An overused phrase during the COVID-19 pandemic has been the “new normal.” People feel obliged to predict what will be permanently changed by it. This sport has spawned some serious efforts. Respected medical quality leader Dr. Don Berwick recently entered this discussion by identifying six properties of general medical care that are likely to change.
He nominated tempo, standards, working conditions, proximity, preparedness and equity as the properties of healthcare most likely to go through some lasting changes because of the pandemic experience. His first area, tempo or speed of learning, intrigues me most. The idea is that we should no longer accept the protracted timeframe for innovations to reach scale.
If we are finding a new sense of urgency, then determining priorities for change is the most pressing step. I would nominate three areas for changing behavioral healthcare. They rise to the top because we already know enough about them to push forward immediately with broad implementation plans. I would prioritize digital health services, peer counseling and evidence-based clinicians.
Digital health services and peer counseling
Since priority lists of this sort will surely proliferate, let me acknowledge that digital services will be near the top of everyone’s list. Let me also emphasize that I do not see this as a solo entry to the list, at least not in behavioral healthcare. I have been fortunate enough to work with a few digital health companies in the past several years, and “the magic” happens when digital and human elements are combined.
The evidence supporting both the need and value of digital services is overwhelming, and yet we still have limited adoption to date. For example, the value of digital interactive modules emulating a cognitive behavioral therapy (CBT) session has been proven in dozens of good studies. Each proprietary product selling on the market today has similarly proven its value empirically. Why the delay?
Berwick notes the often-cited study that the average cycle time for proven, favorable innovations to reach scale is 17 years. Whatever the number and however it might be explained, this is a business failure. It is not a failure of science. If the pandemic creates a sense of urgency that breaks through this inertia, then every business leader should ride this momentum.
The science is far less robust for peer counseling since this is not being developed widely yet as a proprietary product. However, a relevant area of research relates to how various professional therapists compare in the clinical outcomes they achieve. This empirical finding, the absence of a clear advantage based on training or degree, leads to the inference that trained non-professionals can be effective.
The other relevant question is the availability of people interested in working as peer counselors. This inquiry is illuminated by the history of peers providing valuable assistance to those with serious mental illness. This relies on the well-established practice of recruiting people who have successfully managed their own illness and training them as counselors. This is a good guide.
Similar results are likely to be found with peers broadly. Many caretakers, survivors of difficult childhoods, and people who enjoy communicating are likely to volunteer. They will gladly complete required training. Recruitment will likely produce people of both sexes, all ethnicities, and from diverse backgrounds. They will feel privileged to provide support for the millions of people needing it.
It is important that we accumulate studies validating peer counseling, and yet the preferred way to implement these services is in combination with digital health. Why? Digital health services and peer counseling potentiate one another. This is the unpublished finding of new companies operating today. This combination should become best practice and broadly implemented in diverse healthcare settings.
The way in which these services are complementary should be noted. Digital services rely on empirically supported therapy techniques like CBT, mindfulness and relapse prevention. Peer counseling relies on the unique abilities of individuals to be comforting, motivating and therapeutic. Studies will likely demonstrate the combined effect. Unpublished data find that peer support doubles digital results.
Subjective experience is foundational for our field. Yet subjective evaluation of our work has long obscured its value. We can change that. We do not differentiate the value of medicines or psychosocial treatments based on beliefs. We evaluate evidence. We should start sorting providers of care by results. Objective measures can do this fairly by aggregating outcomes for all patients treated.
Many professionals assume the term “evidence-based clinicians” refers to clinicians who use treatments with empirical evidence. This is not the intended reference. The provider of care is a critical part of any care process, and the missing evidence today relates to the effectiveness of the clinician providing care. We can solve this easily since all the measurement and statistical tools are available.
Rating behavioral healthcare clinicians is important for three reasons: 1) identification of outliers; 2) quality assurance to maintain public trust; 3) consistency of norms in our healthcare system. The good news is that a very small percentage of clinicians generally emerge as outliers with results significantly below average. We warrant public trust, and we can demonstrate a measurement culture in our field.
We must evaluate clinicians in our field because our results, especially for psychosocial services like therapy, depend to a large extent on the clinician providing the service. This is unique. Results of physical medicine rely on use of the right pill or procedure, although some get slightly better results based on interpersonal skills. Therapy is a much more personal intervention. Results vary by clinician.
The consistency of empirical norms in our field is especially important if we follow the path of using peer counselors. One of the essential methods for monitoring peers would be to evaluate their clinical outcomes. There is no basis for having this standard apply for peers alone. Results for every digital and personal intervention should include monitoring of clinical progress.
The reality is that our field has not fully achieved public trust. Using a routine process for establishing evidence-based clinicians would inspire more trust. When we move beyond the implicit claim that any licensed clinician is as good as another, the public will take notice. When we assure people that every clinician and peer counselor is scrutinized for their outcomes, confidence in our field will grow.
The new normal envisioned here broadly increases access to services through new modalities. These new capabilities can at the same time bring treatment results to light in a way the public understands. The global pandemic can be remembered as the time we decided to reach more people. Let us quickly leverage known solutions so that, at last, we scale our field to meet enormous need. We can do it.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.