Friday, November 18, 2016

Evidence Based Treatment for Super Utilizers

It seems obvious that in behavioral health we should use treatments that are tried and true.  Hence the push for behavioral health systems and clinicians to use treatments that have strong empirical support like cognitive behavioral therapy (CBT).  This is fine and good.

And naturally we want our clinicians to be trained in best practices and payers want to see that patients are being provided first lines of treatment.  Also fine and good.

Here's the but...

Super utilizers would never meet the criteria to participate in the clinical studies that evaluated these evidence based treatments in the first place.  Providers (especially Medicaid providers) are ill equipped to treat individuals with multiple comorbidities in addition to complex environmental and socioeconomic stressors.  Rarely is it so simple as providing a manualized treatment that solves a specific clinical condition in isolation.  I wish!

So what's the alternative?

Of course we shouldn't throw evidence-based treatments out the window.  Rather we have to support our clinicians by providing them with better and more sophisticated tools to treat patients with multiple clinical and environmental issues.  We have to adapt the tools that we know work, like CBT, to reach a broader base than they were originally developed for.

Take mindfulness-based stress reduction or MBSR which has demonstrated impressive clinical outcomes.  We know that mindfulness works, but if we take a closer look at the clinical protocol, participants are required to commit to an hour per day of formal meditation practice.  As a provider, when I think about some of the super utilizer patients that I have worked with, the actual clinical protocol as defined by MBSR is a non starter with many of these patients!

So the question is how do we repackage MBSR and other evidence based interventions so that they reach more patients, including super utilizers?  And how do we equip our providers with the tools they need to deliver these new interventions effectively?

At Utila, we believe the answer HAS to include patient-centered technology using patients' preferred modes of communication including SMS text.  And at the end of the day providers' and patients' voices need to be heard so that we can refine these next generation treatment interventions.  This is a problem we're passionate about solving, and we're eager to partner and collaborate with others who share our vision!

Monday, August 17, 2015

Before my eyes the pain eased

I was 4 weeks out of arthroscopic hip surgery and back to work full time.  I had just gone down to one and sometimes no crutches.  It wasn't my hip but sciatica that had really flared up.  After a phone call with my physical therapist, I set my mind to follow the plan: ice, anti inflammatory, and back to two crutches.  After feeling hopeless, I had to trust that it would work.  And before my eyes I saw that my progress, though not large, was undeniable.

When you are experiencing pain, it is not uncommon to just want it to go away.  In cognitive behavior therapy, scaling is used to set realistic goals.  Maybe it is not reasonable to think that I will have zero pain tomorrow.  So instead I am going to focus on how I can get my pain down to a 2.  Utila actually helped me feel more hopeful because I could see that I was suffering less.

Scaling the pain also helps you get in touch with your pain as opposed to avoiding it.  Mindfulness--that is, tuning in to the sensation of pain without trying to change it--can be immensely helpful for those suffering chronic pain.  This has also been the case for me--when I actually tune in to my pain and stop trying to avoid it, suddenly it becomes much more tolerable.  The simple act of scaling my pain on a daily basis helped me be more aware of my pain, which paradoxically, made it less distressing.

Tuesday, July 28, 2015

Supplementing My Care With Utila

I recently had arthroscopic surgery on my left hip.  Aside from one thing, the care that I got from Kaiser has been excellent.  Where Kaiser, and other providers fall short is engagement.  To their credit, my doctor, physical therapist, and surgeon gave me great instructions when I walked out the door.  This medication daily, this other one as needed, physical therapy exercises three times per day, this precaution, that precaution.  A week out from surgery I noticed a couple things.  First of all, my PT and surgeon haven't been able to meaningfully track my progress.  They didn't know for instance that for a couple days I wasn't completing my PT exercises 3 times per day like I was supposed to.  They also didn't know that when I started using Utila, my treatment adherence actually increased thanks to the text message reminders that I scheduled for myself.  A growing body of research has shown that text messages are the best way of nudging patients.  See my progress below!

Monday, June 29, 2015

Consumer-Facing Apps Need a Provider

Mental health providers have fought the reputation of being ineffective and unscientific by adopting evidence-based treatment models like cognitive behavioral therapy (CBT).  On the one hand, these models tend to be structured and use some form of protocol or manual.  But regardless of the treatment model being used, study after study has shown that treatment works better when there is a strong therapeutic relationship.

