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