Clinical Case Study: Telehealth for Mental/Behavioral Health

This virtual session provides an overview of opportunities and techniques for delivering integrated mental and behavioral health care via telehealth technologies. Speakers also address telehealth mental/behavioral health opportunities.

Speakers

• Yun Boylston, MD, MBA, FAAP, partner, Burlington Pediatrics, Mebane Pediatrics
• Justin Hunt, MD, medical director of behavioral health, Oak Street Health
• Rebecca Murray, licensed clinical social worker, director of clinical services, Oak Street Health

Hosts

• Christopher Botts, manager of care delivery and payment, AMA
• Bernadette Lim, project manager of digital health strategy, AMA

Explore the AMA STEPS Forward® Innovation Academy on-demand library of webinars on physician burnout, digital health, private practice, BHI and more.

Lim: Alright. It is the top of the hour. Good morning, everyone. My name is Bernadette Lim. I'm the project manager of digital health at the AMA and program manager for the AMA Telehealth Immersion program. Today's session is a clinical case study focused on telehealth for mental and behavioral health, and I'm excited to co-host today's session with my colleague Christopher Botts, manager of care delivery and payment at the AMA and AMA lead for the Behavioral Health Integration. We have a great lineup today featuring case studies from Oak Street Health and Burlington Pediatrics.

And before we get started just wanted to mention a few housekeeping notes. The first is that this session will be recorded and we have structured today's session as a Zoom meeting with the intention to allow for everyone to interact with presenters during the Q&A. We ask that you please keep your mics on mute during the presentations. And during the Q&A portion we will utilize the Raise Hand function so please use that. And then if you have any questions or comments, feel free to type them in the chat throughout the duration of today's presentation. It would be great if everyone could start by introducing themselves by typing your name, your role, organization and what you're interested in learning about today in the chat. And with that, Chris, I'll turn it over to you to share an overview of the BHI Collaborative and introduce today's speakers.

Botts: Fantastic, thank you so much, Bernadette, and welcome, everybody to today's session. We're really excited to partner the Telehealth Immersion Program as part of the BHI Collaborative to bring you all to today’s session. Laura, whoever is driving, if you can move on to the next slide.

Excellent. So just a little bit about the collaborative suite. We at the AMA, among seven other national physician organizations, have come together to create what we call the BHI Collaborative. And it's really focused on catalyzing the effective and sustainable integration of behavioral mental health care and physician practices with initial focus on primary care. And really what we want to make sure is that the identification and management of behavioral health, particularly those mild to moderate conditions, is a core competency of primary care, not the exception that it is today.

Just a little bit about some of the activities that we have going on right now, one of which is educational programming, which includes a webinar series that we had launched back in the fall. And then we have some upcoming events as well, some on-demand content in case anybody is interested, which includes presentations both from Oak Street Health as well as Dr. Boylston and her practice. So please feel free to engage in that content as well as some of our resources and tools that are really geared towards helping practices implement integration and make it sustainable in their practices, as well as the ability to be able to test solutions and practices to make sure that everything that we are accomplishing meets the needs of practices moving forward and ultimately ensure that they are sustainable over the long term.

And with that, we have our first case study for today, and we're excited to have Rebecca Murray and Dr. Justin Hunt joining us. Rebecca Murray is a licensed clinical social worker, director of clinical services at Oak Street Health. Rebecca obtained her master's of science in social work from Columbia University in New York City. Her work at Oak Street Health is focused on developing integrated behavioral health program in the AIMs Center collaborative care model.

Dr. Justin Hunt joined Oak Street Health back in December of 2020, the medical director of behavioral health. Prior to Oak Street Health, Dr. Hunt was the medical director, head of psychiatry at Ginger, an on-demand virtual mental health system of care. Dr. Hunt also has served as a psychiatrist, administrator, mental health services researcher at the University of Arkansas Medical Sciences Psychiatric Research Institute. With that, I will turn things over to Rebecca and Dr. Hunt, take it away.

Dr. Hunt: It's really wonderful to be with everybody today to speak about Oak Street and our experience in collaborative care and then integrating telebehavioral health into primary care. How did we manage to make this transition during the COVID pandemic, to nearly full virtual model? So we will walk you through these different steps.

So the general agenda for our initial 20 minutes here is first, I want to review our overarching model of Oak Street Integrated Behavioral Health, and we really apply the collaborative care model in our value-based payment model across all of our Oak Street Health primary care centers. Number two, Rebecca will discuss our rapid transition during COVID and also our subsequent return to our current hybrid and flexible approach in which we will discuss in detail. So kind of looking at the kind of integrated in-person versus telebehavioral health care that exists at Oak Street currently. And then we'll touch on some successes and growth opportunities as well.

So first we’ll discuss our Oak Street integrated behavioral health model, largely based on the collaborative care model. So there are several goals for our Oak Street Behavioral Health program. As we all know, access to behavioral health care is less than optimal at most all primary care centers across the country. There is often up to three-month wait for psychiatric services, sometimes a one- to two-month wait to be seen for the initial assessment with an LCSW or psychologist. And it just doesn't meet the needs of the acute behavioral health presentations that often appear in primary care. And so we at Oak Street help you address these barriers to access to behavioral health care by consultation through our collaborative care model, which I'll talk more about in detail, and then of course telebehavioral health helps, too. So we think about a consultation being kind of an FTE multiplier, so kind of spreading that psychiatric expertise across a population of primary care patients. And then of course the telebehavioral health aspect of it helps to reduce those geographic disparities of mental health providers. So we know that the psychiatrists, for example, are not evenly distributed across the country. So when you kind of piece those two things together through our model, we can help solve these access challenges.

We of course also have a focus on high quality care, emphasizing evidence-based collaborative care as it was developed up at the University of Washington, as well as evidence-based short-term psychotherapies and of course, evidence-based psychopharmacology. And we believe that when we apply this improvement of access, high quality care, then we can really provide care in a sustainable and fiscally responsible way within our value-based reimbursement model at Oak Street. And of course, this will all have a positive impact on organizational goals, both kind of clinical quality goals as well as financial goals, too.

So in general, this is the overarching shift that we're aiming for. So the traditional approach of mental health is still unfortunately very much a fee-for-service kind of model. So maximum number of visits in order to bring in the maximum number of revenue tends to be kind of an individual provider approach as opposed to a team. Traditionally more of an in-person one-on-one approach. That has changed quite a bit, of course, since COVID with a lot more virtual care coming onto the scene. Then lack of cohesive communication across providers. Often the behavioral health providers at the community mental health center aren't well connected into the primary care side of things in a community and unfortunately a lack of measurement in the traditional approach world.

So as we implement this collaborative care model at Oak Street, we aim to provide quick and flexible access to our behavioral health team, and that can be either in-person or virtual or both, sometimes depending on where the patient is. It really is a very patient-centric process. We have one-on-one care with our behavioral health specialists, which are our LCSWs in our center. Again, I'll talk more about the actual members of our model in a second. And then we also have lots of opportunities for consultation to again spread that psychiatric expertise across a population of primary care patients and not just fill up that psychiatrist or that psych NP right away where then we would kind of end up with the same kind of access problem that exists in most communities.

