In an already challenged, and often under-resourced mental health care system, the COVID-19 pandemic has led to an increase in mental health needs across the globe1,2. The World Health Organization’s models of pandemic impacts project a significant uptick in these needs both in the acute and long-term outcomes of this crisis3. To rapidly respond and continue the vital mental health services we need in the changing reality of wide-spread isolation measures, governments and insurance companies have rapidly aligned to adjust policy for telehealth. These changes have been adopted relatively effectively in financially established systems that already had an infrastructure for telehealth, such as VA settings. However, in many systems, unrecognized disparities in our mental health workforce profoundly impact their ability to implement telehealth as they work around the clock to address the escalating needs in our population during this pandemic.
Challenges in under resourced organizations
The transition to everyday clinical practice of telehealth has not been as swift or as easy for community mental health clinics, safety net hospitals, and some private practice providers. Secondary to the chronic underfunding of mental health care and other systemic challenges, these organizations do not have the infrastructure in place to quickly adopt telehealth and related new policies and support their staff in implementing them. For example, differential access to organizational resources severely impacts providers’ ability to do their jobs. Providers are having difficulties accessing even basic necessities such as their work emails or office voicemails remotely because of their organization’s existing limited technological infrastructure. Thus, in order to even contact patients, they now have to spend extra time (that is already lacking) to resolve these challenges, and develop new strategies to carry out even their day to day responsibilities, such as use of their home phones and emails. This lack of personal and professional division puts them “on duty” at all times, out of a sense of concern for their patients, and at even higher risk for burnout. The lack of work email access also limits the information that organizations can disseminate to their providers to conduct their professionals’ duties, such as ever-changing policies or regulations to their practices, or even resources that were developed to aid their jobs and wellbeing.
In addition, provision of telehealth requires minimal set up requirements that are not equally accessible to all members of the workforce. Despite the availability of commercial platforms to deliver telehealth, providers may own outdated personal devices that are incompatible, and they still must be able to document this type of session in their organization’s charts or electronic health record (EHR) system. The underlying assumption is that among organizations with an EHR, that system would allow for remote access and editing, but not all systems offer this capacity, which is obtained at higher price point that is out of reach for many public mental health organizations. Those organizations still relying on more outdated record systems are even more restricted in remote access.
Challenges for providers
Even when this technological access is an option, providers are still reporting actual or potential loss of income due to reduced attendance at billable appointments. People are losing employment in record numbers, which impacts access to health insurance, funds for co-pays or session fees, and limits ability to pay for phone or internet plans to participate in telehealth. When providers are able to connect with their patients, they frequently find themselves having to expand session time to serve as “IT support” for their patients as they learn how to navigate telehealth – expended time that they are not able to bill for, and which may leave them with fewer hours to see additional patients. In addition to this risk of decreased income, these often underpaid providers are struggling with their own increased costs associated with telehealth, such as heightened expenses related to data plan use and internet access, and the necessity of acquiring or updating technology or equipment such as home computers or other devices to be able to work remotely.
Space. Privacy. The ability to provide telehealth from one’s home in privacy is a privilege. News programs have highlighted patients sitting in their cars to talk with their providers in private. In reality, the opposite is also occurring. In order to protect their patients’ privacy, providers are conducting telehealth sessions on their bathroom floors, sitting in their bathtubs, in the closet, or—if they own one—in their cars. For providers with children or other dependents, finding child care is not an easy nor an obvious option for many, due to financial, health, or logistical reasons. Thus, they are constantly redefining what it means to multitask as they provide effective clinical care and seek to juggle interruptions and minimize background sounds.
There is more that can be done to support our workforce
This is the reality faced by many of our mental healthcare workers. As a nation, we have begun to acknowledge and value the physical and emotional wellbeing of our workforce. We have employed protocols for social distancing, handwashing, and continue to procure protective gear. Companies focused on emotional health have made their products available for healthcare workers for free, and hospitals are prioritizing initiatives that support resilience building and the provision of mental health to our frontline workers. However, these solutions are not addressing the challenges added by the disparities in our workforce. In a field already challenged by high rates of turnover and burnout, these additional stressors may push more clinicians out of the field, further destabilizing the mental health care system at a time when pandemic-related impacts may increase needs to an all-time high and resources to an all-time low.
