Behavioral Health
Community Benefits from Behavioral Health Strategy
Hackensack Meridian Health’s Joseph Miller and Kenneth Esser discuss keys to success
By Sue Ellen Wagner
Interview
I recently spoke with Joseph Miller, Ph.D., and Kenneth Esser about the importance of community partnerships to tackle behavioral health and the leadership role that boards can take to guide strategy in this important area.
Joseph Miller is vice president for behavioral health care transformation services, and Kenneth Esser is senior vice president, chief of staff, corporate services and governance, government relations, both at Hackensack Meridian Health (HMH) in New Jersey.
Sue Ellen Wagner: Can you tell us about your health system and how a behavioral health strategy was developed?
Joseph Miller: Hackensack Meridian Health is a 17-hospital health network that spans the state of New Jersey and includes three academic medical centers, two children’s hospitals, two dedicated rehabilitation hospitals and a dedicated psychiatric hospital, in addition to a school of medicine that, interestingly enough, we’re going to be graduating our first class from the new school of medicine in just a few months.
In addition, we’ve begun to open a new, dedicated, extra treatment facility, up in North Jersey, that’s going to provide both inpatient/residential and outpatient care for those struggling with substance use disorder.
HMH is a network that has more than 36,000 team members, 7,000 physicians and over 500 community-based care locations. As a network — over the past year or so — we’ve provided care in 190,000 inpatient admissions and over 2 million outpatient visits. So it’s a fairly large network in a relatively small state.
The behavioral health segment includes over 400 inpatient and residential beds that are spread over five locations and over a dozen outpatient facilities. We do about 12,000 inpatient admissions per year and over 100,000 outpatient visits annually. We also have psychiatric emergency services in each of our hospital emergency departments and, about 18 months ago, opened the first integrated medical/behavioral health urgent care center in the state. This is the first of its kind, possibly in the country.
Regarding our behavioral health strategy, it really developed out of our core mission which is to support the communities that we serve. HMH came to be where it is today through a series of mergers and acquisitions/partnerships, and each of the entities that became Hackensack Meridian Health ultimately had some level of behavioral health services available. So, for instance, Carrier Clinic has a history of providing behavioral health services since 1910, and many of our outpatient behavioral health centers got their start in the 1960s with the federal Community Mental Health Act. Candidly, it helps with our strategy to have a CEO — Bob Garrett — who completely understands and embraces the need for providing behavioral health services to the community and the critical need for hospitals and health networks to integrate behavioral health into their overall health care strategy. It’s taking care of the whole person physically, spiritually and emotionally, and we see that in just about all of our programs.
Our CEO, Mr. Garrett, is a very passionate behavioral health champion who speaks nationally and internationally on the topic. With that kind of support and history and network services to work with, the strategy evolves itself as we continually assess and understand community need.
Wagner: Please describe the board’s role in this strategy.
Kenneth Esser: It began when we first completed the merger with Carrier Clinic, and in a lot of respects, that merger was not just about the facility itself or the bricks-and-mortar of Carrier Clinic, but it was about bringing in behavioral health experts that would be able to integrate these behavioral health services from our hospitals in Bergen County, all the way down to Ocean County.
As Dr. Miller and the team developed the coordinated approach, the strategy did as well. There are really three different entities that you have to know for getting the support it received. The first is the Carrier Clinic board itself, which is focused on behavioral health services. Some of the folks come from a Carrier Clinic background while others come from a Hackensack Meridian Health background, but their primary focus is on the Carrier Clinic campus and behavioral health services overall and advancing those issues.
The other entity that was critical in developing this is a strategic planning committee, which is composed of a collection of different board members and committee members, to evaluate the strategy — and ultimately endorse the strategy from a networkwide, strategic perspective. The committee members are able to look at a variety of different strategic opportunities for the organization, not just issues concerning behavioral health and the Carrier Clinic.
