Innovations and Technology to Improve Medication Adherence Rates in Behavioral Health Patients

Barry Granek, LMHC, senior director at Coordinated Behavioral Care, reviews medication adherence rates among behavioral health patients, highlights how health care professionals can better ensure patients follow their treatment regimens, and discusses a digital health platform aimed at addressing adherence. 

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Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more.

Today, we are joined by Dr Barry Granek, licensed mental health counselor and senior director at Coordinated Behavioral Care. He reviews medication adherence rates among behavioral health patients, highlights how health care professionals can better ensure patients follow their treatment regimens, and discusses a digital health platform aimed at addressing adherence. Dr Granek?

Hi, Julie. Thank you for inviting me to be on the podcast today. It's first of all a pleasure and honor to be here. I'm Barry Granek, I'm a licensed mental health counselor stationed in New York. I currently work for Coordinated Behavioral Care, otherwise known as CBC. I'm a senior director for the Pathway Home Program.

I got my start down in Maryland. I started off with supported employment, where I worked for a few years with folks with severe mental illness, helping them find and keep employment. Moved to New York, worked for a while with the community treatment, and then came to CBC about a handful years ago to work with Pathway Home.

Today is all about medication adherence. Can you talk a little bit about medication adherence among the behavioral health patient community?

The service needs for those with behavioral health needs are quite complex and multifaceted. If I can take a step back a little bit and talk first about the needs of individuals as they transition from a psychiatric outpatient setting into the community, many don't actually have trusted providers that they can connect to following a discharge.

Many have issues with their social network or family. Some don't have stable housing. Others have food insecurity, they don't have clothing, or some of their basic needs being met. Our service delivery system often is disjointed and they operate independent of each other.

When folks transition from an inpatient setting to the community, it sometimes can be pretty hard accessing services. As a result, people can end up with symptom relapses and often back into the hospital. That's the full picture of individuals that are transitioning to the community. Then on top of all those complexities, they need to actually participate in treatment, including taking their medication.

It's often for a variety of reasons that people are unable to take medication or find themselves not taking their medication. If you think about if someone is trying to find food, or housing, or clothing, or they can't access good outpatient care, those all can be barriers and distractions from continuing to take medication.

For this population, we find that within the first year of leaving a hospital setting, 40% will stop taking their medication. When you look at two years post-hospital discharge, that becomes a startling 75% will stop taking medication.

In addition, many take their medications irregularly. Maybe they miss dosages, which also puts them at risk. What we unfortunately see is that following the hospital discharge, individuals may be likely to be readmitted. In fact, both statewide here in New York and nationwide, we see rates of 20% to 25% of readmission within 30 days. 90 days out, that jumps to an alarming 35%.

Something's not working in our health care system if we're seeing these poor outcomes. It's critical for us to be thinking about how to help among the spectrum of services, and in particular, today, we're going to be talking about medication.

It's important for us to think about, how do we help folks increase motivation, understand the benefits of taking medication as well as with building the skill sets and the habits to manage one’s medication regimen.

We obviously know that repercussions of low medication adherence lead to higher readmissions and poorer outcomes. How can health care professionals better ensure patients adhere to their treatment regimens?

If I may take a step back and talk about some of the work that we're doing at CBC so as to provide some context, CBC is a provider-led not-for-profit organization in New York. It's also an independent practice association, or an IPA.

We're made up of over 50 nonprofit community-based agencies that provide a variety of types of services from mental health, primary care, substance use services, also includes programs that address social determinants of health like food, employment, housing. We also operate one of the largest health care management programs in the state.

CBC created a program model called Pathway Home that is providing intensive care transition services to individuals with serious mental illness and high utilizers of psychiatric inpatient services. If I may talk a bit about the Pathway Home model since that's where I'll be coming from in terms of what we do at Pathway Home to address medication adherence.

Pathway Home is a care transition model. It helps facilitate care transitions and community integration after an individual's transition from a hospital setting back into the community.

The team and the program works to cultivate independent living skills and connections to community resources. It's a nine-month time-limited program. It's focused around specific health care tasks. For example, we have a team that will accompany individuals home upon leaving the hospital.

Staff will arrive before the hospital discharge, sit with someone and ensure that they understand what their aftercare plan is, checking to see that includes follow up appointment medication, that they have a place to go to, that it's safe, that their needs are being met.

Will actually accompany someone back home. On the way, they may pick up the medication, ensure transportation is in order, ensure that they have access through keys or whatever they need to enter their home. Will, through an observational assessment, look to see if there's food and toiletries and if not, step in and fill that need.

