By Justin Hunt, MD, MS, head of psychiatry, Ginger.
Justin Hunt
From banking to healthcare to grocery delivery—businesses and organizations across multiple industries are pivoting to leverage text messaging as a way to reach consumers. And in behavioral healthcare, text-based coaching is paving the way for increased access to support. Traditionally, mental healthcare providers have only offered in-person appointments for individuals seeking care. Today, virtual services like teletherapy and telepsychiatry are gradually growing in popularity among an increasingly tech-savvy population. Now, services like text-based behavioral health coaching offer another meaningful way for individuals to get in-the-moment care.
Consumer Expectations Have Shifted
Consumers today expect instant access to mobile-first, on-demand services. A recent survey by the Harris Poll on behalf of Ginger revealed that Americans–especially Millennials–are more comfortable with the idea of being able to text for mental health support as a way to get access to care. Two-thirds of Americans (66%) say that if they were struggling with stress or life challenges, they would prefer to text immediately with a certified mental health coach who is trained to provide support if given the choice, while 34 percent would choose to wait three weeks to meet with a licensed therapist in person. This trend is strongest with the Millennial population: 69 percent would prefer to text immediately with a professional rather than wait to meet in-person.
For many consumers, a chat-based solution may be less intimidating as a first step than going in-person to see a licensed professional. Coaching is emerging as a way for individuals to access support in overcoming day-to-day challenges, reach goals, and learn skills to reduce stress. While not licensed like a traditional provider, coaches do have credentials like coaching certifications or master’s- and doctoral-level backgrounds in mental and behavioral health. And just this year, the American Medical Association approved new codes for health and well-being coaching. Individuals can work with coaches alongside a therapist and psychiatrist to receive support between appointments and sustain the progress they’re making toward personal growth. Coaching is also effective as a preventative layer of mental healthcare. At Ginger, 68 percent of our members are non-severe and don’t require intensive therapy or medication management.
Text-based Chat is the New Normal
The younger generations that are digital natives have grown up with texting and chatting online as a regular, highly expressive form of communication. It comes as no surprise that they would be comfortable expressing themselves in this way to mental healthcare providers. For them, text-based chat with a coach can help them find meaning and healing. Additionally, both therapy and psychiatry are episodic in nature—with clinicians meeting clients bi-weekly or monthly. But as I’ve found in my work as a psychiatrist, life does not operate on that schedule.
While clients might demonstrate an overall trajectory of improvement, unexpected mini-crises in between appointments can slow down improvement. Immediate coaching intervention at the exact time of need helps to address these natural setbacks that occur between therapy or psychiatry visits. In addition to handling acute issues, coaching can offer a helpful longitudinal approach to goal setting. For example, coaches can check in with clients between clinical visits and remind them of healthy sleep hygiene techniques or provide light motivational interviewing to help an individual reduce alcohol consumption.
Scaling Care to Meet Demand
As mental health stigma decreases, more people are actively seeking services. Earlier this year, in partnership with Dimensional Research, Ginger surveyed more than 1,200 U.S. workers and found that a growing number of workers are proactively seeking out mental healthcare. Fifty percent of workers said they are more likely to seek help now than they were five years ago and 85 percent reported that behavioral health benefits are important when evaluating a new job.
In the face of this growing healthcare demand, the supply of medical generalists has been consistently trailing the supply of specialists. By 2030, a study from the Association of American Medical Colleges estimates a shortfall of between 14,800 and 49,300 primary care physicians, as well as a shortage in non-primary care specialties of between 33,800 and 72,700 physicians.
Compacting this issue, the U.S. population is estimated to grow nearly 11 percent by 2030, with those age 65 and older increasing by 50 percent. As physicians begin to retire too, this problem will be exacerbated.
While digital technology has been positively impacting access to healthcare services for quite some time, efficiencies, such as virtual care, need to be implemented widely in order to address the impending physician shortage, and maximize the delivery of quality care.
