BY , PHCNS-BC, MSN, CCM
At the end of 2020, many Americans thought the worst of the pandemic was behind us. However, as we enter 2022, we continue to deal with many of the same issues we dealt with then. We would all agree that COVID-19 is an international public health emergency unprecedented in modern history. Besides the biological context and the wide and long-lasting changes in daily life it has caused, coping with COVID-19 presents a challenge to one’s psychological resilience as well. What we know from history is that epidemics and outbreaks of diseases have been followed by drastic individual and psychosocial impacts, which eventually become more pervasive than the epidemic itself. This pandemic will likely not be an exception.
The spread of COVID-19 has impacted every person in this country. We also know that people affected by mental health conditions have faced unique challenges during this time. Many of them lost their health and mental health coverage due to COVID-19 shutdowns. They also lost access to support systems at a time when they needed them the most. Congress realized that without addressing this potential problem, there could be even bigger problems to deal with in the months and years ahead.
There are provisions in the Coronavirus Aid, Relief and Economic Security Act (CARES Act), signed into law on March 27, 2020, that help people with substance use disorders (SUDs) and the healthcare professionals who care for them. Congress has recognized that people with SUDs are especially vulnerable during the current public health emergency, and economic hardship is likely to expand the SUD crisis further.
Here are two important developments in the CARES Act:
- The Substance Abuse and Mental Health Services Administration will receive $425 million to address mental health and substance use disorder needs because of the coronavirus pandemic, including:
- $250 million for certified community behavioral health clinics to increase access to mental healthcare services.
- $50 million for suicide prevention to provide increased support for those most in need of intervention.
- $100 million in emergency response grants, flexible funding to address mental health and substance use disorders, as well as to provide resources and support to youth and the homeless, throughout the pandemic.
The federal privacy restrictions found in 42 CFR Part 2 (“Confidentiality of Substance Use Disorder Patient Records”) have been revamped to allow health professionals who treat substance use disorders to share patient records for care coordination purposes if a patient consents.
While we all recognize the need for continuation of services for those people who we know have mental health disorders, another group of individuals who fall into this category and are at high risk of mental illness are the healthcare workers themselves. This group also will be accessing the CARES ACT dollars set aside to address mental illness and are some of the most vulnerable as a result of the aftermath of the pandemic. It is essential that health authorities identify groups with a high risk of developing emotional issues to monitor their mental health and carry out early psychological and psychiatric interventions. Among these are the healthcare workers assisting patients with known or suspected COVID-19: primary care workers, such as nurses, nursing technicians and medical doctors who are in direct contact with patients and their body fluids. These factors can result in different levels of psychological pressure, which may trigger feelings of loneliness and helplessness, or a series of dysphoric emotional states, such as stress, irritability, physical and mental fatigue and despair. The work overload and the symptoms related to stress make health professionals especially vulnerable to psychological suffering, which increases the chance of developing psychiatric disorders.
Health professionals who are in direct contact with infected patients need to have their mental health regularly screened and monitored, especially in relation to depression, anxiety and suicidal ideation. It is suggested that somatic symptoms such as insomnia, anxiety, anger, rumination, decreased concentration, depression and loss of energy are evaluated and managed at the institution by the mental health professionals. It is also recommended that psychological/psychiatric care is provided to professionals in hospitals or other healthcare settings.
People need ways to manage existing mental health conditions and maintain mental wellness while reducing their exposure to COVID-19. This is especially important for people with mental illness who have co-occurring medical conditions or who take medications that suppress their immune system. To address this, Congress is working to eliminate all barriers to widely implementing telehealth in all public and private health plans, including for new patients and with a wide range of mental health providers. Telehealth around mental illness is an effective way to provide therapy and treatments that help people stay on the road of recovery while practicing social distancing. It also allows coverage to areas of the country that might not have access to mental health providers. In addition, through the CARES ACT, all health plans are encouraged to provide extended supplies and/or mail order refills of prescriptions. Restrictions on prescription refills increase risk of COVID-19 exposure for people trying to maintain their mental health treatment.
Other areas of concern that need legislative support are passing funding for Emergency Response Grants at the Substance Abuse and Mental Health Services Administration (SAMHSA), which would assist states in continuing to provide treatment for people with mental health conditions and substance use disorders in response to this crisis. In addition, removing barriers to mental health treatment and promoting coverage for both health and mental healthcare is vital. People with mental health conditions are often uninsured or face barriers to getting needed treatment and supports, particularly during this time of national crisis.
The CMSA National Public Policy committee recognizes the need for better coverage for mental health and has identified mental health as being one of three major priorities for the next two years. Case managers are recognized experts and vital participants in the care coordination team who empower people to understand and access quality, efficient healthcare. The mission of CMSA is to advocate for patients’ well-being and improved health outcomes through fostering case management growth and development, impacting healthcare policy and providing evidence-based tools and resources.
Because mental health services should be part of every case management integrated care delivery model, CMSA is incorporating mental healthcare in the CMSA non-profit Standards of Practice Guidelines, as well as drafting model legislation and amendments that promote CMSA’s Standards of Practice. Additionally, CMSA will look to work with mental health parity advocates to attach case management as a recommended service to their model bills like Senate Bill (SB) 855, which is being introduced in multiple states.
