A crisis in integrated services after COVID-19?

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Children struggle with distance learning and isolation. Parents have been forced to balance childcare and homework. Most people have delayed routine medical exams at some point in the past 15 months – or have been forced to postpone serious treatment – and almost everyone struggles with the stress and anxiety of the illness. pandemic.

The behavioral health toll of COVID-19 in New Jersey and across the country is well documented. Now, some in New Jersey are saying it’s time for a new model of health care, one with added mental health and addiction support, all integrated into one place that also provides primary care or treatment. other medical services.

“More and more evidence shows that there are significant mental health issues as a result of the pandemic. And they’re likely to last a long time, if left untreated, ”said Dr. Arturo Brito, a pediatrician who heads the Nicholson Foundation, a New Jersey-based philanthropic organization that has long advocated for a more integrated system of care.

“There is no better time to review this than at the start of the recovery phase from this pandemic,” he said.

Integration benefits

Integrated care – in which mental health and addiction therapies are coordinated with physical care and a full range of treatments are readily available in a facility – is not a new concept in New Jersey. The idea is that if done right, it can lead to better health outcomes and patient experience while controlling costs.

State officials have worked for years to create a single license that allows more integrated services in one location and have implemented several intermediate steps along the way. With the pandemic and the resulting economic fallout, there is renewed interest in this effort and new legislative proposals that could jump-start the process.

Brito, who is no longer directly involved in state work on this issue, said recent growth in public needs for behavioral health underscores the importance of an integrated system that people can easily navigate. .

The impact of the pandemic on public health alone is significant: State data shows more than one million New Jerseyens have been diagnosed with COVID-19 since March 2020, of which around 26,000 have died. . Millions more grapple with grief, pay cuts or unemployment and other stressors.

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Anxious to return to “ normality ”

The reopening of New Jersey, with crowd limits ending and restaurants adding capacity, may add stress for some people, according to assemblyman Louis Greenwald (D-Camden), a longtime health advocate mental. “You’re going to see a whole new wave of anxiety in people as we go back to work and get back to normal,” he said.

Greenwald – who recently introduced a set of laws to strengthen the state’s behavioral health system – said we now have the opportunity to improve what has become an uncoordinated and disjointed patchwork of physical care providers and behavioral. “This pandemic has really laid bare and exposed this real dilemma, not only in New Jersey, but in states across the country,” he said.

A 2016 study by Professor John Jacobi of Seton Hall identified some of the biggest barriers to integrated care in New Jersey, including a regulatory system that largely treated behavioral care providers and medical clinicians as separate entities. The report led the state to recruit experts, and the group worked with officials from the State Department of Health, which licenses health care providers, to develop a new framework to encourage more coordination and integration.

By the end of 2019, according to those involved, the DOH had prepared draft guidelines for a single, unified licensing system that would allow facilities to provide a greater range of behavioral and physical health services under one roof. But when the pandemic swept through the state a few months later, work on the reform effort appeared to stagnate.

Eliminate behavioral and health barriers

Greenwald’s legislation seeks to address several long-standing issues in the state’s behavioral health system. It includes a proposed pilot program that would allow 24-hour emergency care centers to offer additional mental health services. Another bill would create a loan program to fund integrated community care programs. A third measure would aim to better connect people who went to the emergency room during a psychiatric crisis with follow-up care.

A separate bill (A-5269), co-sponsored by MP Valerie Vainieri Huttle (D-Bergen), would address a second concern pointed out in the Jacobi report: the great confusion among suppliers over what current regulations allow. The proposal would force the DOH and the Department of Human Services, which oversees community mental health and addiction services, to publish an integrated care authorization guide with plain language detailing what is allowed in the existing structure.

“Suppliers are clamoring for” understandable advice on what is now possible under the existing regulatory system, Greenwald said. Behavioral and physical health service providers “are already migrating to each other,” he added.

Greenwald called the integrated licensing guide legislation – which has not yet been scheduled for a hearing or vote – a “critical first step” and a gateway to a more permanent solution. “It’s really about creating a single license,” he said.

Facilitate integration

The DOH has taken several steps over the years to improve regulatory integration, including issuing a ‘shared spaces waiver’ that eased some of the most onerous restrictions on healthcare providers seeking to expand behavioral health services. But the confusion among the suppliers continued.

The exemption did not apply to organizations specializing in behavioral care, which still required separate licenses to establish primary care services. While a few behavioral health service providers have been able to incorporate more medical services – to manage patients’ chronic illnesses, such as diabetes or high blood pressure, or to treat urgent problems such as wounds – Advocates said most had to refer people elsewhere for these options.

This is a constant concern for Carolyn Beauchamp, president and CEO of the Mental Health Association of New Jersey, which represents community providers. People with severe mental illness die on average decades earlier than those without a similar diagnosis, she said, in part because they are less likely to have access to regular medical care. People in this situation may only feel comfortable visiting a regular counselor or group leader and would benefit from being able to get other services on site, she explained.

“It’s a long-standing problem to get physical care for people with severe mental illness,” Beauchamp said. “We are very keen for the Department of Health to promote a single licensing process as soon as possible.”

Christie’s Approach

Former Governor Chris Christie, who has become a strong advocate for mental health and addiction treatment, adopted the Jacobi Report and ordered multiple changes in an effort to create a more integrated system of care. Six months before stepping down, the second-term Republican governor surprised lawmakers and stakeholders by calling on the DOH to remove DHS oversight responsibility for the state’s four mental hospitals and community behavioral health providers .

Just eight months later, Gov. Phil Murphy, a Democrat who has followed Christie and is now seeking a second term himself, reversed much of Christie’s directive. Murphy left mental hospitals under DOH, but returned much of the community governance of behavioral health to DHS. But the authorization process remained with the health department – and advocates continued to push for reform.

Donna Leusner, director of communications at DOH, said work on regulatory reform is ongoing, even under COVID-19. “The Ministry understands the importance of a single license regulatory framework for providers and patients, the impact it can have on the delivery of care and continues to do this work despite the pandemic,” she said. .

Leusner said the agency is also taking short-term action; regulatory changes can take up to a year with public comment and official publication requirements. “To ensure that providers are offered more immediate flexibility, the ministry has issued guidelines and multiple waivers to address the issue,” she said.

The DOH is also working with stakeholders to “identify and overcome remaining barriers” and will issue further orders as needed to “support the more immediate delivery of integrated care,” Leusner said. “The Department also continues to work with institutions on an individual basis to assist them with licensure applications or any barriers they may face.”

LILY: COVID-19: Why it could affect public health in the years to come

LOOK: One year after schools closed, many children are in mental health crisis


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