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Witness Testimony of Diana Birkett Rakow, Executive Director of Public Policy, Group Health Cooperative

Good morning, Chairman Miller, Ranking Member Filner, and members of the Committee.  I am Diana Birkett Rakow, Executive Director of Public Policy at Group Health Cooperative, an integrated health care coverage and delivery system based in Seattle, Washington.

Thank you for inviting me to be here this morning to discuss Group Health’s experience managing mental health appointments for our members.  We recognize and appreciate your leadership in ensuring our nation’s veterans receive the high-quality mental health care they deserve.  While our patient population and the context in which we provide care differ from the Veterans Health Administration, we share a commitment to ensuring that patients get the care they need, in a timely and effective manner, to improve and preserve their health.  We are grateful for the opportunity to share our best practices, and hope this information is useful as the Committee and the Veterans Administration work to continually improve mental health care for our nation’s veterans.

Group Health Cooperative is a nonprofit health system that provides both coverage and care.  Directly and through our subsidiaries, we cover more than 660,000 residents of Washington State and northern Idaho, about 60 percent of whom receive care in Group Health owned and operated medical facilities.  Over 1,000 physicians are part of the Group Health group practice, and we contract with more than 9,000 providers throughout the state.  We offer health coverage through public programs and in the commercial market—in Medicare, Medicaid, the State Basic Health Plan, State and Federal employee programs, in the individual market, and to small, medium, and large employer groups.  We also support employers who have elected to self-fund their employee health coverage.

Today I will discuss how Group Health has created a model and systems that have allowed us to provide, track, and ensure timely access and high-quality care for our patients, in particular those with mental health needs.  Our success in this area is due to the interaction of our philosophy, our model of care, and the tools we employ to establish processes and systems to track and continuously improve performance. 

Group Health is committed to patient-centered care and coverage, a philosophy that guides our approach to mental health services, the subject of this hearing, as well as every other type of health care we provide.  This philosophy provides a foundation for our model of care, which is based on the Chronic Care Model.  This model, designed by Dr. Ed Wagner—the founding Director of the Group Health Research Institute—is an evidence-based framework for health care that delivers safe, effective, and collaborative care to patients.  In simple terms, this means that our model is designed to link all aspects of the health care system together—health insurance, health care providers, clinical information systems, and more—to facilitate productive, continuous interaction between engaged, informed patients and a multi-disciplinary care team.

This philosophy and model of care have been critical to our success, but it has been the more recent implementation of Lean tools and processes that have enabled us to take our work to a new level.  Lean is a management method made famous by companies like Toyota, and in health care it provides the discipline and focus to commit to understanding the needs of patients, to building systems and processes designed around the patient’s needs, and to continuously track outcomes and improve processes to meet to meet quality and performance goals.

Behavioral Health at Group Health

Research shows that 25 percent of people have a diagnosable behavioral health issue—whether a mental health issue or a chemical dependency—arise within a given year, and 50 percent over the course of a lifetime.  Among those with a behavioral health issue, about 80 percent seek help in the primary care environment.  This can be for several reasons: because the patient is more comfortable in that environment, because his condition has presented as or alongside a physical ailment, or because primary care services are most readily available.  About one-third of patients with a behavioral health issue ultimately access help in Behavioral Health Services.

At Group Health, the Behavioral Health Services department is responsible for delivering mental health care in seven of our own outpatient clinics, managing behavioral health care delivered by our contracted network providers, and providing consultative specialty services to primary care physicians who provide care through our Patient-Centered Medical Home.

We employ over 150 behavioral health professionals including psychiatrists, clinical psychologists, Masters-level psychotherapists, nurses, care managers, and chemical dependency providers.  In addition, we have contracts with approximately 800 behavioral health specialists in the network.  Together, these providers offer a full continuum of mental health and chemical dependency treatment services from outpatient to acute inpatient care.  In 2011, Group Health provided specialty behavioral health care to over 50,000 members, about 8 percent of our patient population.  Approximately 45 percent (22,550) of members receiving specialty behavioral health services are served in the group practice clinics and 55 percent (27,561) were served in the network.  The majority of chemical dependency services and all inpatient services are provided in the network. 

The combination of philosophy, model of care, and Lean tools described above has enabled Group Health to address and improvements in three areas critical to mental health services: initial appointment access, follow-up appointment access, and provider capacity and productivity.

Initial Appointment Access

For some patients, ensuring timely access to behavioral health services can literally be a matter of life or death; for all patients, timeliness is important.  Our data have shown that timely appointing is one of the top drivers of a patient’s satisfaction with her behavioral health care experience.  But timely access—both initially and for follow-up care—requires collaboration, sound clinical judgment, rigorous processes, and consistent measurement and evaluation.

