Behavioral Health
Mental Health and Boards: Focusing on People, Patients and Community
Dr. Arpan Waghray shares how boards can make behavioral health a priority
by Rebecca Chickey
Interview
Dr. Arpan Waghray is a geriatric psychiatrist who serves as the CEO of Providence’s Well Being Trust. Dr. Waghray also served as the 2022 chair of the AHA’s Behavioral Health Services Committee, which helps shape the AHA’s behavioral health advocacy, policy and resource development. In honor of Mental Health Awareness Month, Rebecca Chickey, senior director of behavioral health at the AHA, interviewed Dr. Waghray about his experiences working to bring mental health to the forefront in hospitals and health systems.
Rebecca Chickey: Why should addressing our nation’s behavioral health crisis be a top priority for hospital and health system boards?
Arpan Waghray: The U.S. Surgeon General has so eloquently articulated that “mental health is the defining public health crisis of our time.” Mental health disorders are among the leading causes of disability worldwide. Hospitals and health systems have a critical role to play in driving meaningful change and could think about this in terms of the mental health of people, patients and communities.
First, your people. Even prior to the pandemic, mental health challenges were among the leading health concerns for most health care workers across the country and this has been exacerbated over the past year.
Second, across all care delivery, whether you have an emergency department, hospital, medical or surgical floor, you’re doing primary care. Across the entire care continuum, approximately a third of all patients we care for have co-occurring mental health or substance use disorders. When these disorders are untreated or undertreated, they impact the health outcomes for the entire population.
Third, hospitals and health systems aspire to be our community’s partner in health. This requires that we pay attention to Community Health Needs Assessments (CHNAs). Every single CHNA that I have seen in the past decade has addressed mental health and substance use disorders among the top five community needs. This is along with homelessness and other interconnected concerns.
Our people, our patients and our community. If these are not good enough reasons for us to pay close attention to this, then what are?
Chickey: Dr. Waghray, you mentioned communities. The hospital or health system seeks to be the community’s partner in health. AHA’s mission and vision statement speaks to that very strongly. Member hospitals’ CHNAs consistently show a lack of access to, or the need for better psychiatric and substance use disorder services. Are there other resources, beyond the CHNA, that should be shared with board members to keep them informed of the behavioral health needs of their communities, and/or how they can use their leadership position to advance community collaborations to increase access to care?
Waghray: We want to make sure that if someone trusts us with their care, we are always showing up to meet their needs as a whole person — mind, body and spirit. That’s every health system’s commitment to everyone they serve. To do so, it is important for boards to understand what the care gaps are. If your prevalence of illness is, say, 20-25 % across the board and the needs that we’re meeting for those patients is less than 2-3 %, that is a large care gap that we must address. Say you are operating an emergency department where 10% of patients come in with a stroke or a myocardial infarction and you did not have resources to meet those patients’ needs. That would be a significant area of concern for any governing board, right? We should think about this issue in a similar way. We have data on the prevalence of mental illness, yet these major gaps persist. I am not suggesting that every organization has to build capacity to meet all the needs internally. Financial challenges and workforce challenges exist, but what is possible is making sure we understand what the needs are, what systems can be put in place to address the health care delivery system and what strategic partnerships can be built with community health partners. The board can be helpful as they are influential and key members in their community. I have visited many communities and found there are many amazing programs run by community health groups, addressing critical needs. Using community partners, the process can be more seamless for the patient using peer support to bridge gaps.
Again, we should ask the questions we would for any other disease condition, and hold the executive team accountable for addressing them:
- Measures of the prevalence of behavioral health conditions (as indicators of needs).
- Measures of behavioral health treatment patterns (as indicators of the portion of demand that is met).
- Measures of the availability and affordability of behavioral health services (as indicators of supply).
Additionally, a critical opportunity for every board is finding out: how are we addressing quality for behavioral health care? Behavioral health has long lacked measurement-based care and an emphasis on quality, but it is now imperative. Access in itself is important but insufficient if it is not alleviating the most common causes of human suffering and disability. Tying this together with metrics can help achieve the goal of alleviating suffering and saving lives.
It is important to note, every one of these metric dashboards should have an equity lens. I would emphasize making equity front and center. If equity is not built into these metrics, you will not know where your priorities lie. As we assess the metrics, we must also recognize that some groups are disproportionately impacted. For example, if you are a Black male over 70, nationally, you’re 20% less likely to be prescribed antidepressants or get help. If you’re trying to improve a condition and there are disparities in care among some groups, that becomes a significant part of your quality improvement process. It’s very basic, but you need to be intentional to build that into every process. We need to think about it that way as we work to improve our patients’ lives.
