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#023: Rural Telehealth: Transforming Child Mental Health
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Billy West, CEO of Daymark Recovery Services, comes aboard to tackle the youth mental health crisis. Leading a not-for-profit behavioral health provider serving over 50,000 individuals across 38 locations in North Carolina, Billy breaks down post-COVID challenges, social media’s impact, and flaws in the social welfare system. He highlights Daymark’s telehealth expansion, school-based programs, crisis care approach, and the urgent policy changes needed to improve mental healthcare access.
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I really believe the old system's philosophy was correct. It's kind of like saying, well, we shouldn't have a health department. Everybody should go to a private doctor or urgent care. No, we need a health department. We need a public health department. And there can still be a doctor on every street corner. That's fine. But it doesn't mean you don't get rid of your health department. That's kind of how I look at the community mental health center.
SPEAKER_00Welcome to the Adromedis Way podcast, where we have meaningful discussions on the challenges in healthcare and the solutions behind them. I'm your host, Liz Church. Each episode we dive into the complexities of our health and social system, gaining the experiences and insights of the guests that shape our lives and our communities. And we are back another week talking about the mental health crisis amongst our youth for Mental Health Awareness Month. Today, joining me is Billy West, the CEO of Daymark Recovery Services, a not-for-profit comprehensive community behavioral health provider that cares for over 50,000 individuals annually. Founded over 20 years ago during the onset of mental health reform in North Carolina, Daymark has grown to operate 38 brick and mortar locations across 28 counties. Their mission is to ensure immediate access to continuum of care regardless of an individual's ability to pay. From outpatient individual to group psychiatric appointments to crisis and detox services, Daymark's integrated approach leverages technology to provide essential behavioral health and substance use treatments. Billy, trained as a clinical social worker, brings a wealth of experience from both community mental health and large hospital settings. In today's episode, he will share insight into what he sees as the current state of child mental health, prevalent issues, and emerging trends. We'll discuss the mental health landscape and trends post-pandemic, highlighting the significant impacts COVID-19 has had on children's mental well-being. We'll also explore the unique challenges of providing day mark services in rural North Carolina and how telehealth is bridging gaps in access to care, how they support children within the school system and their crisis centers, focusing on comprehensive care that involves both parents and children. Now, without further ado, Billy, to get started with today's conversation, can you provide insights into the current landscape of child mental health, including the prevalent issues and trends that you have observed?
SPEAKER_01Well, you know, Daymark treats roughly 9,000 children annually. Unfortunately, or fortunately, the children we often see are children in the Department of Social Services custody. So they have been adjudicated, abused, or neglected in some manner. The trend we often see there is we have a hard time with placement. So, you know, when we're dealing with the Maslow's hierarchy of needs here, you know, having a place to live is a big deal. So it's very difficult to talk about what's causing a child's behaviors when they've been adjudicated, abused, or neglected, and they literally are staying in the Department of Social Services lobbies, being housed in emergency rooms. We have two child facility-based crisis units, and sometimes kids come in and they're better and need to leave. And it's hard to get people out. So the emerging trend we've seen, and it's happened, a problem trend we've seen, and it's happened for some period of time now, the past couple of years, has been the inability to have uh foster homes, uh, residential placements for kids, uh, just basic housing for kids that are in the social welfare system. Trends I've seen in general with kids, though, kids that are in the custody of their parents or family members, that come in for care, is a sense of their general well-being not being met. And that really happens for, I think, two reasons. One is COVID. We had, you know, kids at formidable years were not in school, were not, didn't see their friends, didn't make friendships. Even older children, you know, didn't graduate maybe with their their normal rites of passage that they normally would have. And you kind of, and I'm not blaming COVID completely, but it was a big deal for those kids and their families. They may have lost jobs, it may have been harder to make ends meet, they may have had chronic conditions coming from COVID, or if if not even a loss of a life of a family member. And then you add to that kind of a an emerging problem that we're having, and in that social media. So you have this deficit in children's lives, and and we're talking about the kids not inside the social welfare system. So you can imagine what this is like for those kids. So you have these kids that have experienced this COVID experience together, which is good, at least everyone has experienced this together. So we all have some commonality there. But now you have social media. And while social media can be a very good thing, in this case, often what we see it sets up an expectation that is simply not real or simply not healthy. Uh, and it's it can be very addictive. And so the the well-being of these kids is different than what I used to see when I was in practice 20 years ago. And the resources available. I'm talking about just some staple resources, like housing is different than what I saw 20 years ago. And and yes, always, you know, 20 years ago it was always something else. You know, there's video games, you know, video games are bad. You know, we heard all this, and to some degree that may have been true, but this I think is a unique experience that today's kids are facing. They're coming out of an environment where their their caretakers have had a life-changing experience, they've had a life-changing experience, and now you have social media, and it, you know, so the trends we see is their general well-being and for family unit to and family unit can mean grandparents, friends, neighbors, you know, the nuclear family, so to speak, also is different now. Uh, and they've had a lot types of different stressors, and and so we're seeing kids that are experiencing those and to varying degrees.
SPEAKER_00And I mean, with these stressors and with social media, there's there's a lot of things where in the development of the mind, there might be too much if they can't handle it. And so then at that point, it's like, where do I go?
