This blog is a follow-up to a recent panel presentation co-sponsored by Comagine, The Institute for Primary Care Behavioral Health and the Collaborative Family Healthcare Association. The chat for the presentation is here. Video is here or just scroll down.
What started out as deep consternation as the COVID pandemic hit in March quickly turned to a burst of energy and creativity on the part of behavioral health professionals in primary care. Behavioral health departments have been some of the quickest to adapt to telehealth workflows and naturally curated a significant amount of business as the public’s mental health needs grew. In many clinics, the month of April was more productive for behavioral health staff than for medical staff and some clinics even reported all-time highs for encounters. This experience is not universal, as some clinics continue to have problems reaching hard to reach populations via phone, let alone video, but the more integrated clinics with well developed care teams seem to be faring well. Now many are positing that these adapted workflows are not going away even as in-person care slowly resumes. The possibilities for a continuation of this increased productivity and increased access to patients, while regulatory barriers are reduced and reimbursement is made available, makes this a veritable golden age for behavioral health. Many have been championing changes like this for years and in a span of a few weeks the opportunity is now reality. In fact, it makes many of us question why it took a pandemic for these changes to happen.
In sum, integrated care and care team work lives on in the world of telehealth workflows and it works well.
Now the questions are, can this be a golden age for behavioral health integration and for primary care in general? Our recent webinar on workflow adaptations for behavioral health integration in the COVID-era answered the first question. Yes, clinics are adapting unique and effective ways of integrating behavioral health personnel. Clinics have developed workflows that include having medical assistants instant message behavioral health providers or a behavioral health provider pool, receiving an instant message back with availability and contact instructions (eg. “Call this cell or send the PT to this zoom”). Care teams have also found ways of huddling with one another virtually to prep patient encounters for that shift and identifying possible candidates for joint work. These workflows have been adapted for all kinds of situations from patients sitting in cars outside of clinics on their phones or holding tablets, to patients in their homes, to patients in clinic. Of all of the imagined complexities of implementing telehealth that were used as excuses to delay this medium of care, one of the resounding findings of the current experience is that the simplest technology is still the most utilized: the telephone. Alexander Graham Bell must be smiling from above seeing how often and how effective the telephone is the medium of choice for care delivery – an important finding which payers must take into consideration as they plan future payment schedules for primary care. In sum, integrated care and care team work lives on in the world of telehealth workflows and it works well.
The second question, whether this can be a golden age for primary care in general is still an open question. It is clear that many if not most of what were in-person clinical encounters need not be in-person. So, will primary care adapt and provide a hybrid of in-person consults for issues that really need to be seen in person and keep the rest for telehealth work? Will the workforce adapt to this as the new status quo or resist this? Will primary care step-up to the challenge of chipping away at seemingly intractable population health issues that have made minorities disproportionately affected by the pandemic? What will training look like for medical students and residents and will it include training on working remotely with patients? And of course a key question to all of the above is whether payers and governmental agencies will prioritize primary care and maintain the current environment that allows for rapid innovation and better reimbursement? To that last question, one fear I have is that the focus of health care expenditure will shift to hospital-based care and pandemic preparedness to the exclusion of the work needed to reduce underlying health conditions which are in primary care’s wheelhouse and which are a significant factor in the mortality rate in the United States.
I think this should be a golden age for primary care. I think the moment is now for primary care to retool from the ground up, from training its workforce to its delivery strategy. This retooling can also propel payment changes (eg. that elusive population payment approach we have longed for) as we naturally shift away from thinking about patient encounters and think towards the plethora of ways we can engage patients in their healthcare. If the optimism and creativity shown on the webinar is any indication of what the future holds for primary care, then the pandemic may indeed turn into a blessing in disguise, albeit a painful one. As Dr. Don Berwick reminds us in this seminal piece, the choice is ours to make.