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By Stacy DiStefano

There is general agreement that health and human service delivery should be guided by measurement-based treatment protocols and standardized evidence-informed best practices (see The ‘Best Practice’ Challenge and Using Measurement-Based Care to Enhance Any Treatment). From there, the agreement ends.

I got a better sense of why clinical practice protocols and decision support tools for service delivery are slow in coming to programs focused on consumers with complex needs during the session I hosted at The 2018 OPEN MINDS Management Best Practices Institute, “Can There Be Best Practices In Complex Care? A Town Hall Discussion”. I was the moderator of an all-star panel – Clayton Chau, M.D., Ph.D., Regional Executive Medical Director, St Joseph Hoag Health/Providence St Joseph Health Southern CA Region; Mario San Bartolomé, M.D., M.B.A., M.R.O., FASAM, National Medical Director, Substance Use Disorders, Molina Healthcare, Inc.; and Scott Zeiter, Executive Vice President, Chief Operating Officer, Grafton Integrated Health Network.

(From left to right): Clayton Chau, M.D., Ph.D., Mario San Bartolomé, M.D., Scott Zeiter, and Stacy DiStefano, at The 2018 OPEN MINDS Management Best Practices Institute

Our discussion uncovered two issues—clearly defining who are “complex consumers”, and identifying and using evidence-based practices (EBP). The first was relatively simple to answer. Dr. San Bartolomé, whose work focuses on addiction treatment services, explained that a “complex care consumer” is someone where transitions of care can go wrong. He said, “They have multiple inputs, so there is an excess of opportunity to mess it up. Each of those worlds are multi-factorial.” I would expand upon that definition and add from my experience in the field that complex consumers are recognized as those with mental health issues woven with multidimensional challenges such as social determinants like poverty, food instability, housing instability, and chronic medical issues.

Our discussion on EBPs was a little more complicated. Stakeholders often have different treatment intentions and take different treatment approaches depending on where they are at in the value chain. This contributes to the lack of use of EBPs.

Dr. Chau explained that most organizations are focused on answering the question, how do we manage care? This often means there isn’t the time or money to pursue EBPs—they are expensive. He said, “It’s not cheap to pursue EBPs that aren’t medication related. If you don’t have the resources, and high staff turnover, and your consumers are hard to deal with, and school doesn’t focus on EBP training, it doesn’t happen.”

Mr. Zeiter added that complicating the issue is that the clinical leadership of most provider organizations probably couldn’t agree on a treatment plan, which means there are seldom set protocols. He said, “Physical health would follow a treatment protocol, and we don’t do that. And some people interpret person-centered planning as hostile to the idea of protocols. There are disciplines that are better at this than other disciplines.”

One of the most important comments I heard on the day came from Dr. Chau who noted that it’s important that payers prioritize and incentivize paying for outcomes based on use of EBP, rather than “submitting to pay” for them. He said, “How do you see and provide incentives based on more than just a CBT code? Would you pay more for someone who got better in a short session versus paying for someone sitting with a counselor for three years? There is the cost of EBP, but there is also the cost of inefficient care.”

Dr. San Bartolomé added, “In some cases it could be the metrics that help payers satisfy their own quality that they have to support. For people in managed care, even in clinical hats, there are ROIs [return-on-investments] attached to outcomes, but there are also ROIs for the part that is financial.”

I found the perspectives good, but I left with a concern that we are a long way off of any “true measures of functioning.” Is the tail wagging the dog, or are health plans driving the treatment? Should provider organizations or consumers bypass the health plans and simply “drive the boat”? I posed a similar question at the close of the day, and Dr. San Bartolomé noted, “I don’t think you need to pick. I think that the best of class is going to come out. There is a role for all of them, and they have different redundancies. The question is how we integrate them.”

For more on clinical best practices and decision support, check out these OPEN MINDS Industry Library resources:

  1. Mapping Performance To Manage Value: The Clinical Data You Need To Manage The Risk Of Value-Based Reimbursement
  2. The ‘Best Practice’ Challenge
  3. Workforce Problems? Technology As Strategy
  4. What Will Mental Health Treatment Look Like In The Years Ahead?
  5. HIE 3.0?
  6. Preparing For The Very Glacial VBR Rollout In Some Markets
  7. Best Practices For Ethical Evidence-Based Prevention Programs
  8. Adaptable Standardization-In Service Of Mission?
  9. What’s Driving ‘Whole Health’ For Children?
  10. Why Do Only A Third Of Consumers With SMI Receive Evidence-Based Treatment?

For more on the trends in health in human services, join me on November 15 at Noon (EST) for the free executive web briefing, Unpacking Four Major Forces Driving Industry Trends In Behavioral Health, featuring Todd Charest, Chief Product Officer, Qualifacts; David LaPlatney, Integration Architect, Behavioral Health Network, Inc.; and Deb Adler, Senior Associate, OPEN MINDS.

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