COVID-19 Tests Integrated Care’s Resiliency

June 8, 2020

COVID-19 Tests Integrated Care’s Resiliency

The COVID-19 pandemic has pushed providers, patients, and organizations toward — and beyond — their limits of discomfort, with the potential to remain this way for the foreseeable future. The healthcare system braced itself as the COVID-19 pandemic shocked our nation. Moreover, the world of integrated care sighed as it looked as if another hurdle was in front of us. In the integrated care space, something has changed.

Integrated care is the practice of treating the whole person, including physical, emotional, spiritual and social aspects of health. Mental health is a considerable dimension of integrated care. The movement toward treating the whole person has faced challenges since its birth, including the stigma around mental health, policy and payment system hurdles, and the healthcare system’s siloed approach to healing the patient. During the COVID-19 crisis, increased physical distance between healthcare team members — and challenges related to payment systems and service delivery — have weighed heavily on the integrated care field. However, through this challenge, innovation, resilience and increased awareness have emerged.

Healthcare has faced a grueling opponent in COVID-19. Some clinics have found themselves against the ropes, narrowing — and some closing their front entrance — just to discover that the leaders of organizations have found a way to open new points of entry. Those new pathways and adaptations established include telehealth, policy regulations changing with sharp and timely intent, and innovative programs, such as Ready Responders COVID crisis teams, acting to preserve hospital capacity. These efforts were established to win this battle against COVID-19, but have led to refining healthcare system practices that will go beyond the pandemic. There is hope to have a lasting impact on healthcare beyond the COVID-19 pandemic. Monica Williams, MSW, LCSW (Northfield, CT), seems to think so:

”During these unprecedented times individuals (and entire families) are needing clinical support, guidance, interventions and coordination of care. The ability to provide these services face-to-face and virtually (visual and audio) has proven to be essential for many individuals for different reasons. In order to meet the greater capacity of individuals and their families, these options are essential for overall quality improvement, as there will be longer and larger impacts beyond this epidemic.”

Mandated quarantine orders across the country have required healthcare facilities and providers — including behavioral health providers — to be creative, flexible, and innovative. A heavy dose of hope, grace, and loved ones’ support has carried behavioral health clinicians to keep their heads up, move forward, and do what they do best: provide an emotionally safe place to patients, and sometimes colleagues, in the midst of emotional distress, procure a solution when a patient is feeling lost, and partner with their healthcare team to innovate and meet patients’ whole-person care needs. We know one thing for sure…the world needs behavioral health professionals now more than ever.

Organizations have launched or expanded their telehealth programs and found creative ways to reach clients. Rebecca Levy, LMFTA (Winston Salem, NC) and East Carolina University PhD candidate describes her perspective as a clinician:

“Anxiety has increased overall in this pandemic. More people are willing to reach out to get help because it’s accessible via telehealth. I think therapy has become less stigmatized.”

The battle against mental health stigma is still ongoing, with a long history of stigma dating back as far as ancient Greece, when people thought those who showed mental health symptoms were possessed by demons. We have certainly come a long way, but a lot of work remains. Today, leaders such as Governor Andrew Cuomo (NY) and Governor Roy Cooper (NC) have taken a strong stance on recognizing the importance of behavioral health as a part of whole-person health.

Governor Cuomo has created funding to expand mental health services and publicly commented, “You know, we’re all concerned about the immediate critical need. The life and death of the immediate situation, which is right. But don’t underestimate the emotional trauma that people are feeling, and the emotional health issues.”

Governor Cooper reinforces this message to North Carolinians as he states, “This pandemic has put a spotlight on the need for more attention to mental health. Taking care of your mental health is just as important as your physical health, and there are newly expanded opportunities to seek telehealth during this pandemic.”

This pandemic has inspired leaders to take the opportunity to advocate for the importance of behavioral health. In the face of COVID-19, the stigma is breaking down.

