Bonus Episode! Perinatal Mental Health and Collaborative Care

This bonus episode for Payment in Practice provides actionable steps to establish a collaborative care model into obstetric practices for the management of perinatal mental health. Dr. Emily Miller, Director of the Division of Maternal Fetal Medicine at the Warren Alpert Medical School of Brown University, talks about her work establishing an integrated behavioral health collaborative care team and how this model can be scaled for many practices.

This podcast episode is sponsored by Sage Biogen.

Transcript

00:00:00 Speaker: Hi, my name is Lisa Satterfield and I'm on Acog's Health and Payment Policy team. We have a special edition podcast series for you. This month is on perinatal mental health, we have a discussion with Doctor Emily Miller out of Rhode Island, who is, and advocate for, collaborative care models, and has some really great tips on how to incorporate collaborative care for perinatal mental health into practices of all sizes. In addition, we will also be having a couple of presentations on the web to support these podcasts on how to bill for all of these services. we're really excited to do this and I hope you enjoy the Our presentations.

00:00:58 Speaker: Hi, this is Lisa Satterfield, and this is Payment in Practice, And today I'm excited to be with Doctor Emily Miller. Doctor Miller, please introduce yourself to our audience. Hi. Thanks so much for having me. I'm Emily Miller. I'm a maternal fetal medicine physician. I'm the division director of maternal fetal medicine at Women and Infants Hospital, Brown University in Rhode Island. Um, I've been in practice for 11 years and am really honored to be a part of Acog's Maternal Mental Health expert working group. Excellent. Thank you. And you all published, the guidance last year. Right. The new guidance on mental health for maternal health. Yeah. Two years ago, actually 2023. Um, time has flown. Uh, it feels like yesterday we were writing them. But there's two clinical practice guidelines pertaining to perinatal mental health, one that's on screening and diagnosis, and another one that's on treatment and management. And both are designed to have very pragmatic, practical tips and tricks for OB GYNs to help support us in integrating mental health care provision into day to day clinical practice. Excellent. Thank you so much. You're exactly the person we need today. So thanks for coming. The reason why I wanted to chat with you today is because of your expertise in models of care that support both the health related social needs and the needs in mental health for pregnant people. I wanted to get your expertise on, those practical things that Ob-gyns can do in their clinics, to deliver these services, So before we get too far down the rabbit hole, can you briefly describe what health related social needs are? Yeah, it's a really important question, and I think really important to set the stage for why it's so important to integrate them into our care provision as obgyns. So taking a big step back. Social determinants of health, um, are the broader Conditions where people live, work, play, and there the systematic conditions around us about availability of housing, where there are where there might be access to nutritious foods, where there are spaces for education or employment or neighborhood safety. So more on the population level. And then as we think about the individual in front of us, we're thinking more about health related social needs. Those are the specific individual level manifestations of the social determinants of health. So does that individual have access to safe, affordable housing? Do they have access to the nutritious foods that they need to navigate through pregnancy and postpartum? Do their children have access to those foods, etc.? the mental health components. It's just they seem just so intertwined and interrelated. How do, um, those health related social needs show up in a mental health assessment that you might do? Absolutely. I think health related social needs and mental health symptoms. Excuse me. As you said, Lisa, they interact in complex and bidirectional manner. Each one influences the onset, the severity, the persistence of the other. So individuals with unmet health related social needs, like food insecurity or housing instability or transportation barriers have significantly increased risks of mental health symptoms like depression or anxiety. And that relationship is cumulative. The more unmet health related social needs, the higher likelihood and the higher severity of mental health symptoms that we see. And there's a myriad pathways that can explain that relationship. So for example, when very concretely, when access to mental health care or access to medications are are barriers, we're going to see mental health further degrade. We're going to see an inability to reach our goal of remission of those mental health symptoms. And the converse is also true, right. Examples. Poverty or neighborhood violence can lead to mental health issues, that they can contribute intrinsically to the exposure of trauma and subsequent mental health conditions that are related to that exposure. Um. Conversely, mental health symptoms, particularly serious or persistent mental illness, can increase vulnerability to health related social needs. The challenges with