In a time when physical distancing and isolation are necessary responses to COVID-19, healthcare clinicians are rightfully concerned about their personal mental health as well as that of their colleagues, family members, and patients. Join our discussion about how COVID-19 has affected mental health needs within your practice and how you are working to address both your own, and your patients’ needs within the current context.
What are your plans for mental health care moving forward in light of events, movements, and topics such as COVID-19, the BLM movement, police brutality, etc.?
What resources are available to you and your staff to address personal mental health needs? How/where did you find them?
There are multiple general resources for patients and providers available for well being strategies found on trusted online sites sponsored by the AMA, AAFP, and other national organizations. Difficulty is noted for locating very specific culturally specific literature. As the need arises it is important to communicate requests allowing these resources to be developed
We had close to zero before the pandemic, then 100% once it started. Now we are at about 80%. I suspect some will request these visits in the future due to travel or other reasons. I am guessing maybe 20% in our practice will be virtual eventually. If reimbursement is the same, that number will go higher.
It is desired for 20-30 percent of sessions to be conducted utilizing a telehealth platform. The telehealth service is contingent upon reimbursement. Patients provide positive feedback for telehealth sevices with further defined strategies for laboratory and urine drug screens to be conducted at facilities closest to their home. Both patient, provider, and physician advocacy for telehealth may convince continued parity payment.
We have provided telehealth sessions in Psychiatry for years before the pandemic. The pandemic shifted it into high gear: 95+% of all ambulatory sessions are by video or telephone. The convenience for patients is significant: our no-show rate plummeted. I believe funders (M'caid, M'care, commercial) are finding benefit for patients with this model and will continue funding- it is up to us to advocate for appropriate compensation based on our work, not the method of delivery. From national conversations, I expect that telehealth provision of psychiatric care will continue post-pandemic, likely between 40-60% of all sessions.
Parents, having to oversee educating their children at home, as well as possibly working from home, has led to a lot of anxiety in that group. I also see children whose parents are being very strict on social distancing, but seeing their friends out playing, having a difficult time.
We have seen a predictable upsurge in anxiety and depression at all ages and a significant increase in substance use of all kinds.
What resources have your clinics provided to screen for the increased risk of Intimate Partner Violence, given the increased time at home during Novel Coronavirus/COVID-19? Have you noticed an increase in patients (adult or children) who have endorsed more IPV since the pandemic started?
We have not done any additional screening for IPV, but have created social programs that are intended to benefit members feeling unsafe in their homes, or to help alleviate stressors. For example, we created a temporary housing program for members who are high risk and have minimal resources. This would provide a safe place to stay and minimize exposure to COVID. Additionally, we created a volunteer courier service for our members and focused initially on parents who we knew might be having challenges obtaining diapers or other supplies that might lead to additional stressors in the home.
Intimate partner violence was noted within the first week of shelter in place. The safety net of domestic violence shelters was a challenge as the facilities did not accept new referrals. The overt cases were reported by the patient directly whereas the covert cases are identified with general screening tools such as PHQ9 and GAD7. Open ended patient interview questions will sometimes allow communication to reveal intimate partner violence.
We have not yet created a digital platform for our members specific to mental health. But to answer your question, I think the most important stakeholder is the patient.
Before anything else, the app has to be easy to use and reliable for all parties: patient, scheduler, clinician. The more specific the use of the app, the more specific the stakeholder groups should be. Rural versus urban; age-appropriate; gender and gender orientation appropriate; culture-appropriate. To address health inequity, it should be usable with very limited resources as well.
Samantha great question: which loneliness screens are people using?
Any other types of support that would be helpful or are needed that you don't have currently, including those enabled by technology?
More online appointments would be both helpful and efficient. It is often difficult to coordinate these with one's EHR. Compliance with follow-up appointments, or even initiating an appointment, might occur.
There are so many opportunities that technology might provide. Here are just a few: 1) Insomnia is one of the major problems we treat in psychiatry. Using wearable technology, we might collect data to guide treatment- to measure movement and sleep quality at night as well as to provide non-pharmacological treatment in real time. 2) Coaching to enhance the benefits of cognitive behavioral therapy. Integrating game-like technology and real-time feedback might provide wonderful support for those dealing with depression, anxiety, and substance use disorders. 3) Focused support for skills acquisition and practice using real-time wearable technology to remind our patients of medication, exercise, time for meditation, diet management- all with reinforcing behavioral economics application. 4) Capturing the data (with patient consent) to guide clinician support and decision making to enhance recovery-oriented treatment.
The traditional model of mental health scheduling - in 30, 45 or 60 min appointments is going by the wayside. People are getting used to convenience and have limited time. We know that brief behavioral health interventions are effective. Technology that supports multiple, brief touch points for boosters, interactive check-ins, and accessible information for behavior change supports can strengthen the impact of clinical interventions. The intersection of clinical visits and patient-centered apps to support the care plan is ripe for technological innovation.
What safety measures have you put in for patients, staff, colleagues, yourself (establishing confidentiality/privacy, insurance, etc.)?
Ours is a medical office, with integrated mental health. As such, we have many measures in place already. The main ones that affect our mental health providers are using telehealth to limit in house clients, spreading out our day (two shifts), so that there are fewer providers at any one time, and using various entrances/exits to limit contact in the hallways. Also, patients are bypassing our waiting room, and brought immediately into a room by a receptionist who is stationed outside of our entrance. Temperatures are taken daily on all staff, and protocols are in place for those staff who are ill or travel or are exposed.
We are continuing our standard screening, triage, and testing processes at all of the clinics. We are planning for clinical density that is 10-25% of our pre-COVID-19 baseline. This means an additional layer of coordination of who will be seen in-person and when they will be seen. We are also planning to maintain as much virtual care as possible to reduce foot traffic in the clinics.
What do patients expect from physicians using these technologies to provide mental health care?
We have moved to over 90% of behavioral health visits via telehealth and consistently we hear two things 1) patients want the platform to be easy to use, and 2) patients want the platform to be reliable. Dropped calls, fuzzy pictures, clunky and multi-step log-in processes make access to care unpleasant and challenging. "Make it easy and reliable" is now included in our vetting of any technology platform for patient care.
I agree and can reaffirm from our experience what Dr. Khatri has shared: ease and reliability of use are critical. We experience profound frustration dealing with our own EHR and technology- and we are professionals. Understanding this challenge from the patient perspective highlights the need for ease of use and reliability.
We've learned that continued wellness checks with patients gives permission to identify if someone is experiencing exacerbated stress or may be without basic needs during this time. While restrictions may have eased several communities we work with have limited access to stores due to closures from demonstrations and civil unrest.
Addtionally, bringing the spirit of wellness checks to employees has been helpful to ensure our staff feel supported during this time.
We have been working with our communities pre-COVID to address health inequities; that work is now accelerating. Our partnerships are growing to more broadly address safety, secure housing, education (we are closely partnered with our regional schools), job training (in collaboration with Virginia Tech and others), and a lot of formal training and work on addressing both bias and structural inequality that leads to disproportionate health and mental health burdens among our minority and underrepresented community populations.