A recent college graduate working remotely at her first job and cut off from family and social life due to physical distancing measures experiences a recurrence of the anxiety for which she was treated as an adolescent.
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A 30-year-old mother, recently out of work because of the pandemic, is tasked with overseeing remote learning for three youngsters at home. Overwhelmed, she begins drinking more at night and experiences a first episode of major depression.
A 55-year-old man was hospitalized with COVID-19. At home and recovering from the acute effects of the virus, he continues to have lingering neuropsychiatric symptoms.
All three of these patients, and others like them, will be needing mental and/or substance use disorder treatment, along with the many already crowding the virtual waiting rooms of primary care practices. Public health experts and clinicians agree: The COVID-19 pandemic is creating a tsunami of psychiatric illness, including substance use disorders.
Before the pandemic, various models of integrating psychiatric and primary care—especially the Collaborative Care Model (CoCM)—were helping to expand psychiatric expertise to meet the demand for mental and substance use disorder treatment in primary care. CoCM is the only model that bundles all integrated services—including the psychiatric case review and recommendations—and is reimbursed by insurance; it is also the model with the most extensive evidence base for improved outcomes.
Now, leaders in integrated care say that COVID-19 has made integration even more necessary than before—and more attractive and doable (see table). “More than ever, hospitals and systems of care need evidence-based, scalable treatment models to meet mental health needs,” said Andrew Carlo, M.D., M.P.H., an assistant professor in the Department of Psychiatry and Behavioral Sciences at Northwestern University. “Everyone in the community and everyone in the health care system is overwhelmed. We are seeing the emergence of new mental illness in the context of the pandemic and the exacerbation of chronic illness.”
Carlo said integrated care, and especially CoCM, “is really positioned to scale treatment to large populations.”
In a viewpoint article in JAMA Psychiatry, Carlo and co-authors Jürgen Unützer, M.D., M.P.H., M.A., and Brian Barnett, M.D., wrote that collaborative care especially capitalizes on the widespread adoption of telepsychiatry. “Although behavioral health care managers must be prepared to conduct in-person visits if needed, they are encouraged to use the electronic medical record, telephony, and videoconferencing for patient care whenever possible,” they wrote.
Using the same technology, Carlo and colleagues said the CoCM team can communicate with primary care providers and the psychiatric consultant as needed.
Carlo and colleagues especially emphasized that CoCM billing codes are designed to account for all the services delivered by the CoCM team, not just those delivered face to face. “Coupled with recent telehealth billing flexibility for physician services, this means that all facets of CoCM—including individual virtual visits between the patient and psychiatric consultant—are billable.”
In comments to Psychiatric News, Carlo said collaborative care “is a neat fit into the post-COVID delivery system, without changing a lot to the original model.
“Everyone knows and can see how overwhelmed the health system is,” he continued. “Part of our professional ethos as psychiatrists is a commitment to public health. Collaborative care provides psychiatrists a chance to contribute in this crisis by expanding their expertise to the care of far more patients than they can see face to face.”
Other forms of integrated care—co-located mental health professionals in primary care settings or, conversely, primary care physicians in community mental health clinics—have proven successful in meeting the COVID-19 challenge. Lori Raney, M.D., a longtime member of the APA Committee on Integrated Care, said that technological innovation and integration go hand in hand.
Raney said that some primary care practices have perfected the hand-off of patients during virtual visits to a co-located mental health professional by employing an open Zoom “room” for the mental health consult. Integrated practices are also figuring out how to use technology to make screening tools—like the PHQ-9—easier to use.
Raney, a psychiatrist for a primary care practice within the Indian Health Service serving American Indians in rural Colorado, said that the pandemic has made proactive screening of primary care patients for mental illness and substance use disorders a priority. She also said patients presenting with PTSD—for example, people at home with abusive partners or health care workers on the front lines of COVID-19—have become more common during the pandemic.
“COVID has put screening on steroids,” Raney said. She added that advanced integrated networks are also screening for social determinants of health—financial stress, food shortages, housing instability, and transportation needs.
Henry Chung, M.D., chair of the APA Committee on Integrated Care and senior medical director of behavioral health integration strategy at Montefiore Health System, emphasized that billable reimbursement codes now exist for “curbside consults”—informal consultations between psychiatrists and primary care physicians regarding patients’ mental health needs.
The codes were introduced in 2019, and Medicare began paying for them in 2020. The codes are to be used when the patient’s treating physician requests an opinion and/or treatment advice from a psychiatrist. (APA produced a primer titled “Payment for Non-Face-to-Face Services: A Guide for the Psychiatric Consultant.”)
Chung also urged psychiatrists to use SMI Adviser, a website and smartphone app that include a wealth of information about treating people with serious mental illness and provide access to clinical experts. Included in the app is a link to “Primary Care for Psychiatrists: Addressing Health Disparities Among People With Serious Mental Illness.” Chung called it “a timely and effective one-hour CME course.”
He said the pandemic is changing the practice of psychiatry in ways that will likely be lasting. “Parts of the country are now experiencing what New York went through in the first three months of the pandemic, when physicians of all disciplines were called into service,” said Chung, a professor of psychiatry at Albert Einstein College of Medicine. “Here at Montefiore, we had an ‘ICU without walls.’
“Today at our behavioral health clinics, psychiatrists and mental health professionals are redoubling their efforts to tackle chronic medical conditions such as smoking, obesity, hypertension, and diabetes. During the pandemic, patients’ routine access to primary care has been made more difficult, so psychiatrists are taking a more active role in reviewing blood pressure medications and helping patients with smoking cessation.”
Chung said, “Most psychiatrists are going to be asked to do more as their local health systems are overwhelmed.” ■
The APA primer “Payment for Non-Face-to-Face Services: A Guide for the Psychiatric Consultant” is posted here.
Information about collaborative care is posted here.
SMI Adviser can be accessed at smiadviser.org, and the app can be downloaded from SMI Adviser here.
“Primary Care for Psychiatrists: Addressing Health Disparities Among People With Serious Mental Illness” is posted here.
Collaborative Care Rises to the Pandemic Challenge | Psychiatric News