Dr Andrew Greenland: 0:00

Welcome back to Voices in Health and Wellness. This is the show where we hear directly from the innovators, clinicians, and thinkers driving the future of healthcare delivery. I'm your host, Dr. Andrew Greenland, and today we're diving into a topic that's increasingly shaping how clinics operate, what generation younger generations expect when it comes to care. My guest is Rotem Moshe, who plays a pivotal role at Stepstone Stepstone Connect, a US-based organization focused on improving access to high-quality mental health services through telehealth. Stepstone Stepstone works extensively with hard-to-reach populations and is part of a movement reshaping behavioral health. So, Rotem, thank you so much for joining us this afternoon and welcome to the show.

Rotem Moshe: 0:39

Thank you for having me.

Dr Andrew Greenland: 0:41

So perhaps you could share a little bit about your journey into mental health and telehealth and what led you into this space.

Rotem Moshe: 0:48

So I completed my master's degree in 2010 and um started off my career working in substance abuse treatment. When the pandemic started, we had to quickly regroup and figure out how to deliver services while on lockdown. And up until then, I never even considered telehealth because we're taught early on in our careers that you're you would miss a lot of things virtually that you wouldn't miss in person. And quite frankly, it just wasn't a platform that any of us considered until we had to. And when the pandemic started, I started to really understand the benefits of it. Um, from a research standpoint, there are a lot of benefits to telehealth. Um sometimes similar effects to in-person and telehealth. Um, it offered convenience, it offered um an expanded reach for clinicians. Uh in 2021, I decided that um I wanted to pursue a private practice. And as I was building my practice, I came across Stepstone Connect through a mute of through a colleague that was um involved with the program as well. And I've been with the company ever since. So from I got I started with Stepstone in 2021, and today I'm the executive clinical director of the program. Um and it's just been an amazing journey. I've gone from being licensed in Florida where I'm from, to being licensed in almost nine states. Um and it's just been such a rewarding experience to be able to interact with people from different backgrounds, different walks of life, and not have any restrictions involved in terms of their access to me and my ability to support them.

Dr Andrew Greenland: 2:59

Thank you. So you said you're executive clinical director at Stepstone. What does that look like day to day? What's a typical day for you if there is such a thing? And how does it fit into the bigger picture of the organization?

Rotem Moshe: 3:10

Every day looks different. Every day looks different. As the executive clinical director, I uh focus a lot on programming, protocols, policies, and procedures. Um, I work alongside a clinical supervisor that really does a lot of the legwork with overseeing the other clinicians. Uh, we all work together in an interdisciplinary team in order to provide the best possible quality of care because there's a lot of challenges involved in telehealth. Um, given that we provide services to almost all 50 states, we need to make sure we really understand the resources available in the event of a crisis. We there's very few, but when they happen, they happen and we have to be prepared.

Dr Andrew Greenland: 3:57

Thank you. And from your perspective, what's the biggest shift you're seeing in how younger generations? Um, we're talking about millennials and Gen Z approach healthcare or therapy.

Rotem Moshe: 4:07

I find that they are more likely to participate in therapy if the access is easier for them. And there's a level of privacy in most situations that you can have at home as opposed to um, you know, we work a lot with first responders. So there is also that fear and stigma of being seen in public going into a therapist's office and things like that. So it kind of takes away some of the discomfort involved in seeking out therapeutic services and the flexibility. So if one of our responders is doing a night shift and there's a therapist at Stepstone that works evenings, then it's perfect. They have somebody that they can reach out to.

Dr Andrew Greenland: 5:00

And what about um how younger patients approaching this are different from older patients? Are you seeing a um distinction between the different generations?

Rotem Moshe: 5:10

I think my older clients are reluctant at first because of the technology piece. Are they going to be able to navigate through it? And best practice with telehealth is to, for clients that are reluctant or afraid of using um, you know, a Zoom platform or something like that, is to give them a test run so they can see that it's not as uh overwhelming as they may think. And uh once they get into it a few sessions in, they don't know how they did life without it. So um I would say that's like the biggest point of contention with my older clients is am I going to be able to navigate through the tech world.

