Using technology for behavioral health integration [PODCAST]

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“While behavioral health integration (BHI) has been a long-standing conversation in collaborative care or health’s team-based approach, it hasn’t always been clearly defined and rarely means more than referring a patient in need to a specialist. The biggest shift over the past twenty years has simply been recognizing just how vital behavioral health is to overall wellness.

To effectively and efficiently achieve true BHI, we must engage people in the digital age we currently live in. This modernization begins with innovative technology at its core to drive connected care.”

Chris Molaro is a health care entrepreneur and CEO, Neuroflow.

He shares his story and discusses his KevinMD article, “Pandemic or not, we’re failing patients when it comes to behavioral health.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Here on the show we have Chris Molaro. He is a health care entrepreneur, and he’s the CEO of NeuroFlow, which is a HIPAA-compliant technology platform supporting behavioral health access, integration, and engagement. He wrote the KevinMD article “Pandemic or not, we’re failing patients when it comes to behavioral health.” Chris, welcome to the show.

Chris Molaro: Thanks for having me, Kevin. A big fan.

Kevin Pho: So we’ll get into the article a little bit, but first off, can you share your story and your journey to where you are today?

Chris Molaro: Yes, I’d love to. I’ve kind of come in the back door of health care in a way. I started my career as an Army officer, deployed overseas a few times, and led a platoon of soldiers. In that experience, I kind of had my first foray when I had a soldier that struggled with mental health and lacked access to that care. No one ever followed up to see how he was doing, and unfortunately, we lost him to his struggle with depression. That’s a personal passion of mine, that I want to try to tackle that problem. But we know that this is a problem that affects 50 million or more Americans a year. So when I got out of the Army, I went to Wharton for my MBA and teamed up with Penn’s psychiatry department to create NeuroFlow.

Kevin Pho: Specifically, what are some of the biggest challenges facing access to behavioral health? What are some of the reasons behind that?

Chris Molaro: I think we’re actually at a really exciting time when it comes to behavioral health. For the first time, we’re finally recognizing that mental health is health, and we’re destigmatizing. People are talking about it more and recognizing that it affects, like, think about how many people have high blood pressure and also struggle with anxiety and depression, yet that mental health component goes either unidentified or untreated. And we know it affects the whole system.

While that’s really exciting and has a big opportunity to treat the whole patient and improve outcomes, it introduces some challenges. Primary care providers already have enough to do in their short time with patients, so having to do more now with behavioral health creates a burden of workflow. There’s a shortage of psychiatrists and therapists in this country, so wait times are longer than, frankly, they should be. And so I think it creates a demand, engagement, and access issue. That’s where we think technology can help bridge that divide, automating a lot of that so that now, we know we’re identifying more people with BH, so you can make these solutions at scale.

Kevin Pho: All right, so you’re going to talk in more detail about what you said in your KevinMD article. It’s titled “Pandemic or not, we’re failing patients when it comes to behavioral health.” So I was wondering if you could go into more depth in terms of what you talked about. Share your article for those who didn’t read it, and maybe share the story of why you decided to write it.

Chris Molaro: If there’s a silver lining to a pandemic, if there can be, one is the adoption, I think, of new technology, of telehealth, and the willingness of people to adopt those. But I think the other one is that it’s brought behavioral health and those challenges kind of to center stage, and we’re tackling them head-on as a community, as a system. The numbers are staggering with the number of people. I mean, the ER visits this year, 2020 compared to 2019, more than doubled because of behavioral health issues, or behavioral health underlying issues.

And so when I wrote the article, I figured the pandemic is bringing this to light, but people need to understand that it’s not just the pandemic that is causing these issues. These issues were here beforehand. So in a post-COVID world, unless we address these more proactively, they’re going to still be there. And so we need to be more intentional about handling them and tackling them.

Kevin Pho: Now, can you share a story or an anecdote that really illustrates the behavioral health issues that you’re describing?

