Ep. 10: Krithika Srivats, MS, VP, Health/Clinical Center of Excellence, HGS Healthcare. Topic: Using Predictive Analytics in Mental Health
Kathy: Hi everyone, and welcome to Episode 10 of the Smarter Healthcare Podcast. Our topic today is the mental health impact of COVID-19 and how technology can play a role in helping patients. Our guest is Krithika Srivats, vice president of the health/clinical center of excellence at HGS Healthcare, a global business process management company. Krithika and I discussed how the COVID-19 pandemic has affected mental health, which populations are more impacted, and how predictive analytics can play a role in improving the situation. Here’s our conversation.
Kathy: Hi Krithika. Welcome to the podcast.
Krithika: Thank you. Hi Kathy, very glad to be here. Thanks for this opportunity.
Kathy: Now could you start by talking a little about HGS Healthcare and the work that you do for the organization?
Krithika: Absolutely. HGS has been providing healthcare services for health plans and providers for about twenty-plus years. We support our health clients across the spectrum of administration and clinical services. So a lot of the work that we do actually is on the administrative side in terms of building products, selling those products to their members, enrolling their members, managing their entire life cycle with us in terms of customer experience management, provider experience management, all of that. A lot of what we also do is on the clinical side of things. So when you look at the spend it’s predominantly coming from how people are not managing their health. And so a lot of our interventions, which includes our utilization management services and population health management programs that really work with individuals with various vulnerabilities across their physical health, mental health, and removing social barriers so they can, we can help them make some healthy choices with respect to their health conditions. My background, though, I am an occupational therapist and I with my Masters’ and fifteen-plus years of focus specifically in dealing with neuro- degenerative and neuro-muscular conditions for the elderly population, and I’ve done a lot of work specifically in the areas of Alzheimer’s Disease, stroke recovery, et cetera. I lead the clinical practice for HGS, and I’m also responsible for new solutions and capabilities.
Kathy: Now COVID-19 has left many people in isolation for the last six months. What have been the mental health-related impacts on the general population?
Krithika: That’s a very good question. There is ample research suggesting that COVID-19 pandemic has significantly impacted mental health in the general population. In fact there are certain surveys, especially the one that was done by Kaiser Family Foundation, which actually finds that people who already have a risk factor for their mental health issues, including anxiety, eating disorders, et cetera, have a higher potential to be led all the way into depression. In addition to that, I think there’s also a significant rise in some of the downstream impact of it. This being, like, a rise in substance abuse all of a sudden. The same survey finds I think about 12% of folks are now newly addicted to substance abuse since the pandemic. So we know that there is significant impact. But one thing that I also want to use this time to talk about is the pandemic has actually helped us look at human resiliency in a different context. So occupational therapists, for long have been using this framework of reference called adaptive behavior. Especially what it is is the ability of an individual to get along and get alignment with great success and least conflict. And a lot of times this adaptiveness installs a measure of their social competence. So if you look at people, they react very differently to stimuli, changing stimuli, like the COVID in itself. On one extreme you have people who are pretty resilient, in terms of how they are able to quickly digest what is happening and come to terms with it and have a fairly non-conflicting way of dealing with it. On the other extreme you have total chaos, total conflict, and most people fall somewhere in that spectrum of coping. So these are called defense mechanisms or coping strategies. And how these coping mechanisms are actually effective is a function of the feedback that they get. So there’s intrinsic feedback, which is how you feel good about, how you’re able to effectively cope with that situation for yourself, and then there’s an extrinsic feedback, which is very dependent on the society. So the social competence, that’s where it comes into play, because now, all of a sudden you’ve taken away that ability to get that social feedback as a result of the lockdown and quarantine. So just within this context of adaptive framework, it’s a significant driver towards those risk factors for mental health, such as anxiety and high contact, et cetera. So overall I would say that the impact of the lockdown has been pretty hard on people with mental health predisposition or with preexisting mental health issues.
Kathy: Are there any populations that have been impacted more than others when it comes to mental health during the pandemic?