SPEAKER_01That is a really good point. You know, the good thing, if there is a good thing about this, we all experience this together as Americans, be it social media or COVID. But the reality is these are kids and they think like kids. So no matter how mature your son or daughter may be, and how they've handled whatever the situation is, it's still a child's brain that is not fully developed. And if those experiences are adverse or very specific to them, they're gonna develop maladaptive behaviors to to cope with them.
SPEAKER_00For this next question I have for you and audience, I'm going to give you a little background. Billy and I met previously planning our conversation, and he opened my eyes to something that I completely disregarded. I live in a metropolitan area in North Carolina, and he reminded me that there is a lot more role than there is metropolitan in North Carolina. This is where I'm gonna go with this. So Daymark Recovery Services has thirty-eight physical locations, and you guys serve 28 counties, and you have two children crisis centers. Can you describe how you treat that vast geographic area of North Carolina?
SPEAKER_01We rely heavily on telehealth. Kid childhood illness, behavioral health illnesses are no different in Raleigh than they are in what I call my A counties, Ants and Avery, Allegheny, you know, the small counties, rural counties, wonderful places. Depression is depression, no matter what county you're in. So you have to treat it with that. But the workforce is different. Uh, you may not have an on-site therapist, or you may have an on-site therapist, but there's not enough business for them to get out of the office and maybe do services in school or services in the community somewhere. You may have, you may not have enough people that are eligible for, say, an intensive services for kids. So there may be an intensive service lacking for children. So we have really made strides and efforts to make sure that these rural areas are connected to our larger service centers. So where we may not have a full-time therapist to see someone five days a week, they can get that telehealth. Where we may not have a child psychiatrist on site, but a day a week, they can have one available to them five days a week via telehealth. Where someone might not be able to get into a behavioral health urgent care because it's in Winston, Salem or Charlotte, North Carolina, but they're in a crisis on a Saturday in a smaller county. This may be far away. If they have a good internet connection, they can still get that comprehensive assessment. And we can offer some suggestions on what to do next. Maybe come in on Monday because it's routine, or this is a crisis situation, and what are the, you know, what are the resources? So we have really pushed technology to bridge that gap between urban and rural North Carolina, because most of North Carolina is rural when you think about it.
SPEAKER_00And that kind of access to care really opens the door to enable people to get the care that they need. But have you noticed any unique challenges by delivering telehealth? I know that might be a silly question, but you know, has anything come up like, wow, this is something we really need to address.
SPEAKER_01Oh, absolutely. Connectivity is one. So when you get out in rural eastern and western North Carolina, just getting a data line out to our clinic, just our clinic alone, and we're a sizable organization, the data line can cost you more than the rent of the facility. Well, that that's a losing proposition. You can't have your cable bill more than you're paying and the rent of the building. So, you know, we had to look at different ways to make connectivity work better and cheaper. Then you look at some of our mountain counties. We have struggled with some of our efforts with law enforcement to bring telehealth to say mobile crisis, be it for a kid or adult. And these are governmental agencies. So you think, well, that shouldn't be a problem. But law, even with a governmental entity, we have very spotty telehealth coverage for for the officers. So parlaying that and thinking about, well, what about the family that lives in some of these rural areas? How do they get the right uh coverage, internet coverage, so their cell phone can pick up a therapist, be it Saturday night or Tuesday at three o'clock in the afternoon? So that has been a real challenge.
SPEAKER_00All right. So now we've learned that telehealth has opened the doors for a lot of people to get the help that they need and now they have a better access to mental health care. And where I'm going with this is when I asked you my opening question about, you know, can you give us a breakdown of the current landscape of children's mental health? Would you say within the last two years, let's go a little bit before the pandemic, we'll say five years. We'll say five years. Would you say that the demand for children's mental health support has increased?
SPEAKER_01Oh, it has, yes, definitely has. And and you know, I'm I'm not even gonna venture a guess is that because there was pent-up need during COVID? Is that because there's just more advertisements or there's been Medicaid expansion? I mean, I think all of those things are contributors, but we are seeing more patients today, at least as an agency, than we saw last year, than we saw a year before last, and so on.
SPEAKER_00Unfortunately, this is something that all of my guests are saying. And it's a little disheartening that I'm going from person to person to talk about the serious topic, and we're all seeing and saying the same thing. So it has to be happening, right? Right. So I would like to go into another direction here, talking about how Daymark was created and the importance of what Day Mark does. And a little definition here for all of my friends that are learning just like I am. Uh, according to the Agency for Healthcare Research and Quality, a safety net provider is a provider that organizes and delivers a significant level of healthcare and other needed services to uninsured, Medicaid, and other vulnerable patients. So, Billy, as Daymark is a safety net organization, and reflecting on the transition from a community health center to the current system, what have been the major impacts on the service provision and the quality of said service?
