The Pandemic-Induced Pivot of the Mental Health
Courtesy of Relate Counseling

The Pandemic-Induced Pivot of the Mental Health

To mitigate the risk of in-person therapy sessions, clinics are using teletherapy to offer services to clients. But increased financial concerns act as barriers to the increased need for help.

The novel coronavirus crisis is taking a toll on many people’s mental health. A new poll from the American Psychiatric Association showed that the majority of Americans are anxious about loved ones being infected by coronavirus. Survey respondents also said they were worried about the impact of the pandemic on their personal finances and the global economy.

That’s no doubt creating a hefty workload for mental health practitioners. And as in nearly every other industry, there’s also the challenge of shifting from an in-person business model to a virtual one. But for many clinics, the need to prevent a gap in care outweighs the struggle of making the transition.

For those already receiving care, the continuation of services is vital to their wellbeing, said Brian Nystrom, the president and CEO of Nystrom & Associates.

“If providers like us had stopped services––even temporarily stopped services––there would have been an uptick in suicide attempts, completed suicides, emergency room visits, chemical overdoses, you name it. This is a pretty serious business,” he said.

Of course, some clinic systems, including Nystrom & Associates, have been offering virtual options for a while now. Nystrom says his clinics have been providing telepsychiatry services since 2012. But the pivot to 100 percent remote services for its 16 clinic locations took quick movement, sleepless nights, and long days, said Peter Nystrom, CCO of Nystrom & Associates. With the uptick in people needing help and support, the effort was well worth it, he said.

“We have more people reaching out than we’ve seen in quite some time, in terms of needing help now in the thick of a crisis––whether that’s because of job loss or because of other crises at home, not knowing how to handle certain family situations with essentially being locked in at home,” Peter Nystrom said.

The strain of isolation

The clinic has also created advice videos for patients and community members, covering topics like making the adjustment to being more isolated and staying sober during isolation.

“It can create more friction, more stress, more conflicts,” Brian Nystrom said. “We’re generally sensing that in the community. The clients that I talk with are just consumed with Covid-19. That’s all anyone is talking about.”

The rules regarding remote mental health services have been relaxed by the U.S. Centers for Medicare and Medicaid Services, under a directive from President Trump. Services are allowed to cross state lines now, and physicians are able to prescribe new medications to patients via televideo. This allows for broader coverage for clients.

Additionally, many insurance companies across the state are saying they will cover telehealth technology as a means of providing mental health services, according to Brian Nystrom.

Clinics are in talks with the Minnesota Department of Health regarding variances in service codes that will allow for telehealth. The state’s health commissioner says that the 1.1 million Minnesotans on state insurance won’t lose coverage during the pandemic, including for mental health services.

“Covid-19 has been extremely disruptive to mental health services. Many services paid for by public health programs are required to be provided face-to-face, a real challenge for safety of workers and people receiving services. We are seeking approval to provide these services by telephone and video,” the department said in a statement.

The state health department is currently preparing an application for Crisis Counseling Programs grants through FEMA, as well, which are used to assist individuals and communities recovering from disasters through community-based outreach and psych-educational services, the statement said. The grants are only accessible once the president makes a Major Disaster Declaration.

Shifting priorities

Right now, with more people than ever seeking unemployment benefits, many facing reduced wages, and everyone looking at the onset of a recession with trepidation, additional bills for things like mental health care can easily become a low priority, said Becky McNattin, director of clinical services for Relate Counseling Center.

Even as a low-cost provider, Relate Counseling has had clients say they’re unable to come into sessions because of job loss. And while they may still be on their former employers’ insurance plans, they are uncertain of their ability to afford the copays and deductibles, McNattin said.

But for every dollar Relate earned, the organization is giving away six in free or reduced services, said David Senior the executive director of Relate Counseling. And the center doesn’t turn anyone away, with a sliding scale fee as low as a dollar.

