The US healthcare system is amid a global pandemic due to the COVID-19 virus. The next pandemic facing the US will be a mental health pandemic. As a country we are already seeing the first signs of this storm that is starting to touch land. Mental illness is already among the leading causes of disability in the US. The economic implications because of disabilities associated with mental illness are projected to rise by five to six times over the next thirty years (Hensel et al., 2018).
The above projection was prior to COVID-19 and did not factor the long-term effects of a global pandemic on those with existing or emerging mental health conditions. Increased isolation, economic recession, and political uncertainty have already impacted mental health conditions nationally. A recent report by the CDC on behavioral health conditions during the COVID-19 pandemic found that the number of people experiencing anxiety or depressive symptoms have double since last year. The reports also identified that since the start of the pandemic, there are as many American adults have seriously contemplated suicide as there are Americans with diabetes (Czeisler et al., 2020).
The existing gaps in the availability of behavioral health professionals nationally has left many healthcare leaders with few options to stem the tide of complex patients seeking mental health care. These gaps are especially apparent with psychiatric clinicians. The US has seen a 14% decline in graduates from psychiatry programs and nearly half of psychiatric clinicians are over fifty-five years old (Mechanic, 2014).
The collaborative care model (COCM) has been adopted by many healthcare organizations to help address the increasing shortage of psychiatric providers. COCM is a method of providing integrated behavioral health care that adds psychiatric and behavioral health providers to primary care teams. COCM expands the reach of psychiatric providers by limiting direct patient care. Instead psychiatric clinicians' function as caseload consultants not direct service providers. This allows healthcare systems to leverage a limited resource (psychiatric clinician time/expertise) to address the treatment needs of a population of patients (Dohl, 2017).
Psychiatric consultants (PC) provide indirect consultation or “curbside consultation” which is often immediately available to primary care providers (PCP) who are treating patients with behavioral health conditions in the primary care setting. Another facet of indirect consultation are caseload reviews where the PC and behavioral health provider (BHP) reviews a registry (usually contained within an electronic health records system) of patients who are not responding to treatment. During caseload reviews the PC and BHP discuss patient progress and response to treatment. The psychiatric consultant provides treatment recommendations (medication or behavioral interventions) for patients who are not responding to treatment or clarification of patient diagnoses. BHP communicates PC treatment recommendations to the PCP who remains responsible for all treatment (Dohl, 2017).
Due to the COVID-19 pandemic many health systems have been forced to depend heavily on health information technology (HIT) to meet patient needs while adhering to public health protocols. COCM and more specifically psychiatric consultation is equipped to maximize HIT utilization. Indirect consultations can be completed remotely via telehealth or phone without disruption of patient flow and can easily be incorporated into primary care workflows. Like onsite stepped care protocols, telepsychiatry consultations also follow stepped care protocols. For example, PC conducting caseload reviews with the BHP can determine if telepsychiatry consultation with a patient is necessary based on information discussed during the review (Fortney et al., 2015).
Electronic health record (EHR) systems are an important aspect of HIT. EHRs can enable teamwork, communication, and task delegation through instant messaging, task management, and population specific data collection. EHRs expand the reach of psychiatric providers and increase patient access through electronic consultations (e-consults). E-consults help facilitate PCP access to psychiatric consultant expertise via synchronous written communication, chart reviews, and patient data. E-consults increase response times and decrease referrals to specialty care by nearly one third (Hensel et al., 2018).
Reimbursement methods are a major barrier to widespread utilization of psychiatric consultants. CMS has updated fee schedules which provide for chronic care management. Under this program psychiatric consultant non direct services can be included as part of chronic care management (Raney et al., 2017). However, many states have been slow to adopt value-based payment systems which support integrated care models such as COCM.
Psychiatric consultation has proven to significantly improve patient outcomes and reduce costs. According to research nearly 60% of patients achieve symptom remission or at least a 50% improvement. One study demonstrated that $6.00 in medical costs are saved for every $1.00 invested in the model (Dohl, 2017). With research supporting the effectiveness of COCM it is surprising that many policy makers delay in adopting value-based payment systems that support psychiatric consultation.
Indirect consultation is a true force multiplier expanding the reach of psychiatric clinicians to many more patients than in traditional psychiatric care models. While the effective use of health information technology can increase patient access to psychiatric expertise exponentially. Investment health information technology infrastructure and psychiatric consultant could address the national shortage of psychiatric expertise up to an order of magnitude (Raney et al., 2017). With the full force of the behavioral health pandemic still to touch shore it is imperative for healthcare systems to implement healthcare delivery methods like psychiatric consultation.
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