As many health care providers work to contend with the immediate impacts of the COVID-19 pandemic upon acute care, many Americans are also faced with a significant amount of stress caused by the fear and anxiety of growing uncertainty and economic hardship. Beyond the negative impact of a traditional economic downturn, COVID-19 presents additional challenges that can compound the impact on our collective mental health. There is not only the real fear of the virus itself for individuals and organizations but also grief from the loss of loved ones, prolonged physical distancing, and associated social isolation. A likely surge of people experiencing acute behavioral health problems has the potential to further strain the healthcare system and add costs to an already unprecedented economic downturn. This could be even more daunting if the increased demand for behavioral health services exceeds that for medical services.
Much like telehealth, the importance of behavioral health - while nothing new for many - is being pushed to the forefront as stress continues to be mounted on the healthcare delivery system. The need for integration between primary care and behavioral health has been recognized but, for many patients, an even tighter sense of coordination will be required along the full spectrum of medical and community-based care. While a number of variations of medical care and behavioral health integration models have been deployed, there are several key foundational principles that should serve to drive how all are operationalized:
Team-Based Collaboration – Supported by a primary care provider (PCP)-led inter-disciplinary team working to top-of-license to address medical, behavioral, and social determinant issues
Care Management and Social Determinants of Health – Activities coordinated by an accountable care manager to facilitate care and transitions of patients across clinical delivery and community settings
Digital Health Platform - Enabled by integrated electronic health record and telehealth solutions
Team-Based Collaboration
A well-coordinated behavioral health team comprised of psychiatrist / psychologist, nursing, social work, and patient education resources is often best-suited to work alongside primary care providers to help develop and manage a plan of care. Each team member should be striving to work towards the top of their licenses so that clinicians aren’t diverting time away from patient care to perform non-clinical support, such as completing housing/transportation paperwork or appointment scheduling.
At the center of this relationship is an accountable care manager often providing telephonic case management to follow-up with patients after primary care visits, educating them on their condition, helping them meet their care plan goals as well as relaying recommendations from the behavioral health team to the primary care provider. Ultimately, the primary care provider (PCP) is in control of making care decisions with the patient. The psychiatrist, care managers, and therapists all work together to keep the PCP informed. For example, a psychiatrist may recommend medication and the care manager will inform the primary care provider to prescribe it.
Care Management and Social Determinants of Health
Effective Care Management is all about getting ahead of the curve in managing this patient population. Untreated behavioral health issues, particularly depression, result in huge costs on the medical side. Individuals who are depressed may not engage in healthcare and seek treatment to improve their medical conditions. On top of that, it may take months for patients to get an appointment with a psychiatrist in private practice. Defining clear care management workflows for primary care providers who can access a virtual team of behavioral specialists enables PCPs to serve as a key point of entry into treatment for behavioral health.
Primary care providers can identify these patients by leveraging appropriate behavioral health screening and assessment (e.g., PHQ-9, GAD-7, AUDIT, DAST) tools. When patients with behavioral health needs are identified, they should be assigned to an accountable care manager who works with the PCP and the behavioral health team to develop a personalized care plan that includes medical and behavioral health goals. Interventions between patients and care managers can be in person or by telephone, and involve the following: 1) follow-up with patients after primary care visits reinforcing what the PCP told them, 2) basic education on their conditions / healthcare choices, and 3) help with setting goals. This follow-up might also occur post-hospitalization to ensure transition back to the community is smooth and that the PCP knows about the hospitalization.
It’s been well-documented how impactful SDOH are in managing patient health and well-being. Behavioral health patients with psychosocial needs should be handled by social workers or patient educators as soon as they are identified or referred. If patients are at risk of homelessness or cannot feed their children, they will often pay scant attention to their healthcare, so prioritizing social needs will improve downstream engagement.
Digital Health Platform
An integrated electronic medical record is a key enabler of documentation and care planning functionality, which in turn fosters effective communication and data-sharing. Across settings of care, it is important to maintain visibility into a unified patient record and care plan that every team member can access and contribute towards. Often, technological hurdles prevent members of a team from knowing what each other is doing. Being able to see inpatient notes for the patient or the physician’s record of a visit or psychologist e-visit in real time so a centralized data repository is critically important.
Additionally, telehealth is continuing to foster robust connections and collaboration among PCPs and behavioral health specialists who can provide services in a virtual environment, effectively removing layers of scheduling and facility inefficiencies. With eased restrictions and alignment of financial incentives due to the COVID-19 pandemic, telehealth adoption is accelerating dramatically and should provide another boost for integrated medical and behavioral health teams.
Many people who suffer from depression, post-traumatic stress disorder, and other behavioral health disorders are more likely to accept behavioral healthcare as part of their routine medical care from a primary care provider. Deploying a collaborative approach to behavioral healthcare will be the most effective way to manage medical, social and behavioral health needs. Engagement of a multidisciplinary team, centered around the PCP and leveraging a population-based approach to care management, is critical. The adoption of screening tools to identify patients at risk along with digital health solutions (such as an integrated EHR and telehealth) will enable data-sharing and provide much-needed visibility into care plan data - ultimately enhancing the patient experience.