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 does telehealth offer that traditional behavioral health services may not? Are there remaining problems that telehealth can’t solve alone? If so, what are they, and what are some potential solutions?
What types of innovative approaches have you used (or have observed being used) to help patients manage their health more holistically? Group therapy sessions? Apps?
At Henry Ford Health System Behavioral Health Services, we have implemented several programs prior to the pandemic: Virtual care, Behavioral Health Integration with Primary Care. We are now working on adding focused digital mental health tools that can help in-between visits and help triage the patients so we can efficiently allocate resources. There are tens of thousands of available apps but if we do not incorporate them in the care of our patients and we do not guide them in terms of how the apps help them be in control of their treatment, we will not be successful. We also need to work closely with our population health department in order to incorporate social determinants of health in our model so we have a comprehensive approach. The pandemic has highlighted health systems' role in public health. We need to look closer at how we can work with the community in terms of educating our 'not-yet-patients' in terms of what is stress vs. distress and give them tools so they can monitor their symptoms and seek help when they really need to.
The pandemic has reinforced the value of attending to the broader system and functioning of the individual, family, and community as part of healthcare. Our system has been integrating behavioral health into primary care for 40 years, and the pandemic challenged us to think and act more creatively to maintain access to comprehensive care, maintain transdisciplinary collaboration, as well as address the new demands of testing, health education, treatment, and more recently vaccinations for COVID-10. We used audio-only visits for high touch patient engagement (e.g. frequent brief phone check-ins), put ipads in hotel rooms, homeless shelters, and wherever needed to provide clinical care for patients in quarantine, used apps for telehealth, set up a COVID-19 crisis hotline for patients, and built makeshift drive through clinics. The pandemic forced us out of the box and changed our mindset towards "innovation" itself. We shifted to an experimental paradigm with the goal of trying new solutions, monitoring outcomes, and pivoting rapidly when needed. "There is no failure, only learning" became our mantra. Innovation emerged from staying true to our mission, listening to our patients and community partners, and being flexible enough to stop, adapt, reverse course, and try something else.
At Caremore Health, when the pandemic hit we quickly shifted to virtual care. Most of our providers had never done a virtual visit and many of our patients did not have access to wi-fi or video technology.
We found that a proactive approach with a simple patient list (registry) was helpful. For each provider, we created a simple report showing all the patients who had visits within the last 12 months, then ordered them with the most frequent visit patients at the top of the list.
Between "normal" virtual visits via phone and video, our providers proactively outreached to patients on their list with phone calls. We found that the pandemic allowed us to get momentum and buy-in for this foundational step of integrated, proactive patient care.
As the pandemic progressed, we accelerated our strategic plan to implement The Collaborative Care Model across geographies. This evidence-based model of integrated care suited Caremore's mission well. For more information on the model (and some free CME!) check out the APA website :
Being at home could be a much less stressful setting than the classroom, but not having a structured schedule at home is likely to reduce the students productivity. For parents it may be difficult to implement learning strategies consistently. Finally, monitoring and follow-up for medication adjustments/refills could be a challenge
Hi, Marian! A lot of our kids w/ ADHD found remote/virtual instruction quite challenging. Kids w/ ADHD usually struggle with attention and motivation, but great teachers and engaging classroom settings can help to overcome some of these challenges. Without these available, many families have struggled to engage and support their kids w/ ADHD in this past year.
We have really had to work with families this past year to be more flexible in ADHD management. We really had to emphasize the importance of increasing the frequency of rewards (e.g. weekly or even daily rewards may be too infrequent). Screen and movement breaks are critical and had to be negotiated with teachers. In less structured days, we generally promoted alternating blocks of instructional activity with recreation throughout the day. Increased frequency and intensity of adult supervision has been helpful, but very challenging for working parents. We heard of many parents utilizing tele-platforms to juggle monitoring their children while they tended to their own work responsibilities. Many daycares developed programs to support students through virtual instruction days.
We also had to be more flexible around initial assessments and pharmacotherapy. Functional impairment across multiple domains is complicated when the child is not leaving the home! We also reviewed with parents that many pharmacotherapy adjustments would have to be revisited next school year, with the hope that some regimens could be decreased or simplified in a more traditional school year/schedule.
What kinds of strategies did you use to manage kids w/ ADHD differently this past year?