Also importantly we emphasize tracking care in a population health registry as delineated in the collaborative care model. And perhaps most importantly we have a strong emphasis on measurement-based what we call “treatment-to-target.” So really focusing on getting those baseline measures of PHQ-9 and GAD-7 and then watching that progress over time and then being pretty aggressive with our treatment to achieve our treatment goals.  

And these are kind of the key principles or tenets of the collaborative care model. And you really need all these things for the collaborative care model to work and to get that meaningful, integrated behavioral health and primary care. I've alluded to kind of all these in the previous slide, but population-based care, making sure we enter all of our behavioral health referrals into what's basically a chronic disease registry. And we track those folks over time. We look at how often they're contacted, we watch their PHQ-9 and GAD-7 scores and then act appropriately to achieve our outcome goals. Measurement-based “treatment-to-target,” again looking at that baseline, monitoring validated and reliable scales over time. PHQ-9 for depression, GAD-7 for anxiety and PCL-5 for PTSD and there are many others for other conditions too.

Of course it all has to be patient-centered. So for example if the patient would like psychotherapy only, but no medication management, we will meet them where they are and really try to make it a collaborative process with the patient and of course, evidence-based care. We don't want to do anything that's not based in the literature. And when all those things are pulled together we feel like we can really achieve good accountable care. And we really do a lot of measurement of health outcomes connected to the collaborative care model and even build that into our bonuses, for example, for both our behavioral health specialists, our LCSWs as well as our psychiatric consultants, too.

This is just a brief little view of what our internal Oak Street registry looks like. So this is based in a kind of homegrown EMR that we call Canopy at Oak Street. And you can see in the red box, that's really kind of pulling out how we're watching PHQ-9 scores over time. So kind of the first column is the baseline, middle column is the most recent PHQ-9 and then we track percent change over time. Have kind of the same dynamic for GAD-7 and there are many other things that we track in the registry as well. But during our registry review meetings between our behavioral health specialists and the psychiatric consultants, they can use this registry to make sure no one is falling through the cracks. And then it also helps us to achieve the measurement-based “Treatment-to-Target,” because we can sort this list of patients, usually kind of arranged by center at Oak Street, and we can determine OK, who's not achieving that 50% drop in PHQ-9, which represents a full response? Who's not showing a drop in five points during the first six weeks? And what do we need to do to really get their treatment on track? But just kind of a little view into this kind of virtual registry that we have.

And this is a brief demonstration of data from Montefiore. And really the main point here is that the CoCM, which represents collaborative care model, shows a greater reduction in PHQ-9 scores than simply just having someone co-located in the clinic, which would be just putting a psychiatrist down the hall or putting that LCSW down the hall to kind of catch therapy referrals. And really this kind of goes back to that slide that listed the five key tenets of collaborative care. And you really kind of need all those things to truly implement the collaborative care model. And if you have all those things then you tend to have more positive results such as are demonstrated here.

And this is kind of a visual representation that we use frequently at Oak Street, particularly as we're onboarding primary care providers or maybe our program managers across all of our 80 centers at Oak Street Health. And it represents all the members of the Oak Street Health Integrated Behavioral Health model, which is all based on the collaborative care model. See, the PCP is at the top. And that's, of course, where the patients enter in at Oak Streets, given that we're a primary care program for adults on Medicare primarily, also with a decent sized dual eligible population. And so that's the initial entry point. And then the behavioral health specialist is the first member of the behavioral health team that tends to see the patient after the formal referral is made to the team. The BHS then enters the patient into the registry, does an initial assessment, might start evidence-based psychotherapy, and then also on a weekly basis, the BHS meets with the psychiatric consultant and they run the registry.

And of course, the psychiatric consultant makes recommendations back to the primary care physician who prescribes, the majority of the time, based on the recommendations from the psychiatric consultant. We, of course, have some more intensive situations, maybe with diagnoses such as schizoaffective disorder or something of that nature, where the psychiatric consultant would then also see the patient virtually in a one-on-one visit, stabilize them and then refer them back to the PCP provider. So we'll talk a little bit more about this diagram a little bit later. And then the nature of the interactions between all these folks. So basically, every arrow in this model, I'll kind of explain how we have used telehealth to make access more efficient. And thus makes our overall interactions on the team more efficient as well.

OK I'm going to turn it over to Rebecca now to discuss our experience making a very rapid BHS transition to virtual during COVID, back in March and April of 2020.

Murray: Thank you, Dr. Hunt. Yeah, so what you just had was a great overview of what is collaborative care, pre-COVID at Oak Street Health. And to emphasize, we definitely were doing the collaborative care model, not the co-located model with our behavioral health specialists. All our behavioral specialists are licensed clinical social workers. When shelter in place was announced, we had 36 hours to get all 40 behavioral health specialists across our company onto a virtual platform, but still replicating the best we can, a collaborative care model.

So we took a we took a page from the American Telemedicine Association where they had a ton of resources, and we adopted a lot of the language―keep everything as similar and as structured as habitual as possible. So what we made sure is that all behavioral health specialists were attending all the meetings they used to attend in person in our centers, the planning meetings, weekly meetings, the weekly meetings with the psychiatrist reviews, to the shared registry reviews―we use Google Suite at Street Health. So using the group chats to talk to the MAs, to the RNs, to the PCPs, to the scribes―all our PCPs have a scribe. So you have quick access all the time to be able to reach out and constantly communicate. We made sure that everyone created a care team group G-chat. We even had a behavioral health program group G-chat per region for the overall arching program as well. We wanted to make sure everyone was getting as much information as possible and continuing the communication quickly as we needed to be able to continue to take care of our patients.

We initially had compliance check that using Google suite Google Meets as a video platform to meet with patients was HIPAA compliant, which it was. So we were able to use Google Meets at first to do video meets with our patients. Most of our patients preferred phone and that was actually the fastest way to be able to continue to check in on our patients, collect the PHQ-9s that we needed to collect, continue to hear how they're doing, making sure they're safe, particularly during shelter in place. And we added an assessment for loneliness to understand how everyone was working through the shelter in place period of time, and that has remained in place as we worked through COVID.  

This is a daily schedule. Again, when you go into a virtual setting, you want to maintain your schedule the same as it looked in the center. So everybody understood exactly where they had to be every hour during the working hours, and the schedule remained the same. There was no change to how we were seeing patients except via video or phone. Communication was going to be through G-chats. We eventually ended up adopting the Improvada system. Improvada is what our PCPs used for their on-call of weekends and overnights. We adopted it as the daytime bat phone system. So if a patient was calling to our call center with a crisis, the crisis call could be routed through to our BHS, through the Improvada system during their working hours. Eventually, Oak Street Health purchased Doxy.me. Or Doximity―excuse me. We experimented with Doxy.me; we went with Doximity. Doximity was the way that we are now currently as we have now returned back to center. But some patients do prefer the phone or video due to being unable to leave their home fearful to leave their home. We have continued to use that platform to continue phone and video visits.

And I'll turn it back to Dr. Hunt to talk about now what this flexible hybrid approach to behavioral health looks like.

Dr. Hunt: Excellent. Thanks so much, Rebecca. What I want to do is just kind of go back to that original visual of the collaborative care model at Oak Street and really kind of explain all the interactions between the members of the team and then of course, the members of the team with the patient as well.

So I wanted to start out initially with perhaps the most important provider within the collaborative care model, the primary care provider. And it still remains―in this kind of intra-COVID to post-COVID state that we're currently in now―it remains very flexible in how the medical provider interacts with members of the team as well as the patient. So with each one of these we’ll start out kind of with the patient interaction.