Then, ultimately, all of this rolls up to our network board, which provides oversight and final approvals. What’s really great about this is that it involves all of the major decision-makers from our board entities, went through our committee and went through the board specifically designated to these behavioral health issues, to really get buy-in from across the network and across the different experiences that are represented for our board members.
Wagner: Can you highlight the role that the community health needs assessment played in this strategy? Please elaborate on the community partnerships that have been critical to the organization’s behavioral health strategy.
Miller: The community health needs assessment provides us with a forum for our community partners, as well as residents in the community, to identify and analyze the most pressing community health needs. The process provides an opportunity to work collaboratively within our hospital network, and prioritizes those unmet needs and develops plans to address them.
Over the course of the CHNA, we’re in touch with hundreds of community partners across the state and thousands of residents taking part in our survey. So, not surprisingly to anybody, that data from the CHNA shows an alarming trend and worsening mental health status. In 2006, for instance, about 8.3% of our community rated themselves as either in fair or poor mental health. And in 2019, that number increased to over 17%. That is almost a10% increase and a metric that we’re not happy to see.
Moreover, 75% of our key informants rated mental health as a major problem in their community. Sadly, of no surprise, is that two of the greatest needs identified recently are in the areas of child and adolescent mental health and addiction. I’m sure we can all appreciate that, in the era of COVID-19, these needs are increasing significantly as a result of social isolation and just having your whole routine turned upside down. As a result, HMH has a multifaceted strategy to address these concerns, including providing increased access to needed services and providers, screening and referring patients for undiagnosed mental health issues, training all of our team members in Mental Health First Aid/Psychological First Aid, as well as joining with community partners to reduce the stigma associated with mental health through community education and engagement.
Again, COVID has really challenged just about all of us, whether you’re a community member or a provider of health care services, and exacerbated many mental health issues. In terms of how we address these issues and how we partner, one of the things that I’ve experienced in my 16 years here is that there’s an appreciation that we, as an organization, as we evolve, don’t have to be the providers of every single behavioral health or substance use disorder service and program that’s needed in the community. What we do appreciate is that we have to be able to identify services and entities that are out there that can provide the service and do it well.
For instance, if a provider meets our standards for quality and is a match for us culturally, we’ll reach out and suggest some kind of a partnership. It absolutely does not need to be a formal merger or acquisition, but it can take the form of an affiliation that works for each of us and meets the needs of our patients and families. Likewise, the community entities need access to the higher-end medical services that we provide. Equally important is to identify community resources and entities that provide services other than behavioral health that can address many of the social determinants of health issues that we all face on a daily basis: issues such as housing, food insecurity, job support and other basic needs that can have a significant influence on the overall health status of our communities. Strategic partnerships like we’re talking about are an avenue to meet those needs.
We also work very closely with state and local government, private and public payers, and other entities such as public and private foundations and other community supports. We’ve found that some of our most effective and impactful programs and services that we’ve developed over the years have been born out of these strategic community partnerships, just by understanding the need.
One that’s been fairly well publicized and is incredibly effective is what we call our Pediatric Psychiatry Collaborative. This program was born out of a partnership with the State Department of Health Division of Children and Family Services and then ultimately with the Substance Abuse and Mental Health Services Administration at the federal level. Essentially what we do is engage with pediatric primary care providers and teach those practices how to screen for potential behavioral health issues during well-child visits. This could be for kids from 18 months old, up to 21–22 years of age when people are still seeing their pediatricians. Once that screening is done, we then offer access to a care management team comprised of social workers, psychologists, as well as board-certified child psychiatrists. For instance, if a pediatrician has concerns about a child that may have an attention deficit issue, prescribing psychiatric medications is not always an area of comfort for any kind of primary care doctor and certainly pediatricians. We offer immediate access to a child psychiatrist who could speak with the doctor, on demand while the patient and parent are at the office, and make recommendations: Is medication a consideration? Should it not be? Can we help with community referrals in the meantime? Then the pediatric office has an opportunity to refer that patient into our care management, and we’ll make sure that the child is getting the services they need.