SPEAKER_01Um, well, I'm going to talk a little bit about the old area program system, and I'll be a bit critical of it because I was part of it. So I think I'm entitled to do a little bit of that. So in the 90s, and that's really where I cut my teeth in community behavior mental health. Uh, the good part about it was we were like, think of us as the health department or the police department or some kind of governmental entity. We were there for the health of the community. And if we made money, great. If we lost money, no big deal. It was a business, but it wasn't, because it was a county-funded organization, a kind of a pseudo-department of government, even when it was multi-county, which meant we were payer source blind, really. If you needed help and you were a citizen of North Carolina, and we you came in, you could get a service, whatever that service was that you needed. There were a few services you had to pay for, like if you know if you've got some type of legal infraction, like a DWI or you were on probation. But other than that, for general voluntary care, it was free or certainly reasonably cost priced. And it didn't matter if we really didn't have the volume of people in the county to do certain specialized services. We just did it because it was part of the service continuum. And if there weren't enough people to make it break even, so what? You still did it. When reform now, the drawbacks to that was whatever you learned in graduate school, that's what you learned. And that was it. You know, you did there wasn't a big push for best practice and evidence-based care. And we all know things change. You know, that's like saying you know, physicians treat ear infections in children today like they did 30 years ago. Well, maybe to a degree, but not really. It's the same thing with behavioral health. And there wasn't a big push on efficiencies in that system. There wasn't a big push for best practices in that system. I'm not saying good work didn't get done, it just wasn't a focal point. For example, we all knew patients that were not doing well, and we kept scheduling for individual therapy appointments that we knew they would miss. Well, that hurt us, it hurt them, no one got better. So, fast forward to this new system where we decided as day mark when we were birthed, so to speak, and and how we got birth was at the onset of reform, the private sector came in and they picked up services that made money. And what was left were about 90 employees and close to 16,000 patients that were on medication, that were indigent, that used emergency services a lot, that were in services that either had no profit margin or didn't make money, and they were there was no provider for them. So we were birthed to be that safety net provider. And maybe it was, I think it was the right thing to do. I don't know, I guess time will tell if it was the smart business decision. We just decided to keep our doors open for anyone that needed care. So we did not want to make payment a barrier to care. Um, we would bill your insurance and what you were unable to pay, you were put on a sliding scale fee based on 300% of the poverty level, meaning most patients paid very little to nothing. So I can't recall the question now, but that's kind of how this came about. We tried to hold on to that area program model, except we also looked at best practices. We were real big on integrated care, where we were not in the old area program system. For example, the old area program system, when I wanted to communicate with a pediatrician, I wrote a letter, I put it in the mail. Some point in the future, before the child graduated from high school and lived the life and had several kids, I'd get a letter back telling me their ADHD Connor score. You know, it was too little, too late all the time. Now we are able, when children come in, we use technology much different. As soon as I see a patient, I can see that they've been to the local pediatrician, that the pediatrician has put them on some type of stimulant. I can see if they've had a checkup, I can see if they've had their immunizations. And these are things we can talk about in the session, even if the session is unrelated to whether or not you've been up to date on your immunizations. We can see it, we can have that conversation at the end. The other piece is making sure patients get what they need. If they're not showing up for appointments instead of rescheduling them, either they don't value the service, it's the wrong service, or it's just not a good fit. We have outreach programs now that can communicate and say, hey, Liz, what's going on? You know, let me help you. You don't have to come back. Where would you like to go? Or, oh, we're offering outpatient. You really need an act. Because you're going to outpatients, like taking a garden host to a forest fire. Well, you need something different. You were sending me a message that you needed something different. I just didn't hear what you were saying.
SPEAKER_00Do you think that Daymark has been very lucky with the transition of the system? Now, the transition of the system and the the birth of the organization was pretty much the same time period. But where this is where that question is tying in, were there other organizations that were just like Daymark that you saw that in the transition of the system there were major impacts to the delivery of care and the services that were provided?
SPEAKER_01Oh, oh, absolutely. We were very fortunate. We were fortunate on a number of levels. Some was just luck, right place, right time. Some was right workforce, right time. And we had good payers, the public payer system. Of all the things you've probably heard in the media that's good, bad, or indifferent, they were very supportive of our model, which was their former model. You know, they were the former area program that providers that became managers. And so they understood that the sheriff needed to bring someone to our walk-in clinic because the sheriff thought they needed to be there, not because the sheriff asked them, Well, do you have Medicaid or Blue Cross? Or is it Medicare? And then I will send you as the sheriff's deputy to where you need to be. No, the sheriff's deputy knew that the legal system is not where this person needs to be. So they just bring them to us without worrying about the payer. And our public payers supported that model. And the other piece that helped us were other providers like we were not the only provider that kept that approach, that approach of, you know, we're going to try to see anyone that needs care. I think the difference was our data management. We had the ability to tell you exactly how many people we saw, how frequently we saw them, the cost of care, the medicines they're on, if they were antipsychotic medications or not, if they had Medicaid or not, meaning if they don't, then we might be the only game in town. They can't go anywhere else. So when you have that kind of data and you go to a payer that says, you know, I just don't think we can support this, and you were able to give the payer detailed data where they can plan and budget and make their network work around the data. You give them versus going in and saying, Well, I know we're working hard. We saw a lot of people, and they seem really happy with our services. Well, the latter is good, but it doesn't tell us anything. And well, what we're really dealing with, and it sounds cold, but we're really dealing with a math equation here. There's so many dollars that are state dollars for indigent care. And then there's Medicaid, and you know, it's only when it's medically necessary that you can bill that. And then you have all your private insurances that do a really good job of having really high deductibles so there's no payment at all, or co-pays that are excessive, or lower rates. I mean, you know, they're not you know, we can talk about parity all day, but there's really not yet mental health parity as you know, apples to apples anyway. But so, you know, we were yes, we were lucky, we were heavily supported by our public system. And I think that made it easy because well, not easy, but easier than others had it, because we had the data to back things up. We took over some regions where the provider actually did a very good job and failed, and we didn't do anything different than they did, except we could report what we were doing, and that was the difference.
