Healthcare CEOs who responded to ACHE’s 2022 Top Issues survey ranked behavioral health and addiction third on a list of 11 concerns, behind only workforce challenges and financial pressures. That’s ahead of such perennial and still very pressing issues as patient safety and quality, governmental mandates, access to care, and patient satisfaction.
The survey indicated that behavioral health and addiction are perhaps intertwined with the two issues that outranked them. Among the most common reasons respondents gave for their degree of concern were “lack of appropriate facilities/programs in the community” (78%), “lack of funding for addressing behavioral health/addiction issues” (77%) and “insufficient reimbursement specifically for behavioral health/addiction services” (70%).
Societal events of the past few years have at least partly driven the need. The proportion of adults with symptoms of anxiety or depression rose from 36.4% in August 2020 to 41.5% in February 2021, according to the U.S. Centers for Disease Control and Prevention. Meanwhile, the proportion of mental health-related ED visits rose 24% for children aged 5 to 11 and 31% for adolescents aged 12 to 17 between comparable periods in 2019 and 2020.
These spikes touched all ages, races and income brackets, leaving patients with months-long waits in some cases due to a lack of available providers or resources in their areas. Behavioral health providers and experts agree fervently that improvements are imperative, and they offer up a bevy of ideas on what needs to be done.
“The crisis is not new,” says Stephen Merz, FACHE, COO, Sheppard Pratt Solutions, a recently formed consulting division of Sheppard Pratt, one of the nation’s oldest psychiatric hospitals, founded in 1853. “There are not enough leaders who know how to successfully manage this vulnerable population, and for many years, we have lacked enough team members to provide care at a scale and magnitude that’s needed.” The demand-side challenges have grown both substantially and qualitatively, “exacerbated by the COVID experience,” he added.
J.R. Greene, FACHE, CEO, Psychiatric Medical Care, Nashville, Tenn., points to the paucity and ambiguity of funding sources. Founded in 1992 by Greene’s father, James A. Greene, MD, the mental health management organization partners with more than 250 facilities in 34 states—historically focused on rural areas but recently moving into urban markets as well—to provide outpatient, inpatient, telehealth and pediatric psychiatry services.
“The funding has not universally been at a rate that would motivate many practitioners to become behavioral health experts compared to other specialties,” he says. And payers don’t have the same hard data about the costs of behavioral health treatment as they would, say, for a hip replacement. “We don’t know the exact costs associated with treating various mental disorders,” he adds. “As an example, we can’t tell someone with adult bipolar illness that they will need a certain type of treatment for a very strict amount of time, at a set industry cost. [That] ambiguity of behavioral health treatment disrupts the funding mechanisms. Insurance providers want to see consistent data to know their realistic estimated cost by treatment. Behavioral doesn’t have this near perfect sophisticated capability—yet.”
Terrie Andrews, PhD, vice president, behavioral health, Baptist Health and Wolfson Children’s Hospital, Jacksonville, Fla., and an ACHE Member, agrees. She cites data from the U.S. Substance Abuse and Mental Health Services Administration showing that the percentage of people experiencing a mental health crisis has risen from 1 in 5 before the pandemic to 1 in 3 today.
“There’s going to be a three-fold increase in the need for outpatient behavioral health services and addiction treatment over the next couple of years,” Andrews says, pointing to estimates from healthcare and hospital system consultant Sg2. Data from the Florida Hospital Association show that “there’s still not enough beds, and reimbursement is extremely low from insurance.” She says insurers need to reimburse at appropriate levels so patients can not only get care when they need it but also so hospitals can provide it at a sustainable level.
Doris Fischer-Sanchez, DNP, FASHRM, a clinical and enterprise risk management consultant at Marsh McLennan, Chicago, says geriatric psychiatry is another area sorely lacking in providers, which means many people 65 and older turn to internal and family medicine practitioners. “Usually, if there’s a budget cut, it’s one of the first areas,” she says. “All of these factors contribute to longer wait times for people to access behavioral healthcare.”
Benjamin Miller, PsyD, past president, Well Being Trust, a national foundation dedicated to mental, social and spiritual health, says treating mental health as a separate issue contributes to the problem, with “different delivery models, different payment mechanisms and different training opportunities that reinforce that fragmented view. When people need help, they’ve got to access a different system and talk to different providers. That works against timely access.”
To grow and support mental health services, hospital and system executives can start by making robust use of their leadership positions to speak up, Merz says. “It’s powerful to hear the leader of the healthcare system talk about the importance of integrating physical and mental healthcare together, and then resourcing it,” he says.
Next, ensure that services are accessible through such initiatives as telehealth, or collaborative care that embeds behavioral health practitioners in a general medical care setting, Merz says. “That breaks down barriers around hesitancy with accessing the level of care, if it occurs in the office they normally go to,” he says.
Given that many patients in crisis end up in the ED because it’s the only resource available, opening behavioral health crisis walk-in centers would improve access, Merz says. He refers to the “living room” model, a place where people experiencing a crisis can go that is calmer than the typical emergency room. This can be a community center or a clubhouse-type setting where patients might get connected to someone who has been through a similar crisis.
