In this episode we talk about population behavioral health with Dr. Nishi Rawat, founder of OpenBeds, a behavioral health treatment availability platform, who now serves as chief clinical officer at Bamboo Health.

Dr. Rawat, welcome to the Move to Value podcast. Can you give us an overview about the current state of behavioral health in rural communities?

Sure I, you know, I think that it's important, first off, to know that the rural United States consists of 97% of the land area and is home to about 20% of the population with 50% of the population living in the South. When it comes to mental health conditions in rural versus urban areas, the prevalence of mental health conditions is the same overall. But the nature of the conditions, as well as the driving factors, are very different in rural areas. We see higher rates of suicide and depression with the rate of suicides unfortunately increasing overtime and the unique driving factors include economic ones like intergenerational poverty and higher rates of unemployment. Social ones like isolation, loneliness, and more stigma associated with such conditions. And finally environmental factors like climate change and natural disasters, which aren't exactly top of mind for those of us that that live in urban areas

When it comes to barriers to optimal behavioral health, can you tell me what differences exist between rural and urban communities?

Again the prevalence of mental health and substance use disorder conditions is relatively similar, but again, the nature and the driving factors are different in terms of access to care, especially access to Affordable Care, that remains - it's a significant issue in both urban and rural areas. But it's particularly problematic, if that's even possible, in rural areas. 75% of US counties are known as mental health practice shortage areas. That means that they don't have enough psychiatrists, psychologists, social workers, counselors, school counselors, and that shortage is correlated to two main factors. Number one, rurality, and number two, per capita income so that the lower the per capita income the higher the likelihood of having a shortage of mental health practitioners.

Now with respect to differences in affordability we know that affordability is the single most important factor correlated to using care. Increased cost sharing is associated with not seeking out the necessary behavioral health treatment that you need. And in the higher cost of services can result in a lower likelihood of going out and accessing behavioral health services. So rural residents are actually they're more likely to be uninsured and underinsured as you know. They're also more likely to receive Medicaid than urban residents. Now Medicaid is a good thing because that's actually correlated with easier time accessing behavioral health care but the problem is that 2/3 of the rural uninsured population live in states that did not expand Medicaid. And then finally those who are covered by private insurance or among those who are covered by private insurance, rural residents are far more likely than urban residents to have a high deductible health plan. So a couple of whammies there for rural residents generally when it comes to affordable access to care or access to Affordable Care rather.

Do you see any perceived stigma of having a behavioral health issue factoring into patients not utilizing resources that are available to them? Are these folks afraid of being seen as broken?

Yeah, absolutely that's one of the again important drivers or differences between urban and rural populations is again the stigma associated with mental health and substance use disorder conditions generally just as as you've described. In addition to that, that stigma plays out because you're not anonymous in a rural community, right? There may or may not be a practitioner, but there may be someone that people see and you'll be seen. And there's fear associated with being seen seeking help. So that that's a significant barrier, absolutely.

The good news is that with the pandemic, care delivery systems that were at the periphery, like telehealth, they're now mainstream and actually during the pandemic 50% of telehealth use was for behavioral health conditions. And people continue to seek behavioral healthcare in a telehealth way, whereas for medical care a lot of people have gone back to brick and mortar services. But where I'm going with this is that for rural communities in particular rural populations this is a mechanism. Getting care via the telehealth medium is a mechanism by which to bypass the stigma.

Outstanding. Dr. Rawat, will you share with us some of the findings from your work around substance use disorder?

Absolutely. So at Bamboo Health we work with 15 States and counting to improve access to both mental health and substance use disorder care. What we do is we work with state governments to establish a behavioral health network that's connected digitally to give those organizations who refer into mental health and substance use disorder services to give them that situational awareness and the ability to connect to providers digitally to find evidence-based care for their patients. We also support state 988 and in-crisis line initiatives. I don't know if your audience - if they're familiar with 988, but what we do is we thread together the crisis care services within that crisis care continuum to ensure that callers in crisis get access to definitive behavioral health assessment and treatment.

Can you share with us more information about the 988 initiative?