And as you can see delineated here with the arrow between the medical provider and the patient, they are back in center now at Oak Street. So the primary care physicians are in brick and mortar, so to speak. So they certainly can see the patients in center. What we have certainly learned at Oak Street is that many patients want to do quite a few virtual visits at home, and that's even at Oak Street, we have a quite robust transportation system that will pick up these folks from their home and bring them into the center. But still, the patients still want to sometimes be seen via video or phone. And with the current guidance from CMS and the feds, we still have that flexibility. So the PCPs continue to use all three of these options―in person, video to smartphone and then good old fashioned phone call.

Now the medical provider, their interaction with the behavioral health specialist happens in weekly huddles that Rebecca alluded to in her slides, and then also importantly, in-person warm handoffs. So when the PCP is actually seeing someone for a welcome visit, as we call them at Oak Street health, and they see that there's quite a bit of behavioral health need too, they might pull the BHS in right then into the appointment, do the warm handoff. The introduction behavioral health specialists might do some even quick interventions, and then we immediately get that person scheduled for an initial assessment. So that tends to be kind of it's more in-person interaction between medical provider and the PHS.

The interaction between the medical provider and the virtual psychiatric consultant is quite virtual and really always has been at Oak Street. And so we were really well positioned there as we moved into the COVID pandemic. The medical providers can do formal what we call direct site consults through our EMR, which is called Greenway, and they can basically pose questions about medication regimens or maybe even quick questions about diagnoses or benzo tapers or you name it. And that gets routed to the virtual psychiatric consultant who is expected to get it back within 24 to 36 business hours to the medical provider. So that's kind of more the formal consultation process. There are also quite a few informal curbside consults that sometimes come through email or G-chat that are more kind of generic questions in nature that we are more than happy to field, too. And we feel like that's an important part of this model to kind of provide that quick service to the PCPs as they're dealing with a problem in their clinic visit. Now if it starts to become more specific, then we might ask them to actually place the formal consult through the EMR. But all virtual. We can certainly pick up the phone and call, but it's more often through the EMR and G-chat that we have the interaction between the psychiatric consultants and the med providers.  

And this is just kind of a quick summary of that primary care activity within the collaborative care model. I won't go through all of this at all, but I think the most important thing is they really develop that treatment alliance with the patient at the very beginning and they set expectations about what the collaborative care model is and the various modes of communication within the collaborative care model. Because it can be a little confusing to a patient who might be much more used to traditional community mental health care. The collaborative care model is certainly a very different model.

OK so now we're going to talk about the arrows that are deriving from the behavioral health specialist. So we've already kind of talked about the medical provider and behavioral health specialists’ interaction in the weekly huddles and warm handoffs. Again, the interaction between the behavioral health specialist and the patient also remains quite flexible at this time. The BHSs are actually back in center now as well. And so they can certainly do in-person visits if that's needed because of the patient's presentation or due to patient preference. But I think still the vast majority of interaction is video to smartphone and then still quite a few phone calls.

And one challenge we have and I think I listed this later in our kind of strengths and opportunities slide is that a lot of our patients―we have a kind of highly underserved population and pretty tough urban areas and some rural areas and they don't have a great amount of tech experience. So like kind of setting up that video call on their phone can be a real challenge sometimes. So they often kind of opt for the phone approach and that can pose a challenge with certain psychiatric presentations. So psychosis, of course, is very tough in that situation, as well as dementia, too.

And so and then finally, the final interaction I wanted to go through is the interaction between the behavioral health specialist and the psychiatric consultant. So they interact on a weekly basis in a 40- to 60-minute registry review meeting where they really sort, mix and match that registry, find the patients who are not moving along as we would expect them to. And then, of course, the psychiatric consultant makes recommendations back through the behavioral health specialist to the PCP, which is kind of classic collaborative care approach.

Also importantly, I want to emphasize that we have an asynchronous consultation approach, too, again this is done through our homegrown EMR called Canopy, and it's actually done through the registry that I showed you earlier. And the behavioral health specialists can place a flag and do what we call a behavioral BHI consult, where they can pose the questions that have been asked by the PCP team and also maybe by the BHS to the psychiatric consultant. They kind of lay out what medications have they been on in the past, what are they currently on, what's their adherence look like? And then the psychiatric consultant can answer that flag any time. So we don't necessarily have to wait for those weekly registry review meetings. The psychiatric consultants are checking their Canopy queue, so to speak, all the time to answer those flagged consults right away. So that's another kind of wonderful kind of virtual interaction we have to keep things really efficient with the collaborative care model.

And this again is kind of a summary slide. And what I wanted to emphasize here is, again, the interaction between the behavioral health specialist and the patient is very flexible still―in-person in-center versus video versus phone. And then fortunately, our BHSs are now back in center for that warm handoff, availability and support, which was naturally a little tougher when they were fully virtual. And everything else on this slide, I'm going to make sure I'm paying attention to time here is pretty classic collaborative care activity with the behavioral health specialist or the LCSW.

Murray: Dr. Hunt, may I make one comment?

Dr. Hunt: Oh, absolutely. Yeah, jump in.

Murray: So one thing we noticed when we had to go full virtual with our behavioral health specialists is that we were able to at least mirror collaborative care as much as possible. One thing we have noticed, Oak Street Health is a value-based company, we need to take care of all our patients, not just the mild to moderate, but also the SPMI. And so our behavioral specialists, that was more of a struggle of figuring out how we were going to take care of those individuals. Coming back into the center allows for those warm handoffs that were not very replicable in a virtual setting as well as now that we're back in person, those SPMI, we can do very high quick touch points to be able to strike while the iron is hot and be able to stabilize a lot faster. So that is one note I want to say.

Dr. Hunt: OK excellent. Thanks so much, Rebecca. That's really helpful.  

I think we just need to touch on the psychiatric consultant role within the collaborative care model, and we've already kind of gone through some of these. So again, your refresher, we have those direct-to-psych consults that come through our EMR from the PCPs to the site consultants and the informal G-chat kind of conversations. And again, kind of same pattern here. The psychiatric consultants can see patients. It's a little bit different because our psychiatric team is fully virtual. None of our psych MPs or psychiatrists are based in a center. They actually work from home, so they're fully virtual. So the most intensive way that they can see a patient is what I often refer to as in-center video. So we have a specific room within our Oak Street Health Centers that we call the consultation room or kind of the telepsych room where the patient comes in to the center, is then roomed in that room. Vitals might be done, AIMs might be done, and then the video visit happens with a psychiatrist. And that's done via Doximity. The psychiatrist can send the Doximity link to the behavioral health specialist or what we call the welcome coordinator, or medical assistant who might be moving the patient into the room. But then we're doing a lot of visits still via video to the home, via smartphone, as well as good old fashioned phone visits, too. Those have been, I mean, there's no doubt that it's helped access and that's even in a organization that's provided quite robust transportation to the brick and mortar center, we still feel like we've really improved access via the televideo to the home as well as phone.

I saw one brief chat comment and that video to the home and phone to the home has really improved the interaction with the family members as well, because it's so much easier for them to be a part of the conversation, often in the home, as opposed to trying to make it to the brick and mortar center at a certain time that might not work with their work or child care schedule.  

