Several years ago, I watched a 60 Minutes interview with a security guard at an airport who recalled one of the worst days of his career. He had unknowingly allowed a small group of conniving conspirators to pass his purview without stopping or interrogating them. While he didn’t know it at the time, this oversight would have devastating global consequences.
The date was September 11, 2001.
While the security guard was one of dozens of airport and airline employees that day who would allow global terrorists to pass before their eyes, the disturbing fact remained: an avoidable tragedy had transpired, leaving these people and millions of others feeling hopeless and helpless as thousands lost their lives. While there is nothing that can be done to change that fateful day, nearly every person hopes to find a way to be truly helpful in preventing or responding to a tragedy, especially those that impact the loss of life.
Unlike 9/11, the warning signs of COVID-19 are now blindingly clear to many who are in a position to help.
As doctors, elected officials, scientists, behavioral health professionals, and armchair epidemiologists offer their guidance, the United States is responding to the healthcare crisis at hand while preparing for the healthcare tsunami that is about to unfold, the latter of which will have epic consequences on our healthcare infrastructure, mortality rates, and social wellbeing if we are not adequately prepared and responding. The world is changing before our very eyes, and we are called to see clearly and act intentionally and thoughtfully.
As a behavioral health consultant, I spend much of my time researching how communities respond to people experiencing psychiatric emergencies. Historically, people in a mental health crisis have accessed care through services designed for people with medical emergencies—namely, 911, emergency medical services (EMS), and hospital emergency departments. Progressive communities have boldly embedded services like suicide prevention hotlines, mobile crisis teams, psychiatric urgent care centers, and residential crisis stabilization programs to provide dedicated attention and focused responses to psychiatric emergencies. Some of these services also have the added benefit of diverting people from psychiatric hospitalization in instances where it is not necessary. These crisis services have reported tremendous results, with each alternative service option typically resolving the crisis without having to access the next more intensive level of care in 70-85% of the cases.
Amid the turmoil of the COVID-19 pandemic, it is imperative that these crisis services remain intact to address both the usual behavioral health emergencies as well as those created or exacerbated by anxiety, isolation, unemployment, limited access to critical resources, increased substance use, and other unintended consequences of social distancing and shelter-at-home declarations.
While the future is never completely predictable, it is possible to see problems unfolding and to infer their effects based on our knowledge of the system’s current issues. Here is a summary of current issues developing within the behavioral health safety net with a corresponding set of proposed solutions to keep us from the worst-case scenarios we all dread—untreated mental health crises and increased deaths of despair, such as suicide or overdose.
Crisis Call Centers are losing capacity due to staffing and technology challenges. There are approximately 700 crisis call centers in the United States designed to support people experiencing emotional distress, extreme anxiety, suicidal thoughts, and other distressing mental states. Smaller call centers are often staffed with a student or volunteer workforce with office-based phone lines. Several confounding variables emerging in this national crisis are limiting their ability to function, including limited budgets, reduced workforce accessibility, and undeveloped remote technology. Fewer staff answering phones means longer wait times and more people hanging up without talking to someone, resulting in less ability to resolve the crisis and potentially divert someone from a higher level of care. In addition, well-intended actions to socially distance “non-essential” staff are having negative impacts: call center workers are willing to work remotely but are unable to do so, putting them at risk for becoming unemployed.
Re-allocate resources to maintain crisis call center capacity. In organizations where outpatient services have been closed or moved to telehealth options, redeploy crisis workers to the phone lines to maintain necessary capacity. Coordinate with information technology (IT) staff and vendors that have successfully navigated this transition with other call center-based service providers to transition people to a mobile platform as quickly as possible.
Train and support staff to assure a smooth transition to telehealth functioning. While crisis call center employees are comfortable with telephonic-based service environment, reassigned mobile crisis workers or outpatient clinicians may not seamlessly transfer their skill sets to the phone lines. Assure that staff are receiving regular supervision and staying attuned to their emotional reaction to their work as well as the ongoing pandemic. Reinforce professional boundaries that balance the tension of building rapport with serving the person in crisis without allowing staff’s unmet emotional needs to interfere with crisis resolution.
Health plans have fewer mental health resources to rely on, leaving members in crisis without adequate treatment. Nearly all outpatient services have been moved to telehealth with corresponding billable services where available. Considering that most hospitals have more than 16 beds, some psychiatric hospitals are decreasing their census capacity in an effort to practice social distancing and comply with state and federal regulations limiting groups of 10 or more. The combination of these two factors may leave health plans scrambling for solutions for their members in crisis.