um executive functioning, challenges with stigma, reduced access to employment, stable housing can further exacerbate social needs. And so this I think, the intertwining of these two concepts really underscore the importance of integrated approaches that address both the social needs and mental health symptoms simultaneously. We really can't disentangle one from the other and expect to achieve meaningful improvements in wellness for our patients. So, talk more about the the integrated part of the care that is provided. So you said that you can't really untangle the social needs from the mental health needs. how does the ob gyn, recognize this? when the patients in front of them and what would you recommend that they do in the immediate. Yeah, I think we have to take a step back as OB GYNs and recognize that we're not the solution to everything. And we can be the conduit to pathways and we can develop systems. But I don't think we're going to achieve success if we shoulder the entirety of prenatal and postpartum care, um, addressing health related social needs and become the the therapist or psychiatrist all embedded into one, that's just not how the system is designed. And the good news is, we have so many amazing collaborators and thought leaders and partners and people that are willing to engage and be a part of our team. So I think that while, of course, we have to focus on the immediate and the patient in front of us, I think our homework is to take a step back and think about how we can design the system around us, uh, to be able to bring those team members on board and to be able to augment the care that we're able to provide at our office. And the good news is, I think there's there are many existing models of care that help support us in doing this. We don't have to reinvent the wheel. We don't have to structure it. There are existing and financially sustainable models and mechanisms that allow us to bring in these additional team members to be able to support addressing both mental health needs and health related social needs. excellent. So I really want to talk about these models of care. That's kind of my sweet spot in my role at Acog. Um, and trying to think up ways that, are financially sustainable for the ob gyn is my primary role within the organization. But also at the same time, I love that you said that you can't be everything to everybody. because I think, intrinsically, that seems to be the heart of a lot of OB GYNs that I meet. So let's pivot to those models of care that can support OB GYNs, in delivering the more comprehensive care for mental health and the social needs. Yeah, absolutely. So the model of care I work with the most is something called the collaborative care model. And I want to be really clear, that's a model of care that's been around for 40 years. There's over 90 randomized trials of the collaborative care model in primary care settings that have demonstrated, with no uncertainty, improvements in somatic health outcomes and mental health outcomes, and quality of life outcomes. When we introduce this model of care into that primary care programming. And I think maybe ten years ago, um, there's been two randomized trials of the collaborative care model in OB-GYN settings, and that I think they're really important trials, because while we are, we try to be everything to everyone. We can't be. And we're very different from primary care clinicians. And I think the differences are really important to reflect on. I think there are differences, um, at the patient level, when our patients are thinking about mental health conditions or health related social needs, there's a whole additional dynamic and stigma or concerns about being labeled a bad quote unquote, bad mother or bad parent or concerns about engagement of child protective services. That's another overlay that we need to be considering when we're integrating this care from the patient level. That's different. I think on the clinician level, we have to acknowledge this wasn't a part of much of our training. Right. I reflect on my seven years of training in residency and fellowship. Um, and I think I had an hour of training on mental health. I don't know if I had training on health related social needs. And I had amazing training. I'm very grateful for my training. But many of us are coming into this acknowledging we have to add this, but we don't have the experience. And I think mental health in particular has been a part of primary care training for a little bit longer. So we've got some work to do to develop systems that help support our ongoing practice led education. And then certainly from a systems level, as we build programs to address this, we have to acknowledge that the structure of our practices is very different than the structure of primary care, where we have more new patients coming in right as they cycle through a pregnancy and the postpartum period. And so it's a time, more time limited relationship. and so more exposure to new folks coming in. And the point prevalence of mental health conditions is higher in pregnancy and postpartum compared to the general population. So all of these factors make us acknowledge that we can't just take something that worked in primary care and plug and play into an OB-GYN setting. We have to be attentive to differences, and I think these two trials really pointed