Peer Reviewed

Original Research

COVID-19 Pandemic Mitigation for the High-Risk Patients Served by the Community Mental Health System

Volume 60 - Issue 11 - November 2020

AUTHORS:
Zakia Alavi, MD1,2 • Raza Haque, MD2 • Ali Haque, MD3 • Dani Meier, PhD, MSW1

AFFILIATIONS:
1Mid-State Health Network, Lansing, Michigan
2Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, East Lansing, Michigan
3Internal Medicine Residency Program, Loyola University Medical Center, Maywood, Illinois

CITATION:
Alavi Z, Haque R, Haque A, Meier D. COVID-19 pandemic mitigation for the high-risk patients served by the community mental health system. Consultant. 2020;60(11):3-13. doi:10.25270/con.2020.05.00020

Received April 22, 2020. Accepted May 6, 2020.

DISCLOSURES:
The authors report no relevant financial relationships.

ADDITIONAL CONTRIBUTIONS:
We acknowledge Meaghan Mormann, MD, in the Pediatrics Residency Program at Northwestern University/Ann & Robert H. Lurie Children’s Hospital of Chicago, for assistance with formatting the tables and editing, and Gabrielle Guzzardo for assistance with editing and the literature search.

CORRESPONDENCE:
Zakia Alavi, MD, Assistant Professor, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, 1355 Bogue St, B240, East Lansing, MI 48824 (alavizak@msu.edu)

 

ABSTRACT: Multiple chronic medical conditions are common to patients served by the community mental health (CMH) system. Medical diseases are present in at least 50% of all patients with psychiatric conditions, and severe mental disorders are associated with significant physical comorbidity and mortality. Early data show that individuals with preexisting multiple chronic conditions have a higher mortality risk when they are symptomatic with COVID-19. Although mitigation guidelines and recommendations are constantly being reviewed and updated, we found no specific recommendations targeting the vulnerable population who use CMH systems or the publicly funded and managed behavioral health entities which serve them. We reviewed the Centers for Disease Control and Prevention guidelines regarding infection control in health care facilities that provide ambulatory care, including behavioral health clinics, as well as reviewed recent population outcomes data. We posit that the population served by the CMH systems is a higher-risk cohort than the general population and offer recommendations for effective infection prevention strategies specific to this population.

KEYWORDS: Mental health, COVID-19, Community Mental Health (CMH) system

 

Mental illnesses are common in the United States, with approximately 46.7 million persons (19.1%) living with a mental illness, and 11.4 million (4.6%) having serious/severe mental illness (SMI), meaning that they experience impairment that substantially interferes with or limits their life activities.1

In the United States, these populations frequently receive treatment through public-sector managed behavioral health, also known as community mental health (CMH) entities, which provide coverage for Medicaid recipients with SMI, developmental disabilities, substance use disorder, or serious emotional disturbances. CMH systems are tasked with serving patients with SMI, a group of patients with high rates of diabetes, obesity, hypercholesterolemia, and coronary artery disease.2 Meta-analyses involving multiple countries in North America, Europe, and Asia show that people with mental disorders have an increased risk of developing chronic physical diseases.3

This article provides a brief review of the current CMH system and its unique vulnerability in the face of the COVID-19 pandemic and proposes a number of mitigation strategies specific to the array of services for the population with SMI.

BACKGROUND

During a global pandemic, infection mitigation strategies are challenging in certain population segments, including nursing homes, assisted-living facilities, and foster homes. Patients who depend on state-sponsored behavioral health services (CMH centers) present a unique situation within this subset due to the substantial variations in operations from one point of care to the next in CMH systems across the different counties and states, and due to these systems’ focus only on mental illness as well as their generally limited resources. This variation is due in part to heterogeneous levels of medical oversight and disproportionate levels of funding.4 Furthermore, this population also presents a high risk for both the spread of disease and its poor outcomes due to physical comorbidities.

CMH clinics have several characteristics that underscore their need for strong mitigation strategies during a pandemic. The bulk of their services are typically provided by individuals trained in social work and psychology or counseling, and these services are delivered in nonmedical settings with limited medical oversight.5,6 The quintessential points of service in this system are the local CMH providers. Typically, the CMH clinics provide services such as group and individual therapy, care for persons with intellectual and developmental disabilities to live independently (including residential services), care in the community for persons with SMI, services to families and children, and psychiatric care. In some states, the CMH clinic is also the point of service for substance use rehabilitation and treatment.

Moreover, the CMH system is organized using a “social-support” model and not a medical model, with an ostensible aim to destigmatize the experiences and treatment of mental illness and to deinstitutionalize the delivery of mental health services.5,7-9 While this service delivery design has many strengths, including its aim to normalize and destigmatize mental illness by using a community-based, person-centered, and locally determined services array, this same model can be problematic in the case of a pandemic. The key to pandemic management is a swift, decisive, and unified response based on population health methods and with a robust, bidirectional relationship with local health departments. The heterogeneous and independent structure of the CMH system can cause the implementation of such a response to falter.

