A new article, published in Psychiatric Services in Advance, explores how the New York State (NYS) public mental health system has fared during the COVID-19 pandemic. This exploration allows for insight into how public mental health systems can be redesigned to be more efficient as we continue to weather the pandemic and brace for what the future will hold post-pandemic.
The authors, leaders of the NYS public mental health system, offer suggestions for directions that the mental health field can move in to improve practice and policy. Thomas Smith, Chief Medical Officer of the NYS Office of Mental Health, and his co-authors write:
“When the pandemic wanes, the crisis will evolve into an opportunity for redesigning public mental health systems. Large budget deficits due to the pandemic will create a further impetus for system redesign.”
Smith and colleagues call for a systematic redesign of public mental health, which includes not only changing approaches to addressing and treating mental health concerns but also in reforming mental health regulations and policy.
They call for a “population health approach,” where high-risk individuals are prioritized for care via an algorithm used by providers and healthcare systems. NYS providers were given access to an information system that charts each individual’s patterns of service use and alerts for high-risk individuals, flagging for items such as gaps in treatment and repeated acute care.
The authors highlight the role that such systems can play in preventative care but also suggest that additional preventative care strategies, such as support lines, be adopted to meet the mental health needs of individuals struggling to cope with the current and aftereffects of the pandemic.
However, others have pointed to flaws in using algorithms to prioritize care. Most notably, an algorithm used by Stanford University to determine who would get the first doses of the COVID-19 vaccine prioritized senior faculty members over low-paid, frontline healthcare workers. Additionally, a recent report examining the electronic collection of mental health data found that individuals with disabilities and mental health service users are placed at risk for privacy violations. Monitoring and surveillance also lack support for contributing to the improvement of healthcare outcomes, raising questions about taking a population health approach to care.
The authors also argue in favor of collaboration between public and private providers, emphasizing how New York City’s public, private, and state-operated psychiatry programs all worked together as one unit during the pandemic. Such cooperation allowed for individuals’ mental health needs to be met at the appropriate level of care, and continued partnerships between public and private systems could allow for continued client access to mental health treatment.
Additionally, they suggest that service delivery platforms be expanded, identifying the widespread use of telehealth services that exploded during the pandemic as an example. Highlighting anecdotal evidence, the authors point to potential benefits of telehealth approaches, such as client preference and decreased “no-show” appointments.
The authors emphasize the need for new telehealth regulations to be accompanied by “measurable standards of care,” suggesting the implementation of standards such as “shared access to electronic mental health records, digital-based supervision of clinical staff, and measurement-based care.” They also offer recommendations as to how telehealth can be used to serve individuals with “serious mental illness,” such as using telehealth in emergency rooms or for discharge meetings.
The authors point to budgetary restraints and moves to downsize physical space in community mental health settings. While they argue for oversight in downsizing, they also suggest that telehealth can be used as a way to ensure that individuals maintain access to care.
Yet, downsides to the technologizing of mental healthcare have also been noted, such as the lack of an evidence base to support mental health apps and concerns regarding lack of transparency by tech companies in the management of client data. Therefore, it is crucial that further research on the benefits and risks of telehealth be conducted and that we proceed with caution when implementing telehealth practices.
Moreover, Smith and colleagues suggest that “best practices” need to be redefined, and new standards need to be implemented. They offer their support for “measurement-based care” in the form of symptoms rating inventories. Also, They underscore the importance of treatment team communication and collaboration, especially in the treatment of those with “serious mental illness.”
Other recommendations the authors make include clearer standards on how those with “serious mental illness” are cared for in settings like nursing homes and community residences, and the adoption of best practices, which entails flexible, continued care and implements motivational interviewing and de-escalation techniques and patient advocacy.
The authors highlight policy changes made by NYS, which allowed for community-based mobile crisis and assertive community treatment (ACT) teams to assist with posthospital care transitions. This transitionary care was crucial, considering community mental health clinics were unable to support these transitions due to staff working from home.
They describe how transitional care is key to positive outcomes and preventing things like suicide and violence, as it fills the gap often left between the end of inpatient care and the start of community care. More widespread policy changes could ensure that clients continue to receive support as they transition from inpatient to outpatient services.
Further, dissemination of information regarding modified care and new policies can be facilitated via virtual platforms, such as Project ECHO (Extension for Community Healthcare Outcomes).
The authors conclude:
“Much more work remains to be done to stabilize and evolve public mental health systems nationally, and state public mental health policymakers understand perhaps more than anyone how to do more with less. Policymakers will need to rebuild public mental health systems while also dealing with marked reductions in funds for services due to the pandemic’s devastating impact on state’s economies. But such crises create real opportunities for change.”
Smith, T.E., Sullivan, A-M.T., & Druss, B.G. (2020). Redesigning public mental health systems post-COVID-19. Psychiatric Services in Advance, 1-4. DOI: 10.1176/appi.ps.202000400 (Link)