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Redesigning Behavioral Health Systems with Allie Friesen of AF Impact · Becker's Healthcare Behavioral Health

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  This is Laura Dierda with the Becker's Healthcare
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  podcast. I'm thrilled today to be joined by
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  Ali Friesen, founder and principal at AF Impact.
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  Ali, it's a pleasure to have you on
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  the podcast today.
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  Thank you so much, Laura. It's great to
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  be here.
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  Absolutely. Now I know that you have spent
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  time as a clinician, a health system leader,
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  as a public servant, and so I'm excited
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  to dig into,
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  our conversation here. I know we talked about
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  behavioral health and a good amount that goes
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  into that,
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  industry because it's such an important topic always,
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  but especially right now. So excited for our
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  conversation. But before we dig in, can you
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  tell us just a little bit more about
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  yourself and your background?
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  Yeah. Absolutely.
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  So I started as a clinician and never
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  in a million years thought I would want
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  to be in leadership. And, you know, that's
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  comical to look back on now.
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  But I loved my time as a clinician
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  deeply, and I kept asking the question why,
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  as likely many of your listeners can empathize
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  with of, well, why do we why have
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  we always done it this way, or why
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  can't we approach our patient care differently in,
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  you know, x, y, or z ways? And
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  that,
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  landed me in a service line position over
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  behavioral health for Oklahoma's largest not for profit
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  health system,
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  which is a multisite health system here in
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  Oklahoma,
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  where I'm from. So that was an incredible
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  experience, but as, again, many of your listeners
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  can likely relate to, going from a full
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  time clinician to a full time leader was
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  a big learning curve,
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  but it was wonderful and gave me exposure
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  to a lot of realities that impact the
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  frontline clinicians and impact ultimately the outcomes that,
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  most of our hospital administrators,
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  care about and and really wanna see.
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  And then after my time in the private
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  sector, I transitioned into a state level system
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  leadership role over the public mental health organization,
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  and that progression gave me a lot of
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  visibility into how care operations
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  and governance interact and where there's opportunity for
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  improvement, where we kind of have consistent fracture
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  points.
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  Absolutely. I think all of that is so
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  important and critical,
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  especially given, you know, where we're at today
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  in the health system space.
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  So I'm I'm curious. How has,
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  the progression of your career shaped how you
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  see today's behavioral health challenges?
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  Yeah. So,
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  again, there's there's a lot that we could
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  say here. There's,
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  a whole list we could spend the time
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  together going through just a list of all
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  of the challenges that we've come up against.
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  But what became really, really clear and kind
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  of encompasses all of those challenges is that
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  behavioral health lacks clear ownership
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  of how it functions end to end under
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  stress. So we regulate behavioral health. We fund
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  it, but no one is responsible for designing
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  how the whole system works together.
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  And what might be a little untraditional today
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  is I'm gonna challenge probably most of your
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  listeners in thinking at kind of a more
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  macro scale, thinking across sectors, and that's what
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  my brain has been forced to do going
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  from private to public. And now through AF
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  Impacts, looking at how those sectors really can
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  better function together and how we can work
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  toward alignment,
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  because there's this kind of palpable frustration
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  of,
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  you know, a disproportionate
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  response in terms of outcomes with the amount
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  of investment in everything from money to time
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  and resources that's been put into
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  making a systemic impact. So when you see
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  the same breakdowns
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  that,
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  that I've observed from the clinical level to
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  the enterprise level to the state level,
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  you start to realize ask after asking yourself
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  a lot of questions that
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  you realize it's not effort. It's not a
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  we're not trying hard enough problem. It's a
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  structural problem.
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  Got it. Absolutely. You know, and I think
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  that's a point well taken because
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  I I know across the board, trying to
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  figure out how to integrate behavioral health and
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  have more of a holistic approach,
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  has been very challenging for organizations, whether it's
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  hospitals and health systems or community organizations and
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  more. And so looking at all of those
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  things, is critical.
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  I'm curious, what are some of the big
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  headwinds, behavioral health providers are facing today, and
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  which of those are structural compared to the
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  financial or workforce related as we've been talking
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  about?
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  Yeah. So
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  the the workforce shortages, I wanna be clear
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  and wanna empathize with all of our our
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  leaders and frontline clinicians that are feeling the
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  impact of the shortages
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  and really the reimbursement pressure because those things
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  are very, very real.
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  But those are
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  symptoms.