Krithika: Yes, absolutely. In fact, there’s a New England Journal of Medicine that recently found that uncertainties of life as a result of COVID and the public health emergency actually has had a worse impact on mental health in individuals. Vulnerability – there’s two types of vulnerability with relation to COVID, right? Typically, vulnerabilities can be physical, mental, social barriers, a whole bunch of things, clinical. However, specific to COVID if you look at the vulnerabilities it’s either because they have a, people have a high exposure to getting COVID, or upon being exposed to COVID, they have a higher risk of having a debilitating outcome. So your high-risk exposure vulnerability is probably for a health care worker who’s treating people with COVID day in and day out, but here you have on the other end people who upon contracting COVID would have a horrible outcome and that type of vulnerability is even more what we are finding today is impacting elderlies about…research has it all the way from 50 to 70% of elderly, of the deaths, have been in people with higher vulnerability as a result of COVID, and so that again goes back to some of this resiliency. People above the age of 70 as it is have a lower resiliency. And there is also another interesting fact. Most people, pre-COVID, and who are above the age of 70, actually were found to have complained of social isolation and loneliness, about at least, I think 33% of folks were found to have complained of social isolation pre-COVID, and that significantly exacerbated since the COVID lockdown for them. And these elderly have a much higher vulnerability when it comes to managing their day-to-day chronic conditions. So yes, absolutely, it has been a major issue, socialization has been a major issue. And that’s been one of the biggest vulnerabilities.
Kathy: What barriers to care has COVID-19 created on the population, especially for individuals who are more vulnerable?
Krithika: Like we said, typically barriers to care can be related to physical, chemical, socio-economic, sometimes racial and health literacy – all of that really contributes to barriers to care. But since the lockdown and the social distancing, we’ve seen a rise in barriers impacting healthy lifestyle and wellness of the population, especially the ones who have the lower resiliency. In fact I think a Modern Healthcare report and several other reports actually really talk about American population putting off healthcare needs since the start of COVID. So that in itself can actually be, like for elders for whom routine medical care is very critical to either preventing hospitalization or preventing drastic decline in function, that’s a huge barrier in itself. But if you look at other areas besides preventive care, people are dependent on food bank for their daily needs, and people are dependent on neighbors and others to help them go pick up their groceries, or meals, or medication. And that has been largely impacted as a result of COVID. There’s also another study that talks about racial inequalities. Racial and ethnic sensitivities, which actually exacerbates during social isolation, because people have language barriers. So if you’re in a community, an asset is you’re unable to have that social connectedness because of language barriers, now all of a sudden you take away the little that they have by way of family coming and helping them, these are all adding significantly as a result of COVID. And then one other thing that I do want to talk about is, again, going back to occupational therapy, there is a framework of reference called Model of Human Occupation. It’s nothing but understanding the perspectives of what meaningfulness and purposefulness is – what that does to the mental health of people, when you’re given an opportunity to fulfill your role through meaningful engagement. That contributes to mental well-being, right? So for example, let’s take an example of a grandma who’s babysitting her daughter’s child, and the daughter is a healthcare worker. And that meaningful engagement that the grandma has is a very big component of her mental health and mental well-being, and now, as a result of COVID, now you’ve taken that away. So across the board we see that barriers to care not just from what used to be lack of transportation, and things like that, lack of meals, it’s just compounded as a result of not being able to leverage on the social infrastructure that they could, that an individual could in the past.
Kathy: And how might mental health conditions impact someone’s physical health as well in terms of chronic conditions or mortality?
