7 minute read

I am writing this post on the tail-end of the CFHA 2020 conference. What an amazing time of coming together and re-orienting ourselves to this work! 

I have to admit to feeling fairly stressed during the conference as a clinician and behavioral health director.  To some extent, this is often the case for me at the conference. I am never sure if that is because I work in a large, private, multi-site Ob/Gyn practice rather than primary care or if that is just my idealistic, aspirational response to wanting to know and do more to make change, inspired by all of you.  This year, I think the stress is from the many programmatic changes my clinic group, like many of yours, has experienced over the past seven months.

The painful reality is that we have had to shift our integrated care model to survive, and in that process we have created  the access problems that our system was designed to avoid. As a behavioral health director, it pains me to see the problems bubble up while my heart also fills with joy to see us reaching more patients through telehealth as well as becoming financially sustainable.

In March, when our world shut down in Oregon, we saw our BHC schedules empty because our clinics emptied.  Our organization went from having 12 physical locations open to having three open.  The other nine didn’t close permanently, but most of them still remain only partially open or are still fully closed seven months later.  Like many healthcare organizations, ours lost millions of dollars and furloughed or laid off a significant number of positions in the first several months of the pandemic.

We, as BHCs, felt, and were, at risk.  Empty schedules mean lost revenue and we had already struggled for years with knowing that the charges sent out the door for visits were not covering the cost of our program. Not to mention the ongoing difficulty of being a team of just five people trying to support 130 medical providers across 12 locations. 

So, we shifted gears, certainly out of desire to stay employed, but also out of a desire to serve our organization’s patients, providers and staff.  That shift, essentially creating a telehealth mental health practice co-located at a medical practice, was timed with another big change.  That change was a shift in billing practices that had been in the works for several years.

We started billing using psychotherapy CPTs in order to improve reimbursement due to the overwhelming number of claim denials and low reimbursement we had experienced with health and behavior CPTs.  In addition to other factors, denials and low reimbursement are likely due to the types of health-related conditions that arise in women’s healthcare that are not “above the line” (payable) by insurance companies, particularly in our diverse payer mix.

Clinically, we struggled with inexperienced BHC’s using a “triage and refer” approach for years due to the workforce and training challenges most reading this post understand. BHCs (myself included, it pains me to say) underselling what we do and being too quick to refer, sometimes spending an entire visit talking about referrals with patients rather than providing needed interventions that we are more than capable of providing.

By May of this year, we found ourselves with a very different problem resulting from what had been survival-based psychological and operational shifts to fill schedules. We were all booked out for over a month with back to back telehealth visits and little wiggle room for warm handoffs, patient outreach and provider consultation.  The good news is we have started to see our revenue streams stabilize to the point that we have been able to hire additional BHCs.  But the loss of access is truly heartbreaking to all of us as well as overwhelming as we essentially try to run telehealth therapy practices with an overlay of integrated care. 

So, we continue to adapt as I am sure all of you have done. Our next phase of adaptation to this temporary but not-so-temporary state of affairs has been to designate a BHC of the day. That BHC’s “job” (supported by a THW and a student) is to respond to every electronic (Epic or messenging) and phone request for a warm handoff or same day connection with a patient while the rest of the team focuses on scheduled telehealth visits and any in-person needs for those working from an open clinic. 

The good news is we have started to see our revenue streams stabilize to the point that we have been able to hire additional BHCs.  But the loss of access is truly heartbreaking.

We are only a few weeks into this new role, watching the data to see if we are able to significantly increase warm handoffs with this setup but so far it seems promising.  However, it is an ongoing struggle to support the workforce (I include myself in this) in continuing to provide brief, focused, symptom-based care when, for all the wonders of telehealth, we are not as clearly connected to the healthcare environment.  We are also challenged by extensive waitlists for almost all specialty mental health care in our community related to these difficult and stressful times.

My thought, and challenge, as I leave the conference this year is complex: the reality is that many of us are a part of workforces not trained to do this work, in systems disrupted by the pandemic that already did not fully accept the premise of integrated care. The BHC role was already messy, ill-defined and felt like too much for many individuals prior to the pandemic.

Personally, I thrive in this environment most of the time. I love the opportunities for learning, creativity and pushing established norms. However, I struggle to hire and maintain a workforce that shares that love and is on board for the many changes we are currently experiencing.  And I get it.  It takes living and breathing this work to continue to carry things forward under the current pressures and not everyone wants to do this. 

So, how do we make these challenges palatable to the broader workforce? Certainly, as was mentioned many times at the conference, working at the graduate level to provide more training to those just starting their careers is a part of it. In my system, we are working internally to set up a more robust onboarding and ongoing training experience.  However, healthcare transformation is a bigger part of it. Again and again, individual practitioners and groups hold the weight of systems change and this weight is too heavy to bear. 

It is only because of an organization like CFHA that those of us bearing this weight can see that we are not alone in this fraught and circuitous journey.  I am grateful to be in the complexity with all of you.