The CMSA Public Policy Committee is committed to being actively involved in ensuring that mental health services are a critical component within the Integrated Case Management Model of Care. Included in the model will be:
- Equity. Illnesses of the brain should be treated like any other illness of the body. Mental health is now being recognized as a vital component of healthcare delivery by patients, providers, healthcare advocates, payers, employers and a wide array of other interested parties.
- Integration. Promoting mental health is a fundamental value of case management and must be part of any integrated case management model of care.
- Resources. A myriad of resources should be used to promote mental health including case management interventions, telehealth, outpatient visits, home visits and CMSA educational programming.
- Outcomes. Utilizing case management programs and services to promote mental health will improve clinical and financial outcomes.
The CMSA Public Policy Committee believes that Complex Condition Management programs should be used, which incorporate and address both the physical and mental needs of each patient and that case management should be used to address all types of individuals with mental health conditions including the homeless and geriatric populations. The committee also believes strongly that screening for mental health needs to be a priority including treatment protocol and reimbursement and that transition of care pathways should be used which include appropriate “step down” and other support programs. Other observations that the committee would like legislatives to address:
- Payer reimbursement historically has been lacking for mental health and addiction services.
- Mental health assessments are often undervalued and not implemented robustly and holistically.
- Need to create homeless shelters that feel like home and provide comfort and support services and bringing in resources in rural/urban settings for successful management of patients.
- Re-think coordination of care conference consultations so they are not simply medical director driven but are fully inclusive of the patient’s biopsychosocial needs.
- Ensure that we are properly assessing complex patients to optimize interventions and considering all patients’ attributes, including geriatric or homeless status, any substance addiction or psychoses.
If these things are addressed, a significant impact would be felt in the following ways:
- Work with mental health provider groups to increase evidence-based pathways, which leverage case management services.
- Optimize case rounds to go beyond utilization management. Build more partnerships with healthcare firms to effect change and to increase awareness of mental health status.
The pandemic took a toll on the mental health of many people across this country. Nursing staff dealing with sick patients, long working hours, managing the communication between family, providers and patients as well as dealing with dying patients who had no one to be with them as they passed, tooks its toll on the mental well-being of the healthcare providers, including case managers. Adding to this was the fear of contracting the virus and significant changes to our daily lives as our movements were restricted in support of efforts to contain and slow down the spread of the virus. Faced with new realities of working from home, temporary unemployment, home-schooling of children and lack of physical contact with other family members, friends and colleagues, it became obvious that we must look after our mental as well as our physical health. There is also clear evidence that the pandemic has not affected all Americans equally. As is often the case, unfortunately, the most vulnerable among us felt the mental health effects most intensely. Job loss, housing instability, food insecurity and other risk factors for poor outcomes have disproportionately hit some communities more than others. The pandemic has raised awareness of mental health symptoms and service needs. Many agencies are working hard to raise public awareness of the resources that are available to support people’s immediate mental health needs, and healthcare providers have made a rapid transition to phone and computer-based telehealth, with widespread adoption across both private and public mental health systems.
The mental health impacts of COVID-19 continue. From all that we know, it is clear these impacts will outlive the pandemic itself. Therefore, it is crucial that we work together to apply evidence-based strategies to support the mental health needs of all Americans and to make these strategies broadly available, especially in vulnerable communities. As a result, mental health is now being recognized as a vital component of healthcare delivery by patients, providers, healthcare advocates, as well as payers and employers and a wide array of other interested parties. Case managers have always promoted mental health as a fundamental value of our profession and continue to promote mental health as a part of any integrated case management model of care.
As we come out of the pandemic, case managers across this country are beginning to reflect on where we were, where we have been and where we go from here. We are recognized experts and vital participants in the care coordination team. We empower people to understand and access quality and efficient healthcare. We are advocates for patient well-being and improving health outcomes both physical and mental. We also impact health policy by providing evidence- based tools and resources.
The Public Policy Committee of CMSA will continue to support both state and federal legislation around mental health and are committed to work collaboratively with other disciplines to understand individual federal and state regulations, restrictions, temporary mandates and directives and to monitor for updated regulation actions for healthcare systems and providers. The PPC is passionate about the work that we do and is committed to turning that passion into policy for the greater good for case managers everywhere.
REFERENCES
https://www.scielosp.org/article/csp/2020.v36n4/e00063520/
https://www.jdsupra.com/legalnews/cares-act-includes-behavioral-health-67531
, PHCNS-BC, MSN, CCM, has a diverse background in both nursing and in case management. She has served as executive director of medical management with physician hospital organizations as well as director of hospital case management for both large multi-hospital healthcare systems and smaller case management departments in the Midwest. She is a Board-Certified Clinical Nurse Specialist in Community Health as well as a Certified Case Manager. Currently she is on the faculty for Indiana University School of Nursing and does private geriatric case management for Senior 1 Care. Susan is chairman of the National Public Policy Committee for CMSA and is a board member and past president of the Central Indiana Chapter of CMSA. She has published nationally and has presented both locally and nationally on case management topics.
