For behavioral health organizations, the emerging movement among acute care hospitals to reduce readmissions represents both a challenge and an opportunity. The opportunity comes from the growing recognition that behavioral issues contribute to many of these hospital readmissions. If behavioral healthcare organizations can find ways to collaborate with hospitals, they can open a new avenue to grow their businesses.
The Hospital Readmission Reduction Program (HRRP), which was enacted in 2012 as part of the Affordable Care Act (ACA), is a federal initiative that financially penalizes hospitals for what are considered “avoidable” readmissions among Medicare patients. The Centers for Medicare and Medicaid Services (CMS) assessed an estimated $428 million in financial penalties for avoidable readmissions this year.
Acute care hospitals are quite motivated to reduce their risk for costly penalties, and consequently, could be eager to find behavioral health partners to help them manage their Medicare patients.
“The problem is that the medical community is not aware of the enormity of the problem,” says John Dyben, DHSc, CAP, CMHP, director of older adult services at the Hanley Center at Origins in West Palm Beach, Fla. “And the behavioral healthcare community is not really talking to the doctors about the issue.”
Dyben recalls one hospital’s patient who had chronic coronary disease. Despite long and repeated hospitalizations, the root cause of the patient’s repeat trips to the hospital was not uncovered until he admitted to having a $100,000-a-year cocaine habit.
Of course, integration is where the challenge comes in. There are plenty of reasons why behavioral healthcare organizations are not already integrated into Medicare’s network of acute care: lack of clear reimbursement; the unacknowledged prevalence of behavioral conditions among Medicare patients; and many behavioral healthcare organizations’ own lack of experience working with older patients.
Framing the opportunity is the first step.
“Everyone recognizes the facts around co-morbidity and that people with behavioral health conditions often do not comply with doctors’ orders or have a lifestyle that is contributing to their health issues,” says Ed Jones, senior vice president of strategic planning for the Institute for Health and Productivity Management in Scottsdale, Ariz. “However, doing something about it is a completely different issue.”
When confronted with the fact that readmissions for patients who have co-morbid substance abuse or mental health disorders is two to three times greater than the average, medical providers are likely to sit up and take notice.
“Bringing that rate down can help hospitals financially, and behavioral healthcare organizations know how to do that,” says Raymond V. Tamasi, president and CEO Gosnold on Cape Cod in Falmouth, Mass. “That becomes the big selling point, and when phrased and packaged appropriately, that is a message the healthcare system is going to want to hear.”
Behavioral healthcare organizations that want to play a more active role in integrated care for the growing Medicare populations as a way to help reduce hospital readmissions—and gain additional business for themselves—need to connect with the right people and organizations.
For example, there is more opportunity to collaboratively treat behavioral health issues among those who have Medicare Advantage plans that are operated by commercial insurers because of the inherent managed care aspect of the plans, according to Jones. Medicare Advantage represents about one-third of the 52 million Medicare beneficiaries and growing. Under the traditional fee-for-service Medicare program, by contrast, there is less patient management and less opportunity for behavioral providers to seek reimbursement.
There is plenty of work to be done. Jones notes that three criteria will impact a patient’s risk of a hospital readmission:
- The quality of the inpatient care they receive.
- The appropriate timing of the discharge.
- Access to adequate outpatient care after discharge.
Behavioral healthcare organizations have an important role to play in the quality of inpatient care and access to outpatient care after discharge. Jones says that Medicare patients with behavioral healthcare issues have historically had low rates of outpatient service utilization.
“Fewer than 2 percent of people on Medicare use behavioral health services on an outpatient basis,” he says. “What are we going to do about getting these folks with chronic conditions, whether it is diabetes or depression or whatever, the help they need?”
Tamasi urges behavioral health providers to begin a conversation with hospital systems, the growing class of accountable care organizations (ACOs), and providers with patient-centered medical home models. Discuss how collaborating with behavioral healthcare can add value and improve patients’ overall health and their ability to manage their own care. As a classic example, in the case of a patient with diabetes, depression might cause poor adherence to doctor’s orders and repeat trips to the hospital.