Has the pandemic helped dismantle such longstanding views? Are folks more comfortable acknowledging behavioral health needs and actively seeking care/treatment? Or has the stigma largely remained unchanged?
The pandemic has been a great equalizer is many ways because everyone was vulnerable to get Covid-19. The fear of getting infected, of not knowing what was to come and the isolation due to quarantine and social distancing have contributed to higher anxiety and depression. "Covid-anxiety, coronasomnia" and other terms that came out as a consequence of Covid-19 somewhat normalized these types of complaints but I believe the stigma has largely remained unchanged. Some patients who were relapsing into alcohol and other substances and patients who were experiencing more severe symptoms justified their symptoms as 'normal reactions' to the pandemic and adopted a wait-and-see attitude, hoping that they will get better as we go back to normalcy. At Henry Ford Health System, we developed Behavioral Health Integration with Primary Care two years prior to the pandemic. This model allowed patients who were struggling with anxiety and depression present to their Primary Care Physicians (PCPs) and get mental health care where they are most comfortable with, at the Primary Care Clinic. Programs like these help de-stigmatize psychiatric conditions because it allows patients to talk to their PCPs about how they feel without being judged. Furthermore, with Behavioral Health Integration, PCPs feel that they have help and resources and do not feel burdened when patients come to them with behavioral health concerns.
I have seen that the stigma around mental health has decreased as a result of the pandemic. People are more aware of the impact their mental health has on their functioning and are more willing to talk about it. I have seen this for MILD to MODERATE mental health issues.
However, I think the stigma around SEVERE mental illness and substance use disorders has remained the same.
Are there specific patient populations that struggle to take advantage of these care options? What are the barriers preventing their use? What is needed to make their access more equitable?
Virtual care was slowly transforming the healthcare delivery system prior to 2020 but this catapulted during the pandemic. In mental health, virtual care allowed us to reach some patients who would not have had the chance to speak to a mental health professional due to distance, transportation, and other environmental conditions. Even patients who were stigmatized walking into a psychiatric clinic were able to get help virtually. While we used to think that the older adult population would struggle with technology, we were proven wrong. I believe that one of the barriers is still the ability to afford technology that allows virtual care delivery (smart-phones, computers, monthly wifi fees, community bandwidth/broadband). Acceptability of virtual visits has increased and continues to increase even as the pandemic is easing up but there are still patients and providers who will prefer in person visits.
At CHS, we remain very concerned about the digital divide and the impact on access to healthcare. As a safety net health system, we serve many patients who do not have access to mobile devices nor do they have internet availability. We have clinics in rural counties that are essentially "virtual deserts" - they have no wireless access or ability to access the internet in their homes. Children had to go to the local Walmart or church to access the internet for remote/virtual school. We set up "virtual access points" through ipads in cubbies, and laptops in private 'talk boxes' that look like phone booths, in a separate corner of the clinic space to provide telehealth as patients did not have the ability to engage in telehealth in their homes. We trained our frontline staff as "digital health coaches" to help patients set up email addresses and learn how to log into a virtual visit. As we continue our vaccination efforts, we are sending community health coordinators and outreach workers to help patients sign up for the vaccine. Consider the rush to sign up for the vaccine online - and the impact on access for people who do not have a device, access to internet, and do not know how to go online to sign up for a vaccine. The digital divide is a significant barrier to healthcare access for vulnerable, overlooked, and marginalized communities that has been amplified during the pandemic.
What measures did hospital systems and physician practices employ to meet and manage patient needs? What did you observe in the environment, and what did you/your practice/system/company do to address those concerns?
I imagine as with many other health systems, a key component was a relatively rapid switch to Telehealth access for behavioral health care. At our child psychiatry clinic, we noted a significant increase in show rate as we switched to Telehealth, likely related to increased convenience, decreased travel barriers. Throughout our behavioral health system, this had to be accompanied by greater degree of flexibility in terms of patient engagement on C/L services, inpatient units, psychiatric emergency departments. We also engaged in some concerted outreach to regional primary care provider practices/networks to increase awareness/knowledge/skills around key MH challenges associated w/ the pandemic and ensured they were aware of and encouraged utilization of our various outpatient/inpatient consultation services. Although some clinics and private providers in the region struggled managing the increased volume of referrals, some of our regional CMHCs were able to pivot to increase (largely tele-) access to treatment for the increased MH needs in the community.