SPEAKER_00Yeah. When when you have that data to back it up, also it helps show where you can assist, where areas can be improved, and then opportunities. And then you and I had discussed previously that if you have the opportunity to go into an area, and there's already there's another provider there, you know, why compete? Would you be able to elaborate on that a little bit?
SPEAKER_01Sure. I mean, if you know, in rural areas, excuse me, in urban areas, it really doesn't matter if it meets our strategic plan and there is a need, we will certainly execute that strategic plan. For example, we know that in Winston-Salem, we know that there are several hospital emergency rooms there, but not to mention a psychiatric hospital and a walk-in clinic. Um, but we pursued a behavioral health urgent care there because we thought one, it's an urban area or urban to North Carolina, they can sustain it. And two, it would be a really good service for people to be in lieu of an emergency room setting if you didn't need all the bells and whistles of an emergency room. Versus, we might hesitate if we have an urban or rural county where they only have one intensive in-home provider for children. Okay, but the county's very rural, and they're having trouble getting referrals for that intensive end-home provider. Why would we go set up an intensive in-home team? So now you have two providers having difficulty with enough referrals to sustain a service that the children in this rural county should have access to if they need it. So I just don't see where that's a good business model. It's not a good way to spend public dollars, and it's certainly not a good way to make the community healthier. So we may refrain from something like that. And I'm trying to think of other examples. I'm setting up, I've had people ask if we would set up clinics in certain counties, and I would say, Well, you already have a provider there. Oh, yeah, but people want choice. I'm like, well, they have some choice. They can drive to the county over where we are, and there's a couple of private providers in the area that are smaller. There's choice, but we want a bigger provider and have two choice. And this is a while back, and and and it's like there aren't enough people in the county. You will have two very weak providers delivering a watered-down service. Now it'll look great on a report, and eventually one of us will go out of business there. Why do that? Just do the math. It's will it work? And if it will work, is it good for the community? And if both of those have to be yes answers.
SPEAKER_00And that is where my mind was going with this. And I thought including that would be very important because we're talking about the good of the community, and it's a really big thing when you're talking about adolescent mental health, doing what is good. So, to get in that a little bit, we've talked about the healthcare system. So let's talk about the education system. How does Day Mark work with the school system, Billy?
SPEAKER_01Uh, you know, Day Mark in the school system, it's interesting. It varies by location, and it it, I tell you, it varies over time. When we were birthed 20 years ago, we inherited a lot of day treatment programs that were embedded in the school system. And it was very, very interesting because as we opened, and I didn't know anything about these systems, we inherited them from the former area program that kind of divested us all. And we found that some school systems were using these programs excellent. Excellent programs. They were, you know, it was in school A in a system, and they would literally send kids from all over their county or their city, whatever it was, to that school for this treatment. Treatment was time limited, the goal was to get back into a mainstream classroom. It was absolutely textbook, those were great. We saw school systems with they were basically using it as an alternative to homebound programming. And whether you needed it or not, it was a place to send kids that they just didn't want in the classroom. And and it was very difficult to do medically necessary treatment plans with this, you know, with with the partners we had. So over time, we ended up either divesting of some of those programs or doing alternative services in those programs, be it school-based therapies or telehealth type programs. It varied by school system. Fast forward to today, and a lot has changed. You have after COVID, where you did you had a lot of people, a lot of school systems not wanting people in their school, which I understand. Uh, the school system maybe lost the program as a result of being closed for a year, or not we're not saying being closed, but but not having kids physically on site for most of the school year. So that changed the dynamic. The rates changed, the workforce changed, school expectations changed. You know, schools have a different uh stressor now. I mean, you know, it's always been difficult to have the right teachers. Now they're struggling to get teachers. They are really personnel, like us, like and we too. So it has changed the landscape where we don't have as many day treatment programs any longer. So that leaves most of our school work now. If it's not the one or two day treatment programs we still have in our 38 counties, a lot of it is outpatient and it's mainly after school or targeted TCM targeted care management. Um, and and we're not necessarily in the school, but we make the school part of the treatment team and and part of the care plan, so to speak.
SPEAKER_00Have you noticed any, besides you know, the workforce shortages and the complications around that, have you noticed any difficulties in ensuring that everyone is, for the lack of a better phrase, on the same page of what's needed for the child?
SPEAKER_01When when we're engaged in a day treatment program or TCM program, everyone's pretty much on the same. Well, once everyone realizes what's going on and what's needed, we've had very good cooperations with the school system and and very they're very good partners. They, like us, are sometimes it's difficult to have enough staff to do what you need to do, if that makes sense.
SPEAKER_00Yeah, and it it all comes down to the workforce shortage, it really does. And but it also comes to understanding that their children are different, not one child has the same brain chemistry as another, and their behavioral habits are different than another. So there's that education and um understanding that you might have to approach things differently. And so that's where when I was asking, having everyone on the same page was a necessary thing.
