Three Digital Tools That Can Help US State Governments Meet Behavioral Health Needs Amidst COVID-19
May 10, 2022;
6 min read
Written by Elaina Faust
The COVID-19 pandemic has sharply increased demand for acute behavioral health care services while dramatically reducing the number of beds in inpatient psychiatric and substance use care facilities in the US. From 2019 to 2021, the average share of American adults reporting symptoms of anxiety or depression increased from 11 percent to over 41 percent. Calls to the National Mental Health Crisis Hotline have increased by a staggering 891 percent during the pandemic. Demand for inpatient psychiatric beds has increased by 40 to 50 percent. At the same time, the number of beds available has been reduced by up to half in order to accommodate physical distancing requirements and to repurpose beds for the treatment of COVID-19 patients. Consequently, it is becoming more difficult for healthcare providers to match patients with available beds and for patients to obtain the care they need. Women, people of color, and low-income Americans have been disproportionately affected by the negative behavioral health impacts of the pandemic. Ensuring patients receive the care they need in a timely manner is therefore essential, not just to ensuring quality healthcare service delivery but to advancing health equity as well.
Patients experiencing an acute behavioral health crisis often receive care at their local emergency department (ED), where they may be placed on an involuntary hold if they are at risk of harming themselves or others. Most EDs do not have a psychiatrist on staff and must obtain a consult for the patient, either by paging a doctor on call or by leveraging telemedicine. EDs are designed to stabilize patients with acute needs, not to provide longer-term care and hospitals often do not have inpatient psychiatric beds. Patients must therefore be transferred to specialized hospitals or clinics to receive further treatment.
Patients wait hours or even days in the ED before they can be relocated to another facility capable of providing the care they need. Though this is true for all patients, patients with inpatient behavioral health needs are particularly impacted. On average, it takes three times as long to identify an inpatient bed for a patient with psychiatric needs as it does to find a bed for a patient with other medical needs. Without relevant digital tools, ED providers must manually identify and contact facilities one at a time, until they find one that is right for their patient. Robert Sheehan, the CEO of the Community Mental Health Association of Michigan, estimated this required an average of 19 phone calls, even before the pandemic began.
Finding an appropriate care facility is complex. Providers must take into account the patient’s insurance plan, diagnosis, demographics, the required security level of the facility, and the facility’s distance from the patient’s home, in addition to whether or not they are currently accepting new patients. This can amount to hours of work. For patients, extended ED stays can increase stress at an already difficult time and delay access to much-needed care. For hospitals, they increase demands on scarce resources made scarcer by the overcrowding caused by COVID-19.
Digital technologies have enormous potential to help alleviate these challenges by streamlining the workflow and decreasing time spent on manual tasks. Yet, when it comes to the adoption of digital tools, behavioral health has historically lagged behind other healthcare specialties. For example, only 30 percent of behavioral health providers in the United States utilize an interoperable electronic health record (EHR) system, compared to 74 percent of physicians overall. A number of factors have contributed to this gap, including reimbursement models that compensate providers more for in-person services, licensure that limits providers to practicing in certain states, and a relative lack of incentives for behavioral health providers in the Health Information Technology for Economic and Clinical Health (HITECH) Act, which made EHR systems mainstream in the US health market.
The COVID-19 pandemic has accelerated behavioral health technology adoption. Due to increasing demand for remote care that minimizes the risk of COVID-19 exposure, both healthcare providers and patients are increasingly open to technology-enabled behavioral health services. Companies such as Talkspace and BetterHelp have normalized online therapy and mobile counseling, even allowing patients to live chat with healthcare providers. America’s behavioral health care sector is therefore at a key turning point, ready to take advantage of technology-enabled solutions to its key challenges. This blog post will discuss three digital tools that can be used in tandem to more efficiently match patients with behavioral health care providers, all of which are supported by Dimagi’s CommCare platform: bed capacity registries, closed-loop referral systems, and public-facing provider directories.
