Thinking Outside the Visit: Digitally Extending the Reach of Behavioral Health

Abstract

O ver 50 % of premature morbidity and mortality is attributable to behavioral causes, and by 2020, behavioral health disorders will surpass physical diseases as the main cause of disability worldwide. [1][2][3] Chemical addictions are particularly problematic, with tobacco smoking alone accounting for over 400,000 preventable deaths per year in the United States. 4 Hazardous alcohol consumption is the third leading behavioral cause of death, and costs over $230 billion annually. 1,2 Obesity has reached epidemic rates, with associated morbidity and mortality from diabetes, cardiovascular disease, and other illnesses. The consequences of a medication-only approach to chronic pain are being acutely felt, as the health care system struggles to respond to an emerging opioid crisis.Primary care clinics offer the ideal setting for identifying and intervening with patients who engage in behaviors that harm their health. Patients can be screened and identified in the early stages of an emerging problem and counseled to change and/or referred to specialty care. 5 Conversations about physical activity, nutrition, fitness, and non-pharmacological pain management can be started in primary care, and patients can be prepared to accept referrals to behavioral health providers.Although effective behavioral counseling strategies have been validated for use in primary care, most busy practices simply do not have the resources or skill sets to deliver behavior change counseling. Commonly cited obstacles include competing demands on provider time, competing patient medical comorbidities, lack of staff, insufficient resources (including billing reimbursements), and lack of provider skill or confidence. When behavioral counseling is attempted, it is often done in an uncoordinated, non-longitudinal way that leaves patients feeling unsupported and unsatisfied. Consequently, the self-help industry is flourishing, resulting in a proliferation of non-evidence-based tools, where patients attempt to change their behaviors on their own without the benefit of a medical professional who may better understand the health implications of their behavior and could better tailor interventions to the patient's preferences and needs.The emerging healthcare climate affords an unprecedented opportunity to address substance use and other behavioral health issues in innovative, efficient, and effective ways. The Affordable Care Act (ACA) and accreditation standards for patient-centered medical homes (PCMH) reflect the importance and value now placed on preventive and integrated behavioral health interventions. Team-based practice models have expanded the range of providers who are able to deliver these services, while increasing the need for tools to coordinate care. Patient empowerment and chronic disease management approaches highlight the importance of creating service delivery models and treatment tools that include the patient and are tailored to his/her social context. Given this climate, and the unmet clinical need, the time is ripe for innovative d...

How Notifications Affect Engagement With a Behavior Change App: Results From a Micro-Randomized Trial

“…A promising solution is behavior change apps, as these are complex interventions that can capture dynamic patterns in human behavior and deliver support when an individual needs this the most [ 7 - 9 ]. Building on evidence that supports SMS text messaging as interventions to help individuals [ 10 ], behavior change apps can provide comprehensive, everyday support within people’s homes and diverse communities to maintain healthy behaviors [ 11 ]. However, a major concern is that insufficient engagement with an app is likely to hinder behavior change, particularly if a user disengages with the app soon after downloading it [ 12 , 13 ].…”