Collaboration is illustrated by the close relationship developed between primary care providers, specially-trained appointing and triage staff, and behavioral health professionals.  When a patient contacts us seeking an appointment, either directly or after having been referred by his primary care provider, a standard process to assess the urgency of the patient’s needs is triggered.   Appointing staff ask the patient a series of evidence-based questions and rate the patient’s level of urgency as routine, urgent, or emergent.  A routine patient is of low to moderate risk and verbalizes that she can wait between 7 and 14 days to be seen.  An urgent patient is in severe emotional distress but able to wait 48 hours for an appointment.  A patient considered emergent may be psychotic, suicidal, have withdrawal symptoms, or a sense of desperation, and needs to be seen within 6 hours.

Under our standard process, patients who convey a sense of urgency on the initial call are immediately transferred to a care coordinator—a Master’s level counselor—to further assess the urgency of her needs.  At this stage, clinical judgment is critical.  Patients judged to be at immediate risk for a suicide attempt, who are going through acute withdrawal, or who are gravely disabled are sent to the emergency room or urgent care.  In some cases the police are called.

These standards for scheduling an initial appointment were adopted from the National Committee for Quality Assurance’s (NCQA) standards for behavioral health appointment access.  Group Health has maintained an NCQA “excellent” level of accreditation since the late nineties, based upon a set of measures that includes access to behavioral health services. At Group Health, we aim to ensure that 90 percent of our patients with emergent needs receive an appointment within 6 hours, 85 percent of patients with urgent needs receive an appointment within 48 hours, and 80 percent of patients with routine needs receive an appointment within 14 days.  These targets were set based on the clinical urgency of the patients and to factor in patient preferences and scheduling needs. 

We are able to measure access to routine appointments that occur in our group practice model electronically, thanks to our system-wide electronic medical record, and do so monthly.  For routine patients who seek care within our contracted network, we do not have an automated way to measure initial access, but review claims data at the end of the year to monitor access.

Collaboration comes into play in one other area related to initial appointing access, and that is in collaboration between primary and behavioral health care providers.  For some patients, primary care is their preferred source of mental health care; for others, it is simply an essential complement.  In 2010, Group Health researcher and physician Elizabeth Lin developed a model called TEAMcare,[1] an intervention for multiple chronic conditions, which has been integrated into standard care in the Group Health Patient-Centered Medical Home.  Within one year—compared with the standard care control group—patients with the TEAMcare intervention were significantly less depressed and also had improved levels of blood glucose, low-density lipoprotein (LDL) cholesterol, and systolic blood pressure.  A recent study showed that by starting medications sooner and managing them more effectively, primary care physicians and nurses could improve their patients’ outcomes for both medical and mental health conditions.[2]

Follow-up Appointment Access

The ability to be seen in a timely manner for follow-up appointments is as important to patients as timely intake appointments.  Our patient-centered approach, combined with proactive planning and, again, rigorous tracking, has led to our positive outcomes in this area.  We track the use of group therapy (a measure that leads to increased capacity and improved follow-up access), the percentage of new patients seen three times in the first six weeks of treatment, and patient satisfaction with access to follow-up appointments.

Since behavioral health is a continuous, as well as episodic, concern—different from many medical issues but similar to other chronic illnesses—we have developed several ways that patients can access mental health care, increasing the likelihood that one or more of these routes will lead to timely access.  Through our electronic health record system, patients can send secure messages back and forth via email with members of their care team, including mental health providers.  Patients can also set up phone visits for times when getting into the clinic is either unnecessary or not feasible.  And, responding to a need among a certain sub-group of patients, in 2010 our staff designed a group psychotherapy program for patients with anxiety and depression.

In 2011, we established a goal of seeing at least 70 percent of patients three times within a six-week period.  This measure is objective, based on what our patients said they wanted and what is indicated in relevant research literature.  Over the last year, we have met and exceeded our target in this area, thanks to strategies and processes monitored by many of the other measures described here.

We have also begun tracking access as a part of our patient experience survey.  We know that a positive therapeutic relationship significantly contributes to patient experience, but have found, not surprisingly, that access matters too.  Like many things at Group Health, we have decided to approach access from an evidence-based perspective, as illustrated by the measure above, but also from a patient-centered one.  To assess patient satisfaction, we have chosen to ask whether patients are getting back into the office in a timeframe suitable to them.  For some patients, this could mean a matter of days—others, weeks.  But over the last year we have seen a statistically significant increase in this measure, with patients saying that they were seen again by a behavioral health provider when they needed to be.