Krithika: That’s a very good question. Actually if you look at the body of literature there’s large research that’s been conducted that evidences mental health’s impact on chronic condition and physical health. But what is little-known is in the pathway of this overlap, there’s a study by Ohrnberger in the Journal of Social Science and Medicine which talks about the effect of lifestyle choices on social competence, and social capital, on the impact of adherence to their recommended treatment program. Physical inactivity is considered to be one of the leading correlated causes of mental health and physical health. In addition to that, cognitive decline has a reciprocal relationship with mental health. So people who have the inability to plan and execute on tasks and lower memory, either as a result of mental health or vice versa, the cognitive decline itself is leading to that lack of social engagement, resulting in mental health issues, those are all common impacts that we see on how that translates into physical health. But anecdotally speaking, I used to manage a post-stroke recovery unit, and one thing that we saw was at least a third of the people with a stroke were diagnosed with post-stroke depression. And what we saw in our rehab programs is that people who had undiagnosed or untreated depression had sub-optimal recovery, simply from not being able to attend their rehab program, not being motivated, having apathy and loss of connectedness to their rehab program. All of these really resulted in poor outcomes, and we see this in our chronic care management programs as well, and our population health management programs, people who have diagnoses of depression and have been untreated, really are unable to stick to their compliance programs when it comes to nutrition and managing their diabetes or managing their medication. One of the concepts that I want to quickly introduce here is something called frailty, and there’s a lot of research around this. They’re also finding that frailty is nothing but, it’s a condition in older people that’s characterized by a loss of physiological reserve, which causes increased chemical vulnerability and results in poor outcomes, and in frailty we came across research that specifically talked about the increase in frailty was associated with a subsequent increase in depression, indicating that there’s a shared vulnerability. So we know that most of the chronic conditions, even though it’s not a direct impact, there’s little evidence that says that just because somebody has a diagnosis of depression or schizophrenia their heart failure’s going to exacerbate or not, it’s not so directly correlated to that, but the shared vulnerabilities, that’s highly evidenced.
Kathy: Now let’s start to pivot a little bit. We’ve heard a lot about predictive analytics technology over the last few years. How can predictive analytics models provide a look at someone’s overall social connectedness?
Krithika: That’s a fantastic question, it’s a timely question. And while there is no clear-cut way to identify people with a risk of social isolation or social connectedness, moreso than ever in our history, we have the opportunity to look at the whole person by looking at data that used to be available to us beyond just looking at health plans’ claims data. Historically when you wanted to identify what are the risk factors, you went to the physician or nowadays their health insurance company, who maintain a fairly large profile of an individual across all the diagnoses and conditions that they’ve been treated for. But if you look at that, that’s just the medical data. Whole person is a lot more than that, right? So when you’re looking at social connectedness, you really need to know who are they interacting with? What are their relationships? What is their – surprisingly, a couple of things that we use in our programs is consumer data. Consumer spend and marketing data. That tells a lot about how many people live in their house? Do they have the ability to interact, do they have a good infrastructure for caregiving support? Where do they spend their money? Do they go out and spend it on having – do they dine outside? Do they go for movies or are they just buying things for the house? So those are things that give us a lot more information nowadays in addition to the claims data. The opportunity however exists with marrying this consumer data, some of the claims data, in more prospective information in terms of lab barriers et cetera with public health information. So if you look at connecting with the public health entities, they have information on who has filed for unemployment, who is on food bank, who’s on food stamps, who’s on housing vouchers? So you have some of those social and economical vulnerabilities that you’re able to identify, through some of the public health data structure, and then marry that to the clinical information that we have, now we are able to really identify not just who is socially disconnected, but who has that social connectedness that’s an actual barrier. Because not everybody is – one of the studies that talks about how social isolation itself is not the issue as much as the loneliness that is being perceived by that individual as a result of that social isolation. So if you want to really target that individual who’s lonely as a result of the social isolation, we need data that’s beyond just what clinical indicators are giving us, and that’s where the real opportunity exists is in marrying that public health information, the social enterprises, they carry a ton of very valuable information. Medicare has this initiative called Blue Button that gives us a lot more in terms of at least understanding diagnoses that might put people at risk for social isolation, in terms of looking at the whole person, but beyond that we need to really marry some of these valuable insights across different entities.
Kathy: So then how can medical professionals then use these insights to reach individuals where they are and really get them the best care suited for their needs?
