BY SUSAN PLOUGH MSN, RN, PHCNS-BC, CCM, AND MINDY OWEN RN, CRRN, CCM, FCM
It is no secret that the pandemic affected many aspects of our lives, not only from a physical perspective but also in terms of how we view mental health. In the past, mental health issues have seemingly taken a back seat in healthcare. The pandemic changed all that. Not only did it escalate the number of issues that people in the U.S. were having around their mental health, but it also brought them to light. In addition to serious mental health and substance abuse disorders, the pandemic also opened our eyes to issues around coping with illness and grief, anxiety disorders and depression, including isolation and loneliness, job loss and financial instability. According to the Mental Health Association, as much as 78% of adults experienced or are still experiencing some sort of mental illness because of the pandemic. This could be a “stand alone” diagnosis or associated with a chronic or acute physical condition.
In a recent Kaiser Family Foundation (KFF)/CNN survey, concerns about mental health and substance use remain high even three years after the onset of the pandemic, with 90% of U.S. adults believing that the country is facing a mental health crisis. This increase in mental health and substance abuse issues comes at a time when resources are already strained, and people with mental health diagnoses often face barriers to care. Here are some staggering statistics that came out of that survey that help support that concern:
- Millions of adults in the U.S. experience serious thoughts of suicide, with the highest rate among multiracial individuals.
- Over half (54.7%) of adults with a mental illness do not receive treatment, totaling over 28 million individuals. Even in Montana (ranked #1), over 4 in 10 adults with a mental illness did not receive care.
- Almost a third (28.2%) of all adults with a mental illness reported that they were not able to receive the treatment they needed. Forty-two percent of adults with any mental illness (AMI) reported they were unable to receive necessary care because they could not afford it.
- 10.8% (over 5.5 million) of adults with a mental illness are uninsured. Hispanic adults with AMI were least likely to have health insurance, with 19% reporting they were not covered by insurance.
- 6.34% of youth in the U.S. reported a substance use disorder in the past year. That is equivalent to over 1.5 million youth in the U.S. who meet the criteria for an illicit drug or alcohol use disorder.
- 22.87% of adults who report experiencing 14 or more mentally unhealthy days each month were not able to see a doctor due to costs. “In Georgia (ranked 51), over one-third of adults experiencing frequent mental distress are unable to afford a doctor’s visit.” (“The State of Mental Health in America | Mental Health America”)
- 59.8% of youth with major depression do not receive any mental health treatment. Asian youth with major depression were least likely to receive specialty mental health care, with 78% reporting they did not receive mental health services in the past year. In South Carolina, the lowest ranking state, nearly 8 in 10 youth with depression do not receive care.
- Nationally, only 28% of youth with severe depression receive some consistent treatment (7-25+ visits in a year). Most (57.3%) youth with severe depression do not receive any care.
- Nationally, only 1 in 10 youth who are covered under private insurance do not have coverage for mental or emotional difficulties – totaling over 1.2 million youth. In Arkansas (ranked 51), nearly one-quarter of youth with mental illness have no coverage or access for treatment.
- In the U.S., there are an estimated 350 individuals for every one mental health provider. However, these figures may be an overestimate of active mental health professionals, as it may include providers who are no longer practicing or accepting new patients.
- “The vast majority of individuals with a substance use disorder in the U.S. are not receiving treatment.” (“The State of Mental Health in America | Mental Health America”) In the past year, 15.35% of adults had a substance use disorder. Of them, 93.5% did not receive any form of treatment.
An integral part of the CARES Act is mental health and changing legislation to address areas such as access to care and recognizing that mental health treatment should be covered the same as a medical diagnosis. It includes the use of telehealth and other remote modalities to reach patients with evaluation and treatment support. Across many industries and occupations, the unprecedented challenges of the COVID-19 pandemic have prompted an increased employer awareness of, and concern for, employee mental health needs. In addition, the pandemic has had a disproportionate impact on people with disabilities due to challenges such as increased loneliness from required or self-imposed isolation, anxiety about health and the loss of in-person interaction with colleagues. (Petri et al., 2020). Moreover, higher rates of hospitalizations and deaths from COVID-19 among Black, Hispanic/Latino, and Indigenous populations have exacerbated the pandemic’s effects for these communities in addition to exposing decades of health and social inequalities experienced by Black communities. As a result, people of color with disabilities have been impacted more acutely.
As case managers, we face these issues on a daily basis. Case managers are recognized experts and vital participants in the care coordination team, charged with empowering people to understand and access quality, efficient and effective healthcare. We are also advocates for change to address healthcare disparities, including the cost of mental health care. Today we see a disproportionate number of providers excluding mental health services, fewer providers accepting insurance payments and/or insurance companies that do not cover mental health services at the same level as they do for physical health diagnoses.