As stay-at-home restrictions loosen across the country, the emotional impact of COVID-19 will last far beyond this season. Whether you are a provider in an outpatient behavioral health setting, integrated care primary care office, or another setting, the way providers are supporting patients has changed. Meghan Lacks, PhD, LMFT (Greenville, NC), expands on this:

“Patients have expressed immense gratitude for adaptations to provide services rather than discontinue them during this unprecedented time. They are especially grateful to have continued access to mental health providers because so many people are experiencing increased depression, anxiety, grief, sleep disturbances, etc. Providers are also needing to be a lot more adaptable and flexible during this time because a lot of patients have increased distractions at home. It is not the same as coming into a quiet, secluded therapy office – folks are in the midst of homeschooling one or more children, working remotely, or just trying to manage general family chaos while attempting to engage in therapy simultaneously. Most patients do not have the luxury or privilege to step away from their families and engage in a 45-minute therapy session with no distractions right now.”

Behavioral health as a profession has found itself carving its niche in the whole-person care space, demonstrating the major role of emotional and mental health, and substance use, in a person’s overall health. COVID-19 has created an opportunity for this role to be punctuated and amplified. Let’s examine this growth. Neftali Serrano, PsyD (Chapel Hill, NC), CEO of the Collaborative Family Healthcare Association (CFHA), a national organization that supports healthcare professionals in integrating physical and behavioral health, offered his insight regarding the status of behavioral health during this pandemic:

“Behavioral health is clearly being seen as a value. This is a moment for behavioral health, and for behavioral health integration in particular. There is a tremendous opportunity to solidify the role of behavioral health as a standard part of healthcare provision. And on top of that, you layer on the access innovation, patients have a much easier time accessing today than they did three months ago. With this innovation, this provides us an opportunity to distribute care in the future. There is a lot of really good stuff happening in the middle of an extremely painful time for a lot of us.”

Something is absolutely changing in the resiliency of integrated care. The change is unquestionably a difficult process. Amidst the plethora of changes that COVID-19 is influencing, there is going to be something different about integrated care after we get through this. Leaders are openly discussing and normalizing issues around mental health and this is tremendous growth. Hospitals and clinics have built new paths to accessing healthcare, including behavioral health. The nation, its people — including providers, hospital systems and patients — have been stunned by the COVID-19 pandemic. We have been forced to address issues with healthcare access, funding, and service delivery. We can only hope that these changes endure past the pandemic as our sights are set on the full embrace of equitable, whole-person care.

Posted in Mental Health Awareness

Maintaining Mental Health During a Pandemic

May 28, 2020

Maintaining Mental Health During a Pandemic by Brady Blackburn, MA

COE was pleased to collaborate on this blog post with the North Carolina Oral Health Collaborative (NCOHC), one of our partner programs at the Foundation for Health Leadership & Innovation, on a discussion of the intersection of mental health, the oral health care world, provider well-being, and COVID-19.

“This pandemic is a perfect storm,” said Dr. Lisa Tyndall, an integration specialist with the Center of Excellence for Integrated Care, a program of the Foundation for Health Leadership & Innovation (FHLI).

As North Carolinians navigate COVID-19 and its various impacts, NCOHC decided to sit down with our partner program at FHLI to discuss how the pandemic poses significant mental health concerns, for patients and providers alike.

Tyndall, a licensed marriage and family therapist, said that the wide range of impacts caused by COVID-19 — from financial stress to anxiety and isolation — are serious stressors that negatively impact mental health.

“The fact that we can’t be with each other absolutely negatively impacts the coping mechanisms most people use of reaching out and spending time with friends and loved ones,” said Tyndall. “We are wired to connect, and right now we are limited in those personal, face-to-face relationships.”

For the provider community specifically, Tyndall worries that we tend to forget that they are humans, too.