Again I don't think I need to run through any of the details here. I think that I do want to kind of reemphasize the virtual weekly registry review with the BHS, which is kind of the heart and soul in many ways of the collaborative care model, those asynchronous consults that are the flags from the registry and then those kind of EMR-based e-consults from the PCP, which are kind of quick med-related questions.

So briefly, I wanted to kind of walk through the step-by-step journey of a Oak Street patient with major depressive disorder, which is our most common presenting psychiatric disorder. So, number 1, this patient would be seen traditionally in person within a Oak Street Health Center in primary care for like a welcome visit. They would do the PHQ-2 and if that was positive, then they would move on with the PHQ-9 and in this situation I said 18, which is a moderately severe score indicating a likely diagnosis of major depressive disorder.

So then the primary care team would complete that EMR-based behavioral health team referral within our home-grown Canopy EMR, the patient would then be immediately placed into that chronic disease, behavioral health registry. Warm handoff would also be completed in clinic where the BHS would be pulled into that initial visit with the PCP and then they would immediately be scheduled for a BHS initial assessment.

Then the next step would be the BHS actually seeing the patient, and that would likely happen in person within the Oak Street Health Center. And then we kind of theoretically said that the PHQ-9 then went up to 20. Patient state's interest in both short-term action-oriented psychotherapy as well as med management. So the BHS then schedules a follow-up visit via Doximity Dialer video into the home via the patient's smartphone. So that's where we kind of made a transition. So they maybe did the initial assessment in person, but then they really preferred to do video visits at home for the subsequent short-term psychotherapy.

Number 6, this is where the BHS kind of pulls in the psychiatric consultant expertise. They place a BHI consult note and flag the patient in the registry requesting psych consultant input on psychotropic medication options. And of course that's all being done in an asynchronous and virtual fashion through our EMR. So nothing has to be scheduled at all.

Number 7, the virtual psychiatric consultant could then review that note and they would make medication titration recommendations within the EMR. And then the BHS is expected to communicate those recs back to the PCP for the actual prescribing.

Number 8, PCP's team could then contact the patient to inform them of the medication management treatment plan recommended by the psychiatric consultant. And then number 9 is emphasizing the BHS calling seven days later to really stay on top of that PHQ-9 measurement and also of course to check-in on any kind of medication side effects. Those are so common early in treatment, of course.

And then finally, 14 days later, the BHS completes that Doximity Dialer video visit by texting the link to the patient's smartphone. And then what basically happens is the patient then clicks on that link and is then connected to a video interface with the BHS for the 50-minute visit.

So that's a pretty standard kind of situation at Oak Street and how we're hopping around a little bit and modality where it's kind of in person and then it might switch to video and then we have these kind of virtual consultation options as well. And it really adds up to be a really wonderful system in which to treat patients.  

And so finally, kind of touching briefly on the strengths and opportunities, so we’ll start positive first. The strengths―there's no doubt that reduces transportation barriers. And like I said―and this is even in an organization that provides a lot of transportation to their patients to get them to the center―there's nothing like going straight into someone's home. It's also great to have that flexibility to find the appropriate level of care or the level of communication that is needed for each patient. Because I like having that flexibility. If someone just has pretty straightforward generalized anxiety, the phone might be just fine, but if you need to have more robust evaluation of someone with psychosis, bringing them on into the center is probably the best way to go. So it eliminates the access barriers caused by what I often call the geographic maldistribution of psych MPs and psychiatrists.

The psychiatrists tend to gravitate toward the coasts, not so much in rural areas or in underserved urban areas, sometimes too. And then of course, then it's the FTE multiplier through the psychiatric consultation that's often virtual in nature, as opposed to always going immediately to the one-on-one care. One-on-one care, it's hard to substitute it in certain situations, but we believe that it's not always needed. And recommendations often can be efficiently used and then the prescribing can be done via the PCP with the behavioral health specialist support, of course.

And the opportunities or some of the challenges that we're dealing with? I would say one of the biggest ones is really just kind of the unknown future of the current telehealth regulatory changes that all came down with COVID in March and April of 2020. So we're still not totally sure how all that will shake out, like how flexible will CMS be with phone visits? So we'll just have to monitor that over time and we'll of course adjust as soon as the official word comes.

It gets confusing sometimes with appointment naming conventions and kind of scheduling confusion, because if you think about it, there's like these three different options basically for seeing patients. It can be like kind of in-person versus—really four. In-person, face-to-face in the flesh. Then we can have the patient in the center and then the site consultant at home and then video to home and then phone to home. So you can imagine how we have to be careful about how we name the appointments so the provider and the patient know exactly what's going to happen in each appointment. So that's something we really have to keep a close eye on.

So one thing that I have struggled with some is more severe patients, and this is going to sound maybe strange to some folks, the folks with maybe a schizoaffective or schizophrenia diagnosis for whom we're caring, might not really want to come in to the center. Or they, you know, we might want to see them and do the AIMs and do all the appropriate things that you need to do when you're prescribing an anti-psychotic. But the patient might not want to. And they know that that video and phone option is available, and they might opt for that or really pressure the provider to go in that direction. And so that can put you in a difficult spot to kind of make that call to kind of move more toward kind of solving the access and barriers to access issue for the patient and become―be more patient-centric? Or do you maybe think more about the quality side of things―where's the best place for us to care for this patient? So it's kind of a unique challenge that's emerged in the past year.

And then there are real broadband differences across different geographies that are very real. And then of course technology skills limitations. I don't want to be ageist anyways, but sometimes in the older population they don't love the technology quite as much. And some do just fine with it but there are some technical skills limitations that we bump up against too when we're trying to do things in the home. That kind of sums it up. And I think that we'll go to the next slide.

And in general, just kind of future directions. We're expanding very rapidly to developing primary care centers or gosh, we've now announced publicly up to 20 states, and we have a goal of having way over 100 centers by the end of this year. So we're expanding rapidly. And we truly believe that integrating the collaborative care evidence-based model of integrated behavioral health care is really the best way to move forward as we grow rapidly. And it's been wonderful to kind of integrate these virtual approaches, along with evidence-based collaborative care model, to even further improve access. And we think quality as well. I think that kind of takes us to the Q&A portion. Hopefully we didn't dig too deep into that.

Lim: No, thank you, Dr. Hunt and Rebecca, really appreciate it. I think I'd like to maybe have folks, if interested, use the Raise Hand function if you'd like to. We're testing this out. We'd love for you to share your video or turn your audio on. The Raise Hand function is under the reactions. And there is an icon there that says Raise Hand. And John, I'm so glad you raised your hand because I was going to ask you if you were interested in sharing some of your questions. So go ahead.

Ovretveit: Yes, thank you very much. May I throw a few at you and you can just pick up those that you want to? First one is we have to be flexible about visit duration. And if you've got a fairly large team, you can have an administrator who, as it were, can see that this meeting is taking quite a while and move on, distribute people dynamically as the time allows, so that you can get a proper amount of time for each patient's needs. So rather than sort of set times, how do you deal with the flexibility and then schedule in?

Secondly, I think you mentioned about the family member. I won't pursue that, but I'm interested. How did patients fill in the PHQ-9? Was there a thing on the app that they just filled in? How did you keep that up-to-date so you could track it?

