A new normal is setting in at Texas’ behavioral health hospitals, where the coronavirus pandemic has upended just about every aspect of delivering care. Across the state, behavioral health hospitals and providers are embracing necessary changes in how they treat patients.
COVID-19 has stressed Texas hospitals and impacted hundreds of thousands of Texans. The health impact, however, is not just physical. Isolation brought on by social distancing has led to many feeling symptoms of depression and anxiety. Job losses, worries about the future and general feelings of helplessness have led to many Texans seeking treatment for mental health conditions.
The value of therapists, psychiatrists and behavioral health hospitals cannot be understated right now. Texans need access to these services more than ever, and providers across the state have stepped up to serve their communities’ mental well-being.
Behavioral health hospitals face a unique challenge to reduce COVID-19 risks while still maintaining access to critical mental health services and treatment. At the same time, the shift to pandemic mode has revealed new opportunities — and is generating new evidence — that telemedicine is a promising tool for closing the state’s persistent access gaps.
Getting Pandemic-ready: Protecting Staff, Preserving Access
Every year, UTHealth Harris County Psychiatric Center cares for about 9,000 Texans struggling with mental illness. It’s the largest provider of inpatient psychiatric care in Houston and the city’s primary safety net hospital for mental health. Closing the doors isn’t an option, even during a global pandemic.
“It was a bit scary at first… we had to be able to keep this hospital going,” said Stephen Glazier, FACHE, the hospital’s chief operating officer. “I don’t even want to think of what might have happened had this hospital not been available for a two or three-week period.”
Preparing a psychiatric hospital for pandemic control is especially challenging, Glazier said, explaining that many of the practices used to treat mental illness — such as group therapy — are more susceptible to the spread of coronavirus. At the same time, steps to prevent COVID-19 transmission — such as isolation — are often detrimental to a patient’s psychiatric state. Even simple COVID-19 precautions like alcohol-based hand sanitizers and face masks with metal nose-bridge wires could be self-harm hazards. “Social interaction is not a luxury here; it’s a therapy,” Glazier said. “Psychiatric facilities and inpatient treatment are designed to get people together, not to keep them apart.”
To keep their doors safely open as COVID-19 spread across Texas, the Houston hospital quickly transformed both its physical environment and its everyday practices. Right away, Glazier said, the hospital eliminated unnecessary visitations, implemented temperature checks for entry, and conducted extensive symptom and exposure screenings during patient admissions. The hospital also set aside a special unit to separate patients with confirmed or suspected COVID-19. It activated protocols to quarantine any unit where a patient tested positive for the virus and then track potential contacts. Patients are spread out more, with fewer sharing a room.
The hospital also had to protect and train its providers and staff, many of whom had little experience in dealing with infectious patients, Glazier reported. About half its physicians and social workers switched to telepsychiatry and began working from home, and small group sessions were suspended. Telehealth services turned out to be universally well-liked, he noted, they and received much positive feedback from patients.
“I think one of the outcomes you’re going to see out of this is rapid expansion and adoption of telehealth in psychiatry and behavioral health,” Glazier said.
Not surprisingly, the hospital did have a difficult time finding proper personal protective equipment and had to build its supply chain from the ground up. As of May, the hospital had had just one patient with confirmed COVID-19, who was admitted to its isolation unit and tested negative for the virus at discharge.
“We’ve been very, very fortunate so far,” Glazier said. “One thing I think we all have learned was that symptom screening, temperature checking, wearing masks and social distancing makes a difference.”
Telemedicine Proves Valuable as Demands, Safety Concerns Rise
Adapting to COVID-19 has undoubtedly been challenging, but it’s also brought practices to the forefront — like telehealth — that could greatly expand treatment opportunities in a state that currently ranks last on access to mental health care.