“I think that we forget that the frontline providers are facing a lot of the same uncertainty that the rest of us are,” said Tyndall. “Especially for those providers who live alone or are caregivers in their personal lives. If a provider doesn’t have a support system, or if their support system is already stretched thin, it is an especially difficult time. There’s a physical as well as an emotional toll to the stress, and it builds up. Providers manage the stress of patient caregiving every day, and then still go home to manage their own households, potentially adding an additional layer of stress.”

“As doctors, we are trained to be the rock,” said Dr. Zachary Brian, NCOHC’s director. “We’re trained to be the provider, there to serve the community, sometimes at the expense of our own physical and mental health.”

Both Tyndall and Brian described a juggling act for providers, balancing service to their communities, personal and family safety, as well as financial well-being.

“It can feel as though you are navigating a sea of conflicting resources, literature, and research to determine the safest way to move forward with your practice,” said Brian. “Given that this is a novel virus, it is not uncommon to see this type of response. The issue arises in that there’s no one clear authority to look to for guidance, which makes informed decisions on behalf of your patients and staff ever more challenging.”

As health experts learned more about the novel COVID-19 virus in recent months, guidance from the American Dental Association, the Centers for Disease Control and Prevention, and other state and national regulatory bodies were released, but were not always in exact agreement with one another.

“The resources for providers that we have seen, although very helpful, have not necessarily always been in parallel,” said Brian. “This has created a surge in confusion.”

What can you do about the uncertainty?

Dr. Brian says, “While the provider community as a whole may be very isolated during this time, forced to make decisions with so many unknowns, there is support within your regional communities. Don’t be afraid to reach out to your colleagues. People need to be very open and transparent, so we don’t have to navigate this crisis in a vacuum.”

Dr. Tyndall says, “We have to lift ourselves up and we have to lift each other up. We don’t have to talk about it all the time, but we also should give a voice to it and not minimize the stress. It is important to have outlets to express uncertainties, fears, and concerns.”

Dr. Tyndall also shared a couple of resources for providers who need help managing their own mental health needs during this time.

The Hope for NC Helpline is a free helpline for people who need assistance coping and maintaining resilience during COVID-19. The number for the 24-hour helpline is 855-587-3463.

For first responders, the University of Minnesota, the Minnesota Department of Health, and the University of Minnesota College of Education and Human Development have released a First Responder Toolkit to help those deployed in emergency response maintain their own physical, emotional, and social well-being. The app can be accessed here (note: a login is required).

Financial uncertainty is another stressor impacting many oral health care providers. This is especially salient in the private sector, where most dental practices are small businesses. On top of figuring out how to keep everyone safe and healthy, while still providing necessary care to the community, providers must also navigate out how to stay above water financially.

“Even though it seems like practices would be bustling during a health crisis, we also know that there is a side where providers aren’t seeing as many patients,” said Tyndall. “So that financial stress — especially for smaller practices, rural practices — is very real.”

Brian said that the oral health profession is on the low patient volume side of the equation. Largely due to the use of aerosolizing instrumentss, dentists, and hygienists in particular, are near the top of the list of most at-risk professions for COVID-19 transmission. In response to the elevated risk, most dental offices have only seen patients for urgent needs during the pandemic.

Brian said that in the oral health care space, safety net practices are facing profound and lasting financial impacts, as well. Practices that see patients regardless of their ability to pay, and who offer care on a sliding fee scale, have very thin to nonexistent margins to begin with. Nearly completely cutting off their revenue stream can be catastrophic.

What can you do to navigate financial uncertainty during COVID-19?

Dr. Brian points to the ADA’s resources for providers, especially the following the guidance:

Return to Work Toolkit Financial Assistance for Dental Practices from Third Party Payers
COVID-19 Coding and Billing Interim Guidance: Virtual Visits
COVID-19 Coding and Billing Interim Guidance: PPE
Financial Obligations to Staff D uring COVID-19

Additionally, the North Carolina Division Health Benefits has issued temporary modifications for telehealth billing, and NCOHC has launched a teledentistry fund with support from the Blue Cross and Blue Shield of North Carolina Foundation.