Absolutely, it's a very important initiative instigated by the federal government. Again, it was launched in in mid-July of this year not with a lot of fanfare. I do believe that the government and states are holding off on marketing for a little bit to ensure that the call centers aren't overwhelmed, but again, for those of you who are not familiar with 988, it's akin to 911 but for behavioral health crises. So just like if you were having a heart attack or perhaps your house was on fire, you call 911 and the appropriate folks, whether it's an ambulance or the fire people would come to your house, put out the fire or take you to an emergency department to get assessment for your chest pain.

Now you can call 988 if you're having a mental health or substance use disorder crisis, you or a loved one, you can be patched through to a clinician who will do a validated assessment and then will get you to the right level of care. So perhaps that's connecting you to an outpatient assessment or treatment episode, if necessary. If you are in need of more urgent care, in some markets or regions, they can dispatch a mobile crisis team to do an on-premise assessment. And then in other regions that mobile crisis team can take you to what's known as a crisis stabilization facility where you can be observed get care and then transition to appropriate outpatient or inpatient care.

Dr. Rawat, how can we create more collaborative care between behavioral health and physical health?

You know, look, we've been talking about this for too long and I think that there are few organizations that are, unfortunately, walking that talk. What we do know, or what I feel strongly about, is that this type of integration between behavioral health and physical health it happens at the point of care. And I can't stress that enough. That said, the appropriate incentives need to be in place for people, individuals and providers for the integration to happen at the point of care.

A good example of incentivized care is the certified community behavioral health clinic model, which is currently a Medicaid demonstration project. It was initiated by the federal government by Medicaid back in 2016 when they selected 10 demonstration states for this project. The participating demonstration States and behavioral health providers need to provide certain core services, which includes crisis care, access to crisis care, for their patients 24/7. They can't turn anyone away. They need to do care coordination collaboration across behavioral health and medical settings and they need to have the appropriate technology in place to be able to do that kind of care coordination. And then finally they're held accountable. They need to meet quality metrics associated with offering these core services.

Do you see a role in this collaborative continuum for the community health worker and community organizations?

yeah sure, so look it's important to meet people where they're at. And given that it's near impossible to travel five hours every week, right, for a treatment, appointment. We need to provide care in the community setting, out-of-the-box places like our schools, grocery stores, libraries, and so I do believe that these community settings are particularly important for rural populations given that the distances involved.

Now I know we just talked about telehealth and how that's made it easier but not everyone has access to telehealth or telebehavioral health, so there's that I also think that it's even more important for people to be served by people who look like them, talk like them, who have similar lived experiences and we see that in urban communities as well as rural ones alike. And so ensuring that the clinical population looks like those who are seeking care that's really important and that's something that I do believe is best achieved by community health workers.

What can a provider do starting today to begin to address some of these issues?

Sure so number one, institute screening for all your patience as recommended by the federal government. So, for example, substance use screening should be integrated into primary care community settings and the emergency department. We've known this for a very long time and others that SBIRT program the screening brief intervention and referral to treatment program that everyone should be aware of. We should also incorporate screening from a mental health perspective.

Recently the US preventive services task force recommended screening all adults for depression and those under the age of 65 for anxiety and then they also more recently recommended that all adolescents be screened for depression and anxiety, I can't remember the exact age group, but this makes a lot of sense because 50% of lifetime mental health conditions begin by the age of 14 and 75% begin by the age of 24. So people need to be screened and assessed early on in life.

And then second, care is inherently local right, we just talked about that. So that's what makes this question so difficult to answer but I would refer people to the American Medical Association's website. They have a behavioral health collaborative there that has compiled a detailed behavioral health integration compendium for providers. It has very very practical advice for providers including a spectrum of 6 levels of collaboration, how to go about picking a level of collaboration for your organization, assessing your organization's readiness, making the pitch to leadership, workflow design, measuring outcomes, it also includes billing codes. So there's a wealth of information there at that website and within this compendium and I do believe that you can very easily tailor that to your local setting and community.

Dr. Nishi Rawat, thank you for joining us today on the move to value podcast

Thank you for having me, Thomas