Banner Health, based in Phoenix, is one of the largest nonprofit health systems in the U.S., serving more than eight million patients across six states in the Southwest. Like many hospitals and health systems, it has been facing many challenges with behavioral health.

THE PROBLEM

Behavioral health is an interesting story for several reasons, said Jeff Johnson, vice president of innovation and digital business at Banner Health.

"First, there is a large unmet need for this type of care that was accelerated by the pandemic," he explained. "Second, there is a lack of licensed clinical professionals in the markets we serve. In fact, Kaiser Foundation research shows Arizona having one of the lowest rates of access to behavioral health specialists in the entire country.

"Additionally, various studies have found that Phoenix, Arizona, suffered the largest growth in behavioral healthcare need of any major metropolitan area during the pandemic," he continued. "Together these factors created a large amount of demand for services that could not be met by traditional approaches of hiring additional clinical capacity."

This is where a digital therapeutic can step in to offer a novel solution, he added. Allowing the digital layer to be available to patients with mild and moderate depression and anxiety allows care teams to have a new type of tool to provide care in this population, he said.

"Diabetes has a more complicated and broad impact on the network," Johnson noted. "And frankly, we are still working to find the right fit for a digital therapeutic in the space. What we hope to get out of a digital therapeutic for diabetes is really more in staff and patient efficiencies. In the current, unmanaged state, we have diabetic patients taking their A1C readings in a variety of different ways.

"These range from on paper to Excel spreadsheets to smartphone apps and finally proprietary continuous glucose monitoring Bluetooth collecting software hardware instances," he continued. "This creates a fragmented experience for patients because, depending on how they collect this information, changes the dynamic they have with their care team."

And the care team must be able to absorb that information from the patient through any of those channels.

"This greatly reduces the amount of time patients and care teams have to focus on other health issues as they scramble to effectively share chronic care tracking data," he said. "Banner is targeting not just out-of-range patients for better A1C control, but also solving for the fragmented care experience, including the especially analog data capture methods that limit our patients and providers having a good snapshot of health that they can make decisions from."

Johnson and staff view a better and more integrated experience as critical in differentiating Banner care for the diabetic population.

"With that said, we are offering enhanced education pathways, about diabetes, in a similar release pattern to our digital therapeutic," he explained. "Additionally, we do notify specific types of patients of digital diabetic care tools available to them through their insurance benefits at the time of scheduling visits to help pair up benefits to those who would get the most value out of point solution benefit."

PROPOSAL

Banner prides itself on doing in-depth evaluations of technology product features and capabilities before it begins to use them.

"Internally we attempt to line up a business need with a clinical need, and then we seek to find a market solution that can meet those two needs," Johnson noted. "We generally use market insights to help narrow down the best-in-breed vendors, we put together an evaluation group, and then we do demos with that evaluation group and the products.

"Next we compare and contrast the strengths of those tools and make sure they can meet our business and clinical goals," he continued. "If those factors align, we then take the specific vendor product through a governance group. This is not dissimilar to a traditional P&T committee but for digital health tools. If that committee comes to an agreement that they feel comfortable using the tool, then we go about contracting and implementation."

Behavioral health fit that arc squarely where Banner had a business need for expanding capacity for care, and it had a compelling clinical need for that expansion helping to reduce overall population levels of anxiety and depression.

"These paired to a relatively mature marketplace that provided quite a few different products to meet our use case," Johnson said. "We specifically sought to decrease the number of patients having unmet need for mild/moderate anxiety and depression treatment, giving our care teams a new tool to help in their care of patients, and finally to reduce some of the burden on traditional behavioral health teams to focus more on higher-need patients.

"And, to reiterate, all of this needed to be accomplished in an environment where there was neither the capability or the resources to hire up on the FTE front," he added.

MEETING THE CHALLENGE

Banner looked at digital therapeutics as a way to use software to address the capacity demands for behavioral health. It also wanted to choose a pure digital therapeutic that had the software, itself, doing the work.

"There are many 'digitally enhanced referral' platforms out there that are a way of switching patients over to telehealth care wrapped around a digital platform," Johnson explained. "That is an approach, but we didn’t want to dilute the clinical experience, for patients, with external care teams. And we wanted to use the software 'at the top of its license,' so to speak, by pairing it up to the proper type of patient.

"Banner currently uses SilverCloud, an Amwell product, that is delivered to patients directly from our Oracle/Cerner workflows through a third-party distribution tool called Xealth," he continued. "This tool is distributed to care teams based on their security role in the Oracle/Cerner system. In the ambulatory setting, most of our end users have access to this distribution tool."

Banner allowed its care teams to have broad discretion on who would use the digital therapeutic products. However, the clinical champions helped with the crafting of guidance on what types of patients would fit within the technology use guidance. Banner views this like Rx indications.

"We then piloted our approach with some of our combined specialty care clinics in Tucson, Arizona," Johnson said. "These sites had training and support of the university chair for psychiatry and psychology who was also our physician champion. Together our teams created training materials, handouts and even a YouTube video series with recommendations on using the tool.

"Additionally, the team would circulate metrics on enrollments, orders and patients monthly to help keep care teams engaged in the process," he continued.

RESULTS

Reduction in both generalized anxiety disorder and patient health questionnaire scores have been observed from patients who have used SilverCloud. Additionally, Banner has noted long duration of use of the product (over two hours per patient who enrolls).

"We hover right around 40% order-to-enrollment rate, as well," Johnson reported. "Additionally, we are in the process of doing an analysis of if patients that used digital therapeutics were less likely to seek other care or decreased drug spend (SSRIs) to find a hard value ROI on cost containment. We are trying to model that approach in a similar way that the National Health Service used Sleepio as their first-in-line solution for insomnia."

ADVICE FOR OTHERS

"An orchestration layer, or a way to put these types of orders into the care team’s workflows, is critical," Johnson advised. "This is why we partnered with Xealth. We know that patients are far more likely to use a tool or product if it comes from their doctor than anywhere else in the network.

"Governance is also a critical piece of the puzzle," he continued. "There are many 'shining objects' that teams can go chasing that may seem like good digital therapeutics to use. However, it is crucial to have the organization lined up on which ones are useful and why."

Finally, clearly defined success metrics and the ability to easily capture that data is necessary, he said.

"A lot of the difficulty in measuring the value of digital health tools comes down to attribution," Johnson concluded. "Are the outcomes you’re seeing because of the digital therapeutic intervention? Or despite the digital therapeutic intervention? Making sure you have strongly defined experimental boundaries and data capture techniques goes a long way to helping you capture that value."

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