I don't think very prepared. It was a system already on the brink. Everything shutdown quickly for concern about consequences of an infection but not the consequences of being locked down. We could have spent some of that down time working on proactive efforts
Wide variety of preparedness. There were increased efforts around mental health screening (in my environment, specifically in pregnancy and the postpartum period with increased touch poitns). This happened through e-charts and via phone where that had not happened previously; historically, it was done in-person with paper surveys. Being able to connect those with positive screens and assessments to behavioral health services was augmented by Perinatal Psychiatry Access Programs.
We talked about child, adolescent, and family mental health yesterday. What other patient populations have been vulnerable to BH challenges, especially during the pandemic?
I think one of the positive outcomes of the COVID pandemic has been increased visibility and concern around health disparities in the US, and across the world.
Unfortunately, individuals from minority populations, underserved populations, rural populations, poor populations, and other groups not in positions of power were more vulnerable to the BH effects of COVID. For many physicians, this is not surprising, since we have seen these health disparities as a chronic problem, not a new problem related to COVID.
I am curious if others are seeing healthcare taking health disparities more seriously due to COVID?
COVID 19 has shone a light on disparities that have existed and have been exacerbated by the pandemic. Many families do not have technology access, have lost employment, etc.
Rapid access has been critical - something mental health is not known for generally. Intake or walk in clinics for people in immediate distress have helped with much needed access. Outreach into the community - with virtual access points and mobile clinics - have opened up opportunities for care for populations who have been marginalized, overlooked, or disenfranchised. Finally, collaboration with community organizations that address social determinants of health has helped engage people who need care the most.
With the decrease of in-person well-visits, there can be challenges assessing social-emotional/mental health needs of children and adolescents, particularly very young children.
Telehealth for children has been a mixed bag. On one hand, the convenient access for families and ability to see firsthand family dynamics and the child's living situation (we have had children proudly give us a tour of their rooms!) has been new, useful, and embraced by clinicians and families. Adolescents love it since it fits within their schema of social media/interaction via screen. On the other hand, it has been difficult to connect and do comprehensive assessments with certain age ranges and presenting concerns. It is difficult to gain information by interacting with a child via screen in the same way as in-person. There have been experiments in meeting the needs of pediatric patients via telehealth. Some have not worked, and some have. We were able to adapt an autism assessment for toddlers via telehealth which was quite successful. We also developed a hybrid model of brief interaction with the family in person combined with a longer telehealth appointment.
Telehealth has allowed for some more formal discussions with parents, where these issues are scheduled as an appointment and there is less barrier to coming into the office for a visit. Additionally, I have seen the benefit of watching the family in the home environment.
Many health care workers have experienced a prolonged period of trauma due to the COVID pandemic. What have you seen at your organization? How are your physicians coping (or not coping) with COVID?
We are seeing this at our organization and also in our work with providers and practices across the country.
I have noticed that many providers are becoming more open about their own mental health challenges. Doing this is critical because as we all share, we can create a community in which we embody that mental health is an important as physical health.
I am very open about my family and I's mental health challenges and the mental health treatment and support we all have. In my experience, others open up when I share. The more we can all do this, the more we can all support each other in prioritizing and taking care of our mental health. Taking care of our mental health should be like going to the dentist, something that we all do to take care of ourselves and our long-term overall health.
I love to see when leaders are able to show personal vulnerability - it is such powerful modeling behavior!
Pending
Telehealth helps with barriers such as transportation or child care and can make care more accessible. The challenge is that unless implemented as part of an integrated care model, it does not decrease barriers due to lack of mental health providers. To truly increase access to mental health care, we also need to leverage the limited providers that are available by building the capacity of non-psychiatric specialists to provide psychiatric care. Models for this include collaborative care and perinatal and child psychiatry access programs.
Connect
Telehealth has been a more convenient way for people to access care - and it also has in some ways made access more private (e.g. no waiting rooms with other people). Many patients prefer it to in-person. However, we have had a significant cohort of patients prefer in-person. Many of our telehealth visits have had to be converted to in-person due to patient request. Patients and providers who prefer in-person state they are unable to connect virtually in the same manner as in-person. Some clinicians feel that they need to be in-person for a comprehensive assessment - this has been particularly true for child clinicians. I think we'll see more hybrid models of care delivery tailored to the individual and family as well as presenting concerns. Some people will want telehealth only, some in-person only, and some a mix of the two. We need to build a system to accommodate all of these access paths.