to the efficacy of this. Programming does apply in ob gyn contexts. And so what we've done is really take that efficacy data, take the fact that this can work in a randomized trial setting and think, well, how do we implement it? Because it's a big gap from doing something from a funded trial with all of the research support that comes along with it. How do we take this and think about implementation strategies so that this can be adapted to each local context? This can fit into all of the variations of practices of perinatal care as we as we deliver it. And that's a lot of the work that I've been, um, invested in over the past ten years or so. That's amazing. And I do want to get back to what this looks like in the different practice types. But first, can you describe some of the elements of collaborative care that make it different than what a traditional care model might be? Absolutely. So I'm going to distill collaborative care, which again, is standing on the shoulders of giants here who have done such foundational work. And I'm going to distill this model into three bullet points, uh, for the purposes of what I think are the very distinct components or ingredients of care that allow you not only to call something collaborative care, but bill for it as collaborative care. And I think that's a really important distinction for sustainability. So the first ingredient and probably the most important ingredient is a care manager. the care manager typically is a licensed clinical social worker. Doesn't have to be. But I think many models of care utilize someone with that degree of clinical expertise. And that care manager is really the cornerstone of the programming. They do two things. Uh, they're embedded in the ob gyn office, and they can, number one, directly provide psychotherapy. And that's huge, because I think we all acknowledge in many of our care spaces, accessibility to psychotherapy is a challenge. waitlists are really high. And getting folks to an office for that psychotherapy, which is a mainstay of treatment for mild to moderate anxiety or depression, is very, very difficult. And so the care manager embedded within the office can provide that link to the prenatal appointment. So you go see your prenatal care and you've got your therapy right afterwards or before. And that's phenomenal in terms of access. But the second piece of what that care manager can do is care navigation their care coordination. And that's fantastic because they take someone when you know, for example, I do a screening as recommended by Acog. I see that they have symptoms of depression or anxiety. And then I refer to my care manager and say, you know, we had a very brief conversation. I expressed the importance of identifying and communicating about mental health conditions and how treatment options are available. I can talk at a high level about therapy or medication management and how I'm supportive of both high level about, you know, risks of untreated mental health conditions. And then the care manager was more than the 15 minutes I have allotted with the patient and have a longer conversation to refine that differential diagnosis, make sure that what we're dealing with is indeed, for example, depression and not bipolar disorder. they can do additional assessments. They can have individualized, personalized conversations about where might there be health related social needs that need to be addressed, that might be contributing to the symptoms, or might be a part of a barrier to getting the mental health treatment? and create an individualized care plan. And so that care manager can do all of that. And then as they're creating that care plan, if it involves a referral out to the community or out to psychiatry because it's a more severe mental illness, they can do that navigation, they can follow up, not just send a referral. But did you make that appointment? Have you been able to successfully, get into that office? Are the waitlist too long? Okay. Let's troubleshoot. Let's go with plan B. And so there beside that patient supporting them in the care pathway because it is so complex. and so that's the care manager. That's number one. The other two a little more straightforward. there is a care registry. Care registry is a commitment to population health. So every single person in the collaborative care model who comes into the model is entered into a care registry. And that's an electronic, collection of patients in their most recent symptoms. So every 2 to 4 weeks we send out screens for we do stress, depression and anxiety. It's managed by the care manager. And we're making sure that that initial treatment plan that we've started is resulting in improvements, that our goal is population level remission of symptoms. And so everybody who's got these screens, we're making sure that they're getting to the goal of subthreshold screens or no symptoms. and the care manager monitors that and flags folks who are in there that are not responding or are not improving. And that leads us to the third ingredient of collaborative care. And that's weekly care huddles. what's required for the collaborative care model as a supervising psychiatrist, to meet with that care manager once a week and review all new patients coming into the program to make sure those initial care plans are evidence based and align with contemporary