Chris Molaro: Anyone, any of your listeners, think back to, as a patient or provider, you’re in an annual wellness visit. Maybe a patient did a PHQ-9 depression screening in the waiting room, or you verbally gave it to them and put it in the EMR manually. And then after that visit, maybe they scored positive, and you said, “Look, maybe see a therapist. Here’s a referral. If you want an antidepressant, here’s that,” or a psychiatrist referral. And then they leave your office, and you don’t see them for another year. That happens all the time.

The problem is most people that have behavioral health issues, I think the last number I saw was about two-thirds of people that have a diagnosable depression or anxiety issue, don’t follow up and get it treated in the regular cadence that they should in order to get better. And there’s no continuity with that primary care provider, so there’s no what we call measurement-based care.

Think about how crazy it would be if I had cancer and I went for my cancer treatment and then the doctors weren’t measuring how I was doing, how it progressed, measured my tumor, and so forth. That would be crazy. If I had high blood pressure, that high blood pressure medication, they’re not going to wait once a year to measure that and see if I’m having negative side effects and everything. Yet that lack of measurement, that lack of follow-up and continuity, is a pervasive problem when it comes to behavioral health. The real problem is that it’s not just about BH; it’s because BH affects those physical health outcomes.

Kevin Pho: What kind of technology-enabled solutions are available currently for most primary care offices?

Chris Molaro: There are systems like clinical decision support tools that can help measure and then make the appropriate recommendations to those PCPs. Some of them integrate with a lot of your EMRs. What they want to look for are systems that integrate with the electronic health record. The last thing that you want to do as a PCP is put another burden in, another platform to log into.

There’s also what’s coming out, which is really exciting: these remote monitoring capabilities, both web-based and app-based. Think about how many social workers or psychologists, PhDs, are calling patients to do an assessment in between their appointments, to check and see how they’re doing. It’s like a gross abuse of a highly licensed, highly qualified professional to make a phone call like that. If you could have technology that automates that, that risk-stratifies them so that psychologists can treat and handle the highest-risk people, that allows them to operate at the top of their licensure. It helps with the demand issue and the bandwidth issue.

So there’s a bunch of apps out there that do that for the lower and mild cases. I mean, look, everybody has mental health issues. Who hasn’t been stressed or depressed at times? It might not be to the point where it’s clinical or it needs medication, but there are some habits and self-service type of tools that you can do to be proactive if you’re rising risk. And so there’s a lot of technologies and apps out there that enable that, and NeuroFlow wraps all those into one package.

Kevin Pho: So I’ve talked to a lot of psychiatrists, and they’re really coming to terms with telehealth and the opportunities that it brings them to connect with patients, especially in rural and underserved areas. Now, what’s the penetration of some of the technologies that you’re describing as it stands today?

Chris Molaro: Well, I think the easiest path to adoption, from what I see, if you look at a lot of the players out there, has been through the employer markets, so going as an employee benefit. I wish I knew going into this. The providers have been fantastic partners to work with, health systems, I mean, because they’re genuinely passionate about treating their patients and wanting to provide the best care. It is a huge barrier to fit into their workflow and to be adopted. And so for us, we’ve seen the companies that have been most successful with partnering have been those that have invested in those direct integrations, so that they’re less of a workflow burden.

I can only speak for NeuroFlow’s numbers. We have 350,000 patient lives under contract on our platform. That’s up from 30-something, 35,000, this time last year, which sounds like a lot, but when you talk about 50 million people that have these, and those are just the ones that we know about, that’s just a tiny, tiny sliver. A lot more work to do.

Kevin Pho: As you said, the mental toll the pandemic brings is really unprecedented, and I think the worst numbers are yet to come. Tell me what you expect in the next three, six, nine months in terms of the mental toll of the pandemic and how technology can help, and what do you see coming down the pike in the next year?

Chris Molaro: The pandemic has been a marathon, and I fear that a lot of people have treated it like a sprint, that they’re hoping that it’s over now. You could already see it in dialogue in our communities, when there’s frustration about the pace at which the vaccine is being rolled out. I think the longer that takes, people are like, “I expect I’m going to get it in March,” and then March comes and goes and it’s April, and then April comes and goes and they still don’t have it. You start to get feelings of loneliness, depression, anxiety. All of those really compound, where I think you’re going to see a higher utilization of the health care system, higher utilization of the ER, because the knee-jerk reaction is, “Maybe I have COVID. I’m going to go to the ER.”

