Our next moonshot – Apollo 13 and the state of behavioral health in Texas

Tags: janet hurley; apollo 13, behavioral health

By Janet Hurley, MD

If you have never seen the movie “Apollo 13,” I highly recommend it. It tells the story of a fateful NASA mission to the moon. In route to the moon, there was an explosion and the astronauts had to use the lunar lander module as a lifeboat. The movie tells the story of innovation, teamwork, and unbridled commitment toward the goal of bringing the astronauts home. The mission was called “a successful failure” because they failed to go to the moon, but they succeeded in bringing the astronauts home alive against terrible odds.

In my role as medical director of population health for my local health system, I have undertaken the task of developing a behavioral health program with the goal of having a behavioral health counselor embedded in each of our primary care clinics and psychiatrist consultants available to review behavioral health care plans, discuss cases with primary care physicians, and receive direct referrals. This is one good way to provide support to primary care while protecting a psychiatrist’s time to ensure that referrals are done for only the most difficult mental health patients. This has been my initial plan for mental health expansion in my organization.

Yet as I have proceeded, I have run across more barriers than any other project I have worked on in my career. I was reminded of a scene in the movie “Apollo 13” when they were discussing the use of the lunar lander module to make course corrections for the entire spacecraft in open space. Clearly the lunar lander was not designed to do that. There was a beautiful quote in that movie from the mission commander when he says: “I don’t care what anything was designed to do. I care about what it can do.“ In regard to my behavioral health project, I have come to conclude that I have to continue searching for the golden nuggets of things that I can do. There is certainly a full dose of things that are the opposite.

For example, I can’t bill the behavioral health collaborative care codes in any of my clinics that have provider-based billing. While I have support from my boss to add psychiatrists and counselors into the next budget, I am tasked with building a business case to add a service line to the organization that has an unfavorable financial return on investment within the broken payment structures available today.
For the one social worker in whom we have already invested, I am having much difficulty with the regulatory requirements of having her direct bill for her services. She is not credentialed with health plans; she is not listed as billing with us in the national database; we do not have any behavioral health payer contracts. Because of these challenges, there is a strong desire by some to just keep doing things the way we are doing them now. Yet to borrow another inspiration from “Apollo 13,” we have a new mission, and it’s time to figure out how to do things differently.

Our social worker wants to train licensed professional counselor students and social worker students in one of our clinics but we have never done that before. That has raised a whole new set of questions. Do we have an organizational standard in other regions? Is there a legal standard? What is the industry standard?

While it took weeks to answer these questions, we thankfully have this issue resolved in my health system. In response we have now added a low-cost behavioral health resource that in the future may expand behavioral health services to additional pods in that clinic location.

We discussed adding tele-psychiatry services to our facilities but having our mental health patients managed by a psychiatrist is only one part of our clinical need. We also need a psychiatrist to work collaboratively with our primary care physicians, giving advice over the phone and reviewing psychiatric care plans. We will have to be creative if we intend to adapt a tele-psych model to meet these additional requests.

During the Apollo 13 mission, the carbon dioxide levels were rising dangerously. The lunar lander module was not designed to support three astronauts, nor did they plan to be in it as long as they now needed to. They did not have any round carbon dioxide filters for the lunar lander module onboard, so they had to adapt the square carbon dioxide filter from the main spacecraft to fit into the lunar lander. A group of specialists were asked to make a square carbon dioxide filter fit into the space for a round filter. Someone took a box of random spacecraft elements and dumped it onto the surface of the table. The line from the movie was simply this: “We gotta find a way to make this fit into the hole for this, using nothing but that.” This quote might as well describe my behavioral health project experience.

Yet I remain undeterred. To borrow one final line from “Apollo 13”: “Failure is not an option.” This issue is simply too important — and the benefits too significant — for us to fail. I am not going to stop until we have success in adding mental health resources to our organization.

Yet what about the rest of you? TAFP cares about meeting this need for all of our constituents, not just those with a supportive infrastructure from a large health system. How do we get this kind of support for all our members?

One key finding from the TAFP strategic planning retreat this summer was clear consensus from all participants that more needs to be done to support behavioral health infrastructure for our members all across Texas. TAFP plans to convene a behavioral health task force to tackle this issue. Perhaps if the task force also uses innovation, teamwork, and unbridled commitment as foundational to its mission, they will also “bring the astronauts home.”

It is time to turn Texas’ behavioral health mission into a successful failure. A failure because it has failed our communities for far too long. A success because we rose to the challenge and made a real difference to meet the behavioral health needs in the communities we serve.

1 Comment

  • Celia Neavel, MD, FAAFP, FSAHM said

    Our clinic has worked towards incorporating an Integrated Behavioral Health model for 13 years. Not that there aren't challenges, and no matter how many resources, it never seems enough. We have been lucky to obtain grants and foundation support. I agree that IBH is important in my practice of adolescent and young adult and primary care medicine within our FQHC.

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