Medical comorbidity in individuals with SMI is widely documented. Medical diseases are present in at least 50% of patients with psychiatric conditions, and severe mental disorders are associated with significant excess of physical comorbidity and mortality.10 According to a recent systematic review by Onyeka and colleagues,2 hypertension (35.6%), hepatitis C (26.9%), diabetes (7.5%), and cardiovascular disease (11.3%) were the most prevalent physical disorders among patients with SMI and concomitant substance use disorders. For patients with SMI without substance use disorders, hypertension (32.5%), endocrine disease (19.0%), diabetes (7.5%), and cardiovascular disease (11.3%) were most prevalent. The Centers for Disease Control and Prevention (CDC) acknowledges that people of any age with serious underlying medical conditions might be at higher risk for severe illness from COVID-19; these conditions are obesity, severe cardiovascular disease, diabetes, chronic liver disease, immunocompromised status, chronic kidney disease being treated with dialysis, and chronic lung disease.11

Given the well-documented high prevalence of medical comorbidities in individuals with SMI, the COVID-19 pandemic poses a unique risk to this vulnerable population. Therefore, it is urgent to evaluate infection control and the ramifications of the pandemic for this population.

METHODS

We examined guidelines provided by the CDC and other sources regarding mitigation and prevention of person-to-person transmission in the health care setting, and how these guidelines can be implemented and operationalized in the CMH system.12

We reviewed the literature published recently about COVID-19 infection and poor outcomes in patients with preexisting medical conditions,13-17 and we reviewed the national medical comorbidities and mental illness data from Medicaid regarding the medical comorbidities in individuals with SMI.18 Finally, we performed a literature search using the keywords “medical comorbidity, severe mental illness.”2,10,19

In addition, the CDC’s COVID-19 guidance documents (https://www.cdc.gov/coronavirus/2019-ncov/communication/guidance-list.html?Sort=Date%3A%3Adesc) and the Joint Commission’s COVID-19 resources (https://www.jointcommission.org/en/covid-19/) were reviewed.

RESULTS

1. Individuals with SMI constitute a cohort that is at much higher risk for COVID-19–related mortality, because they are more likely to have medical comorbidities that are associated with worse COVID-19 disease outcomes.

2. A robust and bidirectional relationship between CMH clinics and their overarching state organizational entities and respective health departments is needed to operationalize the population health and preventive care processes.

Table 1 summarizes the factors that overlap between the population served by the CMH system and those with higher likelihood of morbidity and mortality from COVID-19 infection.

Table 1. CMH Populations and COVID-19 Risk Factors

Population Served by CMH

Medical/Behavioral Comorbidities in CMH Population

Factors That Increase Poor Outcomes Associated With COVID-19

Individuals with multiple medical comorbidities

Hypertension

Higher risk of severe illness and poor outcomes due to viral and bacterial infections20

Hyperlipidemia

Diabetes

Ischemic heart disease

Rheumatoid arthritis/osteoarthritis

Chronic obstructive pulmonary disease

Individuals with neurodevelopmental disorders (eg, autism, Down syndrome, intellectual disability)

Atypical oral/sensory needs (eg, handwashing, touching)

Limited adherence to standard precautions such as social distancing, handwashing, touching)

Higher incidence of autoimmune conditions21

Higher risk of severe illness due to viral and bacterial infections

Individuals with metabolic syndrome22,23 or taking clozapine,24 lithium,25 mood stabilizers,26 or antidepressants27

Leukopenia24

People of any age with serious underlying medical conditions might be at higher risk for severe illness from COVID-1911,13-17

Kidney disease25

Hyperlipidemia22,23

Ischemic heart disease22,23

Hypertension22,23

Obesity22,23

Individuals with substance use disorders

Drug-seeking behavior

Rapid spread of disease due to sharing of drug paraphernalia

Lack of social support from stigma

Contact and distancing precautions may be difficult

Malnutrition

Higher risk of severe illness due to viral and bacterial infections

Close living quarters and unhealthy living conditions

Increased risk of person-to-person transmission

Need for positive therapeutic and social interactions

Inability to see therapists or engage in community.

 

Our recommendations for an effective mitigation strategy during the pandemic, which are based on the unique outpatient structure of CMH clinics, are outlined in Table 2. This is particularly important as the crisis of communicable illness related to this virus is entering into a protracted phase, according to public health experts.28

Table 2. CDC Guidelines and Authors’ Suggestions for Implementation

CDC Guidelines for Ambulatory Care Facilities Including Behavioral Health Clinics12

Suggested Steps for CMH Implementation

Definition of outpatient health care facility (HCF)

• At a minimum, outpatient facilities need to adhere to local, state, and federal requirements regarding reportable disease and outbreak reporting.