Dr Andrew Greenland: 5:54

And are there ways that you've had to adapt as a company to model or change your service delivery to align with these different expectations?

Rotem Moshe: 6:02

Yes, we've been exposed to many different challenges over the course of the business growing. Um, we've had to navigate through finding effective ways to provide services to rural areas because sometimes the internet connection isn't that great, or they may not have the resources in order to have access to a computer, in which case we deliver a computer to them that they can use while they're getting treatment, and then they just send it back once they graduate from the program.

Dr Andrew Greenland: 6:39

You've talked about some of the main advantages of um telehealth for this kind of work and a couple of the technical hitches or resistance around the technology, perhaps older people. What about the actual um relationship between the practitioner and the therapist? How does that kind of work out and compare with you know face-to-face models versus you know the telehealth thing? Is there something missing from the telehealth model?

Rotem Moshe: 7:07

I personally didn't really find much of a difference. Once the telehealth became more widespread and more widely used, it you you almost forget that you're speaking through a screen. We do I developed the same rapport with my clients that I do in person. It's the same relationship, connection. Um I haven't found that many of my clients held back because of the telehealth platform. If they do, it's because um, you know, some underlying fears and anxieties about being in therapy in general, which we slowly work through.

Dr Andrew Greenland: 7:48

And I guess this is technology's been around for years now, and it's like you said, it really kind of um exploded through the pandemic. But does the research back all of this up in terms of you know this being a model which is completely safe and sound and effective from a therapeutic standpoint?

Rotem Moshe: 8:04

There is a lot of research to support that the efficacy is there in a telehealth platform, but there's also a lot of other um factors to consider. You know, it's still the internet, so we have to always be mindful of using HIPAA compliant encrypted platforms in order to avoid any um anybody accessing the platform without that shouldn't be. Um there's a lot of that that we have to be mindful of because there is potential for confidentiality breaches through no unintentional, but we have we do our best to make sure that we are always up to date, always safeguarding our clients, even in terms of uh correspondence with clients. We have a um an app, the HIPAA compliance secure app that's where we guide our clients to reach out to us, and so far, so good. It's been really effective for us. A lot of legwork involved in protecting their privacy, but the resources are there.

Dr Andrew Greenland: 9:14

And you mentioned earlier on about being um being able to respond to a crisis. I mean, how how would that happen? You're operating in one state, somebody's having a crisis in another state. How do you how does your organization kick in in that sort of situation?

Rotem Moshe: 9:29

What we do is first things first, whenever a client hops on a call, we confirm where they're located, just in case something comes up in session, or if they even just arrive to session presenting with some sort of crisis, and we have a running list of um police departments, medical hospitals, providers, things like that in each of our clients' area so that we can quickly reference it. And, you know, if I'm in the middle of a crisis call with a client, I will message one of my teammates, all right, this is where they're located, this is what's going on, send somebody. And that way we eliminate um, especially if it's a situation where there's suicidal ideation or plans and intent, we act very quickly.

Dr Andrew Greenland: 10:17

So there's a fast response element to this. You're kind of all geared for these kind of eventualities, which sounds very, very good. Um, in terms of um clients choosing a provider to work with, I guess there are a number of the uh providers similar doing similar work to what you do. What are the what's the role of you know reviews and social proof um in terms of how people choose where they're going to go for this help?

Rotem Moshe: 10:42

Um a lot of the work we do is we network with a lot of residential programs. Um Stepstone Connects program is an intensive outpatient program, so it's typically a step down from a residential level of care or inpatient level of care to us for continuity of care. And um, so we work a lot and network a lot with different programs around the country, make sure they're aware that the resources that we are a resource to them and their clients. And we've found a lot of success in just making ourselves known and showing our faces. And even um the other day, I was on a Zoom call with um yeah, some responders in Utah to explain the program. So it, you know, it's a lot of networking, I would say.

Dr Andrew Greenland: 11:34

Got it. And then the platform itself, so presumably the client and the therapist will connect through the platform. Um, I guess it's a bit more sophisticated than the Zoom call that we're kind of doing at the moment. What else does the platform offer in terms of functionality to facilitate the interaction between the therapist and the client? Just giving our audience some idea of what this actually looks like.