Similarly, another health care task is accompanying to the initial day of health and physical health appointment. This is an opportunity for one staff to ensure that someone makes it to their appointment because there's often lots of things that can go wrong along the way.

When someone is trying to see their providers, anything from being turned away by the front desk because of some insurance issue or a scheduling issue, with Pathway Home, we're able to be present and problem solve and advocate as necessary to see the whole process through.

Once they're with the provider, they often introduce themselves. They're able to listen to any instructions the provider may have and subsequently follow through in the community to either provide education or hands-on skill-building. Another task is medication reconciliation by a nurse, which I'll be coming back to.

Being time limited also means that over the course of the Pathway Home program, as I said, it's nine months, individuals are gradually becoming more independent, and autonomous, and responsible for their own care.

Very important to the Pathway Home model is incorporating activities and teaching and education that will help the skills stick. When it comes to medication, specifically, that the individual will be able to take medication on their own.

Pathway Home is multidisciplinary. Teams are made up of mental health clinicians, nurses, peers, and care managers. Each bring their unique experiences and expertise and skill set.

The nurses are able to provide education around medical conditions, they make referrals to attending appointments, and they complete routine medication reconciliation following possible discharge, usually within the first couple of weeks.

That means reviewing the medications, ensuring that the member understands what they're taking, understands how to take it, that there's a system in place for them to follow their medication regimen.

Our peers play an important role in that. Peers are individuals with shared lived experience. They're able to talk with Pathway Home members around social, personal, and treatment issues.

Because they're individuals with lived experience, they're often able to do this in a way that, because it's coming from their own experience, they've lived through it, they know it from actually going through the steps, and so they often are able to engage members in a way through example.

We find that that actually quite effectively helps build motivation and understanding about the importance and the benefits someone may receive from taking their medication.

Our clinicians can provide the clinical perspective and clinical intervention. Then our care managers, they're doing hands-on skill-building. What's nice about the Pathway Home model, in particular, is that it's quite intense in the beginning. We're able to spend hours with people over multiple days each week for the first few months.

That allows our care managers and staff to do some hands-on skill-building. It can be anything from learning to cook, clean, and do laundry, travel training. Anything that supports someone's treatments.

When it comes to medication, through this intense program of hands-on skill-building, professionals with a variety of skill sets and expertise are able to, through a variety of interventions that are individualized, are able to help support individuals as they're entering the community after an inpatient stay.

Where do you see the future of care going as more digital health platforms get introduced to health systems and hospitals? How will this impact utilization as well as health care costs?

At Pathway Home, we've embraced new media and digital technologies to improve outcomes. Technology-assisted care allows for additional sets of tools that supplement and enhance the face-to-face and engagement practices of the team.

At Pathway Home, we've started using technology-assisted care tools like texting, ride-sharing, and other mobile tools to help support treatment participation among those we serve. At CBC, we think it's important to remain relevant to the ever-changing world of technology. It's always been important to us to have a seat at the table so that we can have input into how the technologies are built and implemented and seek their direction.

CBC has utilized a variety of media and digital technologies with Pathway Home teams that support the wellbeing and community stability of our members. These are tools that address challenges like remembering to take medication, maintaining sobriety, loneliness, and engagement.

If I may, I can give some examples of different technologies, some of them that we've utilized. The first one, and it may seem very simple, though, we work with the Medicaid and low-income populations. What we were finding was that many were going home and they didn't even have a phone accessible to them.

Early on in the program, we provided members with smartphones so that we can remain in touch through video, and obviously, phone calls, texting, email. This proved to be a really meaningful way to communicate with individuals.

I, in particular, like the idea of video calls because it allows staff to observe, through the video, how a person's doing. They can look at facial expressions, or gestures, or look into the environment. Sometimes as an engagement tool, so if you see a basketball in someone's background, you can say, "Hey, do you play?" and engage in conversation that way.

Or if there's something concerning, it allows the team to then follow up and ask about it and assess whether someone's experiencing symptoms or having trouble in a specific area.

This proved hopeful at the beginning of COVID, by the way, because we were used to engaging individuals, our members, through video, and phone calls, and texting, and emails. When face-to-face encounters weren't possible, we just picked up where we had been already, which was engaging folks through the smartphones.

I will say that our staff began teaching members very early on how to use the phone. Some members who have been inpatient for many years didn't even know how to turn it on.