Operate outpatient behavioral health as HCF as defined by CDC and implement commensurate standards of infection control

Definition of health care personnel (HCP)

• HCP, to be defined as all persons, paid and unpaid, working in outpatient settings and who have the potential for exposure to patients and/or to infectious materials, including body substances, contaminated medical supplies and devices, contaminated environmental surfaces, or contaminated air. This includes persons not involved in patient care (eg, clerical staff, housekeeping staff, volunteers) but potentially exposed to infectious agents that can be transmitted to and from HCP and patients.

Therapists, clerical staff, residential care providers who work in outpatient settings and who have the potential for exposure to patients and/or to infectious materials, including body substances, contaminated medical supplies and devices, contaminated environmental surfaces, or contaminated air. Therefore, they are to be trained and protected as HCP.

Dedicate resources to infection prevention

• Sufficient and appropriate equipment and supplies necessary for the consistent observation of standard precautions.

• Infection prevention programs for all staff to extend beyond Occupational Safety and Health Administration (OSHA) bloodborne pathogens training to address patient protection.

• Assure that at least one individual with training in infection prevention is employed in the role of an infection control officer to manage the facility’s infection prevention program.

Ensure supply of hand hygiene products, injection equipment, and personal protective equipment (eg, gloves, gowns, face and eye protection) to be kept in inventory on-site to be coordinated with the local health department

Implement mandatory infection control programs beyond OSHA bloodborne pathogen training and include training to address patient protection.

Appoint an appropriately trained infection control officer, hired or contracted, to oversee infection control protocols for staff and patients. This individual should be involved in the development of written infection prevention policies and have regular communication with HCP to address specific issues or concerns related to infection prevention.

Educate and train health care personnel

Ongoing education and competency-based training of HCP are critical for ensuring that infection prevention policies and procedures are understood and followed. Education on the basic principles and practices for preventing the spread of infections should be provided to all HCP. Training should include both HCP safety (e.g., OSHA bloodborne pathogens training) and patient safety, emphasizing job- or task specific needs.

Educate all HCP in the basic principles and practices for preventing the spread of infections. Training should include both HCP safety (eg, OSHA bloodborne pathogens training) and patient safety, emphasizing job- or task-specific needs.

Training and compliance with this training to be developed in conjunction with the local health department, which can improve communication and collaboration between publicly funded programs.

Monitor and report healthcare-associated infections

Track adherence to specific process measures (eg, hand hygiene, environmental cleaning) as a means to reduce infection transmission.

To assist with identification of infections that may be related to care provided by the facility, patients should be educated regarding signs and symptoms of infection and instructed to notify the facility if signs and symptoms occur.

Develop a strong bidirectional relationship with the local health department by including the local health officer or designee in policy and practices of the behavioral health outpatient facility.

The infection control officer should assist and education patients as a priority measure, especially those with SMI, those taking immunosuppressant psychotropics (eg, clozapine), and those in group homes/crisis residences/with substance use disorder.

Educate patients regarding the signs and symptoms of communicable diseases (eg, COVID-19).

Establish dedicated communication channels, which can be email, a dedicated phone line, or a dedicated person on site, for patients to notify the facility if signs and symptoms occur.

 

DISCUSSION

Today, approximately 1 in 5 adults, or approximately 46.7 million persons, have mental illness in the United States, and this number is expected to increase in the years ahead.1 This leads us to a well-known epidemiological fact that individuals with mental illness tend to also have comorbidities from their adverse life events risk and treatment interventions, such as hyperlipidemia, coronary artery disease, and metabolic syndrome, as well as from their social determinants and behaviors such as smoking, alcohol use, and substance use. Early retrospective analysis of COVID-19–related illness and death is showing a strong link between comorbidities and mortality in affected populations.13,29,30

In the face of this high risk for morbidity for individuals with mental illness, associated comorbidities, and coexisting high-risk health behaviors, the current pandemic poses a variety of structural and organizational challenges. Incorporating public health and population health principles and using the guidelines developed by the CDC across all managed behavioral-health facilities that receive public funding can be an important first step in protecting the vulnerable individuals with SMI.

The existing system of care for behavioral health runs parallel to but rarely intersects with the physical health care system that is based on the medical hierarchical model. The patients that most use CMH clinics for their mental health care are those who are most at-risk for being exposed to and experiencing worse outcomes from COVID-19. Ergo, the behavioral health system faces unique challenges when dealing with a public health crisis such as the COVID-19 pandemic. These challenges arise because of the disparities associated with the a CMH system based largely on the decentralized operational structure and the complex needs of the population served.

Based on this, we propose that the current operating model of the CMH system may be unprepared to serve patients safely during a pandemic. We have developed suggestions and recommended modifications to the existing infrastructure that can be made in a relatively short time (Table 2).

CONCLUSION

We posit that the patient population with SMI that is served by CMH systems/state-funded health systems are at high risk for worse COVID-19 outcomes. More needs to be done and resources need to be allocated in order to prepare for and mitigate what might otherwise result in tragic loss of life.

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