Health plans should pursue case rate agreements with local crisis service providers to maintain network adequacy and proactively address psychiatric crises. Mobile crisis teams, 23-hour crisis stabilization facilities, and crisis residential services are viable alternatives to ED utilization and psychiatric hospitalization when there are no other major underlying medical issues. In some cases, these alternative services can also treat co-morbid medical and/or substance use conditions. While most commercial health plans have been slow to contract for these types of crisis services, and Medicare does not currently cover crisis services, the impetus has never been greater to broaden the service array and mitigate risk for their members. At some point, all payers will be seeking sources of refuge for their members with psychiatric emergencies that keeps them from imminent exposure to the virus whenever possible. Providers can respond to the call with a bevy of research and data to support the efficacy of their services.
Crisis providers are working without one of their most precious resources—their physical presence. Crisis call centers notwithstanding, moving from in-person services to telehealth is like being forced to use your weak hand to write a two-page essay: you can adapt, but it certainly doesn’t feel natural. Without having the advantage of observing the environment, the entire body for nonverbals, peripheral social interaction, and other cues, it can be difficult for clinicians to effectively do their job.
Double down on wellness, maintenance, and crisis postvention check-ins. Maintaining good rapport and keen insights on wellness and symptoms requires frequent connection. Communities that have already built crisis postvention resources as part of the best practices identified by Zero Suicide are well-positioned to expand these resources to as many clients as possible, starting with high-risk and post-crisis individuals. Identify the critical, basic skill set required for telehealth check-in’s and follow up and engage as many of your staff as possible to pick up the phone or tablet and reach out. Symptom rating scales can also be useful to monitor mood and symptoms. Lastly, provide training and ongoing supervision to assure competency in delivering these services and monitoring staff wellness. Organizations like the National Suicide Prevention Lifeline have developed resources for crisis providers transitioning their workforce to remote settings.
Crisis providers may be excluded from conversations about “essential services” to remain open, limiting their ability to be helpful. Peer respite homes are temporary sanctuaries for people experiencing emotional distress or crisis who prefer to receive support in a non-medical environment. Approximately 75 peer respite homes exist in the United States, but many have closed temporarily in the past week at the discretion of their funders while increasing their warmline (i.e. non-crisis line) capacity, in some cases to 24/7 operation. Other crisis residential providers are uncertain of their fate as census numbers have fluctuated over the past few weeks and their access to personal protective equipment (PPE) is limited in the event a staff or client contracts the virus.
Include crisis providers in community decisions about essential services as the needed adaptability to solve critical system deficiencies. For decades, crisis providers have been the business of finding ways to say “yes” and offering adaptable solutions to community problems. Crisis residential providers are already adjusting to community need by extending the length of stay in their programs to mitigate COVID-19 exposure and setting up tents outside of their facility for health screenings according to CDC guidelines. Some providers are redeploying outpatient practitioners to crisis services to manage the projected surge in treatment need. Public health and disaster preparedness planners would be well-served to invite behavioral health crisis providers to the table to improve planning and response to local, regional, or national crises.
Establish and reinforce a strong pipeline of communication between mental health authorities, providers, and persons served. While many of us are plugged into the 24-hour news cycle, people with less access to resources and more environmental stressors may not be attuned to the latest preventative measures and treatment protocols. When coupled with increased isolation or anxiety from perceived or actualized fears of contracting the virus, it is even more imperative that persons in crisis receive regular updates on how their treatment is being impacted and what providers are doing to promote client health and safety.
Mobile Crisis Teams have been temporarily displaced as their work is typically done face-to-face. While new telehealth laws make it easier to provide these services remotely, most mobile crisis teams are not designed to provide care in this way and may not have the HIPPAA-compliant technology to adapt in this circumstance (although some states are temporarily waiving the HIPAA-compliant requirement at this time).
Coordinate telehealth assessments between mobile crisis teams and EMS, Law Enforcement, and Emergency Departments. Keeping assessment and disposition time short is critical to maintaining capacity for the expected influx of medical and psychiatric emergencies. If first responders can use HIPAA-compliant assessment software on a secured mobile device when dispatched, they can connect the person in crisis with the proper support in an efficient and flexible manner.
I hope that, in the midst of the COVID-19 crisis, we experience our finest hours of coming together to showcase the very best that we can be as health care professionals, as community partners, and as compassionate humans. With careful and conscientious planning and response, we can minimize the tragedies that this pandemic could incur, finding ourselves stronger and more resilient on the other side of this epic, civilization-wide trial.
If security measures had not increased following 9/11, we would consider the Federal Aviation Administration negligent for not working to prevent future tragedies. We face a similar opportunity today as the lessons learned by other infected countries color our prevention and treatment responses.