Greene recommends continued investment in patient data and outcomes, along with the right expertise, which involves not just recruitment but also retention of behavioral health providers—along with adequate training to bring it about. Virtual care should be encouraged whenever possible to ensure wider access, with the caveat that acute needs will still need to be handled in person, he says. “Leaders across all of healthcare need to become more comfortable with a virtual or hybrid level of mental healthcare,” he adds.
Other steps to improving access include advocating for more complete insurance coverage and working to reduce the stigma around mental healthcare, Greene says. One local success he’s seen involves a youth soccer team that has previously seemed hesitant to adopt Psychiatric Medical Care as its sponsor accepting the sponsorship this year, even placing the medical company’s logo on the players’ jerseys.
Fischer-Sanchez is encouraged by the increased use of telehealth services for behavioral health, which she says was no more than 5% prior to COVID-19 but has settled in around 40% more recently. “I don’t think that number is going to go down,” she says. “It’s really a valuable tool. It cuts down on travel for both the patient and the provider, and potentially allows for being able to see more people on a given day.” That, in turn, cuts down on wait time and improves access to psychiatric care, she notes.
To help handle the enormous increase in children and adolescents needing services, Wolfson Children’s Hospital has set aside a portion of its main ED for pediatric patients, which Andrews says has been very helpful in triaging them. Wolfson Children’s is now converting part of its former pediatric intensive care unit, which relocated to a new building in early 2022, to a second pediatric behavioral health facility, which will add 20 new beds. “That’s still not enough, but it’s definitely a move in the right direction,” she says.
To ease the months-long waits for outpatient care, Baptist Health and Wolfson Children’s Hospital have created a “bridge clinic” that serves as an urgent care center, including for those who are about to run out of medication, or who recently have been discharged from the inpatient facility, according to Andrews. Last year, the system also launched a collaborative care model, with a licensed master’s-level clinician and psychiatrist who provides immediate behavioral health access and medication recommendations to the patient and primary care physician, respectively.
“This has been a game-changer,” says Andrews. “Patients are helped immediately. The stigma is not there. It’s a huge satisfier for patients and primary care physicians, and it’s reimbursable by commercial insurance and Medicare. In 22 states it’s reimbursed by Medicaid, too. It’s just amazing to see how fast, within a day, everyone is getting the services they need.” Patients no longer have to wait, sometimes up to a year, for behavioral health services.
Wolfson Children’s also participates in the national Children’s Hospital Association’s “Sound the Alarm” initiative to advocate legislatively for financial support for pediatric mental healthcare funding at the state and federal levels. And it’s partnered with Nationwide Children’s Hospital to bring the “On Our Sleeves” stigma reduction campaign to northeast Florida, Andrews says.
The latter “gives you the tools and techniques to have crucial conversations with children about how they’re feeling, about thoughts of suicide, about how to seek help and whom to speak to if they’re feeling significant emotions they don’t know how to deal with,” she says. “It gives you prompts about how to talk to children and adolescents about thoughts of suicide. ... It helps start crucial conversations so the parent has the tools to intervene and get their child help.”
Prioritizing Mental Health Internally
Another step healthcare leaders can take is ensuring they’re doing everything possible to provide behavioral healthcare to their own workforce. Some systems have pointedly excluded mental health from their employees’ plans under the mistaken assumption that they wouldn’t want to receive it in their own workplace, Merz says.
“What makes behavioral healthcare services different than somebody saying they want to have a child, or have a surgical procedure in their own hospital?” he says. “Why carve out behavioral health and assume that people would want to get services somewhere else?”
Merz urges leaders to consider providing mental health first aid and substance use continuing education to their workforce in the same way they might provide CPR training. “Do we know how to talk to someone in crisis who might be thinking about hurting themselves?” he says. “Do you have Narcan reversal kits for people who might need a reversal of a drug overdose?”
Finally, Merz notes that personal stories often drive home the focus on behavioral healthcare in a way statistics might not. “Administrative leaders and medical leaders who talk about behavioral health make it comfortable for people to talk about it as well,” he says. “As soon as someone says, ‘my son tried to kill himself,’ or ‘my cousin has schizophrenia and has lived in and out of shelters all his life,’ or ‘I’m in recovery and I’ve been in recovery for 15 years, and I struggle with this every day’—those [statements] can be so powerful and really change the dialogue.”
Miller agrees that leaders need to model for employees by acknowledging when they’re stressed and frustrated and otherwise experiencing “basic human emotions that we, as leaders, pretend don’t exist,” he says. “That goes a long way toward an environment where people can speak out about their own mental health. Secondly, provide resources, like an on-site clinician, which might mean revisiting workplace policies to allow for more flexibility. Or it might mean reexamining your coverage options to make sure they’re adequate for people seeking care.”
Any internal effort begins with—but should not be limited to—an employee assistance plan, Greene says. About 36% of Psychiatric Medical Care employees leveraged that benefit in 2022, with many of them using the teletherapy option, he says. Greene agrees that reducing the stigma around behavioral health is a key ingredient internally, as well.