If your practice is a safety net provider in need of teledentistry software, please reach out to ncohcinfo@foundationhli.org for information on how to apply for funding through the NCOHC Teledentistry Fund.

Please note: The aforementioned guidance documents are only to serve as a resource, and are not necessarily founded in scientific evidence, or endorsed by NCOHC or COE.

According to Brian, it is important for providers to be aware of oral signs and symptoms that can alert them to potential mental health needs of their patients.

“You have parafunctional habits such as clenching and grinding that can develop as a result of stress, and from this you can see detrimental effects on teeth and other oral structures, such as extensive attrition and fractured teeth,” said Brian. “I saw that a lot with my patients when they were going through stressful events in their lives. They would come in with three or four fractures in their teeth, sometimes where the fractures extended past the gumline requiring surgical interventions.”

Brian also said that dietary changes due to stress and anxiety can negatively impact oral health. Increased sugary food and carbohydrate intake, as well as alcohol consumption, can both increase risk of tooth decay and gum disease.

“One thing that we’re not talking about enough is that we’re only seeing emergency patients right now,” said Brian. “There are people who are delaying appointments or not seeking care, and by the time they come in, what could have been a simple filling previously has now advanced to the point where it requires a root canal or an extraction. This is also particularly important for routine oral and pharyngeal cancer screenings.”

How can an oral health provider look out for mental health strains in patients?

Dr. Brian says, “Look for attrition patterns from clenching and grinding, fractured teeth, and TMJ pain.”

“As an oral health professional, having a relationship with someone in the mental health space is vitally important, also. You need to have a sounding board to discuss mental health concerns of your patients, and a trusted referral source to help route that patient to proper care.”

“It is crucially important that you have deeper conversations with your patients. Make sure that you take a whole-person care approach by including the mental health of your patients into the patient experience.”

Both Tyndall and Brian agreed that taking time to reflect and take care of yourself is incredibly important for providers during this pandemic. Taking steps to interact with family, friends, and colleagues is an important way to cope with the isolation and stress we all are experiencing.

“Dig deep into your resource and faith buckets, and be kind to yourselves,” said Tyndall. “Take time to make sure that you’re taking care of yourself, too.”

“This too shall pass,” said Brian. “Dentistry remains a profession that allows us to impact our patients in direct ways, see immediate results, and change lives. That doesn’t change with the pandemic.”

Posted in Mental Health AwarenessTagged #mentalhealth, COVID-19

Stress, or more?

May 19, 2020

Am I stressed, or do I have a mental health disorder?

by Ricky Caliendo, LMHC

It was 2014, a fresh box of tissues sat on the coffee table and steam dissipated into the air above a warm cup of coffee. A screech from the opening of the lobby door traveled into my office as a wave of anxiety set in. Immediately, I remembered a not-so-encouraging joke that my clinical psychology professor overused throughout one semester: “Every student should prepare a sorry card for their first patient.” Why was it that this poorly placed joke has found itself cornered into my thoughts as my first patient eagerly waits outside my office?

A professional, middle-aged man sat down across from me, looked at the box of tissues, and offered me a cunning grin. He understood that I was younger than him. Nonetheless, I sipped my coffee and started the session. After obtaining informed consent, and just about finished reviewing the laundry list of office policies, he stopped me with a distinct purpose. He said, “All I want to know is if I am just stressed out or actually going crazy?” I jokingly assured him that there is a thin line between the two. He gave a small chuckle as we both felt the ice in the room breaking. He eased back into the couch and began to disclose the recent detour his life had taken. Between a divorce, cancer diagnosis, and his mother’s deteriorating health, I thought to myself that he had a lot more resilience in him than he realized.

