Leveraging Remote Behavioral Health Interventions to Improve Medical Outcomes and Reduce Costs

Successful patient engagement in a nationally available, remotely delivered behavioral health intervention can significantly improve medical outcomes and lower healthcare costs.
Published Online: February 27, 2015
Reena L. Pande, MD, MSc; Michael Morris; Aimee Peters, LCSW; Claire M. Spettell, PhD; Richard Feifer, MD, MPH; William Gillis, PsyD
ABSTRACT
Objective
The dramatic rise in healthcare expenditures calls for innovative and scalable strategies to achieve measurable, near-term improvements in health. Our objective was to determine whether a remotely delivered behavioral health intervention could improve medical health, reduce hospital admissions, and lower cost of care for individuals with a recent cardiovascular event.

Study Design
This retrospective observational cohort study included members of a commercial health plan referred to participate in AbilTo’s Cardiac Health Program. AbilTo is a national provider of telehealth, behavioral change programs for high risk medical populations.

Methods
The program is an 8-week behavioral health intervention delivered by a licensed clinical social worker and a behavioral coach via phone or secure video.

Results
Among the 201 intervention and 180 comparison subjects, the study found that program participants had significantly fewer all-cause hospital admissions in 6 months (293 per 1000 persons/year vs 493 per 1000 persons/year in the comparison group) resulting in an adjusted percent reduction of 31% (P = .03), and significantly fewer total hospital days (1455 days per 1000 persons/year vs 3933 per 1000 persons/year) with an adjusted percent decline of 48% (P = .01). This resulted in an overall savings in the cost of care even after accounting for total program costs.

Conclusions
Successful patient engagement in a national, remotely delivered behavioral health intervention can reduce medical utilization in a targeted cardiac population. A restored focus on tackling barriers to behavior change in order to improve medical health is an effective, achievable population health strategy for reducing health costs in the United States.

Am J Manag Care. 2015;21(2):e141-e151
  • Inadequately addressed behavioral health issues commonly accompany medical conditions and account for worse medical outcomes and greater healthcare utilization.
  • This study demonstrates that a remotely delivered behavioral health intervention targeted to individuals with high-risk medical conditions can indeed reduce medical resource utilization and lower healthcare costs within 6 months.
  • This study confirms that a collaborative strategy to bridge the gaps between behavioral health and medical health serves as an effective and achievable population health strategy to improve quality and lower cost of care.
Despite tremendous progress in improving morbidity and mortality in patients with high-risk medical conditions such as cardiovascular disease, healthcare expenditures continue to rise at a dramatic pace.1,2 Innovative population health strategies that focus not only on disease but also on sustainable improvements in health and well-being are sorely needed. The anticipated benefits include happier, healthier patients, ultimately leading to lower healthcare costs. Unfortunately, existing strategies to improve health have not adequately focused on addressing the behavioral determinants of health, which when adequately treated, may lead to tangible optimization of medical health and reductions in medical utilization.

For many individuals with medical conditions such as cardiovascular disease, concomitant behavioral health issues—such as depression, stress, and anxiety—are common, and pose substantial challenges to recovery from medical illness.3 Even in those individuals who do not meet the clinical criteria for behavioral health concerns, inadequate resiliency to cope with the challenges posed in the face of a medical or life event can significantly impact health. In patients with a recent cardiovascular event (eg, myocardial infarction [MI], coronary artery bypass surgery, or congestive heart failure), major depression is known to affect as many as 1 in 4 individuals and can lead to adverse cardiac outcomes, greater all-cause mortality, and significantly greater healthcare utilization.4-11 Addressing these behavioral health issues and helping patients to develop the life skills needed to overcome barriers to self-care and self-management are necessary prerequisites to improving medical health and lowering healthcare costs.

Aetna, a national health benefits company, enhanced its care management programs in 2011 by collaborating with AbilTo, a network of behavioral health providers, to provide structured, condition-specific behavioral health programs to its members identified with specific medical conditions. We hypothesized that an intervention that successfully engages patients to address the behavioral health issues that commonly accompany high-risk medical conditions, such as cardiovascular disease, would lead to improved health resource utilization and lower healthcare costs. Accordingly, we conducted a retrospective study to assess the impact of AbilTo’s Cardiac Health program, a remotely delivered behavioral health intervention, on all-cause hospital readmissions and total hospital days during the 6-month follow-up period in a commercially insured population of individuals with cardiovascular disease.

