When the ther­a­pist is a piece of soft­ware

Modern Healthcare - - BEST PRACTICES - By Steven Ross John­son

A few years ago, Froedtert & the Med­i­cal Col­lege of Wis­con­sin health net­work saw that its be­hav­ioral health ser­vices weren’t meet­ing lo­cal de­mand. Pa­tients with mild-to-mod­er­ate men­tal health is­sues would re­ceive a re­fer­ral for one-on-one vis­its with a psy­chi­a­trist or psy­chol­o­gist and of­ten faced a long wait for an ap­point­ment.

Froedtert also dis­cov­ered many of their pa­tients with mul­ti­ple chronic con­di­tions, which af­fect 1 in 2 adults and ac­count for 86% of health­care costs, have un­der­ly­ing men­tal or be­hav­ioral health con­di­tions, which make them dif­fi­cult to treat ef­fec­tively.

So the sys­tem, which has three hos­pi­tals in east­ern Wis­con­sin, looked into de­liv­er­ing cog­ni­tive be­hav­ioral ther­apy, or CBT, through dig­i­tal tech­nol­ogy.

Dig­i­tal CBT works by ask­ing pri­mary-care pa­tients who have been flagged for ser­vices to en­roll in eight to 12 weeks of on­line ses­sions con­sist­ing of ques­tion-and-an­swer mod­ules sim­i­lar to what a pa­tient might re­ceive dur­ing a psy­chother­apy ses­sion.

Pa­tients can move at their own pace, ac­cess­ing the CBT mod­ule at any time by com­puter or smart­phone. Once a week, a “sup­porter” checks a pa­tient’s progress and re­lays their as­sess­ment to a care team that can de­ter­mine whether more in­ten­sive treat­ment is needed.

Rel­a­tively new to the U.S., dig­i­tal CBT tools have been widely de­ployed in coun­tries such as Aus­tralia, where on­line CBT pro­grams are of­fered through the coun­try’s uni­ver­sal ac­cess health­care sys­tem, and in the United King­dom through its Na­tional Health Ser­vice.

They’re get­ting more at­ten­tion now from U.S. hos­pi­tals and health sys­tems, which see them as a way to sup­ple­ment their ef­fort to in­te­grate be­hav­ioral health into pri­mary-care set­tings and over­come a short­age of spe­cial­ists.

John Fryer, a se­nior con­sul­tant with the na­tional health­care provider con- sult­ing firm ECG Man­age­ment Con­sul­tants, said CBT use among hos­pi­tals and sys­tems has grown as a re­sult of the move to value-based care.

Un­treated de­pres­sion and anx­i­ety of­ten leads to a higher like­li­hood that pa­tients end up en­gag­ing in risky be­hav­iors such as smok­ing, poor eat­ing, lack of ex­er­cise, and al­co­hol and drug use. Those suf­fer­ing from un­treated de­pres­sion are also less likely to ad­here to their med­i­ca­tion reg­i­mens, which makes man­age­able chronic con­di­tions more se­vere and costlier to treat.

Many sys­tems face dif­fi­cul­ties in of­fer­ing men­tal health ser­vices to such pa­tients. Re­im­burse­ment is in­ad­e­quate and there is a short­age of providers.

Froedtert will pi­lot an on­line CBT pro­gram at two pri­mary-care clin­ics as part of its so­lu­tion to ad­dress the grow­ing need for out­pa­tient be­hav­ioral health ser­vices. The on­line pro­gram will be of­fered to pa­tients who screen pos­i­tive for mild to mod­er­ate de­pres­sion.

Stud­ies show on­line CBT ther­apy can be as ef­fec­tive as an in-per­son visit with a men­tal health spe­cial­ist. They can use the pro­gram at any time with­out cost, and it also goes a long way to­ward elim­i­nat­ing the stigma as­so­ci­ated with vis­it­ing a ther­a­pist.

“It of­fers an op­por­tu­nity to get help in a way that feels a lit­tle bit more com­fort­able for some pa­tients,” said Mark Stabin­gas, ex­ec­u­tive vice pres­i­dent at UPMC En­ter­prises. In Fe­bru­ary, UPMC’s ven­ture arm in­vested $17 mil­lion in the startup Lantern, which has de­vel­oped an on­line CBT tool tar­geted at self-in­sured em­ploy­ers.

A ma­jor ben­e­fit of on­line CBT pro­grams is that they are far less costly than hir­ing ad­di­tional be­hav­ioral health spe­cial­ists, who are in short sup­ply.

Adop­tion of on­line CBT pro­grams has been slow de­spite their prom­ise and the grow­ing in­ter­est among stake­hold­ers. One par­tic­u­lar chal­lenge has been over­com­ing con­cerns that ther­a­pies of­fered through an on­line CBT pro­gram can pro­vide the same qual­ity of care as an in-per­son visit with a spe­cial­ist.

An­other road­block is that health­care providers are not re­im­bursed for us­ing on­line CBT pro­grams. With­out that fi­nan­cial in­cen­tive, ex­ec­u­tives must de­cide whether the pay­back in terms of im­proved pop­u­la­tion health man­age­ment is worth the cost of new tech­nol­ogy and em­ployee train­ing.

“I don’t re­mem­ber if any of these apps or plat­forms have said ‘Hey look, we saved $1 mil­lion in terms of pre­vent­ing ex­tra length of stay by im­ple­ment­ing this pro­gram at a 500-bed hos­pi­tal,’” said Dr. Steven Chan, a mem­ber of the Amer­i­can Psy­chi­atric As­so­ci­a­tion’s Men­tal Health IT Com­mit­tee. “They may have to pro­duce stud­ies like that or do it on a much wider scale if they al­ready are try­ing to do these pi­lots.”

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