COVID-19 Impact on Behavioral Health: Collaborative Care is an Essential, Cost-Effective Solution

The COVID-19 pandemic has created an increased demand for behavioral health services. In a recent Kaiser Family Foundation poll almost 50 percent of people reported that coronavirus was having a negative effect on their mental health.[1] Contributing factors include increased social disconnection, a compromised sense of safety and worry about financial security (which is also associated with an increased suicide risk).[2] In addition, up to 30 percent of the population may develop new behavioral health conditions.[3] The brunt of this demand will be felt by primary care practices where most patients seek behavioral healthcare. Primary care providers do not generally have the training, expertise nor time to treat patients with behavioral health needs.[4] To address the increased demand for behavioral healthcare they should adopt evidence-based models, such as collaborative care, that integrate primary and behavioral healthcare.

In this brief, we outline five key requirements to quickly and cost-effectively stand up or expand collaborative care.

1. Incorporate Four Core Evidence-Based Features into the Integrated Model

There are many types of integrated models. For the purposes of this brief we will use the term “collaborative care” to describe those models with features that have been demonstrated to be effective through extensive research and our own experience. These features include:

• A collaborative approach to behavioral healthcare as the most effective way to manage both physical and behavioral health.
• A commitment to a population-based approach including the use of screening tools to identify patients at risk.
• Use of validated measures to identify patients who would benefit from treatment and track their progress (e.g., PHQ-9, GAD-7, AUDIT, DAST).[5]
• Engagement of a multidisciplinary team centered around the PCP including a behavioral health clinician, consulting psychiatrist and other potential support (e.g., psychiatric pharmacist).

2. Adapt the Model to Address the Behavioral Health Needs Specific to COVID-19

Strategies are needed to appropriately allocate limited resources based upon the severity of symptoms and risk for developing behavioral health conditions. High-risk groups include seniors, patients with chronic medical conditions, COVID-19 patients or individuals in direct contact with these patients (e.g., first responders, healthcare employees and caretakers) and those whose financial security is threatened. The following strategies are important:

• Modify screening tools to broadly screen and rescreen all patients, to proactively identify individuals at risk.
• Deploy a range of strategies to reach a broader population including systemic approaches to education about coping skills (i.e., information on patient portals and outgoing voicemail messages) and short-term interventions for patients with non-debilitating anxiety/stress symptoms.
• Develop clinical workflows and protocols that can be managed by medical assistants or non-clinical staff (e.g., standing orders guiding automatic referrals).
• Provide additional training to address crisis-specific issues (e.g., isolation/quarantine, exposure) and crisis intervention (e.g., psychological first aid).

3. Use Collaborative Care Codes to Generate Revenue

The collaborative care billing codes developed by the Centers for Medicare and Medicaid Services (CMS) are increasingly being adopted by private payors and state Medicaid divisions. Compared with traditional episode-based billing for psychotherapy, collaborative care code reimbursement is based upon time spent delivering care management and behavioral health services through a team-based approach. This enables the practice to utilize a broader complement of providers and staff with fewer restrictions on how they are deployed when using telehealth. The use of these codes has enabled many primary care practices to build financially sustainable, if not profitable, programs. To be successful, practices should make the following operational changes:

• Optimize clinician caseload and productivity.
• Re-configure roles: (1) ensure that clinicians are working at the top of their license, including nurses, medical assistants and health navigators to support the process; (2) engage non-clinical staff in supporting protocol-guided triage and registry monitoring/update; and (3) utilize furloughed or part-time and underutilized staff (covered by new sources of revenue).
• Build a process to monitor and stay current with compliance requirements for billing and documentation, and other regulatory requirements which are evolving to support new care processes, generally, and specific to the pandemic (e.g., expanded use of telehealth – see below).