Chickey: Speaking of community collaborations, can you speak to how board members can use their leadership to advance these partnerships?
Waghray: Many of our hospital board members might serve as a part of other community organization boards. They have a deep understanding of other community-based services in their markets and can help bridge critical care gaps by facilitating meaningful partnerships.
The other thing the board can significantly influence are community health investment programs. When we do have these proactive investments, they can help ensure they are meeting the needs of our community and creating that ecosystem of care that we talked about earlier.
The third area the board can play a very important role is representing the community by addressing the quality of behavioral health care. At Providence, we have been looking at the quality metrics that are measured for behavioral health and found that there were over 100 different metrics being reported across the 51 Providence hospitals. We brought together our behavioral health leaders, used validated metrics from the National Quality Forum and the National Committee for Quality Assurance (NCQA) and focused on metrics that demonstrated the greatest reach and impact on alleviating suffering and saving lives. We went through a rigorous process to bring these 100 validated metrics down to 30, and finally, down to three metrics that we as a system are holding ourselves accountable for with oversight from the quality committee of our board.
Depression is the number one cause of disability worldwide. Naturally, depression treatment response is the first of those metrics. Suicide, especially among youth, is one of the leading causes of death. Our fundamental belief is that no one should die alone and in despair by suicide. We believe these are preventable deaths, so we have a second metric around suicide care. The third is around opioid use disorder. Every community has been hit so hard by this, including ours. Every organization is different but holding yourself accountable to the governing board and quality committee is a very important step.
Chickey: CMS just announced an eight-state pilot to advance the integration of physical and behavioral health services. As of this interview, CMS hasn’t yet selected those eight states. Regardless, what should board members know about the value of integration and the role that they can play to accelerate integrated care in their own organization?
Waghray: This is such an important question, and I’m so glad CMS is taking this initiative on. When mental health conditions are untreated or undertreated, they have a direct impact on health outcomes for other chronic medical conditions and for health care utilization patterns. For example, if someone has depression and diabetes, and the diabetes is uncontrolled and the depression remains untreated, there is a greater likelihood it will be harder to treat the diabetes. Over 96 randomized control trials over the past 25-30 years demonstrate the value of integrated care across all care settings, especially primary care.
Another important area to integrate behavioral health services is during perinatal care. The number one complication of childbearing is postpartum mood disorders, yet every new mom does not get an Edinburgh Depression Rating Scale reliably and consistently. We must think of this from a broader perspective and recognize none of these illnesses occur in isolation. It is connected with the overall health of a person. This is important when thinking about integrating care. Studies have now conclusively demonstrated if you bring behavioral health into pediatrics, primary care, cancer care, OB care, you have a significant positive impact on not only the mental health conditions, but other medical conditions. This improves people’s quality of life and decreases ineffective and inappropriate health care utilization, such as avoidable ED admissions. It has a very significant impact on the hospital finances and utilization patterns, in addition to the health care quality. That’s why integration of mental health care across all care delivery is not just a nice to have, it’s a must have.
Chickey: Finally, what steps can board members take to ensure that available mental health resources are effectively leveraged at the local level? Or what one thing would you like governance leaders to remember and implement?
Waghray: It is imperative that board members of hospitals and health care organizations prioritize and address mental health in their communities. By proactively monitoring and assessing the mental health needs of the community, board members can ensure that available resources are effectively leveraged to provide accessible and high-quality mental health services. They must collaborate with local stakeholders and promote innovative solutions to effectively address the growing mental health challenges in communities.
Additionally, board members should hold space in meetings for a discussion about mental health where you are able to hold executive teams accountable. Asking questions like:
1. What is the plan to address the mental health of the workforce?
2. What are you doing to create sustainable behavioral health services that will close care gaps for the patients we serve?
3. What are we doing to address the highest priorities for our communities based on our CHNA?
As governance leaders prioritize mental health, we will see change; we will see improvement.
Chickey: Is there anything that we haven’t discussed that you’d like to share?
Waghray: Over 60 years ago, President John F. Kennedy addressed Congress on the topic of mental health. In his address, President Kennedy said patients with mental illness and disabilities “need no longer be alien to our affections or beyond the help of our communities.”
Unfortunately, 60 years later, we have not made the progress that we need, so I would urge our governing boards to really take this to heart and to please make behavioral health care a priority. If it’s not prioritized, it will not get done. Sometimes people can get overwhelmed by the magnitude of the problem. We can all start by taking small steps. If this conversation begins at the board level, I think we’re going to be in a very different place some years from now.
Rebecca Chickey (rchickey@aha.org) is senior director, behavioral health, at the American Hospital Association.
Please note that the views of interviewees do not always reflect the views of the AHA.