SPEAKER_01Yeah, that's normally not a problem. It's just a matter of resources. Little Johnny's supposed to do X, Y, and Z. Well, is XY and Z available? You know, that's do you have an intensive in-home team? Okay, check the box, yes, you do. Is there an opening right now for it? When can he start? That that's the type of problems we run into.
unknownRight.
SPEAKER_00Since we're talking about resources, let's go ahead and get into it. I mean, funding and resources are crucial for mental health care. So, Billy Hunt is Danmark navigate funding challenges, particularly for enhanced and specialized services for children.
SPEAKER_01We have funding challenges like everyone. And one of the things we you know used to be able to do is you used to have therapists at every location, psychiatrists at every location for kids and adults. It was never, you know, a hundred percent staffed, but it was staffed well enough. Fast forward from that old public system to today, and between rates, between a workforce, between everybody wanting to work from home, it is very, very difficult. So, what we had to do is we had to think about, well, first of all, we're gonna have to use technology. And we ran into that barrier of, well, what if it costs? You know, we're not talking about going to charter or spectrum cable and getting a $110 a month line when you're up in the mountains in North Carolina. You're talking about a $1,200 a month T1 line. How do you do that? So we worked with organizations like the NC Telehealth Network Association. We looked at uh U.S. Department of Agriculture grants, and we were literally able to bring federal dollars and you know into these communities to, I'm not gonna say better wire them because, and I'm not a tech guy, so if somebody wants to fact check this, this might not be 100% correct. This is my social work knowledge of this. Uh from a social work standpoint, we got federal dollars, and our IT department was able to purchase and buy things that you didn't have to worry about using special equipment for. And therefore, I'm not charged with a big bill and my uh staff aren't, and it even has accessibility to some of the other community partners we have. So that was, you know, priority number one in order for us to even have a tool that we could use as a navigation tool around some of these other funding, other workforce issues. The other thing is our size. We are, like I said, we are a large organization. Prior to COVID, we had roughly 1,200 staff. We now have about 800 staff, yet we're treating more people and we've opened more programs. So you might think, well, how is that possible? Well, it first it's necessary because, well, you only can hire who's available, and and so there's the workforce just isn't plentiful out there. And second, you only can hire who you have money to hire. So even if you've got a really good nurse or psychiatrist or social worker out there or counselor, they're probably going to command more money because they can. And I'm not saying they should. I'm just saying the rates haven't kept up with this type of inflation and workforce shortage. So, what do we do? Well, we have to do things smart, like we have 28 locations, they all had walk-in clinics, they all had clinics that if you walked in within 15 or 20 minutes, you could be seen by a person. Well, post-COVID, that's a tall order. And we had those discussions. Do we do we close our clinics? Do we make the hours only in the morning or only in the afternoon? When we made the decision, we don't close the clinics. That's how 28,000 people a year access service, children included, with no appointment. And they came in because they felt compelled to come in right then. They they were either in an active crisis or they felt like they were in an active crisis, which you know what? If that's the way you feel, then you are, and we'll talk about it later and calm things down. So we didn't think we should close them. And we did, you know, we have a lot of uh law enforcement and EMS partners and school partners, and we don't want them to have to guess. Oh, I have someone. Do I tell them to go tomorrow morning or can they go this afternoon? Let's just stay open. But how do you make it work? You've got a lot less therapists. So my walk-in clinic therapist in a rural county probably doesn't see walk-ins anymore. They're out delivering real care, you know, ongoing preventative care to people that are actively engaged with us. So who sees the walk-in? We have something called universal access. And there are 26 fully licensed clinicians that are spaced between their home or in our clinic embedded in one of the larger clinics because we hire them where the workforce is, and they're sitting in front of a computer, and we have a command center, and it comes in. Hey, we have someone in Avery County that needs to be seen, and they need they just walked in, and this is their whatever. And we have someone else in union. Oh, we have someone else in for scythe, and even though for scythe's a big clinic, we have more walk-ins right now in the lobby's getting backed up. And these 26 therapists can cut on their computers and they can literally do services, and they're normally assigned to a region, so they have competency in that region. Where, even though I'm the CEO at Daymark, if I saw a kid from Wilkes County, I'm not sure I know all the regions, all the resources there that they may need, and certainly not some of the social welfare contacts, but we'll have someone that is familiar with the two or three county radius. So they know not only okay, how to diagnose a child, how to, you know, engage the child, how to work with their parents, but they also know what resources are available outside of Daymark. Um, also.
SPEAKER_00So with the resources, do you guys have any? I mean, obviously, community support is a really big contributor to positive mental health. Do you work with other like uh I know with the social service networks, you know, that is a system, but do you have any partnerships with the other organizations in because since you do service a lot of people in different counties, do you have partnerships with people in specific areas that can help?