“The relationship between behavioral health and individuals’ inability to manage their health and specific conditions is pretty well-documented,” Tamasi says. “That data then opens up opportunities for behavioral health companies to assist and improve readmission rates.”
Because integration is still an evolving area, these connections may take some time to flourish. For example, behavioral healthcare organizations looking to make connections with ACOs may have difficulty getting their attention—at least, right now.
“So many hospital readmissions have a behavioral health component, and I don't think that a lot of the ACOs are addressing that,” says Tamasi. Instead, “ACOs are focusing on building the necessary infrastructure to deal with chronic conditions like diabetes and cardiovascular disease and manage the overall health of their populations.”
Get the job done
It is up to behavioral healthcare organizations to make sure the growing ranks of ACOs are aware of how behavioral health can impact readmissions and the role behavioral healthcare organizations can play in managing those issues. But patience is key, according to experts.
“ACOs have a laundry list of issues to deal with,” says Jones. “Behavioral health does not yet rise high enough on the list, so an ACO’s behavioral health network resources tend to be very limited.”
This is not to say that behavioral healthcare organizations should write off ACOs as potential future partners. It just may take some time for these efforts to pay off. More immediate, fruitful relationships might exist among hospitals and health systems that have been assessed high penalties by CMS.
“It is important to take a leading role with the medical side,” says Jones. “If we simply wait to be asked to sit down at the table to solve some of these problems, that’s not going to get the job done.”
Dyben suggests that behavioral healthcare organizations could also consider the opportunity to provide education to the medical community, encouraging them to refer more patients to behavioral services at discharge. However, in doing so, treatment centers must also be sure they understand the older Medicare population and how their needs differ from younger patients.
“Behavioral health and especially substance abuse treatment models tend to be designed for younger people, and they don't address the different needs of older adults,” says Dyben.
Indeed, the roadblocks to integrating behavioral healthcare to reduce Medicare hospital readmissions are on both sides. Medical providers often are not prepared to make referrals for behavioral health issues, and behavioral healthcare organizations often are not well positioned to work with older patients.
However, with literally millions of older patients with comorbid conditions, behavioral healthcare organizations are missing an important opportunity to expand their reach if they cannot adequately serve this population.
“The necessary infrastructure is not wildly different, but treatment for older adults takes longer,” says Dyben.
Additionally, behavioral healthcare organizations interested in providing residential care to the Medicare population need robust medical infrastructure that can support the management of multiple chronic conditions and treat a higher level of acuity, he says.
Changes at work
Some behavioral healthcare organizations have begun working with local hospitals and health systems to develop models for this type of integration. Gosnold has worked with a local hospital using private grant funds to embed a nurse and a counselor within the medical-surgical part of the hospital, including the emergency room.
“When you enter an environment where little has been done to treat these issues, the immediate benefit is substantial,” says Tamasi.
One of the key benefits of this arrangement was the support that Gosnold’s professionals could provide to effectively treat hospital patients with behavioral healthcare issues. For example, Gosnold worked to improve the hospital’s screening mechanisms, which were somewhat unsophisticated and used language that was not likely to yield honest answers about behavioral health issues. Gosnold staff also conducted work-based learning with nursing and medical staff to help them identify symptoms of withdrawal.
Clinicians also need help treating withdrawal when it coincidentally crops up in acute care. Someone with an alcohol addiction, for example, who is in the hospital for three or four days for a medical condition could start to suffer withdrawal symptoms. When the Gosnold program began, there was a very high ICU transfer rate for patients in complicated withdrawal, says Tamasi.
“In many cases, these patients had to be intubated and ended up with excessively long stays in the hospital,” he says.
By integrating behavioral healthcare professionals into inpatient care from the outset, the partnership reduced ICU transfer rates by 75 percent and cut in half the length of stay for patients with withdrawal symptoms.
The opportunity is there. It is now up to behavioral healthcare organizations to get their foot in the door and participate in emerging models. The resulting solution can be a win for all involved.
“Hospitals will either build this capability themselves or get it from an able and willing provider,” says Tamasi. “Our opportunity is to put ourselves at the table in a meaningful way and say that we can do this.”
Joanne Sammer is a Brielle-N.J.-based freelance writer.