“I’ve been in the behavioral health world my whole life,” he says. “If we’re all more comfortable talking about mental health, whether we’re anxious or depressed, you don’t have a situation like we had for many years where people say, ‘just push through it,’” or individuals ignoring their mental health needs.
Baptist Health and Wolfson Children’s Hospital have created a therapist team as part of its employee assistance program, which also rounds to check in and lend support to front-line staff within these hospitals. The team provides educational talks on everything from general self-care to how to manage certain types of disorders, Andrews says.
Lastly, for its physicians, the system employs a sports psychologist who also supports the National Football League’s Jacksonville Jaguars, applying performance enhancement techniques rather than psychotherapy for the health system’s medical staff. “I always say physicians are very similar to professional athletes in that they have to be 100% on their game,” she says. “Looking to get them back to their ‘A’ game, using a lot of the same tools as professional athletes—this has been very well-received.”
As tough as the pandemic was on caregivers, a silver lining is that it’s helped spotlight the stress to which perhaps more attention should have been paid all along, Fischer-Sanchez says. Though EAPs are an important ingredient, forward-thinking organizations are trying to put in place supports that address needs before employees even need to access the program.
“It’s a buddy approach where you receive training, and you’re there to listen and understand,” she says. “But at the end of the day, if there really is an issue, you report that up to a supervisor who can help the employee access necessary benefits, while also giving that person an opportunity to feel supported and in a safe space where people care.”
Bridging the Private-Public Gap
Leaders of private and nonprofit healthcare systems and hospitals also need to find ways to build bridges with their counterparts in the public health and social service sector around behavioral health needs and solutions. Intentional communication is critical in this regard.
“The first thing you can do to bridge the gap is to meet with community health leaders,” Merz says. “I encourage [healthcare leaders] to reach out to community leaders and stakeholders to understand their needs and have a dialogue. Reach out to your FQHC [federally qualified health center], reach out to your community mental health center, reach out to your child shelter and residential program, reach out to food pantry leaders and ask them what their challenges are.”
Bridging these gaps is essential for people to get coordinated care, which requires not only human communication but also electronic interoperability to ensure a seamless flow of data, Greene says. “It’s building the relationships—and sharing the information and outcomes,” he says. “We’ve been able to do a lot of this because we work with FQHCs, community mental health centers, academic centers and hospitals themselves.” Information about outcomes can help build the data and algorithms that insurers want, he adds.
“The outcomes we’ve gathered vary based on the patient population, but we work with our partners to share access to key data points that drive care, reduce recidivism and improve outcomes,” Greene says. “A few key data points we collect and share include polypharmacy usage, ED visits for mental health crises, reduction in ED visits over time with mental healthcare access, patient outcomes from evidence-based testing and continuing care instructions between care teams.”
Miller can attest to the difficulties of working with other organizations on a sensitive topic such as behavioral health.
“Sometimes the easiest and most powerful thing to do is simply reaching out to people and connecting,” he says. “It might be a meet-and-greet. It might be, ‘let’s grab coffee.’ There are opportunities for shared accountability across sectors using common metrics. That sounds wonky, but sometimes it’s what’s needed to get people to work together who historically have not.”
In growing their services and widening access, both externally and internally, partly through partnerships with the public sector, healthcare institutions can work to drive down the level of concerns about mental health outcomes and the frequency of reasons for those concerns. Hopefully, a future ACHE Top Issues survey will reflect progress on all those fronts.
Ed Finkel is a freelance writer based in the Chicago area.
Not Every Crisis Is an Emergency
With programs and services throughout Maryland and two hospital locations in Baltimore, Sheppard Pratt has helped manage behavioral health volume in part through alternative settings to the ED for those in crisis. “If you look at the indicators, most people just need time to talk to somebody and be in a safe setting, and their crisis symptoms can be relieved without having to be admitted to a hospital,” says Stephen Merz, FACHE, COO.The provider partnered with a community hospital, where patients were overwhelming the ED, to perform a chart audit that triaged how many ED patients truly needed hospital admission. That resulted in the partner system providing land and startup money for Sheppard Pratt to open a 16-bed crisis center. “You don’t have to be in an emergency department, and you can get the care you need,” Merz adds.
Sheppard Pratt has undertaken similar projects in a couple other markets, usually in partnership with a provider that initially thinks it needs to add 100 beds to handle its volume. “In all likelihood, we recommend that you study this before you commit to building 100 beds,” Merz says. “We can probably find a less expensive and less restrictive environment. … The number of beds then ends up being 60 or less.”
As a provider that’s been around for 170 years, Sheppard Pratt decided two years ago to spin off a consulting arm known as Sheppard Pratt Solutions to assist other healthcare systems. The organization announced three partnerships in the northeastern U.S. in the past several months and intends to take its services nationwide, Merz says.
“Partners say, ‘We have a significant need, we may have resources but we don’t know how to treat children.’ Or ‘we don’t know how to address substance use.’ Or ‘we don’t know how to care for geriatric behavioral health patients. We’re doing it, but we’re losing a lot of money.’ We come in and work directly with the leadership team and help them solve this,” he says. “Behavioral care does not need to be a money-loser. There does not have to be the lack of access. It does not have to be misunderstood. There are outcomes you can measure.”