“Ultimately, mental health doesn’t take a break just because Covid’s here,” he said.

With social distancing orders in place, many people can’t tap into their typical support systems in the community, McNattin said.

“This is enormously stressful for our clients. We have households that were already chronically stressed either with finances or relational issues or ongoing mental health pieces, and that is just exacerbated by people not being able to go to their jobs or go to their school,” McNattin said.

And the isolation that arises from quarantine can worsen chronic mental health conditions like anxiety and depression. It’s a learning curve for clinicians as to how to properly help people seek support and integrate themselves, she added.

“We notice a lot of anxiety in clients. They’re all talking about how Covid-19 impacts their life personally, and their inability to really seek support because it’s only through technology they’re able to do that,” McNattin said.

While people need help facing the stress of the crisis, Relate saw an absolute drop for intake phone calls in the middle of March, Senior said. Calls and client visits dropped about 40 to 50 percent with school and office closures, but it has now recovered with teletherapy sessions and the start of distant learning.

“What was a very busy and extensive wait list has very much shifted in terms of people having to prioritize home day care, having to prioritize filing for unemployment, or just the recognition that their lives and family lives have changed significantly in terms of stocking up on essential items and just keeping the home front safe,” he said.

Relate sees a significant percent of clients in schools, and with the closures and transition to remote learning, school clinicians have also seen mass changes in their work.

“I don’t think any organization has been immune to what has been going on over the last three weeks,” Senior said. “A 51-year face-to-face business model had to pivot very quickly to telehealth.”

Scaling up, virtually

While the mental health industry has quickly transitioned to increasing teletherapy options, some clinics still saw a drop in the middle of March after the state of emergency declaration on March 13. PrairieCare and PrairieCare Medical Group saw a 50 percent drop within a week of the emergency executive order, according to CEO Todd Archbold.

But the offering of remote mental health services started pushing those numbers back up. PrairieCare is now doing over 45 percent of outpatient visits through remote services, and expects that number to grow to 75 percent by the end of April. The concern of clinicians is the impact any disruption in services might have on the morbidity and mortality rate of severe mental illnesses, Archbold said.

And while mental health care may be seen as elective until people are on the edge of a crisis, there still seems to be an uptick in employers’ appreciation for mental health treatment, said Kyle Cedermark, chief psychotherapy officer for PrairieCare.

“The things that we’re doing to stop the spread of contagion and help with population health are the total opposite of what we should be doing for our mental health. You think about isolating as being a symptom of and something that perpetuates depression and anxiety symptoms. It’s a real conundrum,” said Cedermark

But the relaxation of regulations has had a positive impact on clinics’ ability to rapidly develop new programs like teletherapy, Cedermark said. It’s something that may have been on the wish list for clinics, but now has quickly come to fruition out of necessity.

The Hazelden Betty Ford Foundation clinics actually had done a significant amount of planning for offering virtual services prior to the pandemic, said president and CEO Mike Mishek. The three-year plan the organization had launched at the beginning of the year actually included plans to develop further virtual programs.

“Luckily we had done the groundwork and foundational work to be able to very quickly scale up virtual services for the organization,” Mishek said.

Right now, the Hazelden is seeing an increased demand in outpatient services because it can offer them virtually. But its residential services is running at about 75 percent of what it had budgeted, likely due to the fact that roughly half of Hazelden’s patients fly in, Mishek said.

And like the other clinics, Hazelden has not had to lay anyone off, and instead has redeployed people for virtual service offerings.

“We’re really focused on staying open, and making sure the people who are still with us still have work to do,” he said. “Don’t forget, there was an opioid epidemic before the pandemic hit us. And the opioid epidemic has not gone away. It’s still there.”

As the virtual division grows, he also sees hiring more counselors this year.

“This is going to be very dicey for a relatively long period of time and so I’ve asked a number of our teams to be planning to be delivering virtual services for some time now,” Mishek said.

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