And so I think if we can be transparent and communicative about how the rollout’s going, how people are getting there, and then provide resources remotely so people can get that care at home and feel like they’re, I mean, look, the world is a lonely place, especially during a quarantined pandemic. So if we can reach out to them and extend a doctor’s reach through scalable technology, we stand a much better chance in terms of providing holistic care to our communities.

Kevin Pho: We’re talking to Chris Molaro. He is a health care entrepreneur. He’s the CEO of NeuroFlow, which is a HIPAA-compliant technology platform supporting behavioral health access, integration, and engagement. Chris, I think one of the biggest problems I see with behavioral health is simply just a lack of people, especially in some remote rural areas. Tell me some technology-enabled solutions that can help address that, and I guess, what kind of time frame are you looking at in terms of implementing these solutions?

Chris Molaro: You could go the traditional telehealth route. Actually, the FCC just launched a big Connected Care Pilot Program to help rural hospitals, typically with lower budgets, obtain these technologies. So you have all of them, the Teladocs of the world, Doctor On Demand, that have these video capabilities. Video capabilities don’t solve the bandwidth issue, though. You still have a capacity issue. And so a technology like NeuroFlow, and there are other apps out there, that remote-monitors those patients to risk-stratify them so you see the right patients at the right time can be implemented. I mean, if we’re integrated, so we’re in Epic’s app store, athenahealth, that can be turned on literally with the flip of a switch, just like an app I would download on my phone, and we could be monitoring your patients within weeks, or two to three months, as opposed to years. Given that we’re in a cloud technology type of era, we can watch and support populations very quickly.

Kevin Pho: Walk me through a typical primary care scenario.

Chris Molaro: That PHQ-9, that’s still the gold standard. It is evidence-based if you were able to do it at the frequency at which you should. So we’ll do those screenings with your patient, either in the clinic, if they don’t have a smartphone or don’t have access to one, or through a web-based dashboard or a mobile app. We kind of try to make it as ubiquitous as possible in their personal lives. They fill out those assessments. The alert and the scores get sent to the electronic health record. At the same time, the patient will get certain, like, self-help exercises, self-service exercises. And then when they leave that office, it’s not that lost referral. We continue to follow them, and we’ll automate the follow-up, or they’ll do another assessment a month later.

So the patient will download the app, or it’s web-based, and they will access the self-service exercises that their care managers want to make available to them, all of which is automated. Now, if you go back, you go according to your regular day. A month later, two months later, we continue to follow up with them without you having to telephonically call them. So we follow up, we get those assessments, we measure outcomes along the way, and based on trends, we’ll provide alerts to the provider to say, “Hey, Chris really is not doing well. He went from mild to moderate to severely depressed. You want to be a resource team before he shows up to the ER.” And then NeuroFlow has augmented care coordinators to help those providers with an increased demand.

Kevin Pho: And through your lens as a health care entrepreneur, any messages that you want to share with my clinician audience?

Chris Molaro: Let technology companies do what they do best, which is create engaging technologies. We want to collaborate with providers. I don’t want to come in and tell you how to do your job and how to change your workflow. We will never be successful; I would not be in as many hospitals as we are today if we tried to do that. I want to be collaborative and streamline these processes for you, so that the health IT teams at whatever health system you’re at. They’re already overinundated, and so we could really, I think, help solve those problems if we take that collaborative approach.

Kevin Pho: And my final question: What is your take-home message you want to leave with the KevinMD audience?

Chris Molaro: We’re at this kind of precipice when it comes to health care and behavioral health. Twenty years ago, what we’re talking about would never have been possible, and yet more people than ever need this type of support and services. Even you yourselves, as providers: Provider burnout is at an all-time high. There’s no shame in getting that support and getting that help. And thank you for what you do.

Kevin Pho: Chris, thank you so much for sharing your time and insight, and thanks again for being on the show.

Chris Molaro: Thank you.

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