Organizations can assist providers in securing the technology they need to be able to provide telehealth remotely, or provide clean and safe spaces for providers to conduct telehealth sessions. For organizations with a productivity-based compensation structure, considering different ways that workforce can be financially supported during the pandemic would alleviate income-related stress and uncertainty. This may require policies and state or federal assistance such as the Paycheck Protection Program4. An exemplar of a payer facilitating these accommodations is the Medicaid payer (known as Community Behavioral Health) connected to the Philadelphia Department of Behavioral Health and Intellectual disabilities, which has begun to reimburse organizations for services based on their mean monthly service provision in 2019. The hope is that this flexible reimbursement will support staff retention during these unstable times, for the good of the overall mental health care system. As funds are appropriated to mediate the impact of COVID19 across other health systems, mental health must maintain a priority status.
Our healthcare workforce are superheroes at the center of this pandemic. We must be cognizant that in the midst of their dedication and bravery, they also face difficult realities that are heightened by disparities in their own lives. The only way we will be able to flatten the mental health curve that will result from COVID-19 is for our providers to be working at full capacity. It is our duty to support them during this time as they work everyday to support us, and to ensure that our mental health care system survives these challenges intact and has the chance to build back better.
1. Kaiser Family Foundation. The Implications of COVID-19 for Mental Health and Substance Use. https://www.kff.org/health-reform/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/?utm_campaign=KFF-2020-Health-Reform&utm_source=hs_email&utm_medium=email&utm_content=86570097&_hsenc=p2ANqtz--s9BItk72zL7aKaUaS1DnNQvGYNdYfyRYtsxU-pp_ZJhucylHUhM7015HQd6zSnUqy-AtL2ASIvqVKKwnc-WGKGxzmFQ&_hsmi=86570097. Accessed April 24, 2020.
2. Lai J, Ma S, Wang Y, et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020;3(3):e203976.
3. World Health Organization. COVID 19 Strategy Update. https://www.who.int/docs/default-source/coronaviruse/covid-strategy-update-14april2020.pdf?sfvrsn=29da3ba0_19. Accessed April 20, 2020.
4. U.S. Treasury. Paycheck Protection Program (PPP) Information Sheet. https://home.treasury.gov/system/files/136/PPP--Fact-Sheet.pdf. Accessed April 23, 2020.
About the Authors
Soo Jeong Youn, PhD, (ADAA member) is a licensed Clinical Psychologist at the Community Psychiatry Program for Research in Implementation and Dissemination of Evidence-Based Treatments (PRIDE) at Massachusetts General Hospital and an Instructor in Psychiatry at Harvard Medical School. She aims to address the access to care problem and health disparities that exist in mental health and disproportionately impact underserved populations through her clinical and research endeavors in psychotherapy process/outcome, community-based participatory research, and implementation science. @SYounPhD
Torrey A. Creed, PhD, (ADAA member) is an Assistant Professor of Psychiatry at the University of Pennsylvania’s Perelman School of Medicine, and a licensed clinical psychologist specializing in principle-based cognitive behavioral therapy (CBT). At Penn, she leads the Penn Collaborative for CBT and Implementation Science, which emphasizes public-academic partnerships to increase access to CBT and other evidence-based practices in under-resourced community settings. @torrey_creed
Shannon Wiltsey Stirman, PhD, (ADAA member) is a Clinical Psychologist and implementation researcher in the Dissemination and Training Division, and an Associate Professor at Stanford University’s Department of Psychiatry and Behavioral Sciences. Her clinical work and research focus on implementation, fidelity, and adaptation of cognitive behavioral therapies for individuals with PTSD, depression, suicidality, and anxiety. @SWS_FASTLab
Luana Marques, PhD, (ADAA board president) is the Director of Community Psychiatry PRIDE at Massachusetts General Hospital and an Associate Professor of Psychiatry at Harvard Medical School. Dr. Marques is a national and international expert in Cognitive Behavioral Therapies and a leader in bringing science-backed mental health practices to everyone. Her decades of clinical and research experience implementing evidence-based practices encompass all types of roles and settings, from front-line staff to CEOs, diverse communities to organizations, both in the US and globally. @DrLuanaMarques