The COVID-19 pandemic has spurred tremendous momentum for the development and implementation of novel strategies for behavioral health care. This panel will discuss the innovations made amid COVID-19 that specifically address the nation’s lingering challenges with timely, equitable treatment for behavioral health conditions and the need for more integrated, whole person care.
What are some accessible touchpoints for patients that have been valuable to date? Do you see these continuing? New touchpoints/opportunities to address behavioral health with patients moving forward?
The PHE has allowed for additional flexibilities with how physician practices and systems can care for their patients needs, particularly around behavioral health. Which policies (state or federal) should continue to sustain integrated behavioral health care into the future?
Telemedicine support and coverage across state lines without needing licensure in all states where the patient is visiting or located would really improve access.
Agreed regarding Telehealth. We also need continued funding for integrated care programs including collaborative care and Pediatric and Perinatal Psychiatry Access Programs. We also need to incentivize frontline clinicians providing mental health care through reimbursement.
The AAP's Healthy Foster Care America recommends that children and adolescents be seen twice as often as in the periodicity schedule, particularly to assess their social emotional status. During COVID children in foster care may have had the added stressor of visitation being suspended.
How do we ensure such innovative solutions, particularly those around telehealth, don’t worsen existing silos in behavioral health care?
The move to remote work and telehealth presented a challenge for our integrated care teams in the beginning of the pandemic. Once used to sharing the same space for patient care, having multiple touchpoints for coordination, and interacting face to face throughout the day, our providers initially struggled with how to maintain the complicated workflows for patient care communication and coordination in a timely manner and with the same degree of clinical quality. When a significant portion of our visits shifted to virtual care -they tried multiple methods - texts, phone calls, shared video visits, etc. After some trial and error, most of our teams have found their rhythm using a combination of MS Teams (which is open for our care teams all day) and zoom screens in all exam rooms. Shared electronic health records have always been foundational to our integrated model of care, and have been even more critical in a virtual health environment. The lesson we learned is there is higher risk of fragmentation in a virtual environment because it does require modification of workflows and additional effort for communication -- but these risks can be mitigated with deliberate and persistent problem-solving.
What potential benefits can they provide? What are some potential pitfalls to be aware of? How well do they integrate with the rest of a patient's care?
There are many technologies being used. In fact, Eighteen Ventures, my company, published an Informational Brief on Behavioral Health Technology Development & Funding Opportunities. The Brief presents the different types of technologies being used for behavioral health, especially ones that patients can use on their own. For example, Virtual reality, smartphone apps, artificial intelligence, i.e., smart robots, are some of the technologies we listed in the Informational Brief. Our report focuses on the benefits of using the technologies. The Brief is free. I will provide a free copy to anyone who sends me an email: Darrell@eighteenventures.com
There are a growing number of mobile applications for self management of behavioral health problems. These apps have been useful to supplement and reinforce therapeutic interventions as well as a resource for maintenance of well-being (e.g. relaxation apps). There are also some programs that are stand alone behavioral interventions that are showing some promise. I believe we are scratching the surface of the potential for digital health technologies in behavioral healthcare - but I suspect there will be a place for human interaction.
How has your practice/system worked to integrate this into care?
This is a very interesting topic for behavioral health clinicians!
Historically, BH clinicians have been reluctant to monitor other health conditions because it was seen as "outside scope of practice" and putting them in jeopardy with their medical board.
More recently, we have renewed interest in the BH clinician asking about and screening for common physical health concerns. As a psychiatrist, I am trained in treating the whole person the same as other physicians. I feel it is my responsibility to consider physical health as well as mental health when I work with patients.
I anticipate we will see ongoing advancement of integrated care and increased training/comfort of BH clinicians to integrate physical health into their practice.
There is no health without mental health.