Rotem Moshe: 11:55

So actually, we do use Zoom. There are different um plans through Zoom that a provider can use. We use the most sophisticated one that they have that is that has all the security features that we expect. Um, we also have a secure scheduling platform that we use, and basically the clients can access the platform, select time date provider, and schedule themselves. Oftentimes, though, one when they come in for the assessment process of the intensive outpatient program, we'll get an idea of who would be the best fit just from the pre-screening process. And our admissions team will reach out to the individual provider and say, listen, we have a potential client coming in, we think that you'd be the best fit, and then we go from there into scheduling um the first session with them.

Dr Andrew Greenland: 12:53

Okay. And I guess um we can't ignore, we can't not have this conversation without discussing AI to some extent. Um there's been lots of stories around where AA is being used for therapy in some um in some guys. What's your take on that? Do you think um where are we at at the moment in terms of of what's what you've probably heard in the media versus where do you think this might go and what's your kind of take on it?

Rotem Moshe: 13:16

I'm always I'm at this point, I mean, I know that it's going to continue to develop and maybe I'll have a change of heart in the future. I'm reluctant to use AI. I think that there's a lot of potential for confidentiality breaches. Um I don't really know where a lot of the content comes from. I know there's a lot of providers that will bring AI into the appointment and it's listening in on the appointment. And I think that's it, it there's potential for losing a lot of meaningful conversation if the client knows that there's a device being used or software being used that's listening in on them. The the efficacy of counseling is knowing that whatever is happening in the session is staying in the session and that the clinician is reliable and um is invested in their uh experience and their privacy. Personally, I'm not ready to broach the AI phenomenon. Um, but I know a lot of providers that are segueing into that.

Dr Andrew Greenland: 14:29

Is there any technology you'd like to see available to help you do your work? So if not AI in the service that you provide, is there any other technology that would smooth the work that you do in this space with stepstone?

Rotem Moshe: 14:43

I would love to discover any software or program that helps uh streamline documentation. I think that the documentation process can be really overwhelming for clinicians because here in the States we have to navigate through a lot of uh licensing and credentialing boards, the myriad of insurance companies and their expectations and they vary from state to state. And in order to appease everybody, it essentially becomes like a massive, massive amount of paperwork that every clinician has to complete on every chart. If the universe can provide a way to make that piece more manageable, I think it would be helpful in giving clinicians the space to focus more on clients without being burdened or bogged down by paperwork.

Dr Andrew Greenland: 15:42

And in terms of um tracking um your organization in terms of how things are going, what are the things that you're most interested in looking at in a sort of a metric sense?

Rotem Moshe: 15:52

We make sure to send out um self-report surveys and client satisfaction surveys on a regular basis. Um it's important for us to have data points in order to see whether the services we're providing is producing the results we're hoping for, whether it's feedback on group processes and facilitators or the way they feel that their needs are being met in individual sessions, um, even just uh you know clerical issues that we could do better with. Um, we we take a lot of measures in order to have those data points specifically and get feedback directly from the clients we serve.

Dr Andrew Greenland: 16:38

Thank you. And what do you find is the biggest reason for clients disengaging or dropping out, particularly in the sort of the younger uses?

Rotem Moshe: 16:46

In my experience, clients that are externally motivated are not likely to follow through long term. So if they are court-ordered to go to treatment or if their families are pressuring them to go to treatment, but they don't inherently want to want to or see the problem, there's a higher recidivism rate with those clients. Um, for the most part, we do we mostly experience clients that are motivated to be there, maybe guarded at times, but they warm up to the idea with time. So the majority of the resistance would be with the clients that come in that don't really want to be there.

Dr Andrew Greenland: 17:29

Okay. And in terms of your team, I guess you must have a fairly big team across the um the states, because obviously you're a multi-state organization. How have you had to sort of bring them on board? Because I presume you will, some of them are working before COVID in a in a face-to-face environment. How have you had to bring bring them on this journey of transforming the consultation into a face-to-face to a um in a remote consultation?