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  They're not the root cause. Right? So
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  in many community and safety net behavioral health
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  settings, so think more kind of nonprofit and
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  public settings,
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  you have annual turnover for your workforce frequently
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  exceeding 25 to 30%,
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  if not more in some settings.
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  And so that rising labor and operating costs,
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  which is, you know, sector agnostic, you're gonna
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  see that everywhere,
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  those have outpaced the reimbursement
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  growth. So that combination, I mean, is a
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  hospital administrator's worst nightmare. That makes stability
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  extremely difficult to obtain.
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  So you have these symptoms, and
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  it's no fault,
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  of one entity, but you're trying to solve
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  for these issues that are constantly impacting your
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  bottom line and your ability to recruit and
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  retain.
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  But the deeper issue is that these this
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  churn and economic strain is occurring inside a
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  system where that responsibility
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  is so fragmented and the flow isn't clearly
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  owned. And so you have providers that are
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  being asked to carry accountability for outcomes
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  inside structures that they don't control. So
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  put another way, you have really well intended
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  leaders over their units or departments or facilities
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  that are doing everything they can to move
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  the needle to meet those key performance indicators,
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  and they can't get there because there's so
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  many variables that are outside of their control
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  impacting
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  how far they're going to be able to
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  move the needle.
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  So I alluded to this a little bit
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  earlier, but we've invested
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  more public dollars, private dollars, philanthropic
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  dollars. There's been more innovation in behavioral health
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  than at any point in history that I'm
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  aware of, which is great, but we're
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  seeing still
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  emergency department boarding through the roof, public psych
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  facilities that are destabilizing,
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  private psychiatric facilities that are closing,
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  and you still see these high acuity patients
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  that are coming through and cycling through in
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  crisis. So you have this weird conundrum where
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  every part of the system is doing its
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  job and is accountable for something, but the
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  system is still failing as a whole.
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  And that, again, tells us that we have
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  a design problem, that no one is accountable
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  for
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  how things are functioning as a whole. It
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  kinda left leaves everybody kind of,
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  you know, just scratching their head of, well,
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  what else could we possibly do?
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  Absolutely. I think you see that playing out
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  in,
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  hospitals, DDs
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  across the country. And so to see
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  and kind of put that into, more of
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  a perspective or a global perspective is really
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  helpful. And, you know, and speaking of some
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  of that integration, hospitals talk a lot about
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  integrating behavioral health into that broader care. Where
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  are you seeing,
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  that work in practice, and where is it
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  tending to break down?
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  Yeah. So integration
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  is is one of those buzzwords that I
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  think people interpret differently differently based off of
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  their own personal experiences.
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  Right? So
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  to to me, it can mean a lot
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  of different things, but for the sake of
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  this conversation,
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  I I'm gonna apply it more in where
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  the integration opportunity exists within your health system,
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  based off of, like, the normal, behavioral health
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  patients that you're encountering. So you see progress,
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  and we are seeing progress where there's that
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  shared ownership. So shared ownership in things like
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  crisis response,
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  inpatient capacity, discharge pathways,
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  Where you see breakdowns in integration,
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  and
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  I highly anticipate this will resonate with many,
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  is at those care transitions. So
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  crisis to inpatient care, inpatient to community based
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  services,
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  transitioning from medical discharge to behavioral health. So
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  those
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  seams that
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  intersect across organizations,
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  even different facilities within one system,
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  different funding streams, different payers, even different jurisdictional
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  boundaries when you get into some of our
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  forensically involved individuals.
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  And that's when things get really murky and
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  confusing,
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  and because no one owns those processes
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  end to end, and you feel like you
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  kind of have to let the bird out
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  of the nest at a certain point and
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  just hold your breath and hope for the
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  best. So this is why you can see
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  this phenomenon of excellent individual programs within your
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  system or even within your outpatient clinics,
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  and you still see patients boarding in the
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  emergency department for days or cycling through that
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  churn. And in many cases, my opinion is
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  that integration can become more of a concept
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  instead of an operational
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  reality.
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  So my encouragement
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  would be, which in behavioral health, we've struggled
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  with this for a while.
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  We're getting better. My encouragement would be to
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  really, really
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  articulate
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  specific terms
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  of success
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  for integration
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  as an operator, as your behavioral health subject
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  matter expert,
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  comes and sits down with you. Ideally, you
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  want to actually,
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  develop tangible goals for what success looks like
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  in your enterprise's version of integration.
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  That's really helpful to understand. And I think,
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  you know, having those tangible goals really goes
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  a long way,
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  in order to actually then achieving them.