In January 2018, the Milliman Research Report (S. Melek, D.Norris, J.Paulus, K. Matthews, A. Weaver, S. Davenport) titled "Potential Economic Impact of Integrated Behavioral Healthcare" stated that the medical costs for treating patients with chronic medical and comorbid mental health and substance use disorders are two-three times higher than the total cost of those without co-morbid conditions. The projected additional healthcare costs are estimated to be $406 B in 2017. This study looked into about 24 chronic conditions from anemia to stroke. They concluded that the high-severity conditions (anemia, liver disease, CHF, chronic kidney disease and circulatory conditions) have the highest potential for savings on a per patient basis. The high-incidence illnesses (endocrine/metabolic disorders, arthritis, hypertension) have the greatest potential savings across the entire population. This paper further talked about the integration of medical and behavioral healthcare. There are several evidence-based models of care that can make this possible. For example, the Collaborative Care Model (AIMS, University of Washington) for example has more than 80 randomized-controlled trials that proves this model works. While we have data to back us up, health systems continue to struggle to implement integrated behavioral health and show value due to many reasons which will be discussed in other parts of this forum.
Shift from a "one-size-fits-all" to a more tailored approach?
In my experience in working with obstetric practices to help them integrate mental health care into their workflow, it is "one-size-fits-none." Every practice differs and a tailoring the approach to each practice setting is so important. The option for virtual appts can make care so much more accessible. As it relates to mental health, it is important to 1) integrate mental health screening into virtual appts, and 2) make sure that positive screens are discussed and responded to appropriately.
What models have you used in practice/have seen colleagues use that have been successful?
My practice is engaging in a training program for pediatricians to learn more behavioral health as child psychiatrists continue to have a backlog
What solutions emerging amid the pandemic do you think will become more standard practice moving forward?
Telehealth. It makes care so much more accessible by overcoming barriers related to lack of transportation or child care.
Agreed - telehealth and use of mobile health technologies for behavioral health are here to stay. Provision of behavioral health services in general became more adaptable to patient need and overall demand - our percentage of brief therapy visits increased substantially, use of peer specialists and others to enhance and strengthen care in a team based model also increased.
I agree with the statements above. Telehealth increases access to care as patients do not have to worry about commuting to clinics/hospitals for their appointments, coordinate child care if needed, etc.
Rural practices are instrumental in increasing access to behavioral health care in their communities. What additional support is needed to ensure such practices can continue to provide this support for their vulnerable patients?
In pediatrics, a key strategy for mental health services in rural areas are the child psychiatry access programs (cpaps). Primary care clinicians can access consultation in real time, and have access to psychiatry, a licensed mental health professional, and a care coordinator. Services include assessment of the individual child, consultation re treatment, including therapies and medication, and assistance finding local resources for the family. The American Rescue Plan has funding for states without such a program to establish a cpap
Collaboration and outreach into community settings - such as churches and schools (via telehealth, mobile clinics) has been a critical part of behavioral health access for CHS. For telehealth to work in rural areas, we will need an investment in IT infrastructure support.
Similar to CPAPs, Perinatal Psychiatry Access Programs help frontline ob providers manage mental health conditions among perinatal individuals. These programs provide access to training, consultation with perinatal psychiatrists and resources and referrals. More info on whether your state has one can be found here: umassmed.edu/lifeline4moms/Acc...
To follow-up to Dr. Byatt's post, as an Ob/Gyn and engagement director of the MA Perinatal Psychiatry Access Programs (MCPAP for Moms), I can attest to the fact that these programs have been a game changer for obstetricians addressing perinatal mental health and substance use disorders. Most Ob/Gyns are inadequately prepared to address these common pregnancy complications. Access Programs provide the training, in the moment support through perinatal psychiatry consultation, and needed linkages to resources and referrals. There are approximately 18 active Access Programs across the country, covering a wide variety of geographies including rural settings.
Integrating behavioral health into settings where these concerns present will be important for expanding access to care, reducing stigma, as well as an avenue for prevention and at-risk intervention. These settings include primary care, specialty mental health, as well as schools, community and faith-based organizations such as shelters, housing developments, churches. Digital technology can be a force multiple for such outreach and expansion efforts. We have put ipads for virtual health into shelters, schools, and community centers.
Agreed. We need to connect with these community settings and organizations because the health care setting will not be the best place to engage all populations. We need to move beyond health care settings to engage and close gaps in care for populations that have been underserved.