The interesting part about this program is that it is now statewide, and our health system oversees it. We’ve partnered with five or six other health networks throughout the system — all of them are our competitors. It is something that is for the greater good and has just been an incredible service for the community, for our pediatricians and certainly for children. To date, we’ve screened over 200,000 kids in the state, and we just hope this keeps on going because it’s been a great win for everybody.
Similar to that, we have integration of behavioral health services into our adult primary care practices. To date, we’ve been able to establish, through a telehealth platform, having licensed clinical social workers available to primary care physician offices. Again, if they screen an adult who they have any concerns about and would like a behavioral health consultation and referral, we’re there for them, using a telehealth platform. This has been a much-welcomed initiative by our primary care doctors because you take that 15 minutes that most primary care doctors have for a patient visit and, if the patient presents with a behavioral health issue, that 15-minute visit could very quickly become a 30- or 45-minute visit. Unfortunately, there are often challenges in making referrals for behavioral health care in the community. Again, we give that resource and assurance, and we provide education and support, and, in the end, the patients and families are the ones who win.
The last thing I’ll give for an example is that we’ve established a fairly comprehensive telehealth strategy for behavioral health. It’s something that we’ve been looking at strategically for the past three years as part of our strategic plan, but the COVID-19 pandemic fast-forwarded it. Over the course of two to three weeks, we were able to transition 90% of our outpatient behavioral health and psychiatry practice into telehealth. That is something that continues today. We’ve leveled off at about 65% of our outpatient services provided via telehealth, but it’s really helped us to better understand how to create access points for the community to obtain our services. As long as you know the policies and the payers continue to support this, I think this is going to change the direction of behavioral health and expand it to get the services to people who most need them and have challenges accessing it.
When you have the support and vision from leadership that we have, these opportunities just present themselves. And you take them and you run with them, knowing full well that you’re providing a great service to the community, which is what it’s all about.
Wagner: Did the board have any influence on these partnerships? If yes, can you tell us more about that influence?
Esser: It’s very much all of our board members, committee members. We’ve got a bunch of different boards. I mentioned Carrier Clinic network board, and we even have a school of medicine board. So everybody’s got their own unique experiences and relationships. It’s all kind of one big family.
A lot of times, referrals come in from these different areas, or we are already talking with someone we have a relationship with. We can either use that to vet the company that we’re talking to now and serve as an important referral, or not, or as lead generation. There are a bunch of different ways that they ultimately come together, especially given how closely we work with all of our different boards and committee members through our work across our organization.
What’s exciting about some of this work that we’ve been doing over the past year is it’s about expanding access and making sure that our behavioral health services are ultimately universally accessible. We’ve got a long way to go in order to achieve that. So right now it’s more accessible than it was. That’s why we pursue different things like the Retreat and Recovery at Ramapo Valley [treatment center] up north in Bergen County, but also the urgent care facility across the street from Jersey Shore, with the behavioral health services and the telehealth services that Joe was talking about before.
All of these things come together to try to create an environment that gives people more opportunities. This includes easier opportunities to access behavioral health services. Not only does that bring the immediate benefit of, maybe, somebody will actually get help now that it’s more readily accessible, but also, for example, the urgent care clinic across the street from Jersey Shore gives people the option to go there instead of across the street to the emergency room for that treatment. This puts them and us in a win-win situation.
Those are all the different initiatives we have underway, and the board stays pretty active. We’ve got regular meetings. The Carrier Clinic meets about four times a year, and they’re never shy about bringing their own experiences and relationships and recommendations to the table — and that helps move everything along.
The way I’d answer the question most simply is that it’s all one team trying to move this in the same direction because we’re all on the same page about the strategic direction we’re trying to take.
Wagner: Do you have any advice for hospitals and health systems that are looking to enhance their community partnerships for behavioral health?