Through the years in practice, and navigating through diagnostic and treatment recommendations with colleagues, the answer to the question that my first patient had has changed. Although humor has sustained, with a more sincere explanation now, I would not jokingly hint toward this line between stress and mental health disorders as thin; on the contrary, the line is thick yet permeable.

Is stress common? Definitely. We all experience good stress, such as excitement, and then there is stress that challenges us. This is a normal part of life.

Do mental health disorders exist? Of course. Mental illness can mean many different symptoms and experiences, but we do have a way of capturing the range of mental illness through diagnoses.

Making a diagnosis is very important in guiding evidence-based interventions and psychopharmacology. However, the person, and their uniqueness, exists before the diagnosis. A diagnosis can blind the individual differences in patients. Understanding the person, their experience, unique stressors, and even more importantly, how they respond to those stressors, will always exceed the importance of a diagnosis.

Our body and mind have a fundamental response to uncomfortable internal or external conditions. Stress is the umbrella of responses that can occur in relation to this, although this experience is hardly uniform. And, while every human being on this earth has experienced stress, everyone has not experienced a mental health disorder. So, what is the real difference?

Rather than dissecting the 5^th edition of the Diagnostic Statistical Manual of Mental Disorders and providing a quiz at the end of this blog, let’s look at this in a different way. The size of the stressor may influence the size of the response. For example, a global pandemic that creates media hysteria, economic crisis, broken routines, and social isolation is likely to create a more persistent and intensified stress response compared to running late for work and burning your toast. However, there are variables — such as genetics, traumatic occurrences, and biological influences — that can make these stress responses less predictable and proportional, and even alter the likelihood of developing a mental health condition.

Given that we have already established that everyone has experienced stress, one may imagine that there are some shared manifestations of stress. Trouble with sleep, concentration, appetite, drive and motivation toward pleasurable activities, and irritability are some common internalization responses to stress. The intermittent slam of the door or giving someone the silent treatment may be common externalized responses. These can also be signs of depression. But the severity — how it impacts your functioning — and other symptoms need to be considered before naming a mental illness. Some of the more concerning symptoms related to clinical depression may include hopelessness, trouble with memory, increased alcohol and substance use, and suicidal ideation, to just name a few more concerning experiences. Certain things like good self-care, support, and treatment, can impact the degree of permeability of the line between mental health disorders and stress.

Remember, if you’re having a bad day, or your environment is providing you with an extra stressful situation, it is normal to not be at your best. Allow yourself to have a stress response and remind yourself that this is uncomfortable, but it is normal, and there are coping techniques that can help reduce your stress. If persistent, disproportioned emotional or behavioral responses continue — with a negative influence on your quality of life, relationships, and functioning — it may be time to dig a little deeper to explore support for your mental health.

For Mental Health Awareness Month, we wanted to bring attention to this important distinction between stress and mental health disorders, and remind our partners and communities that there is help and support available for both. Connecting with a behavioral health professional — such as a counselor, psychologist, therapist, or psychiatrist — can help you determine if what you’re experiencing is stress or a mental health disorder. Additionally, your primary care provider will be able to support your whole-person health needs, including your mental health. Many primary care offices are homes to behavioral health professionals, and providers work together as a team to deliver whole-person health. You may be able to speak with a behavioral health clinician right at your primary care office!

We hope you all are staying safe at home and in the community. Take time to care for yourself and your loved ones. Feel free to explore our resources and blog posts related to Mental Health Awareness month.

Posted in Mental Health Awareness, ResourcesTagged #covid, #covid-19, #mentalhealth, #stress

Uncertainty in the time of COVID-19

May 13, 2020

Grace in Uncertain Times

by Lisa Tyndall, PhD, LMFT

In the midst of COVID-19, most mornings I wake up unsure of how the day will find me. I know what I am supposed to do, and how I am supposed to feel. The experts say I should slow down, take time to be grateful, some say to meditate during the day, and we have all heard the ever-present suggestion to get outside and exercise. Don’t get me wrong, I like all of these suggestions – it is just that ironically sometimes it feels impossible to do these tasks that are supposed to make life easier right now. How hard is it to just take a time out for 10 minutes to breathe?

