By the end of February, the world was on notice of the dangerous intersection of Covid-19 and psychiatric facilities. In a psychiatric unit in one hospital in South Korea, all but two out of more than 100 individuals contracted the virus, and outbreaks in psychiatric facilities are starting to be reported in the United States.
Psychiatric hospitals and other mental health facilities or residential treatment settings face unique challenges in controlling the spread of COVID-19. Like other health care settings, people in these settings often eat and bathe in shared facilities. An added challenge that is unique to behavioral health facilities is that many facilities still rely on restraint, seclusion, and involuntary medication– interventions which, while already dangerous, now have increased risk due to close contact.
These characteristics of congregate mental health care, added to the fact that people with “serious mental illness” have increased comorbidities with conditions associated with increased risk of complications with COVID-19, such as asthma and diabetes, heightens the risks even more.
Increased risks during COVID-19 pandemic
These increased risks necessitate increased considerations in delivering mental health services. SAMHSA recommends reevaluating the necessity of inpatient mental health services. This could involve restricting inpatient admissions to situations where there is actual risk to life if the person is not hospitalized, and making mental health services available by telehealth whenever possible. Stemming the tide of admissions will be particularly important, as the pandemic is already slowing discharge planning and transitions to appropriate integrated, community-based alternatives.
Still, states must also find ways to ensure continued access to mental health services, particularly given the impact of COVID-19 on many people with mental health conditions. Fears about COVID-19 and isolation due to necessary physical distancing may cause increased stress and worsening of symptoms of anxiety and depression, which in turn often lead to adverse impacts on physical health.
Use of telehealth services
Mental health providers must pivot to alternative methods of service delivery, including telehealth where appropriate. State Medicaid programs already have broad authority to cover services provided via telehealth. In general, no federal approval is necessary to reimburse for telehealth in the same way it does in-person visits, although a state plan amendment may be needed to change billing methodologies. For states that use 1915(i) waivers to provide community-based mental health services, federal regulations already permit telemedicine for needs assessments.
Reducing barriers to mental health telehealth services
States can reduce barriers to mental health telehealth services by:
- Eliminating any requirements for use of videoconferencing. Many individuals may have limited access to the internet, and/or limited data plans available, and providers must be able to bill for services provided by telephone;
- Creating new billing codes to facilitate telehealth;
- Educating providers about good faith exemptions from certain federal health privacy rules during the pandemic and examining any state-specific privacy laws to ensure that good faith exceptions exist in this period.
Medicaid programs and billing codes
Medicaid programs in several states, including Washington, have already created new billing codes so that mental health services delivered by videoconference or telephone are covered and billed at the same rates as in-person visits. New York has waived face-to-face requirements for most behavioral health services and has instructed providers to screen people for symptoms of or exposure to COVID-19 before delivering services face-to-face. California clarified that even those intensive services that require an established site of services, such as residential treatment, still have components that do not need to be provided in person. For example, counseling could happen in a resident’s room via telephone, if appropriate to protect both residents and staff. Last, Hawaii’s guidance suggests that providers affirmatively identify individuals who do not have access to telephones and make alternative arrangements, such as providing services in person while remaining physically distanced.
Co-occurring substance use disorder
Because many individuals receiving mental health treatment have a co-occurring substance use disorder, continued access to medication assisted treatment for substance use disorder will be essential. The federal government has already taken steps to reduce the multiple barriers to such treatment, by allowing states to request flexibility to provide more take-home doses of certain medication and by clarifying that initial consultations for other kinds of MAT may be done via telemedicine. Although these are important steps, states and providers will need to work together to implement these flexibilities.
Advocates should monitor the actions their states are taking to change the way behavioral health treatment is delivered during the pandemic, and advocate to ensure that services are disrupted as little as possible even as they may be delivered in different places and using different methods to avoid COVID-19 exposure.