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  I'm curious, you know, when you think about
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  those types of goals, where do you see
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  people, in leaders focusing in on? What is
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  a realistic goal that they can have if,
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  you know, to this point, they've been rather
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  fragmented in how they deal with behavioral health?
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  Yeah.
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  So I think probably
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  the best, most reasonable place to start depending
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  on on where you're at in your behavioral
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  health maturity
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  would be to start with the data and
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  look at where those highest risk individuals
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  are kind of leaking through your system.
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  And I don't mean leakage from a market
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  share standpoint. I mean, your safety and your
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  quality
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  risk. Where are they falling through the system?
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  Where are you getting that, you know, 5%,
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  10% that keeps coming back through your emergency
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  room? Where are your safety events,
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  the highest?
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  And digging into those events and trends and
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  patterns with your subject matter experts
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  and
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  looking at where's your biggest area of opportunity.
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  Right? So if that is your serious safety
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  events across your med psych unit, for example,
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  then that's where you start. If it's your,
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  discharge and return to the ER in thirty
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  days or less, start there,
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  because that's when you're gonna start closing the
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  seams, if you will, or capturing that opportunity
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  the fastest.
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  And if you can do that in a
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  way that's methodical
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  and that maps out where
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  you're you're kind of fracturing in the process
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  that's gonna allow you to fix, hopefully,
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  potential root cause of a lot of your
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  problems.
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  Thank you for digging a bit deeper there.
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  It makes a ton of sense, and it's
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  helpful perspective.
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  Now I wanted to ask you a bit
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  about some of the policy,
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  in execution side of things as well. Looking
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  at some of the current policy environment, a
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  lot of uncertainty, what are some of the
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  changes or initiatives,
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  that carry the greatest
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  execution risk, and what would help them translate
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  into a better outcomes on the ground?
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  Yeah. So this might be, again, a different
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  or maybe untraditional
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  perspective,
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  but I've spent,
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  quite a bit of time reflecting on this
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  after my experience in the private sector and
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  public sector, seeing what both sides do well,
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  and where we have opportunity for improvement.
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  And
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  it's
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  been sitting with me for a while that
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  the execution risk from a policy perspective,
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  it comes really from expanding the expectations
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  across public and private sector without redesigning the
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  system underneath them.
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  So, again, we regulate behavioral health. We fund
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  it. We enforce compliance. Meaning, if you mess
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  up, we're gonna come back on the other
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  side, and we're gonna make sure that that
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  issue is fixed. And all those things are
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  good,
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  but regulation
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  checks standards.
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  It doesn't
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  design stability.
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  So,
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  again, challenging us here, hopefully.
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  In other high risk sectors, which I would
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  argue behavioral health care is certainly a high
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  risk sector no matter how you slice it.
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  You have defined
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  architecture
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  layered responsibility
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  for system coherence. Right? You have
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  aviation that has the FAA. You have finance
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  that has the federal reserve. Nuclear energy has
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  centralized safety oversight.
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  You have entities that are designed to stress
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  test the system,
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  make sure that pieces of the puzzle are
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  in the position they need to be and
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  that everybody's clear on ownership. Right? Even acute
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  medicine has evolved with that layered infrastructure.
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  You have Medicare payment design. Think EMTALA stabilization
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  requirements. You have different regional trauma designation
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  systems.
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  Every health system has their own enterprise governance.
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  It's not perfect, but it's developed this kind
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  of
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  structural scaffolding, if you will, over decades.
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  So there are there's infrastructure
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  in place to understand
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  ownership across all of those work streams,
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  and behavioral health
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  is so unique
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  that we've expanded
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  rapidly
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  without comparable
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  architectural
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  development.
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  So
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  when policy expands access or mandate services, increases
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  funding, all of which can be good,
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  it often assumes that the systems
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  in which they're asking these things,
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  or telling these systems to do,
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  they're assuming these systems can absorb this complexity,
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  but we haven't clarified who owns the patient
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  flow, who has escalation authority
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  when capacity is constrained across public and private
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  settings, and how do we identify
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  failure before people get hurt? So
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  forgive the analogy. I'm an analogy person as
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  a former therapist, but without that clarity, it's
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  like you have
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  a house where you can see the next
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  floor where you need to go, but there's
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  no stairs. So the destination is clear.
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  The systems know what we need to be
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  doing,
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  but the pathway to get there isn't clear.
