Accessibility of Outpatient Behavioral Health Care in Nassau and Queens Counties During the COVID-19 Pandemic Maya Vasser, BA, Daniel J Coletti*, PhD, Leslie Rosenberg*, LCSW, and Lauren Block* MD, MPH
*Division of General Internal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell NY Results
Introduction
# of Facilities
• A total of 42 facilities were included in the study from across Nassau County and Queens. • One in five of US adults experience mental illness annually. Despite the ACA’s expanded insurance coverage • “Questionnaire success” indicates the ease which with we were able to contact live personnel. however, the majority of patients with mental illness do Questionnaire Success Access to Treatment 25 not receive treatment. 20 • The USPSTF recommends screening for depression in Never, 20 18 17 16 12% primary care as of January 2016, “with adequate systems 15 3rd call, 13 Immediate , 12 in place to ensure accurate diagnosis, effective 12% 31% 10 treatment, and appropriate follow-up.” 7 First 2nd call, 4 • The COVID-19 pandemic has led to widespread use of 5 26% Voicemail, telemental health services. It is unclear whether use of 0 19% 0 telehealth interventions has facilitated access across Intake Treatment Medication within 1 week within 1 month >1month to never socioeconomic lines or whether barriers exist that may may exacerbate health disparities. • The majority of facilities had intake appointments and treatment appointments within one month, and medication management appointments after one month.
Objectives
• We investigated patient access to behavioral health intake, psychotherapy, and psychiatry services. • We examined access according to insurance type and comorbid conditions in two suburban-urban counties. • We describe changes to behavioral health service delivery in response to the COVID 19 pandemic.
Methods Facility called
Answer
No Answer
Voicemail left
No Answer
Called again
Percentage of Facilities with Services
Additional Services Offered 90% 80%
81%
76%
70%
57%
60% 50%
73% 40.50%
40%
24%
30% 20% 10% 0%
Treat Children and Families
Treat ADHD
Additional Languages
Chemical Dependency
(up to 3x)
Return call
11%
/
0
Crisis Services
Smoking Cessation
Walk-In
• The availability of additional treatment services at each location varied widely • Additionally, 79% of facilities accepted an assortment of public and private insurance plans, and 79% of facilities had an income-based sliding scale of payment for uninsured patients Appointment platform:
50%
Percentage of Facilities
45%
• We called every hospital, university, and /or community mental health facility in Queens and Nassau Counties. • Facilities were compiled from the Northwell DGIM Outpatient Behavioral Health Service Directory. • Facilities were called during business hours in June and July of 2020. • For consistency, calls were made by single caller using a structured script. • Procedures had been reviewed by the medical center’s Institutional Review Board (IRB) and assessed as constituting quality improvement initiatives.
Day Treatment Domestic OR Partial Violence OR Hospitalization Rartner Abuse Program
Additional Services
COVID-19 Related Changes Questionnaire completed
21.50%
40% 35%
43% 37% 32%
32%
30% 25% 20%
22%
19.50%
15% 10% 5% 0%
Volume Increased Plan to Come Back Acuity Increased Maintain Removed Walk-in Removed in Person Telehealth into the Hours Weekday/Evening Fall Hours
• 100% of facilities offered telehealth with 86.5% utilizing telephone services and 62% offering video services • 21.5% of facilities provided video-only services for psychiatry appointments. • 11% of facilities had in-person appointments, reserved for acute patients.
• The affects of COVID-19 varied widely across facilities and not every interviewee was willing to answer questions about COVID-19 related changes • Additionally, 5 facilities expressed communication difficulties was the biggest challenge for their organization during this time and 3 facilities plan to add video services to complement telephonic services
Conclusions
• While numerous resources for outpatient behavior health are available in our catchment area, practical access to said resources is more limited. • Results suggest that patients face long wait times to establish consistent behavioral healthcare. • Access prioritizes (a) patients with urgent needs, as they are fast-tracked for appointments, and (b) patients with perhaps milder behavioral health symptoms, who can manage long wait times to treatment. • Patients with moderate symptoms may lack access as they struggle to wait for treatment yet fall short of needing urgent care. • The COVID-19 pandemic has pushed nearly all behavioral mental health services to a telehealth platform making access more difficult for patients without technology to participate fully in these services. • The pandemic’s impact on outpatient behavioral health care is constantly changing and differs across facilities, creating uncertainty for patients and providers alike. Study Strengths and Limitations • Strengths of this study include consistency in data collection and analysis as well as standardization of study procedures. • The study was limited by its cross-sectional design, giving only a glimpse of a changing reality, especially during the COVID-19 pandemic. • The study was performed by a medical student calling from a hospital-affiliated internal medicine practice. Whether intake personnel’s responses to inquires about appointments information would have differed if provided to an actual patient remains an open question. Future Directions • We hope to repeat the study in a few months to see how the COVD-19 pandemic continues to shape mental health access. • Performing the study with the investigator playing the role of a a “secret shopper” would more closely approximate the patient experience. Acknowledgements: The authors would like to thank Hannah Spellman, MD for her early contributions to this project. References •
Siu, A. L., MD, MSPH, USPSTF. (2016, January 26). Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement. JAMA 315(4), 380.
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Mental Illness. (2019, February). Retrieved 2020, from https://www.nimh.nih.gov/health/statistics/mentalillness.shtml
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Fact sheet MEDICARE TELEMEDICINE HEALTH CARE PROVIDER FACT SHEET. (2020, March 17). Retrieved May 01, 2020, from https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
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Kannarkat, J.T., Smith, N.N. & McLeod-Bryant, S.A. Mobilization of Telepsychiatry in Response to COVID-19—Moving Toward 21st Century Access to Care. Adm Policy Ment Health (2020). https://doiorg.medproxy.hofstra.edu/10.1007/s10488-020-01044-z