METHODS

Study Design

A retrospective, observational study design was used to compare individuals who had completed at least 7 weeks of the 8-week AbilTo program with those who had completed the initial assessment and 2 or fewer weeks of the program. Individuals with partial program completion (ending anytime between week 3 and week 6) were not included in this analysis.

Study Groups

Commercially insured patients were included in the study if they met the following inclusion criteria: 1) referral from Aetna to AbilTo’s Cardiac Health Program based on evidence of a recent cardiovascular event; 2) completion of an initial consultation with an AbilTo therapist; and 3) availability of continuous enrollment with Aetna 6 months prior to and 6 months post AbilTo program intake. This approach was selected so that baseline behavioral health symptom scores were available for all individuals, as these symptoms can independently affect the utilization and cost outcome measures. All participants had Aetna as their primary healthcare benefits provider. Cardiovascular events were defined on the basis of hospitalization or outpatient claims submitted with a principal diagnosis code from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for myocardial infarction (410.xx), intermediate coronary syndrome (411.xx), or cardiac dysrhythmia (427.xx), or with a principal procedural code from Current Procedural Terminology-10 (CPT-10) for coronary artery bypass surgery, valve surgery, coronary stenting, or angioplasty.

Participants

Between September 2011 and May 2013, 552 participants were referred to AbilTo’s Cardiac Health program and completed an initial consultation. Of these, 251 individuals completed 7 weeks or more, 241 completed 2 weeks or less of the program, and 60 participants were excluded on the basis of partial program completion (completing between 3 and 6 weeks). After applying the requirement for 6 months pre-intake and 6 months post intake eligibility for Aetna medical benefits, there were 201 individuals remaining in the intervention group and 180 individuals in the comparison group.

Intervention

AbilTo’s programs are based on widely accepted behavior change tools, including cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), mindfulness, motivational interviewing, and other related, evidence-based best practice approaches. All protocols are crafted by AbilTo’s clinical team in collaboration with an advisory group consisting of psychiatrists, psychologists, and other medical professionals. All programs are delivered remotely by telephone or secure video, and the care is administered by a specially trained provider team consisting of a behavioral health provider (a licensed clinical social worker [LCSW] or equivalent) and a behavioral coach. All providers receive Association of Social Work Board–certified training administered specifically by AbilTo in order to ensure delivery of AbilTo’s best practices treatment protocols.

The programs are all 8 weeks in duration and consist of 16 sessions in total. Program participants undergo a one-time clinical intake session (“initial consultation”) with an LCSW followed by separate weekly one-on-one sessions with both an LCSW and a behavioral coach for a total of 8 weeks. Providers participate in case conferences under the guidance of an LCSW clinical supervisor during the course of each program to review the participant’s progress. The clinical supervisor also reviews all case notes on a weekly basis to ensure high quality and adherence to the treatment protocols. A proprietary content management system ensures consistent delivery of program content and provides a secure platform in compliance with the Health Insurance Portability and Accountability Act (HIPAA) to allow sharing of clinical notes among the LCSW, behavioral coach, and clinical supervisor.

Primary Outcome Measures

The primary outcome measures were all-cause hospital admissions and total hospital days in the 6-month period from the date of initial consultation. Additional outcome measures included: total emergency department (ED) visits; outpatient visits, including behavioral health (BH) visits; and cardiac-specific hospital readmissions and hospital days. Outcome measures were derived from Aetna medical claims data that included facility and professional services. Claims for AbilTo sessions were adjudicated as behavioral health visits by the participants’ health plan, and were included in the overall BH outcome metric.

Secondary Outcome Measures

Severity of depression, anxiety, and stress were evaluated using the Depression Anxiety Stress Scale 21 (DASS-21), a scale to measure these behavioral health dimensions that has been widely validated in multiple clinical populations.12-14 The DASS-21 was administered by an LCSW at baseline (for both groups) and at program completion (intervention group only). Baseline demographics and presence of clinical conditions were collected from Aetna’s administrative databases. Scores representing each participant’s risk of future healthcare usage were calculated using Ingenix Episode Risk Group software.15

Statistical Methods

The descriptive analyses of baseline differences used t tests for continuous variables and χ2 tests for categorical variables. Multivariable logistic regression was used to test the odds of binary outcomes—such as likelihood of an inpatient admission or ED visit—controlling for demographic and baseline differences between the groups. Poisson or negative binomial multivariable regression was used to test the differences in count data such as inpatient admissions, ED visits, and office visits between the groups. All analyses were conducted using SAS 9.2 software (SAS Institute Inc, Cary, North Carolina).

RESULTS

Patient Population and Engagement

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