This implementation will be somewhat natural as patient access and services continue to evolve from live voice interactions to leveraging digital solutions. Several healthcare providers have made this step toward virtual care already, and are showing strong results for patient satisfaction.
A virtual visit pilot program conducted by Brigham and Women’s Hospital found a 97 percent satisfaction rate among patients with access to these new communications and care options, with 74 percent stating “that the interaction actually improved their relationship with their provider.” They also found that 87 percent of patients said they would have needed to come into the office to see a provider face to face if it weren’t for their virtual visit.
Kaiser Permanente Northern California (KPNC) have a similar offering, providing a suite of apps enabling members to exchange secure messages with their clinicians, create appointments, refill prescriptions, and view their lab results and medical records. As a result, the number of virtual visits has tripled to 10.5 million over last six years.
At Valley Health, a tele-ICU has provided a viable solution to reduce mortality rates. During the first year of its implementation, the technology helped save 125 lives, reduce ICU length of stay by 34 percent, and also reduce the sepsis mortality rate.
These examples show how virtual care can aid patients for when they first need help, but the care journey does not stop there. It continues with prescriptions, labs, imaging, and referrals to other care providers. In these instances, virtual care can be used as a follow-up and check-in tool so that patients no longer need to visit their physician in-person, they can quickly interact with them from the comfort of home.
Rural healthcare organizations and their patients are up against a myriad of challenges, from minimal funding and resources to limited access to care, social determinants of health, and more barriers that stand in the way of effective care delivery. Unfortunately, nearly half of rural hospitals operate at a negative margin and are struggling to survive, according to iVantage’s 2017 Rural Relevance Study.
The number of rural hospital closures has risen to 87 in the last eight years, according to the National Rural Health Association (NRHA). The closures create a large gap in healthcare resources available in rural communities, as the residents cannot always drive or fly great distances to access needed care. Virtual care technology can address gaps in care and help rural providers continue to deliver care for the vast populations and geographies they support.
Increased re-admission rates amongst rural patients are driven by inadequate care and support after the patient returns home. Home health organizations now play a critical role in helping hospitals reduce these rates by providing care to rural patients, especially during the initial thirty days after discharge. Home health organizations are actively implementing virtual care platforms to automate the post-discharge follow-up with a rural patient by sending reminders to schedule appointments for post-discharge virtual visits via the communication channel of the patient’s choice – e.g., text, SMS, email or even a phone call. Follow-up care can be provided in a cost-effective video call (for home health providers and patients) which optimizes the caregiver’s productivity by minimizing excessive transportation time, travel costs and related liabilities typically associated with driving to/from patient homes.
To help home health agencies, there has been a longstanding Medicare rural add-on for home health services. Federal add-on payments through the Center for Medicare and Medicaid Services (CMS) have been crucial to these agencies operating in rural regions of the country. The 3 percent payment modifier to reimbursements for services provided in rural and underserved areas helps these agencies which face higher overhead expenses through factors such as increased travel time between patient visits and demands for extra staff. This payment modifier is imperative so that rural agencies will be able to keep their doors open and provide necessary care to home-bound patients.
However, the Centers for Medicare & Medicaid Services (CMS) has proposed payment rules which may impact the delivery of home health care in rural communities. The shift was mandated by the Bipartisan Budget Act of 2018. Under the new methodology, CMS is varying add-on amounts depending on a rural county’s home health utilization, population density and other factors. Unlike the current standard of a 3 percent three percent rural add-on, CMS’s proposed payment rule segments counties into “high utilization,” “low population density” and “all other” categories:
High-utilization counties are “rural counties and equivalent areas in the highest quartile of all counties and equivalent areas based on the number of Medicare home health episodes furnished per 100 individuals who are entitled to, or enrolled for, benefits under part A of Medicare or enrolled for benefits under part B of Medicare only, but not enrolled in a Medicare Advantage plan under part C of Medicare.” Low population-density counties are designated due to their population density of six individuals or fewer per square mile of land. The all-other category includes counties and areas that don’t fit into either definition.
