Listed below is an article from Forbes highlighting the movement of New York’s behavioral health system to providing services remotely during COVID. There has been a great deal written about telehealth and its impact as a clinical intervention for individuals in the public mental health system.
Clearly telehealth has had a huge impact and undoubtedly, both in New York and Federally, there will be broad discussion about efficacy moving forward. Scott Thomas, the Division Director of Clinical Rehabilitation Services at the Columbia-Greene MHA, stated it well in the article saying, “Post-Covid there is some sort of hybrid model that allows for Medicaid reimbursement using both virtual and in-person services”
How Covid-19 Challenged Behavioral Health Services
Jackie Rocheleau Contributor
I write about the brain, public health, or both at the same time.
Like many other industries, in March New York’s behavioral health organizations went from business-as-usual to mostly remote in a matter of days. Behavioral health organizations, which provide mental health and substance use disorder services, and their staff faced technical as well as financial challenges, in addition to the emotional strain of caring for people during a global health crisis.
Ann Murphy, director of the Northeast and Caribbean Mental Health Technology Transfer Center (MHTTC), and her team surveyed 238 behavioral health organizations in New York state, ranging from residential facilities to outpatient offices, to see what challenges most heavily affected these organizations. Almost all reported that financial troubles stemming from the lockdown threatened their ability to take care of staff and clients in addition to the business. And the switch to telehealth services wasn’t as easy as telling counselors and case managers to go home and set up Zoom. It revealed a digital divide that affected how staff could connect with clients, and also who could continue to receive regular behavioral health services.
These challenges come at a time when more people are experiencing mental health problems. “Demand has skyrocketed,” said Regine Galanti, clinical psychologist at Long Island Behavioral Psychology. “That’s good for business, but the challenges of delivering services have increased dramatically.”
Murphy and her team surveyed organizations from across New York state, asking administrators as well as staff who interact with clients what challenges COVID-19 brought during the month of April. A disproportionate number of organizations were from New York City and Long Island, and outpatient programs were over-represented. But the authors write that the state’s diverse population and mix of urban, suburban and rural areas might make their findings more broadly representative.
The challenges respondents reported included sustaining business operations, accessing necessary technology, developing Covid-19-related safety protocols, communicating with everyone in the organization and setting up and providing telehealth service.
“Telehealth has been in existence in the mental and behavioral health field for quite some time, but at the edges,” said Murphy. “And with Covid, within days almost all the services that could shift to telehealth did.” Clinicians had to resume services with little if any training on how to use the technology or adapt their offerings virtually.
“I treat young children, and how to engage them on a telehealth platform, to use therapy in a way that works for people, has been a difficult problem,” said Galanti.
Despite the challenges of engaging younger children, generally one-on-one counseling works well virtually, according to both Galanti and Murphy. “But in the public mental health system that’s a small percentage of what’s actually delivered,” Murphy added. Programs may involve group meetings or skill-building activities, like helping people with serious mental illness manage medications and daily living activities, which is challenging to convert to a virtual format.
Most of the survey respondents were from publicly funded organizations, which usually have fewer resources than privately funded practices. “The people they serve often have lower resources as well, and many of them are on Medicaid,” Murphy said. Some clients don’t have computers, have limited call minutes or have poor internet connection, and can’t attend virtual appointments. Some staff reported they also lacked access to the technology. “There were barriers on top of barriers,” said Murphy.
For residential behavioral health programs, virtual work wasn’t an option. The survey respondents reported that personal protective equipment shortages left staff and clients without adequate protection. On top of that, organizations reported that they had to reduce service offerings, which meant less income, and less money to buy masks and other supplies.
Staff also had to cope with stress and burnout largely alone, away from the support of coworkers. With millions of New Yorkers facing unemployment, more clients became food insecure and lost housing, which can not only exacerbate mental health issues, but also make it harder for staff to support them. Staff also worried about their own health, that of their families and coworkers, and grieved the deaths of colleagues, clients or family from Covid-19.
“People were commenting on death, the loss of clients, the death of co-workers,” said Murphy. “There’s no real time to process that, mourn or grieve. It was heartbreaking.”
“Our staff is caring for people who are in a great deal of stress during this time,” said Scott Thomas, division director of clinical and rehabilitation services at Mental Health Association of Columbia-Greene counties. “And [staff] have to partially carry that emotional burden at the same time that they’re living it.”
Murphy and the MHTTC, as well as behavioral health organizations themselves, have begun addressing these issues. “We’ve provided trainings on telehealth delivery, created products on how to engage with participants using telephone and text,” said Murphy. “We’ve also done work around self-care for the behavioral health workforce themselves.”
They’ve set up calls for staff and administrators, giving them space to talk about their struggles and feelings. “There’s a lot of concern for the wellbeing of the people who have been providing supports all of these months,” Murphy said. And supporting behavioral health workers needs to go beyond advising staff on self-care.
“People are tired of being told to do more yoga, do deep breathing — it becomes another burden.” she said. “We need to be looking at how to modify the organizations to relieve some of the stress.”
But some changes to behavioral health services have had positive effects, too. In some group settings, virtual meetings have worked well. “We have people with social anxiety and all of a sudden they’re jumping into groups. People who were holding back have come out of the woodwork,” said Thomas.
Turning toward telehealth, as well as insurers’ reimbursements for telehealth services during the pandemic, has also expanded access for some people. “In a rural setting like ours, transportation, in winter especially, is a huge deal and people get isolated, they get lonely and their problems snowball from there,” said Thomas. And, he said, for people who might be too sick to attend in-person appointments, virtual services ensure they’re still getting what they need. Before the pandemic-related changes, if clinicians in Thomas’s organization wanted to follow up remotely, they would not be reimbursed if the client was on Medicaid.
At the moment, Medicaid reimbursements for virtual mental health services are temporary in New York. Those benefits are extended on a monthly basis as the state evaluates the Covid-19 situation. “Everyone is hoping that post-Covid-19 there is some of sort of hybrid model that allows for [Medicaid] reimbursement using both virtual and in-person [services],” Thomas said. “A blended model would allow us to provide a much better safety net.”