The last thing is for clinicians, we're more likely to burn out if we're doing video all the time. And we do, you know, for our own satisfaction and for variety, we need to see patients and sometimes actually lay hands on. But also in some ways as important is all that communication that goes through the body language. So for SMR patients I can see the dilemma there, especially if you can't even do video for body language. I'll stop there and you can pick up whichever of those you'd like to.

Dr. Hunt: You know, I guess I'll just kind of go into order, John. So the duration of visit is a wonderful recommendation, and I love that idea of kind of targeting the appropriate amount of time for the level of intensity of the presentation. I would say that we are not there with our―the sophistication of our scheduling software, and then also kind of bringing our clinicians on board. But I think that would be a wonderful goal to strive for in the future. And it's always been like in the back of my mind, but it's really operationalizing that via technology and then making it work with your specific EMR system and then also kind of bringing the clinicians along too, who are very used to having those scheduled appointments. We're having enough of a challenge just kind of pulling them into the implementation of the collaborative care model and kind of thinking in this population health mindset. But a wonderful goal and in the future, I would say. Rebecca, if you want to respond to the PHQ-9 one?  

Murray: We serve a population that is an underserved urban areas. We have actually a high prevalence of illiteracy that we discovered. So we have our behavioral health specialists verbally ask the questions and do the “not at all,” “several days,” “half the days,” “more than…” they verbally go through it. And so that shift, when we had to go virtual, it was verbal. But we do have, to make it easier for our behavioral health specialists, so they're not scoring it, they're not asking from a piece of paper, our in-house EMR Canopy, we've uploaded the screening. So the screening can be on the screen, on half the screen, while you may be looking at the other screen, half screen, looking at a patient. You can do the questions real quick and it scores it for you. We also have not just the PHQ-9 but the GAD-7 and the MDQ up as well. And this has allowed us to do something a lot faster and be able to habitualize our behavioral health specialists who are also adapting to understanding how to work in a population health mindset.

Dr. Hunt: And then finally, I think the other one was that this is a very important point as well, that kind of the idea of video burnout as opposed to having that kind of frequent in-person interaction. And gosh, I can just kind of speak from my own personal experience. I'm going into my third year of purely virtual work. My previous company, Ginger, was all virtual, and then our psychiatric team here at Oak Street is all virtual as well. And it can be a challenge sometimes, and the ways we try to mitigate that is to try to have as many collegial interactions as we can have, both kind of peer interactions between the psychiatric consultants and then also frequent one-on-ones between me as the supervisor and the psychiatric consultants on a weekly basis.

And then we actually try to just meet them where they are, too. So if they live in Chicago and they have decent geographic access to an Oak Street Health Center there―and they're all over the city―then we are more than happy to support them, to go in to the center, to kind of meet the primary care physicians, to see the BHS kind of when they're on site at the brick and mortar facility. So I would say this is more of a challenge for our psychiatric consulting team because we're fully virtual.

Our BHSs actually do have quite a bit of collegial interaction. It's not necessarily mental health collegial interaction, but they have a lot of primary care collegial interactions since they're working in the same center where the primary care providers are. But we do intentionally connect the BHSs virtually in regular peer discussions to try to reduce that burnout. But excellent observation and a very real challenge, no doubt.

Lim: Great questions. Alright, we have a couple from Shamala Fatima, and I'm going to verbally read them to you. So the first question is, were any behavioral health clinical trainings utilized to help providers conduct more effective virtual evaluations? I'm curious of trainings aside from telehealth etiquette, webside manner and technical troubleshooting, et cetera. So I'll start with that one.

Dr. Hunt: Rebecca, I'll let you field that one.

Murray: That's a really good question. We did do a quick training with all our behavioral health specialists, since it was new to them. Our psych providers had always been virtual so this was not a new world for them. We did do a quick training based on etiquette of making sure that you look presentable, especially if it's going to be video. This is still a workplace environment, even if it's an at-home environment. Some of just the basics that I think we all had to recognize and adapt to. You know, please don't show up in your pajamas, things like that. So definitely did that. I believe that most of our patients, we can't train them, so we had a lot of patients show up in very interesting situations. And so we had to do a few trainings regarding how to make sure that patients … we prompted patients about how to prepare for the visit. If it's doing the reminder call asking some basics of please make sure you're in a private area. Please make sure that your camera is on. Please make sure that you're fully clothed.

Dr. Hunt: Yeah, yeah, so lots of training there. And then there are lots of good options. You know, like the American Psychiatric Association has lots of good telehealth training, as does the AMA as well, of course.

And then I see the other question here too, I’ll save you from reading it, Bernadette, it says do the LCSWs see patients that approach behavioral health directly or do they need to be first seen and referred by medical? So that kind of goes back to what we discussed as far as warm handoffs. So it can happen immediately. But they do―they are scheduled with the PCP team initially and then when the behavioral health need is picked up on, the BHS can be brought in right away. Rebecca, do you have anything to add there as well?

Rebecca: Yeah, one quick thing, because I know we're way over time, but for Oak Street Health again, since we're value-based, our behavioral health program is a specialty in house for Oak Street Health. So therefore, all of our patients have to have their PCP as an extra health PCP, they have to have it assigned. So we do not take anybody outside of the Oak Street Health community. And so therefore, yes, it is a referral only from PCP within Oak Street Health.

Lim: Wonderful. Alright. Let's go on and move to our next presenter, Dr. Boylston. Laura, I'd love if you could pull up the slides again. And then, Chris, I'll turn it over to you to introduce Dr. Boylston.

Botts: Absolutely well, thank you both again, Rebecca, and Dr. Hunt for that great presentation-discussion. I think was really insightful. The journey about during COVID 19 and where you are trying to go. And I think we will hear from Dr. Boylston and Burlington Pediatrics is a little bit different population, right? A little bit different model, some similarities and potentially some differences in their experiences.

Dr. Yun Boylston is a pediatrician at Burlington Pediatrics and Mebane Pediatrics located in Alamance County. As a physician partner, she champions innovative strategies and operational effectiveness, builds and sustains a thriving independent practice. In March of 2020, Dr. Boylston led her practice to adopt and scale telehealth operations, which now accounts for over 15% of visit volume. A leader across health care's continuum of care, Dr. Boylston is a trustee at Cone Health System and board chair of Carolina Complete Health. She also serves as a board director at North Carolina Pediatric Society. Dr. Boylston, I will pass the virtual baton over to you.

Dr. Boylston: Great, thank you so much, Chris. And I can't thank the AMA enough for this opportunity. Bernadette, this is such a thrill to be here. And Chris and Sam, I love that we get to continue to work together in support of the BHI Collaborative. So thank you and welcome to our audience. I learned so much from Rebecca and Dr. Hunt, and I think this is a really great way to complement the versatility of telehealth and how it can be customized to the needs and strategy of an organization. So I love being able to show two different parts of the spectrum here.  

Thank you, Laura. Great. And so a little bit about my practice. So Burlington Pediatrics and Mebane Pediatrics, we are an independent pediatric primary care practice located in the middle of the state of North Carolina, and we serve a suburban, rural population. We are located kind of between two large metropolitan centers. So if you're familiar with Research Triangle Park, that is to the East of us and Greensboro Triad area, that's to the West. And so we're right in the middle.