Miller: First and foremost, it begins with understanding your communities, the communities that we all serve, and what their needs are, and understanding the data that’s out there from the CHNAs. Once you have ascertained that, you do a simple SWOT analysis related to needs in your community. For us, our community is basically the entire state. Within those local communities, what are the needs, how do we prioritize them, and then, do we have the services that are needed? If we do, how do we improve access? If we don’t, should we be developing those services? If it’s no, since it’s really something that somebody else is either already doing or should be doing, then we go looking for that partner — and we’re very proactive about it. As I had mentioned, there are organizations out there that do a wonderful job in dealing with employment support or helping folks with housing or benefits or food insufficiency. We find a way to partner with them and make sure that those services are available to our patients.
One additional thing I want to mention is that we are going to be graduating our first class from our medical school in just a couple of months. There’s also an obligation on the part of hospitals and health networks to prepare that next generation of health care providers. For instance, at our medical school each of our incoming medical students is assigned a number of families in the community around the medical school and, for the three or four years that they’re at medical school, their job is to work with that family and understand not only their health needs but also the environmental and societal needs that they have, along the social determinants continuum. We feel like that makes for better providers, when they graduate and go on to further training.
The other piece that we’ve taken on and see as a significant obligation is through our academic programs and training programs. We currently have two psychiatric residency programs where we’re training the next generation of psychiatrists. Also, over the past two years, we started fellowship programs in child adolescent psychiatry, addiction psychiatry and geriatric psychiatry. We’re going to be launching a final one in what’s called consultation liaison psychiatry to deal with the incredible shortage of behavioral health providers, helping to address that as part of our core mission.
I think it’s important that health systems and hospitals look at the needs of the community — both the lay community and the professional community — and say what can we do here? Can we do it ourselves? Can we do it in partnership? I would recommend having the broadest definition and reach as possible when you’re defining “partner” because they could come from many different places — it doesn’t just have to be behavioral health providers. Sometimes a partner is a competitor, but you find that you can effectively deliver much-needed services by partnering with that competitor and that makes it a real good partnership.
Finally, one of the greatest things that hospitals, health systems and boards can do is to talk about behavioral health and take it out of the shadows. In other words, we do not need a stigma around this. Mr. Garret [our CEO], very often when he’s giving talks, says remember back in the 1960s and beyond, folks were afraid to say the word “cancer.” They would say “C” or they would whisper or something like that because they were afraid to talk about it. Well, people now talk very openly about cancer, and we’ve made great strides in dealing with it.
Similarly, we need to be comfortable in talking about behavioral health and mental illness and addictions, and I think we’ve made great strides in developing new programs and doing research and providing services to folks. I think that’s in large part because we’re willing to talk about it, and our boards are often the greatest ambassadors that we have. So, if they’re out there in the community saying, “Hey, this is okay to talk about and we all experience it,” I think that can only help all of us and makes it that much more important to develop that strategy and implement it.
Wagner: Can you offer any suggestions for boards who are looking to develop their organization’s behavioral health strategy?
Esser: Two suggestions: One is this was part of our strategic goals, and we made it one of our strategic priorities as an organization. Right out of the gate, it keeps everybody honest and focused and knowing directionally where we’re trying to go. Two is having people who are passionate about this issue.
In a complex network like ours, it’s important that we have people who are passionate on a number of issues, cancer being one and behavioral health being another. I think it’s important to have that group of folks with the experience and passion to keep focused on these issues and advance them forward because no solution is easy. If it was easy, we all would already be doing it. I think that passion and expertise really help bring another set of solutions and opportunities to the table for us.
What worked out well was the fact that we did merge with Carrier Clinic, which made available the opportunity to have this board created. That board really is focused on these behavioral health issues, and we ended up seeding it with several members who, for a variety of reasons — some professional, some personal — are passionate about this. I think that really helps to form small “p” partnerships between folks like Joe and the Carrier Clinic board to advance these causes. All of that’s been really helpful in creating a fertile environment for these ideas to grow and to advance these initiatives.
Sue Ellen Wagner (swagner@aha.org) is vice president, trustee engagement and strategy, at the American Hospital Association.
Please note that the views of interviewees do not always reflect the views of the AHA.