Sometimes it's very basic starting from the very beginning of how to use the technology. So we felt strongly that this is the world that we live in and so it's important for the members that we serve to know how to access and utilize this technology.

Another use of technology-assisted care is through Uber Health. This is a ride-sharing app, Uber, that has a platform specifically for health care providers. It's built for health care providers in mind, which is an add-on to what most people know about using Uber.

It's a way to ensure that transportation is never an issue with someone participating in their treatments and care. If there's a mobility issue, staff can utilize Uber to get someone to their appointment. If there is a public transportation issue, someone's running late, someone may have anxiety about using public transportation.

One of the services, Access-A-Ride or Medicaid Transportation, is still in the application process. Pathway Home can utilize Uber to temporarily help someone get to their appointments. Sometimes it's as simple as someone has a lot of belongings when they leave the hospital and not comfortable or maybe even not even possible to use public transportation with all their belongings.

It's often a nice engagement method for staff to say, "Why don't we hop in an Uber and we'll take you home this one time?" The members feel like someone cares and paid attention to them seeing that they had some trouble with using public trans.

We also use a mobile messaging application to communicate with Pathway Home members. This is a secure texting engagement platform. What it does is it sends out reminders regarding clinical goals like taking medication and appointments, and there are some texts around healthy living education that is geared towards specific diagnosis.

Someone with diabetes may receive texts directly to their phone that provide tips on how to eat healthy, for example. What was nice about this platform is that staff can even go in once a week on Monday morning and put in all their texts for the week if they know when the member's supposed to take medication or appointments and just schedule the texts.

They can either customize it, there's also a library that they can choose from. The library has a variety of different language that's used. On Monday, for example, if we're talking about taking medication and a pop-up that says, "Hey, don't forget to take your medication." On Tuesday, a different type of different language will come up so it gives that human feeling to the text messages.

We've utilized smart medication dispensing machines. These are machines that use audio and visual cues to remind people to take medication. By visual I mean a light may flash, and it's connected to a member’s smartphone if they have one.

What's also cool about this technology is that if someone doesn't dispense their medication, the machine knows, and you can set it up that it lets a family member or even a team nurse know that the medication wasn't dispensed. Then they can call the member and say, "Hey, I noticed you didn't take your medication. Everything OK?" so that they can intervene in real time.

Then the one I'm most excited about is Wellth. Wellth is a mobile app that combines behavioral economics and mobile technology to assist with keeping track of health habits and helps our members build lasting habits.

CBC has partnered with Wellth to offer this mobile app to the Pathway Home population. We just published some initial findings in a peer-reviewed journal, "Health and Technology," so listeners can check that out.

I'd love to talk to you about this technology because we are seeing significant success. We at Pathway Home are using it for two main habits. One is taking medication, and the second is with monitoring glucose levels for individuals with diabetes.

For those that may not be familiar with behavioral economics, this is a field of study that leverages psychology and economics to explain why everybody... we all make seemingly less optimal decisions regarding our health.

For example, I certainly have experienced where I say I'm going on a diet and then there's a yummy piece of cake in front of me and I can't help myself and find myself indulging. Or perhaps I say I’m going to exercise more and then find myself not necessarily going to the gym as much as I said I was going to.

Sometimes we have the full intention of engaging in certain health activities or stopping certain unhealthy behaviors, and we don't. What behavioral economics looks at is, in short, humans are irrational but in predictable ways.

There's this false assumption that if we only provide enough education to individuals that they would make better decisions, but that's a false assumption. We utilize the concepts of behavioral economics to build, or Wellth does, to build this technology to engage people in taking medication and monitoring their glucose levels.

Do you have any concluding thoughts summarizing everything we've talked about today? Anything you want to add to the conversation.

For us at CBC, we intend to continue to utilize new technologies to offer to either the Pathway Home members or other future programs. We believe technology can be a really transformative way of delivery of care.

I will say that none of the technologies that we use are ever meant to replace the face-to-face work. That's really critical. I see all these technologies as an enhancement and a supplement to the work that we're already doing.

Also say that some of the technologies that I talked about, in particular with medication management, they're certainly not meant to be coercive. We're talking about individuals that are probably motivated or interested, and have expressed this, in taking their medication, and so these are tools that we want to ensure that they have access to.

We know that there's many health disparities with low income and certain populations and communities. We want to make sure that by utilizing these technologies, we're ensuring that all populations have access to them. That's critical for us.

We hope to continue to engage digital health platforms and to try them out, and test them, and be part of the conversation.

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