We have been in business for 50 years. And something really special and cool about us is that we are actually very good at generational care. And so we have grandparents who were patients at our practice who now bring their grandchildren to come see us. So we certainly feel very privileged and we have a very active and innovative team. For a very scrappy and lean team with limited resources, as is true for all independent practices, there are a lot of things that we like to take advantage of and pursue, and some of that is actually reflected in our integrated behavioral health work, which we've really championed for our area, primarily because we see the need and we thought, well, we can recognize the need and dismiss it, or we can really embrace this and maybe do things that weren't formal in our training. And so a lot of us are leaning in and developing skills and growing as providers.

And some of the other things that we do to really optimize what a medical home can do and what it can mean for patients and patient care. We were in a collaborative to implement same-day long active contraceptive management, which is pretty cool. So we provide that as part of primary care. Currently we're active in a program to enhance sexually transmitted infection screening in our population. And we are a prior recipient of a grant from the American Academy of Pediatrics to improve developmental screenings in our younger children.  

I would love to say there was a lot of intentionality to our work. But as is true for probably everyone on this call and a lot of my independent practice colleagues, telehealth really is the story of “necessity is the mother of invention.” And so initially telehealth was adopted for us as a way to really save the practice. It was an operational undertaking. And it really wasn't until the pandemic evolved that we really understood the magnitude of the behavioral health issues that were confronting our patients. So really we want to say that we had this all road mapped and that everything played out perfectly, and of course it didn't. I mean, this was really innovation and being able to―flexibility was really the name of the game.

And just to give you some ideas of what you're seeing. So in one of the snapshots, that's Dr. Minter. So we thought, you know, life still had to go on. We still had to advocate, we still had to take care of growing children. We still had to vaccinate. And so during 2020, we sponsored a voter registration drive, in our masks, and during COVID. The middle phone that you see, that is our first telehealth-focused promotion on social media saying, “hey, we now have telehealth visits.” And I believe that was in late March of last year and then some of the other promotional campaigns that, “hey, we need to mask up.” And so I'm trying to make this very friendly without being scary. You know, that was a big part of being in the pediatric space for us in the past year.

And currently we, as Chris mentioned, about 15% of our 2021 visit volume is virtual. And there were points during COVID of the past year where the monthly visit volume was greater than 25% telehealth. And so it's definitely here to stay. We do recognize that some encounters really need to be in-person, but I think we've been really pleasantly surprised by what actually can be done via telehealth and behavioral health is such a great utilization of that.  

With regard to how telehealth just really blossomed for us as a vehicle for behavioral health care delivery, this is a snapshot of our patient population. So while it's incredibly hyperlocal, I think that this will resonate with everybody, even maybe some of our global colleagues who are on the call.

And so in January of this past year we conducted an informal survey of our patient population just to really get a pulse check on how their families were doing, how their children were doing, the access to care and other concerns that they had. And what became really evident was, last year wasn't just about COVID, even though for health care that was a really big part. It was really the convergence of so many events―the national landscape, George Floyd's murder and really the recognition of systemic racism and vulnerability. COVID really was a big revealer and not a creator of health disparities. And so all of that was in the mix of what our families were experiencing, what our children were experiencing. And so, as you can see, a very straightforward question, “I'm concerned that my children show signs of being depressed, being anxious, being angry, being lonely, socially avoidant.” And you can see the majority of the parents who responded noted that their children showed one or more of these behaviors.

And just more of that longitudinal look, we asked, “I'm concerned that COVID will have a long-term effect on my children's physical, mental, academic or social health.” And the majority of parents replied that, yes, they were concerned that at least one of these domains would be affected in the long term for their children. That's a pretty heavy realization that we have going forward, that COVID will cast a really long shadow for quite some time to come.

And so in light of and in recognition of what our patients were experiencing, we also had just the logistical concerns of it just became harder to get in for appointments. We eliminated our waiting room, which meant that our scheduling templates had to change. And so it just became harder to see less. And I think that's true for everybody who delivers this kind of care. And at the same time our community therapists, reasonably so, many of them temporarily closed, many of them limited access to new patients. And so we were really stuck in terms of bridging the gap of behavioral health needs that our patients experienced.  

This is just a really great snapshot, I'd love to walk you through one of my patients. I'll introduce her as Jada. And of course, for privacy reasons not Jada, but we will call her Jada. And so this kind of started organically, and this is just a really great example of many, many encounters similar to this. And so Jada's mom and I were on a telehealth visit regarding her younger sister. And Jada's younger sister has complex medical needs. She's non-verbal, she has cerebral palsy. And we were actually doing a post hospitalization follow-up via telehealth, which is also a really great utilization of telehealth platform. During this call, Jada's mom said, “hey, can I talk to you about Jada?” Of course. And she said, “I'm concerned about her. She's not acting like herself. She's really withdrawn. It's hard for me to tease out exactly what's going on, you would you meet with her and speak with her?” And I said, yeah, let's do this.

And so after that call I said, “Hey, Jada's mom, get together with Jada, find a time that works for her, and I'd love to see her via telehealth.” And Jada is somebody that I've known for close to 12 years, so over 10 years. And so sometimes some of that longitudinal history really helps because you understand families, you understand their dynamic, and you basically watch them grow.

And so the second step in this, what I did was at the same time that Jada's mom was contacting the office, I reached out to her to our behavioral health team at our practice, and I asked them, hey, “I talked to Jada's mom. We're going to set up a visit with me. Please reach out to their family, offer our counseling resource list for our community providers. And I'd also like for her to complete some screens prior to our visit.”

And so Miranda, our care team coordinator, reached out and Jada completed her surveys. She sent them back in securely. We do that via email or a portal―a lot of portal usage in a lot of this care delivery. And then on the day of the appointment during the morning, our receptionist or front office contacted Jada and her mom and said, “hey, we're all set, let's do some brief registration, we'll collect the copay if necessary and just complete the check-in process.”

And then once that was done, our receptionist emailed Jada's mom our telehealth link, and we use the Doxy.me platform. And so at the time of Jada's visit, she logged in. She was greeted by our receptionist who said, “hey, great, let's make sure your audio is working. Let's do a little bit of troubleshooting and you're all set. Please hold one moment and then Dr. Boylston will be with you shortly.”

And then at the same time from up front in our office, so all of our visits have a superbill. It's not really used. It's actually kind of like a dummy flag, for lack of a better word. But it kind of signals―it accompanies the patients when they're physically in the building to the exam room and it sits in the door to show in a visual way, along with the EHR flags, that the patient is waiting. And so that's one of the keys to our process to making this as efficiently operational as possible and to really conform to current practices. Given everything that our staff and our providers were experiencing, the last thing we needed to do was contribute to the burden by creating different and separate workflows, different documentation systems. And so for us, the secret to telehealth success was really compatibility with what we knew worked and what we were comfortable with.

And so Jada's superbill gets put into room number 2 and I bring my Mac Air laptop. I recognize that Jada's flag is there. I enter room number 2, I close the door and I start the telehealth visit as if she were in the room. And so that workflow works well for us. One, because we wanted patients to feel that they were getting the same standard of care or comparable standard of care as being in the office. We wanted them to recognize that security and privacy were still just as important as if they were in the office. And we wanted to make sure that they didn't feel like they were getting an undervalued or discounted version of a visit. And so that's worked out well for us. Other clinics may do something differently.