Years from now, I hope the 60 Minutes story that profiles behavioral health services during COVID-19 is one that we can be proud of, knowing that we were the most helpful in the greatest time of need.The photo credit is: Photo by Braden Hopkins on Unsplash
A friend recently shared with me her experience of training staff at a behavioral health center in trauma-informed care. She asked for participants to share an example of when their work had triggered their own trauma response and her question was met with a gripping silence as a blanket of tension pressed heavily on the room. It was clear participants did not want to share or didn’t feel safe enough to share. Rather than simply moving on or providing a cookie cutter example, she took a risk. She chose to be vulnerable and share her experience of being triggered during a family session due to trauma she experienced in her marriage. Her intentional choice to be vulnerable and share something personal opened a doorway for others. The feeling in the room shifted and a participant was then able to share their own trauma response experience.
Another friend participated in a national behavioral health leadership program and returned from one of the conferences energized and passionate about the power of vulnerability in leadership. So, I did what any person like me would do when something piques my interest: I googled it. I spent a few hours reviewing articles on trauma-informed systems of care and the power of vulnerability. I also reflected upon my time working at two behavioral health organizations as staff learned to adopt a trauma-informed culture.
These two incidents occurring so closely together made me pause and consider how a leader’s level of vulnerability might be correlated with the degree to which that organization’s culture is trauma informed. The basic characteristics of a Trauma Informed System of Care (TISC) include safety, trustworthiness, choice, collaboration, and empowerment. To become a TISC, an organization must examine multiple aspects of the system, including the physical environment, clinical assessment, and interventions, staff relationships and morale, organizational communication, response to secondary trauma, etc. It is a culture, not a set of services or interventions. Leaders must learn to be vulnerable if there is any hope for their organizations to truly adopt this trauma-informed culture. This culture must include everyone, from clerical staff to the cleaning crew, to clinicians and perhaps most importantly (and often overlooked), leadership.
Regardless of where your organization is on the journey to becoming a TISC, as a leader in your organization, challenge yourself to explore how vulnerable your team is willing to be, and your own reactions to vulnerability. Do you avoid it? Do you see vulnerability as a weakness? Do you become anxious or tense at the thought of sharing personal experiences with your co-workers? Do you feel your co-workers need to “suck it up” and not be so “needy”? Do you view co-workers as overly dramatic and attention seeking? Do you feel disconnected from others at your workplace? Do you rationalize your emotional distance by telling yourself that you shouldn’t have meaningful connections with others at work or that you need to maintain an image of strength? Do you find yourself fighting back when someone criticizes you or your decision?
Or, do you embrace your vulnerability? Brene Brown and Myric Polhemus both discuss the critical importance of connecting deeply with the people with whom you work. A leader must be vulnerable in order to truly connect with her staff. Are you self-aware? Do you reveal your thoughts and feelings to others, even when doing so makes you feel emotionally at risk? Are you open to considering you made a mistake? Do you admit it when you’re wrong? Do you approach your imperfections with humor and grace? Do you ask clarifying questions to better understand your co-workers, especially when you disagree with them? Do you truly listen to their perception of events and allow this to alter your perceptions?
By opening yourself up to be vulnerable, your employees will follow your example, and find motivation from a genuine interest to serve (relationship power), rather than feeling coerced (role power). By fostering deep and meaningful connections with your staff, they will learn to feel safe, a fundamental requirement of a TISC. I have observed that when staff on my team felt secure (in their position, in the organization) they were more likely to provide needed feedback to the organization and to be more innovative. Leaders work tirelessly to ensure that those served by the organization feel safe, supported and that the systems of care do not re-traumatize them. As leaders, we should settle for no less for our staff.
We seem to have a love/hate relationship with them. Even if we try not to, we find ourselves using them in meetings or in discussion with co-workers. In healthcare, the “Triple Aim” is one of these. The concept is great: Improving the patient experience of care AND improving the health of populations AND reducing the per capita cost of health care.
“Triple Aim” has definitely become “a buzz” within the behavioral health community over the past few years. Many behavioral health organizations have included it in their mission, vision or strategic plan. These important tools identify the direction of the organization.
But if the focus on the Triple Aim never escapes the C-Suite (CEO, COO, CFO, etc.), there is risk that it will not become embedded within the workplace culture and actually impact workflow, outcomes, and ultimately, the people whose lives it could benefit most.
It is far easier to discuss buzz words than actually adapt our business to reflect a new reality. To adapt to a new environment or the presence of a new variable is challenging. It’s also necessary. Adaptation can take years but ultimately can determine your organization’s survival.
Biologists are very familiar with this concept. Rosemary and Peter Grant are two researchers who spent almost 30 years researching the finch population on two small islands, Daphne Major and Genovesa, in the Galápagos archipelago, Ecuador. They found that there was a difference in the size of the ground finches’ bills between islands. The size of the bills was conditional upon which other finch species were present. To survive and thrive, these animals had to adapt. I propose that program managers within your organization need to be like those finches.
