STRATEGIC PLANNING
How One North Carolina System Rewrote the Rules on Behavioral Health Care
WakeMed Health and Hospitals faced a perfect storm in the system’s seven emergency departments just a few short years ago. The population in its North Carolina service area had exploded, bringing tens of thousands of individuals with complex medical, behavioral and social issues and nowhere to turn.
Clinicians tried to plug all of the leaks, but they were quickly running out of resources, said Vice President and Chief Strategy Officer Richard Shrum. In 2017 alone, the Raleigh-based hospital system logged more than 40,000 encounters in its EDs for substance use and behavioral health. They maintained an average daily census of 150 patients with behavioral health conditions with no psychiatric beds or organized programs to treat them.
"I said to our CEO Donald Gintzig, ‘We need a big idea because we cannot navigate through this without a larger, more comprehensive strategy.’ We were at a very serious point,” Shrum recalled. “Our community and WakeMed were becoming overwhelmed by the very real needs of our patients and families that we serve.”
A large portion of the required counseling and behavioral therapy services already existed in Wake, Johnston and Durham counties, but they weren’t optimally integrated, Shrum noted. For WakeMed, the solution would require stitching together and coordinating among all these disparate organizations to form its behavioral health network.
About two years after that crisis point, they’ve created a “circle of support” around patients, built to address all of their needs beyond medical care, to include social determinants of health (food, housing, transportation, personal safety, employment etc.). And they’ve implemented an ambitious new intake policy that requires screening, risk-stratifying and treating every patient, regardless of how and where they entered the system.
One simple, yet pivotal, change in this process was beginning to make behavioral health and social determinant screening standardized and routine, noted Michael Rhoades, CEO of Blaze Advisors, which assisted WakeMed in the project.
“We need to stop making behavioral health the hidden disease,” he said. “One of the principles of these networks is there is no wrong-door access. We will screen you; we will talk to you about it; we will assess you in any environment at any time and make mental health screening normal. It’s about getting you to whole-person care.”
At 18 months past the start date, WakeMed was already making marked progress. Length of stay has dipped by about 27 percent and average daily census had dropped another 40 percent.
“It’s created unbelievable community collaboration, and great care for our patients,” Shrum said.
How They Did It
To begin shifting the tide, WakeMed convened all its disparate partners to better understand the complex issues surrounding behavioral health. WakeMed started by launching the Network for Advancing Behavioral Health, comprised of outpatient providers delivering timely access to psychiatric, outpatient therapy, wrap-around supports and evidenced-based programs like medication-assisted treatment.
Based on the success and learnings of that initial effort, WakeMed convened a sister network of social service organizations, the Connected Community, to help improve access to services that mitigate social insecurities such as food, housing, transportation and personal safety. Finally, WakeMed organized a council of regional and statewide acute and inpatient psychiatric providers to standardize access protocols and improve throughput. All three of the councils fall under the same umbrella, but each has its own governance structure.
All told, this vast health network includes WakeMed and its three hospitals, nearly 1,000 beds across several inpatient behavioral health institutions, and 10 more provider entities on the outpatient side employing 1,500-plus clinicians, as well as 15 Connected Community member organizations. No money changes hands among the participants, Shrum noted, however, the network does hold each other accountable to several key performance indicators through its governance process.
Patients are tiered from 1 to 4 when they visit the ED based on severity of illness. Tier 1 requires an outpatient appointment, for instance, while the other end of the scale calls for inpatient services. Rather than keeping patients waiting for months, providers ensure that Tier 1 patients have their outpatient appointment slated within seven business days. If they’re Tier 3, teetering on inpatient status, the goal is one day. It sounds ambitious, Shrum admitted, but providers are hitting these indicators at an 75% clip. “I’d put that up against anybody in America.”
Rhoades added that this initiative has required sophisticated tools to analyze its service area and match patient need to the right provider. There are more than 3,000 distinct behavioral health diagnoses, and not every clinician is skilled at treating each indication. So, they’ve looked to match patients in the same fashion as a search engine, profiling and referring them to providers who have the right skill mix nearest to the patient’s home.
Analytics tools further monitor behavioral health patients to pinpoint sentinel events, readmissions, no-shows and poor engagement. Everything is risk-driven to ensure that patients in higher tiers receive the resources they need. An electronic system across the network serves as the “brains” to sound the alarm when high-risk patients are readmitted or miss an appointment.
All of these layers are producing dramatic results, including a 79% decrease in state hospital referrals and a 52% decrease in avoidable bed days (time spent waiting at WakeMed for placement at a psychiatric or substance-use provider in the community). The outcomes are drawing interest from payers and other providers, Shrum added, and they’re now exploring other ways to expand the network and spread their success.
Shrum pushed back against hospital leaders who insist they do not “do behavioral health” because for most, if they “have an ED, they have a behavioral health need.”
“We want to be the convener in the community and I would challenge all of you: Where is a better spot to attack this huge problem in our country than to lead through our health systems?” he asked. “It’s our duty and I think it’s something that every hospital should step up and consider.”
This article features an interview with:
Richard Shrum
VP, Chief Strategy Officer
WakeMed Health and Hospitals
Raleigh, North Carolina
Michael Rhoades
Chief Executive Officer
Blaze Advisors
Wilmington, North Carolina