And then Jada and I got down to the nuts and bolts. We talked about how she was feeling. She may have seemed OK to people who didn't know her, but I think part of what helps me in a lot of my behavioral health encounters is we know that. And so I know that Jada is an honor roll student. She's going to summer school this summer. And so I knew her aspirations. I knew where she wanted to be. And I knew that her PHQ score of 16 and GAD-7 of 14 did not align with that. And so we came up with a plan.

The other part that I really love about telehealth that I really didn't expect to was you really get to see people in their element. And as Rebecca alluded to, sometimes you find situations you're like, we need to stop or you need to put on your shirt. I mean, so they are definitely very rare and few situations like that. But in general the vast majority of encounters you really get to see, I believe, the most authentic self, especially for adolescents, and they're way more at home with this. You know, this is generational to some degree. And so I find that they're able to open up. You really get to see their home environment. And so this has been very positive.

And at the same time for telehealth, a lot of things get streamlined. So for Jada, it was, hey, this is great. Since we've talked about this medication that I'd like for you to start, let's follow up in two weeks. Can you get your schedule out? Let me know when it's convenient for you and I'll put you into the schedule right now. And so there's no calling back for an appointment. She knows what she's doing. Her mom is comfortable with her doing this. And we're continuing to provide this care for Jada and I actually just saw her recently.

Some of the uses―so certainly behavioral health is a very big use and has great potential for primary care. I just wanted to briefly highlight some of the other uses because we are a primary care practice. At the end of the day our initiatives have to be financially solvent. And so there are a lot of other credible reasons to expand a telehealth program if you don't already have one.

Kind of the urgent need for us was just expedited care. Because we had limited in-person office visits due to safety protocols, this was really a way for us to provide the same kind of urgent care. At our baseline we provide same-day urgent care. So it's walk-in service. And because we were unable to do that, this helped meet some of that need.

The other thing that if you're primary care, whether you're pediatrics or internal medicine, you invest a lot of time, resources and money into providing triage care. And so telehealth was a great way to convert some of those cost-incurring encounters when you're on the phone. “Oh, a rash—it started yesterday? Well, how about this? Can you hold on a moment? Would you be interested in a telehealth visit? One of our providers is available right now.” And so that kind of conversion has become a lot more seamless for us.

And then warm handoffs―with our behavioral health team, so Dr. Caputo, who has been with us for a couple of years, she recently was recruited to be a director of a behavioral health program at our local health system. And so we're actively recruiting now but during the past year, what would happen is there's one Dr. Caputo, who is a clinical psychologist, three office locations. And so we actually used telehealth quite a bit―she would be in one office location and then one of us would say, “hey, would you like to meet Dr. Caputo very briefly? And that way we can kind of talk about the plan for you?” And so we would utilize telehealth within the office, communicate between providers with the patient at the center.

And as I mentioned, regarding Jada’s sister, it's also a great way to connect to care coordination for our vulnerable or medically fragile population, the ones who really could not afford unnecessary exposures. And frankly, when it's really hard that if you're bringing in the wheelchair and the oxygen tank, and you're worried about your medically fragile child, having to wear a mask, this really helped bridge a lot of care that was required and needed for them to continue to receive services. And so that was a really good, good use.

The other way that we utilized telehealth was actually to achieve staffing efficiency. And so even today, we do this daily—we have a designated telehealth provider on the schedule. And because of the lean model for telehealth, basically just a provider is pretty much self-sufficient once they have their schedule up. And so the nurse that would be designated to work with that provider dyad, that person actually operates our drive-thru testing services for COVID. And so that's worked out really well.

The other utilization for optimized staffing, fortunately we never had to take advantage of this, but there was a real fear that we would lose a provider due to a quarantine event or an isolation or illness event. And so for a number of months what we did was we had a weekend provider because we have weekend clinics Saturdays and Sundays. We had an additional weekend provider provide exclusive telehealth services from their home. And so we had the workflows kind of hammered out in the event that we would need to have somebody who was still capable of working but couldn't be in the office. And so that worked out.

My favorite of the uses that I wasn't expecting but really am pleased that it worked out this way is our expanded footprint. So while we cover essentially a five-county geographic area, we realized that when our college students go away to Greenville or Charlotte or Asheville, it's really hard to keep that connection. Sometimes it's like they'll call and we'll say, “hey, yeah, I can send in your birth control refill to Charlotte, but when you're in town over the summer, come see me.” And that really isn't the best of care. And so we realized that as long as you're in the state of North Carolina, we are happy to see you. We provided and continue to provide a ton of behavioral health to our college students because I would consider them very much a vulnerable population within transitional care, not at home, and frankly the student services from all the colleges and universities around us, I mean, they've been inundated with similar needs. And so we feel like we do it better. We know them, we know the students, we know their family history. And so they feel very comfortable just meeting with me in a dorm room and talking about their needs and their care.

I really had a light bulb moment in terms of the versatility of telehealth. About two months ago I had a mother approach me and she said, “I really I don't know what to do because I really need care for my daughter. I believe she's incredibly anxious and depressed, but I can't bring her because I'm in the ICU with my husband, who's incredibly sick.” And that was probably about an hour and a half away from where she lived. And I said, “let's do this. Let's do a three-way call. You call me from the hospital. You find a room there. Have your daughter log in with her grandma at home and I will be here.” I really felt like as a physician, that was a time where I really met the patient where they needed me and I met them where they were. And so I look forward to bridging that kind of gap much more in the future.  

And so I didn't want you to just hear it from me. These are some of my esteemed colleagues and teammates at Burlington Pediatrics and Mebana Pediatrics. And I think this is actually quite funny because the providers, of course, because they're scientists, they have a little bit of a tempered or measured response to telehealth. And of course our staff love it. And it's just the next best thing since sliced bread. But Trevor Downs is one of our PA's and he says when it all works well and everyone knows there's an asterisk because we're in an area where we definitely have some broadband challenges, as Dr. Hunt alluded to. But he says “when it works well, I get the feeling that the patients and their families like it a lot. That saves time.”

And Dr. Minter, one of my colleagues and a former North Carolina doctor of the year, she says, “Mental health services are perhaps the most frequently used. My patients with ADHD, depression and/or anxiety use these appointments for follow-up.” And that's a great use.

MoRhanda Fox, our lead care coordinator with our behavioral health team: “Telehealth is not only the new norm, but a new way for medical professionals to interact with patients without barriers.” And I just love, love those words.

And Amber Davis, our receptionist, she says, “I feel this is one of the best things we have done to promote immaculate patient care here at our practice.” And that just imbues the pride that our staff and our practice, we have for the work we do. And so just wanted to share some of those thoughts.  

And so future directions. So what are we doing? What are we looking at? And so for us really the true north for us in continuing telehealth work, sustainability, making sure that there's a high standard of care and continuing to innovate. And so for us the measures are, we have the tools and so professional development is foundational for us. And I think someone in the chat box had alluded to competency and this is definitely a skill set that we need to bolster and expand and improve.

And so for our practice, a lifeline has been the NC-PAL program. So in North Carolina, this is the North Carolina Psychiatry Access Line. And I'm actually really thrilled because Chelsea Swanson, the program director for NC-PAL, I believe she is with us today. And this has been instrumental in providing the framework for us for primary care to be able to have confidence and to have professional development to deliver these services. So NC-PAL is a grant-funded program that offers provider-to-provider psychiatric consultation. And then they also run a primary care behavioral health development program called REACH. And so several of our providers have taken part in this and we have several up at bat to take part in future educational cohorts. And so I would highly recommend that if your area does have something similar, I strongly encourage you to reach out.