Rotem Moshe: 17:51

So we have an extensive interviewing process. Um, you know, whenever we have a specific state that we're interested in, we make sure to uh focus and zero in on interviewing clinicians in that area. Um to be honest, a lot of clinicians are already fairly familiar with telehealth. So it hasn't been that complicated. However, it just like any other workplace, we have to get to know the provider. And after like the initial hiring period, we kind of get a feel of all right, this person is or is not a good fit for our um population. Um, but for the most part, they it they transition rather seamlessly to the telehealth world. Um, we do extensive training in the beginning of when they're being onboarded so that they understand what our process looks like, ethical considerations to take when working um in this capacity and how it differs from in person.

Dr Andrew Greenland: 18:56

Because you you do have a remote, you have a remote workforce by design. I just wonder what the challenges are of having that. You know, you're not working in one building where you have your therapist in one place. How does it work from the point of view already being spread out? Not necessarily ever going to connect in person. How do you kind of keep that cohesion together with everybody and a kind of common um common goals in the way that you're trying to run your business?

Rotem Moshe: 19:20

A lot of communication. We stress communication in our organization. And you know, we give every clinician the resources to do it with. We all have each other, like we have email, texting, phone numbers. Um, we have regular Zoom meetings among the staff in order to assess where our clients are at, how our clinicians are doing, what's working well, what needs improvement. Um, so yeah, it's it's a lot of discipline and communication because you can't just pop your head into the therapist's office and ask the question on the spot.

Dr Andrew Greenland: 19:57

Um, you alluded a few moments ago to the insurance thing. So do you think regulation and reimbursement models is keeping up with the way that we need to be delivering care? I guess I know the answer to this, but I'd be very interested to hear your take on it.

Rotem Moshe: 20:10

I think that it could be better. Um I think that there's a lot of uh it's becoming a little bit more rigid, which means that we have to get creative in how we advocate for our clients. Um I would say it's challenging overall, though.

Dr Andrew Greenland: 20:32

Um what are some of the bottlenecks with the whole insurance thing? And I I asked a question because I've spoken to many, many clinics across a range of different niches in North America, and they're all saying roughly the same thing. I'm just curious to know what the kind of the real nitty-gritty of the bottleneck is with the whole insurance model.

Rotem Moshe: 20:50

I think having to prove to their satisfaction that there's medical necessity for the client, especially if it's a client that has a history of multiple treatment episodes. A lot of the feedback that I get from insurance company is, well, nothing's working, so why should we cover this? Whereas they're not seeing the person as a person that has been through significant life challenges and traumas, and it may take more than two or even three episodes of care in order to make implement change. And I think that's the biggest issue is I get that it's a business and they don't want to pay, but you they're your customers and they're paying for a service.

Dr Andrew Greenland: 21:42

Got it. So, what do you think is the role of um telehealth platforms over the next five to ten years? What are we going to have a massive expansion in this kind of thing? Is the face-to-face model kind of dead in the water? Where do you think we're going?

Rotem Moshe: 21:57

I think that it's going to become a lot more widespread. I think that, or at least I hope that, um, there's opportunities to expand reach even further to other countries. And hopefully there will be options and um uh options to be able to be a clinician in the States and work with someone overseas that happens to need my expertise and niche in order to get through their the struggles that they're experiencing. Um, do I think that face-to-face will become obsolete? No, because there are still some people that prefer that face-to-face interaction and really just getting up and getting out of the house and having somewhere to go to meet with their therapist. Um, but there are a lot of more and more clinicians that I'm seeing now that are working from home and doing the telehealth route.

Dr Andrew Greenland: 22:57

And what are the plans for stepstone over the next six to 12 months? Do you have any um direction that you're looking to take the company in?

Rotem Moshe: 23:05

Our goal is to service all 50 states, um, to find providers in all 50 states. We have a lot of clinicians that are licensed in several states. Um we want to make ourselves available to you know different needs and populations. Um, like I said, we have a special programming for first responders. So I would love to see that part of the program expand even further and normalize mental health for first responders.

Dr Andrew Greenland: 23:40

Amazing. And on that note, Rotem, thank you so much for your time this afternoon. Really interesting hearing about you, your work at Stepstone, your mission, and the direction of travel going forward. It's been really interesting. Thank you so much.

Rotem Moshe: 23:51

Thank you so much for having me.