standards. but also folks who are not improving. And the goal there is to identify opportunities for stepped care. And stepped care is just adjustments to care, plans to be able to get to remission. And sometimes I found Ob-gyns feel a little overwhelmed at stepped care. It's not really a part of what we've learned or done for mental health in the past. but it's a concept we're familiar with. We do this with hypertensive disorders of pregnancy. We do this with management of diabetes or gestational diabetes. But you don't start someone with new onset hypertension on, nifedipine and just send them on their way and not follow up. Of course, we wouldn't do that. That would be silly. We follow up with their blood pressure at a set interval, and if their blood pressure increases, we adjust their medicine. It's the exact same concept, but the registry and the weekly huddle allow for a systematic approach for population wellness and led by the care manager. So it's not the responsibility of the OB-GYN. You've got support. You've got help that can be in your office. All of those together lead to improvements in population health for the office setting, which is really fantastic. So the care manager and the care plan I love that you say care plan, because that is very much where, the tailored prenatal guidance is trying to, direct the profession is the idea of an individualized care plan for the patient and not just the same thing for everybody. Right? So I love that there's a care plan by the care manager. And would that then be incorporated through the weekly huddles into like a larger care plan. that would include the OB care as well. Or how does that work? Yeah. Typically those conversations really center on the mental health needs and health related social needs. And then what's really important and to your point, Lisa, is those are transcribed into the obstetric clinical record so that the OB knows what that care plan is and what the next steps are, what their trajectory has been and can be integrated as a part of that care team. And so it's really important as we integrate this, that it's not just plugging something in. It's facilitating communication among this additional team member and the ob gyn to make sure that those care plans are harmoniously implemented and everyone's on the same page. Right, right I love that. And I imagine that's even more important when you're talking about a patient traveling in for appointments. The care plan is coordinated not only just to the the the treatment plan itself, but even the the visit schedule and all of the touch points that happen. Absolutely. Yeah. And it's a lot to shoulder. And that's where I think it's foundationally important that we're introducing a new team member to support that. I think far too often an OBGYN or probably on all clinical care settings. The ask is we'll just add this, we'll prioritize this. Add this to your session. And I think at a certain point that just doesn't become feasible. And so having this additional person who is can champion meeting these mental health needs and these health related social needs as a part of their job description, and then support the navigation and communication of that information to the OB, who can have a broader view of the entirety of the care is really helpful. Talk a little bit more about this care registry. Is this a national registry that's being held up or is it within a is it system by system? Yeah, it's a great question. It's system by system. It's certainly not national, but it is required to be able to build collaborative care codes. And so there's a lot of systems in place, a point to a few resources. It could be very much as simple as an Excel spreadsheet where you enter the person's name and you have their most recent the dates of each of their scores. It does not need to be complex, but it's a place where you can house symptoms. The limitations of that are obviously that doesn't. An Excel spreadsheet doesn't get sent to your to your patient. Or, you know, communication can be a little more complicated. I know some electronic health records have registries built in, have expansion opportunities so that you can have a registry and have the ability to send out through a portal, survey, mental health symptom screens. And then those can populate back into the registry. So those are available, the Aim center at University of Washington also has a registry that's available for purchase. What we've done in our programming is we use Redcap and we use Redcap because much of our work has a research underpinning. And so it allows us to utilize, data for that purpose. But Redcap also has a lot of tools that allow for electronic sending of surveys. Interesting. Are there ways for those smaller, um, practices in rural health clinics? are there ways for them to implement a collaborative model when they don't have all of the resources that a larger institution has? Absolutely. So all that is required is those three ingredients the care manager, the registry and the the supervising psychiatrist that can be scaled anywhere. And so there's a lot of helpful information. Again I'd point to the AIM's website as one good resource. I would imagine that there are, um, some pretty compelling outcomes that can help people show payers and their community that efficacy of this kind of model. Yeah, I agree, there's a ton