SPEAKER_01Oh, absolutely. So it's interesting. You're hopeful I don't take us down a rabbit hole. So 20 years ago, there was case management in North Carolina, and those what you just said was so easy. We had you know case managers, like I was a therapist. There were three case managers I worked with just for my caseload. They did everything. I would just see a family for family therapy or a kid for individual or whatever group, but I didn't have to worry about the school system, the going to the pediatrician's office, if uh juvenile justice was involved, if something was happening at the local family services that would benefit the family. The case manager was on it, and they were able to make sure all that happened and the relationships were there. And it was very much email, memo, snail mail driven. Go out to visit your system. At the onset of mental health reform, that service went away. And for 20 years we didn't have it. Well, it we had it, but we had it in the sense of it was with an insurance company and it was over the phone. We now have targeted care management back for the first time in 20 years. We're doing that. So we have a semblance, at least especially for kids, because they have a high incidence of Medicaid. We are able to engage, have someone that does nothing but care management for their caseload to engage them in a number of systems, whatever those systems are, be it DSS, be it school system, be it another provider for whatever their tells them. So we have that back, and that is very, very helpful. Students in all of our community, excuse me. The other thing we do is we use technology. Even if we were overrun with staff and money was no object, we need real-time information, we need real-time data. We do not need to basically waste efforts, and certainly not our patients' efforts and their families' efforts, because often they're doing all they can to get to us and use that bus voucher or spend that gallon of gas to get there. So often, you know, we can, when someone comes in, I touched on this earlier, if they haven't had their wellness check, if they haven't had their immunization, if they're on a certain medication and we see that they have not had it refilled, because all that information is right in front of me when I see a patient. It's part of the high tech act, it's called the part of the Sequoia project. We call it integrated care alerts for research and engagement. It's eye care. So what happens is kid comes in to see me. I, you know, I see our record, and then on the right hand side, I see these little icons that'll say, you know, P4, meaning there's four pharmacies this kid goes to. That that I gotta check that out. And I click it, and then I see what's happening. They might be on two medications and they're expensive. So parents are just shopping, you know. So that's helpful because I could say, I noticed you're not on Medicaid, or I can talk to the psychiatrist to see if this medicine's on a formulary, or you know, so you're able literally to engage in real time. Now, sometimes you can't do anything about it, but sometimes you can. Um, I noticed the kid has type 2 diabetes, they're on metformin. I noticed there hasn't been a metformin prescription field in 90 days, but they've only been getting 30-day Medicaid. So, can we have a conversation about oh, you haven't seen your pediatrician in 90 days either? This is serious. You know, you it changes the tenor of the conversation. There isn't any more we've had people come in, just just to give you another example. Person is diabetic, person's telling me how difficult, how they don't they don't feel like the medical psychiatric medications are working. They're they have a Mountain Dew in hand. I know they have permission to smoke from their parents, or well, I know they do, and their parents have just given up. And I know that they haven't refilled their diabetic medication in a long time. And so you have that conversation. Is this about the medications we're prescribing aren't working? Or is about you're you haven't done anything to change your lifestyle. You're drinking a full-fledged hot octane mountain dew. No, you're smoking, I can smell it. And you haven't refilled any of your medications. This might not be about tax or as a loft here, you know, the way you feel. It is a whole different way. It it teaches our staff, and that's part of the efficiencies. You know, you practice at the top of your license. And that technology helps us do that, makes us more efficient. We can deliver a higher dose of care with a lot less effort than we used to back in 1993.
SPEAKER_00Mm-hmm. Did you say I've had I had a conversation with somebody about data and the importance of having data, sharing data, because you know, there's there's potential for collaboration where you can find issues and work together with other organizations, organizations to solve those issues. But when you look at the perspective of, I mean, I know 1993 was 30 years ago. Or that, you know, it was a long time a 31 years ago.
SPEAKER_01Not remind me.
SPEAKER_00And it was the way the data was collected was vastly different than it is now. And I would only I would imagine that at least within the last 10 years, data collection has gotten even better for you to um what's the word I'm looking for? Make the evaluate.
SPEAKER_01Would you say that it's been consistent in growth or uh it's been consistent in growth, it's it's mainly what you've invested in it. And we were fortunate early on in the process to be allowed both from some of our payers and our my board to to invest in technology because there's really two types of data sets now, or three. There's data you can collect. And type in on a spreadsheet. And sometimes that's very accurate. Unfortunately, it is what it is, and it only is as good as and as fast as you can type it in. And you spend so much typing, you never get a chance to analyze it. And it's only analyzed on that sheet, not with all the other extraneous data. Then there is data that goes to the state HIE health information exchange. And often that's data based on billable claims. Well, it's billable claims, it's going to be there's going to be a delay. And that's assuming it's even made it upstream. For example, if I go to the emergency room today and for a psychiatric condition, and I have Medicare, Medicaid, and I leave and I see my therapist Friday. Well, I've seen them within seven days, and that's great. And the therapist builds Medicaid. And Medicaid says, Oh, you got Medicare, and they deny the claim. Well, the billing's not going to go out anyway until the end of the month. So we're already close to 30 days out. And now the claim gets denied. Now the claim has to be worked. And then three to six months later, the claim finally goes through and everything goes, and it shows that I went to the emergency room and then I had an appointment within seven days. Well, there's a lot of ifs, ands, or buts around that. Okay. Where our and we use that system. And but our system also works on, like I said, it's part of the high tech act. It works part based on other meaningful use systems. So if you're the Liz Church counseling agency and you have an a well, let's say you work for HRIM or Novon or one of these large hospital systems, and you're in an outpatient practice, and somebody comes in to see you, you're a you're an endocrinologist, and they see you, and and you write your note in the ethics system, which is you know meaningful use certified, you know, very expensive and compliant with everything. As soon as that note is written, within 12 hours, we will have maybe not access to the actual note, but it will show they visited you on this day for this diagnosis and what medications may or may not have been prescribed. And we will see that. So if I'm relying on the HIE, I'm still waiting. One for them to bill it, two, for the bill to get paid, and that could be a delay. So so data has become immediate if you have the right system and set up. What to do with the data is the struggle. It is so much data in front of us. Um, so you know what how much can a therapist address and what amount of time that you're allotted without losing the patient, too. You don't want to it to turn into let's go over your medical history. Well, they've already done that with their medical provider last month.