4. Adopt Telehealth as the Primary Vehicle for Delivering Collaborative Care

Despite compelling evidence that telehealth is as effective as face-to-face clinical encounters for most types of outpatient behavioral healthcare,[6] regulatory barriers have limited its adoption. With the advent of the COVID-19 pandemic, CMS has eased regulations for the use of telehealth for behavioral healthcare and other clinical services to mitigate the barriers to access resulting from the need for social distancing.[7] The transition is already occurring in many primary care practices that are seeing dramatic reductions in in-person visits. Using telehealth has quickly moved from an “innovation” for early adopters to an absolute requirement for all practices to deliver care.[8]

• Tailor the type of virtual encounter (e.g. videoconferencing, telephonic interaction) based upon clinical need, patient preference and access to technology including hardware and high-speed internet.
• Given the risks related to COVID-19 exposure, limit in-person consultation/therapy to more complex patients or those who may have greater challenges staying engaged with treatment.
• Ensure that providers and patients have access to the appropriate HIPAA-compliant technology and protocols to support virtual connection.
• Provide appropriate training/procedures to manage patients in crisis, including a process for emergency referral, when connecting with them virtually.[9]

5. Launch or Rapidly Grow Collaborative Care Programs in the Next 30-60 Days

Healthcare organizations must be innovative, practical and strategic to quickly stand up or expand collaborative care programs to meet the increased demand for behavioral health support due to the pandemic. Fortunately, there is over 20 years of industry experience that can provide useful guidance and insights.[10]

• A significant financial investment is not needed for the essential components: a registry (using a simple spreadsheet), a part-time behavioral health clinician/care manager and part-time consulting psychiatrist, and a method to track time in the EMR (if using the collaborative care billing codes).
• For some organizations, outsourcing may be a potential option to provide the expertise and/or additional bandwidth required to meet demand in the short term, while gaining the experience to become self-sufficient.

Conclusion

The COVID-19 pandemic is forcing dramatic changes in how primary care is delivered. Many of these changes will likely endure as we learn new ways to deliver care more efficiently and conveniently, particularly through telehealth. Integrating behavioral healthcare through the adoption of the collaborative care model is critical to address the full impact of the pandemic and to position primary care practices for the future.

Sources

1. https://www.kff.org/report-section/kff-health-tracking-poll-early-april-2020-the-impact-of-coronavirus-on-life-in-america-coronavirus-findings/
2. Nordt C, Warnke I, Seifritz E, Kawohl W. Modelling suicide and unemployment: a longitudinal analysis covering 63 countries, 2000-11. Lancet Psychiatry. 2015 Mar;2(3):239-45. doi: 10.1016/S2215-0366(14)00118-7. Epub 2015 Feb 25.
3. Bonanno GA, Brewin CR, Kaniasty K, Greca AM. Weighing the Costs of Disaster: Consequences, Risks, and Resilience in Individuals, Families, and Communities. Psychol Sci Public Interest. 2010 Jan;11(1):1-49. doi: 10.1177/1529100610387086.
4. Crowley RA, Kirschner N. The Integration of Care for Mental Health, Substance Abuse, and Other Behavioral Health Conditions into Primary Care: An American College of Physicians Position Paper. Ann Intern Med. 2015;163:298–9.
5. PHQ-9 (Patient Health Questionnaire), GAD-7 (Generalized Anxiety Disorder scale), AUDIT (Alcohol Use Disorders Identification Test), DAST (Drug Abuse Screening Test).
6. Hilty DM, Ferrer DC, Parish MB, Johnston B, Callahan EJ, Yellowlees PM. The effectiveness of telemental health: a 2013 review. Telemed J E Health. 2013 Jun;19(6):444–454. Available at https://www. ncbi.nlm.nih.gov/pmc/articles/PMC3662387/.
7. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
8. Mostashari F. COVID-19 pushing primary care to the brink of collapse. https://www.modernhealthcare.com/opinion-editorial/covid-19-pushing-primary-care-brink-collapse.
9. [iii] https://www.healthleadersmedia.com/clinical-care/how-telemedicine-can-drive-change-behavioral-health-services
10. Dissemination of integrated care within adult primary care settings: The Collaborative Care Model. American Psychiatric Association Academy of Psychosomatic Medicine. https://www.integration.samhsa.gov/integrated-care-models/APA-APM-Dissemination-Integrated-Care-Report.pdf

Authors

Mark B. Wenneker, MD
Principal, Behavioral Health Segment Leader, The Chartis Group
[email protected]

Virna Little, PSyD, LCSW-r, SAP, CCM
Chief Operating Officer and Co-Founder, Concert Health
[email protected]

Jennifer Pinto, LMHC
Senior Vice President for Clinical Services and Innovation, Old Colony YMCA
[email protected]

Alejandro Dan Mendoza, MD
Director of System Integration, Department of Psychiatry, Beth Israel Deaconess Medical Center
am[email protected]

Pamela Damsky
Director, Service Line Planning, The Chartis Group
[email protected]