As I replay my experiences from the recent CFHA Conference in Houston, two primary themes emerged as key take-home messages. The first, voiced by Executive Director Neftali Serrano in his eloquent plenary address, highlighted the central role of relationships and connections to the organization as exemplified by the mantra (paraphrasing) ‘don’t be afraid to gently accost people in the hallway for an introduction, question or conversation’. The second message—crucial to the continued evolution of Integrated Care—was crystal clear: as passionate advocates for Integrated Care, we as a community are tasked with providing the empirical evidence to support its continued development. While the call was clearly heard at CFHA to unleash our members formidable research apparati and implementation science colleagues, we might be well served to not forget the humblest symbol of Integrated Care—the warm handoff (WHO).
The WHO has long been a key element of Integrated Care and most notably of the Primary Care Behavioral Health (PCBH) Model. Its simplicity and power in affording patients and providers instant access to behavioral health services is, as one primary care doctor expressed to me, “intoxicating”, particularly when compared to the Lord of the Rings-like travails required for a successful referral to outpatient treatment. It is the rare provider that speaks ill of the WHO experience with the wealth of anecdotal evidence supporting its benefits. It is typically a win all-around. But do we have empirical evidence to support this important element of PCBH?
Like the kids say, “Not so much.”
The concern about the empirical base for the WHO was raised in this very blog in a compelling post by Elizabeth Horevitz in 20111. She noted at that time that “the warm hand-off has never been rigorously tested. We have no proof of its effectiveness in enhancing follow-up to behavioral health treatment.” She cited her own research which she later published2 suggesting that in her population of English speaking depressed Latinos, the WHO was associated with four times less likelihood of attending a follow-up session with the BHC. The trust and rapport associated with the WHO3 was affected by factors including the patient’s primary language and the quality of the referral process and therapeutic relationship. Clinicians responding to Horevitz’s post, themselves cited their own local data with either a small or no impact of the WHO on follow-up treatment.
Since then, there have been few studies to further the research base of the WHO. For one, Van Houten and Johnson4 reported an impressively high return rate—80%-- for the WHO as compared to 40% with less direct referrals, suggesting some impact on reinforcing patients’ connection with behavioral health services. But aside from anecdotal reports, there is not much more in our literature. Of course, as a part of collaborative care studies, the warm handoff is one of the elements that allows for facilitating the management of patients’ behavioral health concerns in primary care5.
This came as a surprise to me as a psychologist who is relatively new to the integrated care world and someone who had transitioned from outpatient specialty care. Everything about the WHO make sense, for the primary care providers, for the patients and for us. While there are many variations on the WHO, the essence of the initial contact is the immediate connection between the provider, patient and behavioral health expert, connecting them as a treatment team at the most optimal moment to respond to their needs6 . Considering that the term is borrowed from the customer service world, it is a fitting referent to the reaction often reflected in anecdotes of satisfied ‘customers’.
But what should we expect of the WHO? Certainly, the one-two punch of patient and provider satisfaction has helped many practices and organizations establish an initial foothold for the development of Integrated services. In our organization, one internally grant-funded BHC position that introduced the WHO was the springboard for a systemwide transformation, based on compelling satisfaction data. More than 90% of patents reported that they would not seek behavioral health care outside the practice as a result of this innovation. Beyond satisfaction, we also have seen the importance of using the WHO as a measure of utilization, engagement by Integrated Care teams. Shelley Hosterman and Monika Parikh from Geisinger presented data in Houston on the functioning of their BHC team across multiple practices5. They not only tracked the frequency of WHOs across clinicians and practices, but also the use of WHOs by hour during the day, day of the week and season of the year, allowing them to understand and adroitly address the changing demands.
So, at this moment in our Integrated Care evolution, we have developed some important elements that have guided our work on the WHO. We have established that our customers—patients and providers are incredibly satisfied with this humble tool. Once introduced, it is hard to imagine one’s practice without it. We have also seen, as exemplified by our colleagues at Geisinger, how data about the WHO can improve efficiency and the process of care. Elizabeth Horevitz’s research challenges us to look beyond (or behind) the shiny headlines, as not everyone seems to respond in the same fashion to the WHO. We are still looking for the answers to many questions. For example, while we are aware of the broad outlines to the WHO how might variations in their implementation—time spent, level of therapeutic communication/intervention, quality of the working alliance—impact outcomes? Is care improved with more or less education provided or more or less intervention provided? Do WHOs which lead to internal versus external follow-ups impact show rates or outcomes differentially? And what patient factors, aside from those discussed above contribute to a successful WHO and improved care? With these questions, among others, we have our work ahead of us.