SPEAKER_00Get the clipboard out and the paper.
SPEAKER_01Right. Right. No clipboards. That's going backwards, but anyway.
SPEAKER_00Oh, you mean the high-tech tablet that we can scroll.
SPEAKER_01Yeah, yeah. Oh, get a tablet, right. Tap tap in the same thing you would write, but anyway.
SPEAKER_00Yes, exactly. It's it's great to hear how data is used. I'm getting more and more ingrained in it as I talk to other people and understanding how it's used because I think the perception that many people have is that it gets put into this giant database and it spits out something really fast, and you immediately have the answer. You know what to do. And it's I technology hasn't gotten there yet. And the other, like you had said, there's the other thing is is knowing what to do with it. And that takes a lot of resources and knowledge from other people because they may, you know, those my my analytical friends that know how to look at numbers so quickly and know what to do with them, those are the people that have to really put things together. So it's fantastic stuff. That was a little bit of a segue.
SPEAKER_01Well, it's important, that's where the system's going. I mean, a lot of people think, well, I have a well-trained therapist and I really, really like them, and I'm I'm making, you know, good, good progress toward my recovery. And all that's great. But there's a whole system of administrative stuff going on behind that really good therapist. You know, if if they're handwriting notes and putting them in a chart, sticking them in their drawer, though that's just never going to be a sustainable model. They're gonna have to, they're probably using some type of electronic platform. They're using an evidence-based practice. My guess is if they're working for a progressive agency, they're gonna come to them and say, you know, there's not enough of you. We have to give you an omnipresence. And here's a computer with a camera, because some of our patients can't make it in. And so things are a lot different than you know, when I was in practice in the mid-90s.
SPEAKER_00So we're talking about how technology has evolved, the evolution of the delivery of care. So to kind of get a little bit into this, we've talked about Billy and I spent, I want to say, a good long time talking about the fragmentation and siloing of services and the significant challenges that it brings in mental health services. So, Billy, what strategies would you say that Daymark employs to integrate services and ensure the continuity of care for patients?
SPEAKER_01So, yeah, that that was a pet peeve of mine when we first divested and became Daymark. When we were the county mental health center, we did pretty much everything except for residential. We're just talking about kids now, residential care for children, like level three, level four type group homes. We did everything else, though. We even had a therapeutic phosphorhome program, which kept me up a lot of nights. But when we became Daymark, we had outpatient counseling, we had psychiatry, and we had emergency services for kids and adults. Three services with zero profit margin to losing money. And that's why we have because there wasn't a bunch of folks that raised their hand and said, Yeah, I'll do that. Um, so where did the other services go? The the siloed services, the intensive in-home providers, the day treatment providers. Now we inherited a few day treatment programs, but not many. The PSR providers, the ACT providers, where are they? They all took off with these individual little services. And they built services around them, but but not to the extent we did. So what we did, we had to do it. We had to do a couple things. We had to say, well, first of all, we have to get bigger to defray overhead, because an HR department costs the same. If you got three clinics or 10 clinics, it's gonna cost the same. You got to have an HR director, you got to have a thing, a process payroll. Same thing with an IT platform. You know, until you get a certain number of users, it's gonna cost the same. So we had to get bigger to defray the overhead. Otherwise, I'm telling a therapist, not only do you have to see enough patients to pay your salary, but you got to pay for all this other stuff too. It's impossible to do. The second thing we had to do is build our own continuum. It just makes sense sometimes when people would come in for a behavioral health issue, and they were also kind of cat side the bag. It's obvious you have a problem with alcohol. Now it would be more so benzodiazepine. So, what do we do about it? Well, let's build a continuum. Let's build an IOP program, let's build a substitute counseling program, let's build an opportunity for persons to go inpatient and get detoxed or induced. I use the word detox. It depends. You can get detoxed from alcohol and technically induced from opioids, but most people get induced with a Suboxon or something like that for you know maintenance medication. So we were able to build those, so we kind of built our own continuums. And of course, where there were resources that could take referrals in the community, we just used those resources. We didn't try to reinvent the wheel where it didn't make sense.
SPEAKER_00Well, obviously, because you you've talked about the appreciation with the way that old things were, and at this point, reinventing the wheel isn't absolutely necessary. As society and technology grows and more innovative strategies for treatment plans, it we're evolving. We evolve, we grow, and uh it's always coming back to evolving. Going further on how mental health can be a community-wide issue, and based on your experience, what systematic changes do you believe are necessary to improve mental health care and accessibility and effectiveness?