Program managers within behavioral health organizations have a great opportunity to use the Triple Aim as a foundation for program evaluation. My experience has been that a program manager’s time is often consumed by meetings, staff supervision, reviewing staff documentation, updating policy and procedures, preparing for audits and accreditation surveys, as well as the ever popular and time-consuming HR problems. With all these demands, it is no surprise that it can be very challenging to actually engage in meaningful program evaluation and identify any areas in which the team may need to adapt.
If you are leading a behavioral health program, such home based therapy or case management, the Triple Aim framework can be used to evaluate and improve the program.
Does your team utilize patient satisfaction measures? Are they meaningful or a survey that staff pass out once a year that most patients throw away? How are your staff collecting patient report of satisfaction on an ongoing basis? Do they simply check “satisfied” in the progress note if the patient didn’t seem upset about their services that day? Or do they have meaningful discussion with persons served about how services are helping them and any changes that need to be made? How do you measure quality of your services? Do you use fidelity measures for best practices? Once patient satisfaction and quality metrics are measured, do you share this information with staff? With persons served?
This one can seem pretty overwhelming. Behavioral health clinicians work very hard to keep those they serve out of jail, inpatient units, etc. Improving their health may feel like an impossible task — but it’s not! Start small, pick one population you want to target, such as children taking atypical antipsychotics or adults with diabetes and depression. Define clear goals and measures. Work closely with your information specialists and analysts to identify a way to collect data and track your outcomes. Implement Plan, Do, Study, Act (PDSA) cycles to improve care. Research shows that persons with severe and persistent mental illness die, on average, 25 years younger than the general population, often due to treatable conditions*. Therefore, it is critical that we adapt the care that we provide to be more integrated, focusing on overall health.
In some behavioral health organizations, program managers may think “How am I supposed to impact cost? Isn’t that the finance department’s job?” If you feel out of the loop regarding the cost of your program:
These activities only focus on the cost of your team’s services. That’s a good start. But to impact per capita cost, you have to look at all health care costs. This is a significant challenge.
Even though we now have growing access to encounter data and various data analytic software packages, many do not include cost data. There are some creative efforts at the local level to engage in dialogue with other health care providers via regional health improvement councils. What’s needed are data sharing agreements or releases of information to gain patient consent so that protected health information data can be shared.
Dialogue with community providers can help you identify ways to reduce the cost for specific populations. You could also try contacting a player, such as a Medicaid HMO, that provides coverage for a large portion of the population you are addressing. They may be willing to work with you on a pilot project and would be able to track the overall cost of your participants (for which they provide coverage).
In the ever-changing landscape of healthcare reform, it is increasingly critical for behavioral health providers to be competitive within the larger health care market. Now more than ever, we need to be able to demonstrate effective outcomes (evidenced by data!), competitive costs, and high patient satisfaction.
We encourage you to use team/individual goal setting and process improvement teams as an opportunity to integrate Triple Aim principles into your workflow and agency culture. This will help you to flourish in the era of integrated, value-based care. Implementing Triple Aim goals at the program level and monitoring progress with data will help ensure your success.
* For additional information please see Morbidity and Mortality in People with Serious Mental Illness,” published in October 2006 by the National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council (http://www.nasmhpd.org/) and an earlier report by the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration (SAMHSA), Sixteen State Study on Mental Health Performance Measures. Rockville, MD: DHHS Publication No (SMA) 03-3835; 2003).
In behavioral health treatment, the pendulum of personal and professional experience has slowly swung from side to side for the past century. From Alcoholics Anonymous to the advent of Vet Centers for returning Vietnam veterans, peers have exemplified the power of empathy by supporting one another through shared life events. Their firsthand knowledge helps to bridge the chasm of fear that clients carry that they will not be truly understood.
While peer support has grown and evolved, so, too, have the clinical professions and their effectiveness. Identifying and implementing best practices in therapeutic settings have helped change the face of clinical services, from a nebulous, undefined journey through the subconscious to a meaningful service that delivers results.
As recently as 5 years ago, graduate training programs in fields such as psychology, counseling, and social work did not give substantial attention to peer support or sharing personal experiences as an effective treatment tool, instead advocating an approach that all but extinguished self-disclosure in a therapeutic setting due to fears of transference and crossing professional boundaries.
Empirical studies that validated the tools and methods of clinical professionals are now affirming the effectiveness of peer supports in treatment settings, demonstrating similar outcomes to their more educated constituents. In the last 10 years, many states have formalized the training and certification process for peer support specialists, bringing a level of credibility to their work that has not previously been seen. To make matters more complex, clinical professionals and peer supports are now working side-by-side in recovery-oriented systems of care, forcing both parties to recognize one another’s skills while working together to provide effective treatment.
In a healthy recovery-oriented treatment environment, clinicians and peer supports would complement one another in doing what is most helpful for the client: supporting their recovery. With all of the changes that have occurred in both fields, what will the next 100 years bring?