Krithika: You asked one of my most favorite – you used one of my most favorite terminologies, which is meeting people where they are. I think today at the philosophical level, the most under-researched area in healthcare are interventions to meet people where they are. They’re a long way from that. However, specifically in the context of COVID, and related to isolation and loneliness, the analytical insights really are identified to specifically target the thermal barriers. We need to leverage some of the technological advances. In fact, we’ve seen about a 30-33% increase in digital adoption, in even the vulnerable population, in COVID for telehealth and telemedicine technology. So with that, we need to leverage some of those technologies to really be able to get people to the care that they need as soon as possible. There is also a shortage in trained formal caregivers, specifically in the mental health areas. Some of the social organizations, they sort of de-coupled how they approach, how they intervene, especially when there’s a large scale rise in crisis. So you have, you leverage upon volunteers, you leverage upon community resources, health coaches that are available in the community to get to those people and then hand off and triage it to those trained clinicians for the specific interventions but at least now you have a mechanism for people to identify, acknowledge, take information about them and then triage it to the clinicians, so in that process you don’t make the person just wait around on getting them the right trained help and you have a process, a mechanism, for them to be connected along the way. One other thing that I want to quickly mention in this context of meeting people where they are, an area of opportunity for us is really looking at therapy such as cognitive behavior therapy and motivational therapy and these are well-evidenced to be highly effective in people who are at the earliest stages of or lowest risk of really having a full-blown mental health episode. And a lot of these coping strategies really look at the whole person again, and not just at the current moment of what they’re going through, but also connects with them at the physiological as well as spiritual context to be able to help them cope with some of their issues. And those are very effective and transient mental health issues that people are going through as a result of COVID, such as anxiety and sleep disorder, et cetera. So I think leveraging some of these tools and techniques that are out there in addition to the professional caregiving, that’s really the way to go to meet people where they are.
Kathy: And are there any other resources that are available for people who might be in need of mental health care right now?
Krithika: I’m not a mental health professional, so I’m not qualified to answer this in whole, however, as an occupational therapist, we focus on whole person, or person-centered approach. Holistic care is actually a multi-disciplinary engagement, so in order to identify and address the lowest, to address the larger mental health issues, there are several tiers of that which require to be addressed at various levels. So for example, an occupational therapist can help plan, help the individual sort of plan and manage their day amidst all of the challenges they are facing as a result of the depression or anxiety so that at the output that is required of them in terms of managing their day-to-day activities, their self-care, their caregiving responsibilities are not significantly hindered. Similarly, there are other interventions but again going back to leveraging telehealth, leveraging social entrepreneurship, there are so many referred resources available today specifically for mental health issues with social entrepreneurships really leveraging them, and then also looking at body of evidence that’s available in alternate therapies and using those as part of the coping strategies and some of their interventions are very critical and that’s probably where we need to spend a little bit more time in researching.
Kathy: And let’s look ahead five years. In what ways do you anticipate 2020 will have changed our care of people around both their mental and physical health?
Krithika: Very good question. Very well-needed question. Again cautiously stating my opinion as a non-mental health professional, the optimistic view is the stark realization in human resilience, including but not limited to digital adoption. That’s - historically there’s been perceptions that vulnerable people can not use digital technology and COVID has sort of slewn some of those myths. In fact there’s a Northern California counseling center that showed a reduction of no-show in their mental health services from 60% before COVID to 11% post-COVID all of a sudden now because they have the telehealth provider network expanded, as well as they have multi-lingual capabilities in their expanded network of telehealth providers. Those are all very important measures to adopt in becoming a mainstream mental health management resource. In addition to that, I think there is an opportunity for public health and regulatory convergence and collaboration between health plans, providers, public health entities, et cetera, and not just in data sharing, but also being able to sort of hand off the patient through the various functions seamlessly so that care doesn’t get interrupted. So those are absolutely two areas where I feel if we make the right investments and right collaboration, five years from now should look much more positive.
Kathy: Krithika, thank you so much for your time today, I really enjoyed this timely and important conversation.
Krithika: Thank you, I really enjoyed our discussion.
Kathy: Thank you for joining me for this episode of the Smarter Healthcare Podcast.
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