far between. So you're really trying to train that primary care practice to provide that basic mental health service just with providing that sort of curbside consultation, asynchronous kind of work. And you also wanna kind of save that psychiatrist for the more difficult cases, right? So the folks that need the higher level of care, hopefully, you're not utilizing that psychiatrist hours treating the less severe cases when they're able to actually engage with and treat the more severe ones. So one of the nice things about a partnership is referrals can occur back and forth between the two organizations. And Ray certainly provides psychiatric services across the country. So it's possible for some of those patients to get directly referred in or for us to assist them in finding local resources. Okay. What about if maybe you had utilized like NPs or other physician extenders that might be more readily available for supplying that type of care? I think part of the reason the program was very well received in that area was simply because there weren't any folks around, right? So the region that we were providing this care within, I think had a pretty significant dearth of mental health professionals in general. So yeah, I think the NPs probably also were not available. Yeah. And particularly for that direct care access. Cool. Thank you so much. Thank you. We have, we're at time, but we'll, we have one more question for Dr. Rao. It's a two part question. The first one is, is there data regarding the use of audio only care in mental health versus video telehealth? That's the first part of the question that says, we found some clinicians and patients hesitant to adopt video during the pandemic with an overall reliance on audio only care. How do we balance meeting patients' needs and delivering care? Yeah, it's not an easy, it's not a quick answer, but maybe you can start with the first question, first part of the question. To be perfectly honest, I am not readily familiar with data on audio only care. So I will admit to that right away. My personal experience with audio only care is, one, it's not well reimbursed. So that's an immediate financial issue. As a practitioner, I prefer video over audio because I think I get better information if I have that visual connection. So I would have to dig into that, to be honest, to figure out what the data looks like. I have not really run into clinicians that are very hesitant on adopting the video system. So I'm curious to know where that question might be originating. But in terms of meeting patient needs and delivering care, I think it's important for us to continually advocate for and develop as many access points as possible. So while I prefer video, if I can only see a patient by phone, I'm gonna do that, right? If somebody just doesn't wanna come up on the video screen with me, then I'm gonna give them a phone call and I'll let my business department figure out the compensation. I think we wanna sort of throw a shotgun approach at this and make sure that we're providing as many access points as possible with whatever that patient and clinician pair are comfortable doing. That's our time. Thank you so much for joining us. Thank you.

telebehavioral health

innovation

integration

Dr. Hossam Mahmoud

Dr. Nicole Christian-Brathwaite

Dr. Shane Rao

population health

telehealth benefits

COVID-19

measurement-based care

digital health ecosystems

collaborative care models

equitable care