Medical and physical health are not in silos, far away from behavioral health. Every year, healthcare providers become more aware of that fact while integrated models of care and case management become the norm.
The effects of COVID-19 have brought behavioral health issues to light — and, in some cases, the handling of the pandemic has even caused behavioral health problems.
“We’ve seen anxiety as a result of burnout and uncertainty, depression due to isolation and loss, change of lifestyle, and an increase in suicidal ideation,” says Melanie Prince, MSS, MSN, BSN, NE-BC, CCM, FAAN, president of the Case Management Society of America. “Of course, the physical loss of a loved one is significant. But there are also children who can’t process what is going on, they’re internalizing more, social media is replacing human interaction, and the lack of a sense of normalcy for both children and adults has been a struggle.”
Moving forward, “we’ll continue to see the results of the pandemic’s toll on relationships — as relationships are deteriorating, it may be a long-term toll,” she adds.
With more patients presenting with mental and behavioral health issues, it is more important than ever to consider a collaborative model of care.
Collaborative Approach
Patients receiving care in the context of the collaborative care model benefit from a healthcare team comprised of a primary care provider (PCP), behavioral healthcare managers, psychiatrists, and other mental health professionals. The patient also is considered part of the care team, and their input is sought throughout the course of treatment.
According to Toni Cesta, PhD, RN, FAAN, this model should include shared care plans, incorporated patient goals, a familiar location for treatment, and the reduction of duplicate assessments.
Specific practices for collaborative care include:
- evidence-based care coordination and brief behavioral interventions;
- supporting treatments such as medications initiated by the PCP;
- providing evidence-based, brief/structured psychotherapy, such as cognitive behavioral therapy;
- face-to-face services and a continuous relationship;
- engagement with the patient outside of regular clinic hours, as necessary.
“There should be an emphasis on engagement, shared decision-making, and anything where the patient is a part of [the team],” Prince shares. “This can help make things easier between the patient and case manager relationship and reduce anxiety altogether.”
The collaborative approach also helps patients feel like they can change what happens to them, which is quite different from how many patients — and certainly those experiencing mental or behavioral health issues — perceive things.
“In many cases, the patient may feel like things are happening to them, so we need to consider the most effective ways of addressing the patient’s concerns,” Prince says. “Case managers will need to break through the walls of misinformation and help the patient understand the plan of care. I know there is not always time to do that, but sometimes it also helps to bring in a mental health professional to talk about the plan.”
In any event, it is worth working toward a collaborative care model to provide well-rounded care. This model also boasts several positive outcomes, such as:
- clinical effectiveness;
- demonstrated higher effectiveness than usual care;
- better outcomes for depression, anxiety disorders, bipolar disorder, and schizophrenia;
- cost-effectiveness;
- cost savings in every category of healthcare costs examined, including pharmacy, inpatient and outpatient medical, and mental health specialty care;
- return on investment of $6.50 for every dollar spent.1
Cesta also notes, “The Centers for Medicare & Medicaid Services published final rules that allow federally qualified health centers (FQHCs) and rural health clinics to bill for behavioral health integration services, chronic care management, and the collaborative care model.”2
Caring for the Caregivers
The mental health of case managers and other care providers also should be of concern.
Especially during times of high hospital census, providers may experience anxiety and fear of contracting a disease while working to cope with profoundly high numbers of patients and deaths.
Pre-pandemic, “It was almost a rarity to have someone die on your shift, but during the last couple of years, clinicians have been dealing with three, five, 10, or more deaths in a 12-hour shift,” Prince shares. “When serving in the Air Force, I underwent training and practice in seeing what hundreds of body bags would look like on a field. But my civilian counterparts have likely not had that kind of training, so it may be more difficult to cope.”
Prince notes nurses and other providers she knew left the medical field due to inability to cope with the demands of the pandemic, anxiety, and, for some, the nightmares they experienced.
“To not be able to use all of your skills and instead to watch people die, especially when — as some clinicians believed — these are preventable deaths, it was very difficult,” Prince says. “There was a snowball effect and vicious cycle with availability of staff, workforce numbers, and even the lack of gratitude that grew out of the whole ordeal. Patients were becoming verbally or even physically abusive, and wanted to dictate their care based on what they were hearing in the media. When clinicians were not doing what [patients] wanted, [patients] would get angry.”
Case managers were the patient advocates in these situations, but sometimes the requests from patients would contradict their own best interest. It was an increasingly stressful situation, Prince adds.
With scenarios like this popping up all over the country, workplace wellness and provider self-care has become even more important. One facility with which Prince consults contracted with massage therapists, chefs, an exercise physiologist, and others to help prevent provider burnout and to support mental health.
For others, Prince recommends case managers recognize the signs and symptoms of a traumatic response in the body to be better prepared to seek trauma care early.
“Providers should also ensure that they have time off to recover, and they should fight for their work/life balance — and it is a fight,” Prince says. “It may help to create internet-information-free time zones throughout the day and find ways to replace that time with something you love, like reading, music, or an activity. Providers should also be aware of vicarious trauma.”
REFERENCES
- Unützer J, Harbin H, Schoenbaum M, Druss B. The collaborative care model: An approach for integrating mental and physical health care in Medicaid health homes. Center for Health Care Strategies. May 2013.
- Centers for Medicare & Medicaid Services, Medicine Learning Network. Behavioral health integration services. March 2021.
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