As health systems strive to establish higher quality care for more patients at lower cost, group treatment offers a solution. Catholic Health Partners, a large Midwest health system, has developed a systemwide initiative to provide evidence-based group treatment. While the initial focus has been in behavioral health acute and partial hospitalization settings, Catholic Health Partners has plans to train practitioners to work within primary care practices and to provide effective shared medical appointments.
Some Important Facts
In the United States, adequate cost-effective treatment for those suffering from mental illness is sorely lacking. This is especially disturbing when the uninsured and underinsured are in need of treatment. According to the Substance Abuse and Mental Health Services Administration, one in 20 Americans suffers from serious mental illness — that's 17 million people. This number is much higher if we include the full range of mental illness affecting people today.
The Bureau of Labor Statistics estimated in 2010 that access to mental health professionals is worse than for other types of doctors: 89.3 million Americans live in federally designated Mental Health Professional Shortage Areas while 55.3 million live in primary care shortage areas. Mentally ill people in crisis often end up in emergency departments, escalating costs and demands on practitioners who are often poorly equipped to deal with severely mentally ill patients.
Recent comprehensive research conducted by Gary M. Burlingame, Bernhard Strauss and Anthony S. Joyce supports what many group psychotherapists have long known: Groups are a powerful treatment for most disorders. The researchers acknowledge that while there are some disorders for which individual psychotherapy may be more promising (e.g., specific trauma-related disorders), for the majority, individual and group psychotherapy generally produced equivalent treatment outcomes.
Addressing the Challenge
Catholic Health Partners has taken four steps toward helping the mentally ill through group therapy: training group practitioners; encouraging insurers to reimburse for group treatment; providing data that prove group therapy works; and spreading the word.
Training group practitioners.Like many health providers, Catholic Health Partners lacked trained, certified group practitioners to implement an intensive, group-based treatment model. Given the dearth of group clinicians, it became critical to develop a training model that would prepare as many clinicians as possible in a short time.
Catholic Health Partners used the American Group Psychotherapy Association to train and certify group clinicians. All master's level (or higher) clinicians who would be conducting group treatment attended an intensive three-day training during which they participated in the required 12-hour group therapy course and examination. They also practiced leading a specific form of short-term therapy with a constantly changing and heterogeneous group of patients in the acute setting.
To lower costs for future staff members preparing for certification, Catholic Health Partners videotaped the training course and made it available on the system's intranet. It provided each acute care site with an iPad so clinicians can transmit group therapy sessions to the supervisor for live consultation.
Therapists participating from across the system's seven regions conduct group supervision weekly. Using the iPad, they have face-to-face encounters in which they view and critique one another's work and gain insights from the certified group psychotherapist who is supervising.
Catholic Health Partners developed a standard daily schedule and follows it across all acute behavioral health facilities. It is developing a similar standard daily schedule for partial hospitalization and intensive outpatient programs. The schedule allows therapists in various sites to observe one another's work and have set times for peer consultation. It also allows therapists reflective space to evaluate their work and to feel comfortable being transparent with colleagues.
Drawing further on the therapists' expertise and best practices, Catholic Health Partners is developing a standardized manual for psycho-education groups. Face-to-face meetings through the iPads eliminate the time spent commuting to various sites. They also create a learning community that supports practitioners as they work in a demanding and challenging environment.
Work toward reimbursement of group treatment.It would seem logical, given research findings about the efficacy of group treatment, that third-party payers would see value in reimbursement schedules that cover group treatments. Sadly, this is all too often not the case. As a result, many practitioners in behavioral health disciplines have had limited training in group treatment and have opted instead to base their practices on reimbursable and more costly individual psychotherapy.
Given the growing needs of the population for mental health care and the clear cost-effectiveness and treatment efficacy of group therapy, it is more important than ever to train practitioners in group treatment and to work with payers to cover group psychotherapy in health insurance plans.
Prove the point through metrics. To help convince public and private insurers to fund group treatments, Catholic Health Partners is collecting Press Ganey Patient Satisfaction measures and the Lambert OQ-30.2 treatment outcome measure. Scores gathered from the pre-group program serve as a base. Additionally, it has initiated two measures of job satisfaction and pre- and post-group program intensification: the Gallup Survey and the Maslach Burnout Inventory for mental health workers.
Both groups of stakeholders — patients and clinicians — have made numerous comments expressing how much they appreciate the opportunity to engage in meaningful treatment. Patients note that they have been able to talk about their struggles, discover that they are not alone and receive the support they need. Experiencing the universality of their condition, along with altruism, hope and cohesiveness, is palpable for these patients.
Clinicians commented that they were finally able to engage in the work they were trained to do, that administrative leaders were making it possible for them to deliver the kind of care that led them to enter the field initially, and that they felt as though they were valued as clinicians and not simply as custodial care providers.
Spread the news. Moving beyond acute care and partial hospitalization programs, Catholic Health Partners is making further inroads toward improving the behavioral dimension of population health. Behavioral health clinicians are becoming collaborators in primary care physician practices across the health care organization. Providing group treatment richly enhances the health of our communities.
Group therapists provide leadership in facilitating shared medical appointments and wellness groups directed toward smoking cessation, health management, weight management, grief support, mild depressive conditions and many more topics. Catholic Health Partners is investigating measures that will provide treatment outcome information for these groups.
Power of the Group
Despite barriers, it is indeed possible to train practitioners and implement high-quality group treatment programs across a large geographic area. As a larger cadre of practitioners becomes available, significant cost savings will be realized: Greater numbers of patients will be treated by fewer but highly trained mid-level practitioners in acute and ambulatory settings. The journey toward population health through group intervention can begin with a healthy dose of creativity and with the commitment and passion of clinicians who believe in the incredible power of the group to heal.
Donna J. Markham, Ph.D., A.B.P.P., is the vice president of behavioral health services at Catholic Health Partners, Cincinnati.