And I notice somebody, I think Rachel Thornton on the call, I don't know if she's still with us, but is joining us from ACOG. ACOG has or the NC powerline has a similar program called NC MATTERS for maternal and perinatal behavioral health. And so that might be something you can look into as well. And as part of the professional development we've really done a lot of introspective work. We have a very robust workgroup comprised of providers, receptionists, clinical leads and our behavioral health team in creating the roadmap for our behavioral health workflows. You know, what does this look like? How often do people need to be seen? And so we can provide a very consistent standard of care and really a standard patient experience.

As well as one of the things that we're doing is how do we provide same day care for suicide ideation just because we know that conventionally you just divert them to the ER, which is really I mean, for except for very few cases, that really results in poor outcome. It results in just losing a lot of that trust in seeking care for our adolescents. And so we're really trying to again, lean into things that maybe we weren't doing before, but we know is going to be a part of good patient care.

And part of our telehealth experience, I think, really involves advocacy and outreach. We surveyed our providers recently and their top three concerns in delivering behavioral health care were scheduled disruption, which we all to be true. Two, challenges coordinating care for the patient. And three was level of comfort with addressing suicidal ideation. And so we recently had a suicidal ideation workshop with our friends at NC Health, coordinated with Dr. Manning, a psychiatrist there, which was really helpful. And then our schools, we collaborate with our local school district, with their school nurses, to discuss how do we create the safety net and create improved communication. And we've also done like lunch and learns and meet and greets with our local child protective services agency members, because a lot of times we end up making these really urgent phone calls and we really felt like mutually it would be great if we kind of knew the person on the other side. And so that's been incredibly beneficial for us.

And then certainly a part of that is expanding our behavioral health provider network, meaning getting to know local psychiatrists, which we have really good collaborative relationships with, getting to know the community therapists. And so that's been―it just fundamentally helps us just bridge the gaps and provide better care. And then certainly things kind of pie in the sky things that we look forward to―advancing care delivery. These have been on our bucket list for the past year and just really trying to create a financially sustainable model like, what could we do with this? But we would love to be able to provide more support for chronic illnesses, our LGBTQ community, gosh, our adolescents really deserve and need that support and enhanced services through our behavioral health team as we continue to expand. We don't currently, but we would love to have a licensed LCSW on that team. And then continue our work with providing greater support for early childhood mental health.

This is a gratuitous photo snapshot of our team in action, and this is one of our current initiatives. We are a sponsor for the North Carolina Department of Health and Human Services, “Let's bring summer back by vaccinating everyone 12 and up.” And so this is our my last message. I encourage everyone on the call, please vaccinate if you are eligible and encourage others to do so. Thank you so much.

Lim: Thank you so much, Dr. Boylston, and thank you for sharing just I think really comprehensively your experience. So really appreciate that. We'll take any questions that anyone might have for Dr. Boylston. You can raise your hand using the reactions or type in the chat. I'll just give it a few minutes.

Dr. Boylston: I see Chelsea Swanson is on the call and thank you so much for providing that link just to see what the NC-PAL program is about. So thank you.

Lim: Questions for Dr. Boylston … I had a few, but you answered all of my questions.

Alright, let's see here. Alright. Well, if anyone has any questions feel free to type it in the chat and we'll follow up afterwards as well, answering anything that might come through. Laura, would you mind pulling up the slides again for us?

OK, I have just a couple of slides here at the end here. One, wanted to mention the BHI Collaborative webinars. So Chris spoke about the Collaborative earlier in the presentation. And if you're interested in joining additional webinars focused on the BHI Collaborative, here are some upcoming sessions and we'll include the registration link in the follow-up email as well.

Botts: I just want to add it real quick, just because Dr. Paul mentioned suicide ideation, that is also going to be one of our topics for the fall. So again, if you have interest in upcoming topics as well as our past webinars, please go to some of these links that will be included. Just wanted to call that out specifically since I know Dr. Boylston you had emphasized that at the end of your presentation.

Lim: And then the BHI Compendium is a resource that we have available as well for those that are interested. This provides a helpful framework for how you can make BHI effective in your practice. And we'll include a link to this as well. And that's Chris's contact information if you have any questions.

And we have a number of presentations coming up. Laura this is great. The next one will be on June 24 from 1 to 2 p.m. Eastern. This will be focused on just empathy, so Health Care Technology and the Human Connection. We will be having Dr. Adrienne Boissy, chief experience officer at Cleveland Clinic joining us for this. So if you are available and able to attend, please register. Should be a good session.

And then my contact information is here. If you have any questions about the Telehealth Immersion Program, any suggestions? If you'd like to participate in a future clinical case study presentation, please feel free to contact me directly with any and all questions that you may have.

And with that, we will end today's session. Again, thank you so much to our presenters for joining us, Dr. Boylston, Dr. Hunt, Rebecca, thank you all so much for taking the time out of your busy day to join us. And actually, maybe since we have just a minute, I see a hand raised from Amy. Amy, do you want to just ask your question?

Amy: Sure, here in the final minute, sorry about that. Took me a minute to get my thoughts together. Really enjoyed everything and learned so much. I'm originally from North Carolina so just kind of curious, Dr. Boylston, would love to hear your thoughts on kind of overcoming some of the cultural barriers to behavioral health care in rural populations. Having grown up in Surrey county, which I'm sure, you know  is close to Mebane, I hear a lot of resistance to kind of getting that level of support. And even among my parents, you know, who are isolated and older, wanting them to have that support and just resistance. So just, how you all have bridged that divide and overcome that barrier? Just curious your thoughts.

Dr. Boylston: Amy, that is such a great question and I feel like when and that's part of where, how do we really achieve health equity? I think this is the space where we see it in action. And so we try to do things on several levels. One of our offices actually has a really high Latinx patient population and so we have Spanish-speaking providers. And I think that's really essential because very few things translate. It's hard to make that connection in terms of just language, but behavioral health, that's uniquely challenging. And so having providers who are fluent in Spanish is really important. So that would be one.

The other step is when we look at screens, we really try to make sure that there is at least a Spanish or it's available in other languages because again, translation doesn't work that well.

And I think the third point is just really having cultural humility because especially for our historically marginalized populations sometimes … I think that if your family just has … it's very unique to have a parent who says, “I think my child is anxious; I'd like for them to be seen for an anxiety consult.” But reality doesn't happen that way, right? Especially in children. It's you know, my kid has chronic belly pain and I don't know what to do about it. My kid has headaches. My kid is crying when they are dropped off at school. And I don't know what to do about that, you know?

And so I think a lot of times for behavioral health, we almost assume that you have to self-diagnose to get there. But in our experience, every visit is a behavioral health visit. And if you don't go looking then I think then that's when you miss it. And so for this reason, this is why we are really big and intentional about screening. We do PHQ-2 screenings for everyone 12 and up, and I think that's really important. And then just utilizing a lot more of just having a really low threshold―we even use things like the SCARED survey, which is an anxiety survey for children. We're certainly moving into the PST-17. I mean, use your tool and use the tool that you're comfortable with. But I think go look for it because if you don't, then you're just missing it.

Amy: That's great. Thank you.

Lim: Alright, everyone, thank you so much. Have a great rest of your day.

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Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.