Alan L. Schwartz, PsyD
Behavioral Health Consultant/Psychologist
Family Medicine Center-Foulk Road
Christiana Care Health System
1Horevitz, E. (2011, December 22). Integrate this: Evidence-based practice in integrated primary care. Retrieved from http://www.cfhs.net/blogspot/689173/136267/integrate-This-Evidence-Based-Practice-In-Integrated-Primary-Care
2Horevitz, E., Organista, K.C., Arean, P.A. (2015). Depression treatment uptake in integrated primary care: How a “warm handoff” and other factors affect decision making by Latinos. Psychiatric Services, 66(8), 824-830.
3Integrated Behavioral Health Partners. (n.d.). Accessing the behavioral health counselor. Retrieved From http://www.ibhpartners.org/get-started/procedures/accessing-the-behavioral-health-counselor/
4Van Houten, P. and Johnson, M. (n.d.) Integrating behavioral health in primary care settings.
5Serrano, N. and Monden, K. (2011). The effect of behavioral health consultation on the care of depression by primary care clinicians. WMJ, 100(3), 113-118.
6Strosahl, K. (2001). The integration of primary care and behavioral health: Type II changes in the era of managed care. In N. A. Cummings, W. O'Donohue, S. C. Hayes, & V. Follette (Eds.), Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice (pp. 45-69).
7Hosterman, S.J. and Parinkh, M. (2017, October). It’s all in the handshake: Patterns and outcomes from warm handoffs in integrated pediatric clinics. Presentation at the 19th Annual CFHA Conference, Houston, TX.
I’m so glad Dr. Schwartz has taken the time to reinvigorate the conversation about the efficacy of the warm handoff, and the need, in general, to expand our evidence base for such IBH-specific practices. Since I published my study, I’ve been asked to give many presentations about the effectiveness of the WHO as a patient engagement strategy to various health care organizations, and the response from practitioners has been extremely interesting. Specifically, in spite of mounting evidence showing that the WHO may not be an effective patient engagement strategy for Latinos (and may have the opposite of its intended effect among English-speaking Latinos), I inevitably get multiple comments from IBH practitioners about how wonderful it is, and how it just feels like the right thing to do.
However, we have yet to establish which components are effective for which intended outcome (is the goal provider satisfaction? Patient satisfaction? Engagement? Clinical intervention?). Like any clinical activity, a warm handoff is both an art & a science, and if we are to devote significant clinical time to it, it is imperative that we move beyond doing things that “seem” like the right thing to do when the published data shows them to be ineffective at best, and detrimental at worst.
Until we understand the effective components better (who, what, when, where, why?), I am using the evidence we do have to inform my practice. For example, at my clinic, we save the warm handoff for crisis intervention, rather than prioritize it as an engagement strategy. When my clinicians have no-shows, we happily fill the slots with warm handoffs for purposes of initial assessment/intervention, but I have asked that our PCP colleagues not interrupt an active session simply as a means of patient engagement, given the lack of evidence to support such a practice.
For purposes of patient engagement, perhaps a better use of time would be to use the warm handoff address specific patient barriers to care—time, money, transportation, stigma… I urge all of us to move in the direction of implementing practices backed by effectiveness research. And, for those of us in the practice world, we can start by making use of our QI departments to help with the initial steps of testing some simple changes on-the-ground in a rigorous way to point us in new and improved directions.
Elizabeth Horevitz, LCSW, PhD
Director of Behavioral Health
Marin Community Clinics
UC Berkeley, School of Social Welfare
Thank you to Dr. Schwartz for his timely commentary highlighting the limited empirical evidence on outcomes from WHO activity. It is crucial that CFHA members continue to lay down the “research gauntlet” in this way so we can continue to partner in advancing the evidence for integrated care models and key components. The 2017 CFHA presentation was our Geisinger team’s first attempt to examine WHO data in a systematic way. I was surprised that even this first, very simple review of the data carried some clear operational and clinical implications for our team. We consider WHO activity an important and powerful part of the model. Although we believe this is the case and “feel” this is an important part of our model, our group has yet to generate evidence to support this assumption. Our group has several projects in progress designed to answer some core questions posed by Dr. Schwartz. Specifically, we are conducting a study of three years of clinical data that will examine access and utilization variables across integrated care clinics and the traditional outpatient therapy clinic within our system. That study will examine influence of clinic type (integrated or traditional), wait time, WHO, and distance to services on outcome of first schedule visit. We look forward to sharing those results with the broader community and to watching how other programs and investigators approach this research challenge. Generating empirical evidence for WHO outcomes will be an important piece of the puzzle in our case for value-based payment models. We are anxious to see how the story emerges from our data.
Shelley J Hosterman, PhD