In our roles as case managers, as we take the first step in assessing our patients, families and support systems (who are integral to an individuals’ overall healing process), it is important to approach care from a holistic perspective. Implementing a plan of care to manage a patient’s mental health condition is no less important than assessing their physical diagnosis. As we know, this is not always easy or simple. We, as case managers, have the tools and expertise to access resources and provide this support to the patient and their family. This encourages patient choice in the plan of care process and prepares the entire team to reevaluate the plan for changes, as they occur.
However, as we have stated earlier in this article, the resources can be very limited and gaining access to them may be difficult. This is why, as case managers, we continue to use our voice with local, state and federal agencies to encourage expansion of the Cares Act. As we partner with payors to increase access and funding for mental health services, we continue to advocate for those we serve.
While the stigma of a mental health diagnosis is lessening and the awareness has heightened post COVID-19, there continues to be significant work to do. We as case managers can and should lead the effort too:
- Provide a voice in the care planning process.
- Lead the collaboration with the patients’ multidisciplinary team.
- Assess all patients for a “stand alone“ mental health diagnosis, or as a complex diagnosis including a physical condition.
- Create a holistic plan of care for all patients we serve.
- Encourage and support ongoing evaluation of the plan of care.
- Provide support and tools for the patient and care givers.
Case managers play a unique and vital role in the healthcare system today. Our practice setting may include an acute care system, a post-acute facility, a community agency, a mental health clinic, a payor organization, a risk-based plan or a worker’s compensation program. No matter what our practice setting, we bring a voice of expertise, knowledge and compassion to all we serve. At this point in time, let’s use this voice to continue to raise awareness of the toll mental health issues are taking on our collective families and communities. Let’s be the drivers of change to incorporate tools and resources to address these critical issues into the care planning process. And where we do not find adequate resources, let’s raise awareness and help be the driver of change, so that our patients will benefit from holistic care planning. We can be part of the solution by encouraging the building of a much stronger, robust health system for all of us in the future.
This is the value of case management.
References
https://mhanational.org/issues/state-mental-health-america
https://www.kff.org/statedata/mental-health-and-substance-use-state-fact-sheets/
https://www.advisory.com/daily-briefing/2022/10/07/mental-health-crisis
https://www.cnn.com/2022/10/05/health/cnn-kff-mental-health-poll-wellness/index.htm
Susan Plough, 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.
Mindy Owen, RN, CRRN, CCM, FCM, began her career in health care as a critical care specialist in neurosurgery and rehabilitation. She spent three years as the charge nurse of a neuro ICU, and the step-down unit at Milwaukee County Medical Complex. She then joined the team that designed, developed and implemented a SCI-TBI rehabilitation program affiliated with Wesley Regional Medical Center in Wichita, KS. Mrs. Owen was instrumental in preparing the program for both CARF and JACHO accreditation, as well as serving on the national board of ARN during the eight years she directed the program. Her case management career began in 1984, as the midwest regional director of CM for Intracarpal leader in disability, UR, and CM services nationwide. She was asked to be one of the founding board members of CMSA, helping to establish the organization and became its second president. Mrs. Owen has served on the CMSA Task Force (Outcomes and Accountability), the Commission for Case Manager Certification (CCM Chair–1996 and 2005), ACCM Leadership Council, the editorial board of The Case Manager magazine and Lippincott’s Case Management Journal, the Case Management Standards of Practice Task Force sponsored by URAC, and advisory boards for NMHCC, Contemporary Forums, Mosby’s, Ortho Biotech and Glaxo Welcome. Currently, Mrs. Owen is the principal of Phoenix Healthcare Associates, LLC, Coral Springs, FL, a consulting firm specializing in education and development of case management and disease state management programs. She completed an extended assignment as the interim director of case management services University of NC Hospitals, Chapel Hill, NC. Previously, she was the lead consultant to the state of Florida and Pfizer in a DSM initiative to implement a new DSM program for Medicaid recipients. Mrs. Owen is presently serving as the lead consultant for a case management integration and implementation initiative at a large academic medical center in AZ. Mrs. Owen has published numerous articles, monographs, and curriculum; and is acknowledged as a contributing author of Case Management in HealthCare–2nd edition, 2003. She is a much-requested speaker, serving on several health care national speakers’ bureaus. DISCLOSURE: Presenter discloses that she had advisory board membership with ACRP as a public member. She also has been an honorarium recipient of CMSA; and had editorial board involvement with the “Professional Case Management,” a Lippincott publication.
IMAGE CREDIT: ISTOCK.COM/VISUAL GENERATION