of data to support this. Again, this has been around for 40 years. This is not new. It's not novel. It's not innovative. It's it's tried and true. So and I guess maybe now is a time to break down. What are the what are the codes that are used to sustain this programming? Really the core of the cost is the care manager, right? At the end of the day, once you've built the registry, it's fairly low maintenance. Um, and then of course, the cost of the supervising psychiatrist, which is a lot less than the care manager because it's a smaller portion of their time and the care manager supports these codes or the program via two codes. One is for psychotherapy, and that's just basic psychotherapy billing codes. That's not controversial. an independently licensed social worker can absolutely bill for psychotherapy, whether that's individual or group. And so that's tried and true. And most programs the the care manager is going to deliver psychotherapy that covers about maybe 30 to 40% of their time. The rest of the codes are these collaborative care billing codes. And again, to build them you have to be able to prove that you've got the care manager, the registry and the supervising psychiatrist and the billing codes are designed to be able to support all of the other stuff that the care manager does to navigate the patient to the resources that they need to screen for those social health related social needs, and be able to provide linkage to resources to make sure that the communication from the weekly team meeting gets back to the OB, so that everybody is aware of the care plan. So that documentation and coordination and what I love about them is they're time based. And I think that's that, I guess insofar as any fee for service model can be equity centered, it allows for people who have more needs, who need more time from the care manager to get more services. Right. And so folks who have more complex mental health conditions that need a ton of care coordination, that have transportation barriers, if the care manager spends more minutes, there's more reimbursement. And so there's an incentive to align needs with what's delivered. We've had an amazing partnership with the Policy Center for Maternal Mental Health. Um, they are wonderful and very eager to hear if if perinatal collaborative care is not being covered, uh, they can give contact information for who you should be reaching out to, and they're happy to partner with you. And they've just been really fantastic group to advocate for the changes that we need to see. That's great. And actually I work with them on several issues, so I'm familiar with them and their team at the Policy Center and have worked, with them on a, in a few states to get, mental health, maternal mental health services covered through Medicaid programs, when you said the care manager can bill for the psychotherapy and the other services, I think that it's really important to, call out that, um, in most states and by most plans, they do have to be licensed providers in this state. So that's where the licensed clinical social worker, piece of that is very important because if they're not licensed or certified according to the state, each state has their own rules. But if they're not, then they're likely not able to build, right? Absolutely, yes. So Any final thoughts? I mean, so much great information here. applicable to many practice settings. You made it very easy. but what final advice would you give to Obgyns who are interested in, just making sure that they're offering the best, comprehensive care to their patients with with mental health needs. Yeah. I mean, I think the central point is you don't need to go it alone. it can feel overwhelming to build a system. And I've had many people, when they come see our programming, say, oh, gosh, well, we can't possibly have that. And I would argue that. Absolutely you can. It takes a little bit of homework, it takes a little bit of legwork to get built. But and we're so happy. Our team is so happy to partner with you on the journey to help navigate, to help troubleshoot. Happy to work with Acog to to do the same. I think there's so many opportunities to be able to build systems of care, and I think at this point acknowledging the contribution of untreated mental health conditions to adverse outcomes, including pregnancy related mortality. The onus is on us to really step up and build these systems to make sure that we've got comprehensive, systematic, equitable care provision that includes mental health. Great. I'm so excited that we connected today. And just thank you so much for for not only sharing your experience, but just really giving practical, action items that everybody can take back with them to, um, look into implementation. And I'm going to do the same. I'm going to look at how we can better support, collaborative care. so that, it's not as scary, So thank you so much for your time today, Doctor Miller. Of course. Thanks for having me.

00:27:27 Speaker: Again, I want to thank everybody for their participation in this series on perinatal mental health, for the Payment and practice podcast and videos. and a big thank you to our sponsors, Sage Biogen, for providing the resources necessary to get this evidence based, solid, advice out to OB GYNs across the country. Thank you, Sage Biogen, for your ongoing support of this program.