Bed capacity registries
Digital bed capacity registries are web-based electronic databases of available behavioral health beds. Bed registries may include beds in public or private psychiatric hospitals, psychiatric units within general hospitals, crisis stabilization units, and rehabilitation and substance use recovery centers. A bed capacity registry has the ability to create one searchable statewide repository of providers, saving time by eliminating the need for repeated phone calls to verify bed availability. As of 2019, 17 states were utilizing behavioral health bed capacity registries.
Closed-loop referral systems
A closed-loop referral system allows providers to assess patient needs, electronically refer patients to appropriate facilities, and communicate with other providers regarding the transfer of care. When referring via phone or fax, it is difficult for providers to learn whether their referral has been accepted and whether their patient has received the intended care at the external facility. A closed-loop referral system gives providers access to real-time updates on the status of their transfer requests and flags overdue or rejected referrals, reducing the risk that patients will be lost to follow-up.
Public-facing provider directories
A public-facing provider directory is a publicly-available, searchable, web-based database of providers in the state. It can be thought of as a public-facing version of a bed capacity registry. The information included in a public-facing provider directory may vary. For example, some directories publish information on bed availability to the public. Others may only include information on the services provided by various healthcare providers, in addition to their location and contact information. Public-facing provider directories allow patients to locate and contact relevant providers directly, increasing patient autonomy, decreasing the time it takes to receive care, and decreasing the burden on healthcare providers to match patients with facilities. To date, four states provide public access to a behavioral health provider directory.
Challenges and Considerations
Adoption of these digital tools is not without challenges.
If the bed registry does not have accurate, complete, and timely data, it will not add value for its users. For example, if an emergency department physician leverages the bed registry to locate a nearby rehabilitation center and refers her patient there, only to discover the data was outdated or incorrect and the facility does not have space for her patient, this could lead to adverse patient outcomes and expose the physician to liability risks. Similarly, if the system does not contain data about all of the relevant facilities, providers may underutilize important resources because they are not aware they exist. Once users lose trust in the data, they will be uninclined to use the tool in the future. It is therefore essential that the data be updated frequently and accurately. To accomplish this goal, providers are often asked to manually update registry data twice per day, during scheduled shift changes.
Generating buy-in from participating providers (such as hospitals and healthcare facilities) is essential to the success of the project since each provider must update data in the system frequently to ensure it remains up-to-date. However, providers may have reservations. As with any digital health tool, providers may be concerned that data entry tasks will take away from patient care. Additionally, providers may have concerns that participating in a referral network will decrease their autonomy over which patients they choose to admit. Early and frequent engagement with participating providers can help combat this challenge. Additionally, some states leverage legislation to incentivize or require provider participation.
Regulatory and Policy Environment
An enabling regulatory and policy environment is key to mitigating the data quality and provider participation challenges discussed above. A statewide registry requires state-level coordination. Implementation is typically driven by state governments, such as state offices of behavioral health, which have taken various approaches to bed registry regulation. In Virginia, participation in the bed registry is mandatory and legislation dictates the intervals at which providers must update bed availability data. Connecticut provides financial incentives to encourage providers to update bed registry data regularly. Massachusetts has incorporated data update intervals into managed care contracts. In addition to legislation and incentives, enforcement and accountability mechanisms are necessary to ensure compliance.
Capacity registries and related digital tools are likely to become a foundational component of the behavioral health ecosystem in the United States as more states move to adopt them. These tools have the capacity to become even more impactful by being further integrated with existing systems. For example, integrating digital capacity registries with existing EHR systems has the potential to reduce the time allocated to manual data entry and increase the timeliness and accuracy of capacity registry data.
As we enter a new phase of the pandemic and Americans start to resume some aspects of their pre-covid lives, we must continue to respond to the behavioral health challenges the virus has left in its wake. Tools that assist health care systems in providing timely, and appropriate services for those with acute and emergency mental and substance use disorder needs will be an essential component of this response.
To learn more about how Dimagi’s CommCare platform can be leveraged to meet state behavioral health objectives, please contact [email protected]
Elaina Faust is a Project Manager with Dimagi’s US Health division and a Master in Global Human Development candidate at Georgetown University’s Walsh School of Foreign Service.