Belong Health has formed a medical group to help payer and provider partners address gaps in care for dual-eligible patients.
Belong Medical Group is a transitional care organization that will operate as a separate unit within Belong Health to develop clinical programming and wraparound services for its partners. Those partners include payers, providers and provider groups caring for members with chronic conditions during changes in their care plans.
Belong Health initially formed in 2021 to partner with providers and regional dual-eligible special needs plans under the Medicare Advantage program. In 2022, it expanded to serve Medicare fee-for-service beneficiaries. The organization supplements existing care infrastructure with virtual and community-based resources. Its team includes operators, clinicians, registered nurses, licensed clinical social workers, and community health workers.
The first clinical solution available through Belong Medical Group is Mental Health Connector, serving patients without a current mental health provider or worsening chronic mental illness. These patients are identified during health risk assessments or hospital and ER admissions as having unmet health needs that require follow up.
Dual eligible members experience high rates of chronic illness. Many have long-term care needs and social risk factors. Per 2020 data, full-benefit dual-eligibles were more than twice as likely to have had a mental health condition compared to Medicare beneficiaries without Medicaid coverage. These patients account for a disproportionate share of spend in Medicaid and Medicare.
MVP Health Care, a regional nonprofit plan serving New York and Vermont, is the first to offer the Mental Health Connector program. The plan has already seen “notable” improvements in depression scores among its members, the plan’s Chief Medical Officer Carl Cameron, M.D., said in a press release. “This heartening progress reinforces our belief that collaborative efforts can truly shape a brighter future for those with diverse health care needs,” Cameron said.
Patients enrolled in the program get mental health treatment from Belong Medical Group’s clinicians virtually for about 90 days -- about how long it can take to find a therapist, executives told Fierce Healthcare. They are then transitioned to either a primary care provider or mental health clinician in the community.
The goal is to diagnose and address unmet mental health needs and then triage the right level of care for the patient long-term, executives say. This transitional care reduces costs and improves quality scores, they argue.
“We want that condition treated, not just labeled,” Ramon Jacobs-Shaw, M.D., president of Belong Medical Group and chief clinical officer at Belong Health, told Fierce Healthcare.
Often at discharge, the mental health needs of a patient fall by the wayside, Jacobs-Shaw said. Belong Medical Group has access to ADT feeds to see at discharge what conditions a patient has, including mental health conditions. The care management team then reaches out to the patient to get them connected to a psychiatrist for evaluation.
“The goal of what we want to do is really serve as a cushion or soft landing for people transitioning out of hospitals or ERs,” Jacobs-Shaw said.
Every patient in the program is screened upfront for depression and anxiety using standardized questionnaires PHQ9 and GAD7. The scores are then tracked over time, with each visit, to measure progress. The systematic collection of symptom data in behavioral health is known as measurement-based care.
“We want to be able to follow those key metrics to see what is the impact of our program on our patients,” Jacobs-Shaw said.
While substance use disorder (SUD) is a major issue, Jacobs-Shaw acknowledged, and the Belong psychiatrist can treat patients as needed, there is currently no specific focus on SUD within the Mental Health Connector program. The organization’s first partner, MVP Health Care, has a robust network of treatment centers focused on SUD that Belong Medical Group can refer to, Jacobs-Shaw said.
“What we know now is that the whole of a person needs to really be taken care of throughout their care journey,” Jacobs-Shaw said. Mental needs cannot be separated from or ignored compared to physical conditions. “They all just kind of intertwine.”