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  So even after these well intended policies are
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  in place, we end up reacting
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  after we collapse
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  instead of designing the systems to prevent failure
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  in the first place. And,
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  candidly, I think that this collapse is actually
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  much closer than we would all like to
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  think and
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  explains likely a lot of burden that our
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  hospital administrators are feeling around
• 15:48
  why isn't any of this working.
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  Absolutely. You know, what a great point and
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  definitely underscores the need for a more thoughtful,
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  and systematic
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  approach to dealing with behavioral health and certainly,
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  you know, wanting to make sure that you're
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  not putting yourself in a position where there
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  could be failures, where patients and others are
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  are in a position where they're getting hurt
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  or or or where there's not the right
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  type of care in place. And so,
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  having that more of a proactive mindset,
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  and approach makes a lot of sense.
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  From your perspective, where do you see the
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  most,
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  sustainable opportunities for growth in behavioral health, and
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  what needs to be in place structurally to
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  scale without destabilizing
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  delivery or the workforce as you've been talking
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  about?
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  Yeah. So, again, I don't have a a
• 16:37
  crystal ball, but based off of, the experience
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  that I do have and what we're seeing
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  across the nation,
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  the most sustainable growth opportunities that we see
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  in behavioral health aren't necessarily about adding volume
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  faster.
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  It's about reducing
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  friction. So the strongest areas for responsible growth
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  are gonna be in those well designed crisis
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  continuum,
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  specialty care for high acuity populations,
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  and those models where you align your clinical,
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  operational, and financial accountability
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  across settings. So
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  when you see that or where you see
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  growth become
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  destabilizing
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  is when capacity expands without redesigning system flow,
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  which is exactly what I would argue
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  we're all feeling right now is that the
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  growth has happened so quickly
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  that we didn't even have time to assess,
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  let alone course correct any of our
• 17:35
  systemic infrastructure and those basic components of how
• 17:39
  large systems work together.
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  So, for example, if you have beds but
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  you don't clarify discharge pathways, then you get
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  bottlenecks. Right? If you scale up your outpatient
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  services without stabilizing
• 17:52
  inpatient capacity,
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  you increase that churn and that cycling. So
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  growth without the structural
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  coherence
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  simply is gonna accelerate that strain and kind
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  of that disconnect that a lot of feel
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  people are feeling right now. So what has
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  to be in place, and as you and
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  others can likely pick up on this is
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  the theme of the conversation is that
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  architectural
• 18:16
  clarity, that design clarity of your system, that
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  defined ownership,
• 18:21
  aligned funding incentives, shared metrics across all of
• 18:25
  your care continuum
• 18:27
  and your partners ideally.
• 18:29
  And that is going to give you early
• 18:31
  visibility
• 18:32
  into workforce and capacity
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  risk.
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  So in
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  to kind of put a bow on things,
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  if it's probably not a bright red bow,
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  but maybe a muted red bow,
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  Behavioral health is now operating
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  at a scale and acuity level that requires
• 18:50
  this structural coherence,
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  and we haven't had the luxury of
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  decades of developing this infrastructure
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  like our acute medicine colleagues have had.
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  So without this coherence,
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  our complexity that we're experiencing
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  is only going to increase,
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  and it's gonna outpace
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  any coordination
• 19:13
  attempts that we have.
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  So the encouraging part
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  is that this isn't some kind of mystery.
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  We don't know why we're in this conundrum
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  or feeling like we're stuck in a hamster
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  wheel
• 19:25
  trying to solve a problem that we can't
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  solve.
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  It's a design problem,
• 19:31
  and design problems are
• 19:33
  solvable. We just have to start addressing them
• 19:36
  and acknowledging
• 19:37
  them and calling it what it is
• 19:39
  from every single level, from one outpatient clinic
• 19:43
  all the way up to the national infrastructure
• 19:45
  level
• 19:46
  to make sure that we take the appropriate
• 19:48
  time to develop that concrete infrastructure that will
• 19:51
  allow
• 19:52
  the weight of the system to actually hold
• 19:56
  so that our patients and our loved ones
• 19:59
  and family members that are navigating through these
• 20:01
  systems
• 20:02
  actually have a chance to navigate through a
• 20:04
  system that makes sense and that is designed
• 20:07
  to succeed.
• 20:09
  Thank you, Ali, so much for your time
• 20:10
  today. This has been a fascinating discussion, and
• 20:12
  I look forward to connecting with you again
• 20:14
  soon. Thank you so much, Laura. I appreciate
• 20:16
  it.