Ian Bennett, MD, PhD, shares with us his thoughts on the emerging educational issues for training primary care providers in integrated behavioral health (IBH), the most promising innovations, and tips for new IBH educational programs.
Q:One of the biggest barriers we’ve been hearing about from stakeholders across the country over the last year is that it’s really difficult to think about developing evidence-based training programs for residents and medical students when our current clinical workforce isn’t trained to do this. Could you talk a little about that?
IAN: It takes an exceptional resident who could force change in something that is already in place. Otherwise, they’ll end up, I would predict, succumbing to whatever model is already in place in their workplace. I’m the director of the Healthier Washington Practice Transformation Support Hub Resource Portal which is a platform for supporting wide scale practice transformation and training. I have a real interest in the way technology can help with getting to the point when it is oriented to the needs of the providers in place, experiencing these changes that we’re talking about. It’s fine to work individually with sites, but it can be very difficult. Even if you use coaches who are a little bit easier to manage, they need as much support as possible. The Portal is a technology platform designed to support that. We don’t have evidence to know if it works yet – but we have developed this platform and we’re working on how it’s used to help with these large-scale practice transformation efforts.
Q: Is it your sense that folks are still in the developmental stage and that is why it’s hard to find out what is going on or are not as many states doing what Washington is doing in terms of harnessing this power of technology?
IAN: There’s a lot going on, but everything is still fairly new, so there aren’t a lot of publications that support what’s happening. That’ll change over the next few years. We’re submitting posters to the American Medical Informatics Association but at this stage, until you have actual clinical outcomes, the general literature is not going to be interested in publishing. It’s only going to be the informatics people. Getting people to pay attention to what we’re doing is difficult as it’s a relatively small group of people who are recognizing the potential. So I think it’s been part the timing - you will hear a lot about it over the next few years.
But even in states which are fairly comparable to Washington in terms of the investments being made in IBH, they are not putting a lot of effort into technology. They have websites, but they aren’t exploring how to harness them. Take, for example, how Amazon sells shoes. How could we apply that same knowledge to how we sell health care, either to patients or to brick and mortar delivery sites.
Q: What are the emerging educational issues for training PCPs in IBH? What is most salient for you right now?
IAN: I would say that the biggest issue is to make sure that we are moving the existing workforce to a place where they can integrate existing evidence-based models into their ongoing work. So it isn’t that they have to stop and go back and get another degree or additional licensure because that’s not pragmatic. We have a large, existing highly-trained and experienced workforce that has been accomplishing the work every day with patients in ways that we now know are less effective than other models. Actually, we’ve known it now for at least 15 years that for IBH, we need a team-based approach that includes some key components around the management of panels of patients. An approach that brings together skills that aren’t solely relying on PCPs but also leverages the ability of LCSWs who are increasingly more present in these settings and are working in parallel rather than in separate teams to take care of patients. And there’s also the presence of electronic tools such as patient registries that are structured to longitudinally manage the needs and follow-up care of patients. These kinds of things are quite innovative and can work in a way that moves people forward. That’s my main focus: how do we get the existing workforce to step up their game and make changes to their practice that enhance and make care more effective – critical to achieving the quadruple aim.
Q: As you view this challenge of getting that existing workforce to buy into this new model or to frame how to bring evidence-based practice into their current workflow, what are some of the biggest barriers?
IAN: Especially in areas targeting vulnerable populations, rurally isolated settings, there is a sense of people tending to feel maxed out at the management level and vision level for where things are going. It’s really hard to ask people to add on to their work. The key is to frame it as something that is more of a lateral move or a transition to a more effective means of working. Probably one of the largest incentives to move folks forward or, rather, the obstacle to overcome if you think of it that way, is reimbursement for the roles or activities needed to implement team-based care. CMS has taken a huge step forward by actually calling out the chronic care management (CCM) codes for collaborative care and now, as long as things like a registry are in place, they will pay for different tasks that are done to support individual visits with patients than what’s traditionally paid for. For example, calling a patient and following up with them (telehealth) and case review by psychiatric consultants to review patient panels. Now that that’s being paid for, you can bill for Medicare patients because it’s a CMS policy. Barriers remain for Medicaid patients and private insurers. As far as I know, Washington State is the only state that has created, at every level of insurance, reimbursements for those codes and that is something that is going to be, as I work across the country on other implementation projects, a huge barrier.
Q: Being able to change policy at the state level to facilitate or incentivize providers to change clinical practice falls in line with the second question. What are some of the most promising innovations in IBH training or education that have caught your attention?
IAN: I’m currently doing work with the Academic Unit at the University of Washington at the Rural PREP center. We’re exploring the idea that the work of a psychiatric consultant results in ongoing training and enhancement of primary care site capacity to take care of patients with BH issues over time. That’s the concept that folks doing telepsychiatry consultation at rural sites have used. They have established a consultation relationship with primary care sites where they call-in and review a registry with the care manager or other members of the team, instead of saying, ‘have this patient do this, have this patient do that’, they have a framework which is to generalize the learning to a broader set of patients. That is a really interesting concept that hasn’t been evaluated. We’ve found that it enhances the care manager’s ability to care for patients but also for the PCPs and staff that are supporting the team.
We created a conceptual model based on the idea and then did a qualitative study to explore the perceptions of whether or not information travels through the site. We then used that to develop a survey which was delivered to a bunch of sites in Washington using this specific telepsychiatric model. We have pretty good evidence that that information comes through the care manager, disseminates through the practice, and results in a perception that they do enhance their practice. The concept is based on the observation that PCPs initially have a lot of questions around standard anti-depression medications, but within a year or two, they’re asking questions about more complicated things like bipolar disorder medication use and have a much higher level of perceived sophistication. So it’s an example of what I talked about before: You put into place some kind of enhancement of care and then actually deliver the training over time as part of ongoing practice. It’s leveraging technology by utilizing telepsychiatry. You’re not having the provider do direct care for the individual patient. Instead, it’s a consultation model where the care manager is giving information about the cases and the consultant is able to provide input on how to take care of that patient. That ends up not only improving care of that individual patient but enhances, in a more generalizable way, the ability of those providers to take care of all their other patients.
Q: Do you have any insight or advice to share with clinicians?
IAN: If you’re going to take the role of a champion, it is absolutely critical to engage a range of people at your practice that have different roles. You need to bring in nursing, behavioral health, administrators, the folks that do billing. You have to be able to bring all of them to the table and then be the champion that makes the argument of why this is important for their work using the framework of the quadruple aim because it is a really salient set of goals. Make sure that you connect with a resource like the AIMs Center, use their tools, see if you can take advantage of ongoing implementation efforts, and don’t spend your time on models that have no evidence, even if you think they’re great because we already have models that have a high degree of evidence. We are at a transformational moment where there’s tons of stuff going on. There are hot spots for these things in the country, but it’s definitely going to ripple out, and we should be looking for opportunities to move forward based on what's happening. It’s a really exciting moment to be a health care provider who is concerned about the behavioral health of their patient.
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