The most effective treatment providers are able to build a strong alliance in part by adapting the protocol to an individual's particular needs.  Treatment is much more than an algorithm, which is why technology will never completely replace the role of a doctor or a therapist.

Because the relationship is such a strong predictor of behavioral health outcomes, consumer-facing technology should leverage the provider.  Not surprisingly, patient education and remote monitoring are less effective when they feel cookie cutter.  For example, patients are more receptive to educational content when it is shared directly by their provider than when it is sent as a bulk email blast.

Utila was built on the premise that the provider relationship should drive treatment.  Utila allows providers to engage clients with individualized content that reinforces face-to-face or videoconference sessions.   Just ask yourself: would you rather get a personalized message from your provider or generic advice sent out to everyone?

Monday, June 8, 2015

Pitfalls of Value-Based Care in Behavioral Health

As healthcare reimbursement moves from a volume-based to a value-based payment model, technology will need to help in the implementation of this paradigm shift.  In theory, value-based payment seems to make sense.  Shouldn't the best treatment providers be financially rewarded?  Problem is, how do we measure performance?

Consider for a moment how education policy has tried to implement the analogue of value-based payment in schools.  No one disagrees that educational policy should somehow incentivize school and teacher performance.  Students, parents, teachers, administrators, and policy makers all seem to agree that test scores are not a meaningful reflection of a teacher's competence.  Yet test scores are what we're stuck with.

I am worried that behavioral health could fall in the same trap as the education system.  That is, policy makers will require the adoption of outcome measures that aren't meaningful to clients, don't reflect the quality of care provided, and fail to paint an accurate picture on a population level.  And once we are stuck with standardized measures that no one finds meaningful, just like the education system, we will be stuck with a necessary evil.

Technology solutions like Utila need to help policy makers and treatment providers avoid the obvious pitfalls.  Specifically technology can help the implementation of value-based payment in behavioral health by:

  • generating both provider and patient-generated outcomes data
  • striking a balance between population-wide and individualized metrics
  • streamlining the amount of data required of providers and clients
  • promoting interoperability of data collection systems
  • improving the validity of outcomes measures through innovative methods
  • capturing provider and client feedback throughout the implementation process

Thursday, May 21, 2015

Anthems For Mental Health

What songs inspire you to feel good?  We asked ourselves this question--here are the top 4 songs that the Utila team came up with.  Please feel free to comment with songs that inspire you!

1.  Bleachers - I Wanna Get Better

"I didn't know I was broken until I wanted to change"

2.  4hero - Another Day ft. Jill Scott

"I don't know how you feel, but sometimes I feel like I'm working for nothing, trying to get something [...] but I gotta get up"

3.  Passion Pit - Take a Walk

"I'm down on both bad knees, I'm just too much a coward to admit when I'm in need"

4.  The Beatles - Getting Better

"I've got to admit it's getting better, a little better all the time (it can't get more worse)"

Tuesday, April 14, 2015

Putting Health in Patients' Hands

We are gearing up to release our newest set of patient engagement features, designed to put patients in the drivers seat during the treatment process.  With Utila's improved interactive text messaging features, providers can not only deliver individualized messages on specific days and times, but patients can interact with the messages and even chat with their providers.  Here's what it looks like from the patient's perspective.

As other healthcare organizations like Kaiser have already concluded, we believe that text messaging is one of the easiest and most convenient ways of engaging patients.  The effort required to respond to a text message is minimal.  The total time it takes from message delivery to response is on average 15-20 seconds.  This contrasts with a patient-facing portal that requires considerably more effort to log in.

We have also found that text messaging can be a relatively discreet method of engagement.  Patients can choose to respond in the moment, or wait until they are in a situation where they feel comfortable to do so.  Furthermore, engagement via text messages actually motivates patients to log into the patient-facing portal where patients can see data over time.

Putting patients in charge of monitoring themselves is empowering and can serve as motivation to improve the measures that they are tracking.  As an example, I tracked my stress for a month using our interactive SMS feature.

The provider and patient portals display trends at a glance so that providers and patients can gain insights from patient-generated data.