SPEAKER_01Well, you know, I think there's always room for private providers. When I say private providers, I mean smaller providers. Uh when I left the behavioral, when I left the community mental health center, that was where I was going before I took this job. I was going to go into a private practice. I'd already done a little business plan. I knew the caseload. I knew what physician I was going to work with. And I think there is always room. But you made the comment to me about I have an appreciation for the old system. I really believe the old system's philosophy was correct. It's kind of like saying, well, we shouldn't have a health department. Everybody should go to a private doctor or urgent care. No, we need a health department. We need a public health department, and there can still be a doctor on every street corner. That's fine. But it doesn't mean you don't get rid of your health department. That's kind of how I look at the community mental health center. There needs to be private providers, specialty providers, but there needs to be a community mental health center. And my goal was not to destroy what the or re totally redo the old community mental health center. It was to take what was good, the philosophy behind it, and improve upon it. We could have done a lot of things better, from efficiency to best practice, to you name it. But it didn't mean we throw the baby out with the bathwater. And in this case, we I see, you know, we've had 20 years of success because patients chose with their feet and said 50,000 of us a year choose to grace your door because of this inclusive model of whatever service I need, even if it's one you don't have, you will find it for me wherever it happens to be in the community. That's what a community mental health center used to do. And you see things coming out of like SAMHSA and things like that now, the CCBHC model. These are just community mental health centers, is what they are, if you really look at it. They're they're collaborative, they're it's just a new word for community mental health centers or CMHC, community mental health center. You hear these words thrown around. And North Carolina really supported that early in reform. They had some providers fail, trying to do it, which in retrospect, that's not unusual. It was lucky we it wasn't us, but they supported it. And so they did have one-stop shops, they did have places people could at least get access to care and then figure out where to go. Um, and as we move forward and things get more fragmented in the payer system, and we have, you know, we have prepaid health plans now for Medicaid, you know, in the and the tailor in the uh standard plans, and your and then your former area programs that became LMEs or local management entities that became PHPs or MCOs are now called tailored plans. So they've had a lot of changes in how they identify, also. So they're now called tailored plans. You know, that they've decreased the number of tailored plans to have to count them on my hand to tell you a number. So everything is becoming uh there's a lot of change afoot, let's just say that. And it's making it harder to say, hey, we're gonna have a a CMHC model, community mental health center model. Because that's what I think needs to happen in North Carolina. And I think the the federal government has that CCBHC certification, or not certification necessarily, but designation that's out there. So I think this is the way the feds are going. So I don't think I'm off base in saying what we had was not terrible, and where we're going is likely a newer version of what we had, if that makes sense.
SPEAKER_00It does make sense. It is the growth, the evolution. And it's my new favorite word today. Now, to wrap everything up, Billy, what would you say is necessary for community members and other stakeholders to do to advocate for better access for youth mental health services?
SPEAKER_01Um, well, a couple of things. One, if you have an insurance card, public or private, call it, find out where your provider is. Everybody gets is encouraged to know who they're get a PCP so they can have an annual physical. I'm not advocating everybody has to see a therapist annually, but understand if you need one who to call. Just, you know, it's like having a a list of important numbers, so to speak, on the refrigerator, you know, taking me back a while saying that. But but and really know who your community is. The second piece is if you have trouble finding who that provider is, or even if you don't, call your local management entity, your your tailored plan. Even if you are privately insured, they should be able to say, this is where this is the direction you go in. The other thing I would do, the third thing is I would be involved locally. I would be involved locally if there's a chapter of NAMI, if there is a family-to-family chapter. You do not have to be a consumer or a patient somewhere or have a family member in care to be a part or be supportive of a group like NAMI. Talk to your county commissioners about what they're doing. They write, we still have a public system. And right now, they are still sitting on the boards of payers. Ask them what's going on, ask them where the money's going. Tell them it's important to you, not only for you to be able to get your once-a-year cholesterol screening, but if you ever needed behavioral help or a family member, you can get it. Uh let them know that. Those are very, very important things. And you'll be surprised. There are a lot of elected officials out there that are, well, most of them understand it's important, if not all of them. The depth of their understanding varies by their experience. And some have a lot of experience, both uh professionally and and personally in the field. So I think you'd be present pleasantly surprised when talking to your policy and lawmakers and commissioners about service services, I should say.
SPEAKER_00It's a starting point for you, my friends. So what do you have to do?
SPEAKER_01Get involved if it's important.
SPEAKER_00The Adromatus Way is produced by me, Liz Church. Editorial assistance for this episode was by my fantastic team at Adromadas. I would like to express our heartfelt appreciation to our guests who've shared their expertise, stories, and insights with us on the podcast. And finally, a big thank you to our listeners. Your support and engagement have meant the world to us at Adromatus. We're a boutique consulting firm with the imperative mission of creating healthier, more resilient, more equitable communities. I encourage you to connect with us. Let's continue these conversations and work together towards positive change. You can listen to all of our previous episodes on our website, Adromatas Consulting.com slash Adromatus Dash Way. That's A-R-T-O-M-I-T-O-S. We can also be found on Apple Podcasts, Spotify, Amazon Music, or wherever you get your podcasts. We'll see you next time.