Turns out that 10 minutes can actually be hard to find indeed. Everyone has different working situations right now, some are working more than ever on the front lines of the healthcare system, some are working remotely, some are dividing their time between the office and home, some have been furloughed, and some have lost their jobs entirely. Our work environments have changed dramatically. Clinics can be deserted, and some may be overrun. Co-workers can become second family if they were not so already, and those at home may be squeaking out a somewhat professional and quiet work-space that invariably will compete with the other life demands peeking from behind the cracked door. For me it is a new “work from home” environment, which includes children home from school but yet somehow still in school. While there have always been best practices as far as remote working is concerned, these days I come across even more “work from home” tips floating around various websites and depending on the day I am either fairly receptive or I want to tear them up into little pieces.

If you are at home, be sure to keep a schedule. Shower and get dressed every work day. Wherever you are, be sure to take a daily meditation break. Be present with your family, either in person or through a glass door. Slow down but meet your work expectations. For those of us with kids, don’t forget to add to that parenting, refereeing fights, fending off questions about hanging out with friends, teaching, and don’t forget to flagellate yourself for the increased screen time.

You get the picture – there are a million potential directions a day could take and often does take – during this time where we are supposed to be adjusting to the “new normal.”

When you read all of the advice columns – it seems like it should be simple. And yet, what we are often missing is the layer of uncertainty that drains the energy from each of us like an app open on your phone which can never close. It isn’t the same right now. We aren’t just working from home some, changing our clinical workflows, having lots of zoom calls and for some, working in pajama bottoms. Whatever your environment, a large percentage of our energy is going towards emotionally processing the uncertainty that looms over the entire world. What will it be like when the world re-opens? How long will it look like this? Will we get back to celebrating life’s milestones? Or will we even get back to being able to be at someone’s bedside during their last moments? Surely the basic human needs for touch and connection won’t be forever gone from our reality…will they?

I do believe that this collective trauma will eventually be settled. What “settled” looks like I am not sure – but I know that developmentally and all through life when the hardest of times has come as people and as a country, there is a pendulum of reaction and response that swings but eventually finds the middle and settles. We all wish for the return of the freedoms we once took for granted, but are currently hazardous, to stop being afraid of seeing people in masks in the store, to wish to start seeing more people in masks, to learn how to work from home while missing live human interaction with others, we all want to feel productive and balanced again. As human beings, we always want to rush through the uncomfortable parts – and it is very uncomfortable right now to say the least. How in the world do we sit in the waiting for this pendulum to settle?

In those moments where I feel guilty for not being more productive, guilty for not parenting better, guilty for still having a job, yet afraid of the very clear temporary nature of jobs we never deemed temporary, there are so many conflicting emotions and states of being. In these moments, I do my best to choose grace. That also sounds simple – but it isn’t. It takes my village of people to remind me to choose grace for myself. It takes my spiritual practice to remind me to choose grace. It takes what I know as a therapist to choose moments of grounding and gratitude to eventually get lead back to grace. The irony here is that I also have to forgive myself for the moments I forget to choose grace, when my pendulum swings too far to one side or the other.

There are enough suggestions out there in the world for how to handle and cope with the current situation, both personally and professionally, a few even on our own website! And with May being mental health awareness month, we are particularly aware of the importance of taking care of not only our mental health, but our behavioral and relational health as well. My experience has been that those, as well as our physical health of course, are all connected. Keeping those connections in mind, how you choose to manage the swings of the pendulum is up to you. But overall I would say listen to your heart, give yourself and others large amounts of grace, and take it one day (even one minute if need be) at a time.

Stay tuned for more from the COE team during Mental Health Awareness Month 2020!

Posted in Mental Health AwarenessTagged COVID-19, Mental Health