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    Jessica Scruton
    Jessica Scruton, BSN, RN, CCM
    One of the most comprehensive studies to date about hospitalized COVID-19 patients found that 94% had at least one chronic condition, while 88% had two or more. The conditions highlighted in the study are familiar physical illnesses, such as hypertension, diabetes and obesity; however, the analysis did not mention the behavioral health conditions of these patients, which can have a profound effect on outcomes.
    It is important to recognize the global pandemic’s impact on mental health. Life disruption, furloughs, economic collapse and the constant fear of exposure to a life-threatening virus that has no effective treatment or vaccine is exacerbating anxiety and depression, which has been shown to affect management of physical chronic conditions such as hypertension and diabetes, two of the main comorbidities identified in the COVID-19 study.
    It is possible, however, to prevent mental and physical health exacerbations simultaneously by intensifying your care management strategy. This requires analyzing data to risk-stratify patients using refined parameters, deploying targeted outreach and coordinating with community organizations, where available, to help overcome obstacles interfere with patients’ successful management of their behavioral and physical health conditions.

    COVID-19 impacting mental health

    A Gallup Poll conducted in early to mid-April found that less than half (48%) of respondents said they could maintain social distancing practices indefinitely before their mental or emotional health would suffer. More than a quarter (26%) of poll respondents ages 18 to 44 said their mental health is already suffering due to the restrictions. An earlier scientific survey found more than 36% of respondents spent several days with elevated anxiety due to COVID-19.
    Although there is likely to be much more published literature on this topic, a review of the small number of published scientific articles thus far on mental health and COVID-19 found anxiety and depression were the most prevalent mental health conditions reported among participants surveyed. These conditions also can disrupt sleep. As the pandemic wears on, the acuity of mental and behavioral health issues might intensify, leaving healthcare providers with a greater management challenge if they do not intervene now.
    The quarantining and social isolation risk to patients extends beyond exacerbating their mental health conditions. Rather, as anxiety or depression symptoms worsen, the status of other chronic conditions will almost definitely deteriorate. A review of nearly 100 studies found patients across a broad spectrum of mental health conditions are “up to twice as likely to be obese and have diabetes and cardiovascular disease compared to the general population,” which are the most at-risk conditions highlighted in the JAMA COVID-19 study. Conversely, a study of elderly patients found that the better they felt about their mental health, the more likely they were to follow a complicated medication regimen, while how they felt about their physical health had a much weaker association with medication adherence.
    Such at-risk patients require a proactive, integrated care strategy to help manage both types of conditions.

    Available data to drive decisions

    The first step to manage these patients is to leverage all available data to identify and reach out to those at risk. Certainly, social determinants of health (SDoH) information would be ideal to determine who is at the highest risk of straying from medication regimens or self-care, but these types of metrics are not always available. Instead, analyzing existing information can pinpoint the patients most in need of intervention.
    For example, by using a population health management platform, a care manager in a health system or accountable care organization (ACO) could create a cohort of patients with documented depression or anxiety diagnoses in addition to high-risk conditions such as asthma, chronic obstructive pulmonary disease (COPD), diabetes, hypertension and obesity. The care manager could then search this cohort to identify patients who skipped appointments before COVID-19, left messages unreturned or failed to renew prescriptions of chronic condition medications. This information should be easily available to care managers and would be reliable predictors that the patient is non-adherent to their medication regimens or other activities of daily living that help manage their conditions such as cooking, sleeping and self-testing.

    Initiate outreach

    Along with medication, patients with depression, anxiety or other ailments likely have a consistent appointment schedule with some type of counselor or other mental health professional. Those encounters, like most other non-COVID-19 healthcare appointments, were either canceled or postponed for weeks or months due to state-mandated or health system-imposed restrictions.
    For the time being, telehealth can fill the gap and reconnect patients with those providers. If a virtual visit through a computer or mobile device is not feasible for the patient, a phone call, email or interaction via a patient portal messaging system is a good start. These conversations increase a patient’s focus on their health and help reinforce their care plans and increase a provider’s visibility into known and new health issues.
    If community-based organizations that address SDoH are operational during this time, coordinating outreach with an at-risk patient may be an option to offload some of the burden on the care managers.

    Same strategy, greater intensity

    The population health management (PHM) strategy during the COVID-19 crisis is not drastically different from the strategy used at other times, just with less in-person contact and perhaps a more intense focus considering the distressing time we are all facing.
    Importantly, organizations can bill for much of these telehealth and outreach services thanks to loosened restrictions on Medicare-reimbursable telehealth services. Medicaid rules vary by state, but many have also loosened payment rules. Under federal guidelines, patients can receive care from a variety of healthcare providers, including clinical psychologists and clinical social workers. Physicians can now bill for services such as mental health counseling and preventive health screenings for patients with chronic conditions at greater risk of COVID-19 complications.
    While PHM may seem significantly different at a physical distance, in reality little has changed. Healthcare providers can still use the same processes and tools they had available to connect with patients, just as they did before the pandemic began. That way, when this has ended, the gaps in care and engagement will not seem so insurmountable.

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