Supply & Demand, Measures of Capacity and Productivity

Behavioral health is a poignantly human issue, but access to care can also be a simple one of supply and demand.  To meet the demand for care, we must ensure that there is adequate supply, as measured by capacity in the system, and productivity to make the most of existing capacity. 

In a group practice model, such as Group Health, unused capacity in the system (such as unfilled appointment slots and providers being less productive than benchmarks) leads to waste that can ultimately impact patient access.  Therefore, we track a number of capacity and productivity measures, including appointment fill rate, number of new cases per provider, and relative value units (RVU).  (RVUs are a measure of value used in the Medicare reimbursement formula for physician services.  They are nonmonetary standard units of measurement that indicate the value of services provided by a health care provider.) 

We seek to fill at least 90 percent of the appointments available in a provider’s schedule on a given day.  Each morning, clinic administrative staff members try to fill any open slots in a provider’s schedule first by calling patients who are on a waiting list for an earlier appointment, and then by calling patients who are scheduled beyond 14 days to see whether they are available to come in earlier.  Through this process, we have seen a reduction in wasted appointment slots and are currently filling 91 percent of all appointment slots.   We have also set standards for new case targets.  Each Masters-level counselor and psychiatrist has a weekly target number of new cases to ensure adequate initial patient access.

Developing and Monitoring the Measures

While measurement is critical, measurement in a vacuum is worthless.  The Lean approach starts with a focus on assessing and working around the needs of the patient, then developing systems and processes to meet those needs, developing measures to assess performance, and continuously looking for and developing new ways to improve.  Leadership, in commitment to this system, is key, but so is listening to patients, and to the people on the front lines who are caring for them and working with them directly.

To continuously track performance and to make it visible and transparent to staff at all levels, visual systems and checking tools are developed to monitor metrics on a daily, weekly and monthly basis, and to reflect whether targets are met.  Lean suggests what are called “tiered checking tools” to ensure that information is shared up and down a management chain.  For example, an identified metric will be measured at the tier one level by the staff doing the work; at the tier two, or departmental, level; and at tier three by primary care leadership.  The highest-priority metrics are reflected and reviewed in tiers four and five by our CEO and Executive Leadership Team.  These tiers refer to visual illustration of performance on these measures, over time and by clinic in the form of charts, graphs, and other tools, which are posted conspicuously on the walls in our clinics so that performance is visible to staff doing the work and to unit managers.  Clinic staff meet each morning to review challenges for the day and discuss how to address them.  Departmental leaders conduct “rounds” on the clinics’ visual systems at least monthly to monitor performance, and more importantly, to coach the staff in solving problems that arise.

These tools can help give patients, staff, and leaders confidence that performance is high, but they can also identify gaps.  Our culture supports continuous improvement through the identification of gaps and the application of countermeasures to ameliorate these gaps.  For example, last year a group of behavioral health staff tracked appointment patterns and identified a high number of appointments that went unfilled, were cancelled, or weren’t attended by the patient.  They used these data to develop a new process of monthly checks and adjustments of appointments across the week and time of day to increase the probability of increasing the number of appointments kept, and they began to review medical records monthly to identify and track patient preferences for appointment times.  These strategies and others have allowed us to meet challenges as they arise, to address the needs of a broad range of patients, and to significantly improve the access to and quality of behavioral health care in our system over the last several years.

Group Health’s journey with Lean began in 2007, and in behavioral health we first began using Lean to develop a care management system for our most vulnerable patients. Lean offered us a method for making work standard, visible and actionable via the coordinated efforts of individuals and teams.  Although there were some significant challenges in changing and adapting to new processes and a new culture, the results were unquestionably positive. Patients received better care that reduced their suffering and improved their lives.  And, our total cost of care (per member per month) was less in 2009 than 2008.  In part that was a result of better management of inpatient care—our largest controllable expense. 

Over the last five years, our systems, processes, and measures have continued to develop and improve.  We are proud of our model and its ability to provide timely, high-quality access to behavioral health care—and all health services—for our members.  But we also acknowledge that this is a journey.  Our system is built around a culture of continuous improvement—putting the patient and her needs first.  Thank you again for the opportunity to share our experience and for your attention.  I welcome your questions.



[1] New England Journal of Medicine  2010 Dec 30; 363(27):2611-20

[2] Annals of Family Medicine January/February 2012 10:6-14; doi:10.1370/afm.1343