The United States leading up to the COVID-19 pandemic had been experiencing a suicide and opioid epidemic. In 2018, suicide was the 10th overall leading cause of death in the U.S. with a total of 48,344 fatalities. The suicide rate increased in the United States by 35% from 1999 to 20181. In 2018, there were 67,000 intentional overdose deaths. Drug overdose deaths more than tripled from 1999 to 2017, going from a rate of 6.1 per 100,000 to 21.7 per 100,0002.
In line with the escalating behavioral health crisis in the United States, behavioral health-related visits to the emergency department increased significantly. Between 2009 and 2015, behavioral health visits for patients under the age of 18 increased by 56.5% and adult behavioral health visits increased by 40.8%3. A subsequent report was released by the U.S. Centers for Disease Control and Prevention that behavioral health-related emergency department visits increased another 25.5% between 2017 and 20184.
Enter a global crisis. As the COVID-19 pandemic has hit the United States in 2020, a general fear has swept the nation to stay away from the emergency departments and hospitals due to the risk of contracting COVID-19. Hospitals all over the country are reporting significant decreases in emergency department visits. The XFERALL patient transfer network, which is used at more than 150 hospitals in the southeast, saw a decline of 15% of interfacility transfers for inpatient psychiatric hospitalizations from March 15 through April 30 compared to the prior 45 days, for example.
Accessing care for patients experiencing a psychiatric crisis has traditionally been complicated during “normal” times, hence the reason why numerous patients landed in the emergency department for an emergency psychiatric assessment. With call volume for the Disaster Distress Helpline, a federal crisis hotline, increasing by 891% in March 2020 compared to the same month a year prior5, it is clear that the decreased rates of patients showing up to the emergency department in crisis is not due to a lack of individuals needing treatment, but rather a fear to access traditional avenues due to the trepidation of contracting COVID-19.
With the COVID-19 pandemic creating significant stressors and specific risk factors for suicide, including loss of employment, loss of income, sudden and drastic negative life experiences, social isolation, relationship problems, underlying mental health conditions, loss of a loved one, and high levels of anxiety and uncertainty, where is the patient in crisis supposed to turn? Numerous safety nets have been impacted, including fear of going to the emergency department, face-to-face visits with healthcare professionals, access to walk-in clinics, in-person support groups, and meetings such as AA.
A solution is needed
Our mission as healthcare professionals must stay the course to mitigate negative outcomes and deaths by suicide, intentional overdoses, and preventable deaths due to mental health crises. The behavioral health system has been fragmented, and the COVID-19 crisis has further exposed the flaws of the system.
As behavioral health clinicians, executives and leaders, we must develop a system of care that is easily accessible and feels safe for patients along the entire continuum of care. There is an opportunity during these exceedingly challenging times to develop creative solutions that will not only be answers for today, but an opening to create a sustainable system of care that meets mental health and addiction treatment needs for the decades to come.
In order to provide the best care possible to our patients, the system must:
- Be easily accessible to patients
- Be efficient and streamlined
- Connect patients to care in real time based on their clinical needs
First and foremost, we must address how patients will access needed services. The potential outcome of neglecting to address this situation is that symptoms will be left untreated and preventable fatalities will increase.
Recommendation #1: Create “remote” behavioral health emergency psychiatric assessment options through telehealth solutions.
Create remote 24/7 psychiatric emergency rooms that can be accessed via telehealth for patients that are in crisis, but fearful of presenting to the emergency department. If clinically indicated, a transfer can be secured to a behavioral health or substance abuse treatment facility or program for the patient.
Recommendation #2: Identify specific inpatient behavioral health treatment facilities for patients that are positive for COVID-19.
Patients experiencing a mental health emergency that is life-threatening who are also positive for COVID-19 will need treatment options. It is recommended that hospital units are identified in each region or state that can accept patients in a mental health crisis and positive for COVID-19.
Recommendation #3: Create intensive remote treatment programs for patients at high risk during a psychiatric crisis.
As concern increases for COVID-19 infection as a result of inpatient hospitalization for patients experiencing a psychiatric crisis, it is critical to review intensive outpatient interventions as an option to safely stabilize individuals in crisis. Successful models, such as the Assertive Community Treatment Team approach, should be considered. The recommended approach includes a psychiatrist, licensed clinical social worker, psychiatric RN, and therapist to provide intensive outpatient treatment to a patient in crisis. All services are delivered to the patient in their home or community and intensify as needed based on the client’s symptoms. Services are recommended to be provided either “safely” in the home or via telehealth platforms. The service is recommended to include medication evaluation, delivery of medications, medication education and monitoring, check-ins up to 3-5 times daily, and therapy sessions. In order to be successful, these programs need to be reimbursable by insurance and for unfunded patients need to be funded through state programs. Intensive intervention in the community often can mitigate the need for inpatient hospitalization. However, currently, these options are not accessible to most individuals through their insurance plans.
Recommendation #4: Utilize digital solutions to clinically match and secure appropriate treatment options for patients in crisis.
Currently locating an appropriate treatment option that meets the patient’s clinical needs in the appropriate geographic location in a timely manner can be a significant challenge for healthcare providers, especially during a crisis. Digital solutions will provide healthcare professionals with a technology to quickly identify the appropriate treatment program and automate the referral process securing a treatment option in minutes, rather than hours or days.
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As healthcare providers and leaders, our solutions must be creative and expansive as we look to close the gaps of the fragmented systems during the COVID-19 pandemic. Closing the gaps of the mental health system and creating an innovative system of care based on evidence-based treatments, digital solutions, and a streamlined care continuum will finally provide a system that meets the needs of our patients wherever they are, literally.
Shana Palmieri, LCSW, is co-founder & chief clinical office at XFERALL Patient Transfer Network.
1 Hedegaard H, Curtin SC, Warner M. Increase in suicide mortality in the United States, 1999–2018. NCHS Data Brief, no 362. Hyattsville, MD: National Center for Health Statistics. 2020.
2 Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999–2018. NCHS Data Brief, no 356. Hyattsville, MD: National Center for Health Statistics. 2020.
3 “45 Trends in Emergency Department Mental Health Visits from 2009-2015.” Santillanes, G. et al. Annals of Emergency Medicine, Volume 72, Issue 4, S21.
4 Reinberg, S. (2020, January 20). Number of Americans Headed to ER for Suicidal Thoughts, Self-Harm Keeps Rising. Retrieved from https://www.usnews.com/news/health-news/articles/2020-01-30/number-of-americans-headed-to-er-for-suicidal-thoughts-self-harm-keeps-rising
5 Jackson, A. (2020, April 10). A crisis mental-health hotline has seen an 891% spike in calls. Retrieved from https://www.cnn.com/2020/04/10/us/disaster-hotline-call-increase-wellness-trnd/index.html