The shift to telehealth could also help ready behavioral health providers for a spike in need, as many more Americans report symptoms of severe psychological distress and declining mental well-being due to the pandemic. Already, millions of Texans struggle with mental illness, many experiencing symptoms so severe they require emergency care. Rebecca Corona, Ph.D., lead psychologist at Parkland Health & Hospital System in Dallas, said she’d seen a rise in anxiety and stress among many patients, as well as a rise in demand for outpatient services, both of which can make expanded telemedicine a critical lifeline.
“I do think it’ll stick around for patients,” Corona said of new telemedicine options. “It finds patients where they are. We’re very excited and hopeful about the possibilities.”
At Parkland’s community-based primary care clinics, outpatient behavioral health services had been primarily delivered face to face, Corona said but switched to 100% virtual — or via phone — to stay safe during the pandemic. She said patients were “more than willing” to transition to video or telephone and the number of completed behavioral health visits have gone up since the switch.
“When we’re not limited by distance and transportation, we’re able to get access to care to patients much quicker,” Corona said. “And I think most patients would say it’s been as beneficial as coming in. The relationship is still key.”
On the inpatient side, Parkland’s psychiatric emergency department activated new COVID-19 screening protocols in March. If the virus got in, said Kurtis Young, LCSW, director of social work for Parkland’s Behavioral Health Services, it could force the hospital to quarantine the entire unit, which would negatively impact capacity. Fortunately, Parkland has rapid testing capabilities, Young said, so any patient at the psychiatric ED who raises concern during COVID-19 screening can get quickly tested — sometimes, getting the results in just a couple of hours.
Parkland’s RIGHT Care team, which provides rapid response to mental health emergencies out in the community, is also continuing through the pandemic with extra precautions such as wearing additional PPE. Young said visits to the psychiatric ED and calls to the RIGHT Care teams both dropped off dramatically in the initial weeks of COVID-19, with numbers still below pre-pandemic levels as of early June.
“I hope that we’ll learn some viable lessons about new ways to provide services that aren’t just valuable to patients, but to providers,” Corona said.
JPS Health Network is the largest psychiatric care provider in Tarrant County, seeing around 20,000 patients a year in its psychiatric emergency center and about 40,000 behavioral health patients via outpatient services. It also runs a 36-bed local commitment alternative unit for patients committed by the state. The health system implemented many of the same safety precautions as other behavioral health hospitals to prepare for coronavirus, including opening a 14-bed inpatient unit for behavioral health patients infected with COVID-19.
"We’re so proud of the nurses working on that unit — they all volunteered, we never had any staffing issues,” said Zelia Baugh, executive vice president for behavioral health at JPS Health Network. “It’s been amazing what our nursing team has accomplished. It gives me the chills to think about it.”
Before the pandemic, Baugh said JPS offered little in the way of behavioral telehealth services. But within the span of a week, the staff was ready to transition to video and telephone encounters. Like Parkland, she said the shift has resulted in more people making it to their appointments, with the no-show rate for first-time visits with providers at its lowest point ever.
“Telehealth services will stick around,” Baugh said. “If there’s one positive from all this, it’s ramping up our technology. This pandemic has allowed technology to come to the forefront and moved us quicker than we would have gone otherwise.”
Telehealth will be especially helpful in meeting rising demands for mental health services. Baugh said JPS had experienced increased demand across its outpatient and inpatient behavioral health services. Its access call center, which helps residents find appropriate mental health care, began receiving hundreds of additional calls each month starting in March. At the same time, Baugh said, the hospital district is facing many of the same pandemic-related financial hardships other hospitals are reporting, such as declines in reimbursements. For example, while telehealth coverage has expanded, Baugh said many insurers are only reimbursing the provider, not the facility.
“I’m concerned long-term about the impact COVID-19 is going to have on people needing access to behavioral health services across the county,” Baugh said. “People are facing job losses, social isolation, school is out — families are just struggling across the board. I do think demand will continue to rise, and we’ll do everything in our power to meet it.”
Texas’ behavioral health practitioners continue to provide care for their communities as COVID-19 cases surge. There is much uncertainty for many, but providers are confident that they are ready to face challenges that come their way.