By Jeni Miller
It has been reported that mental health has collectively plummeted in the wake of COVID-19.
The Centers for Disease Control and Prevention reported that nearly 20% of U.S. adults were living with a mental illness in 2019 — and that percentage shockingly doubled to 40% in 2020. For young adults in particular, the rate of suicidal thoughts rose to an alarming 25%.1
Since hospital case managers typically have a front-row view of what is happening in the healthcare world, they no doubt have seen these statistics firsthand.
“COVID has had a direct impact on mental health, and it has compounded things that may have already existed for some people,” says Laurie Signorelli, DBH, LMSW, ACM, national healthcare consultant with the Center for Case Management (CFCM). “Even among people who were never troubled before, COVID-19 has left a lot of people feeling very uncertain, unsettled, and isolated, and none of those things are good for mental health. Especially for the aging and infirm populations, who may have barriers to communicating properly through masks and FaceTime, it has had a profound impact on emotional health and well-being.”
According to Signorelli, the case manager’s job is made increasingly more difficult as mental health concerns in patients make hospital discharges more challenging, especially at a time when discharges are needed to make space for more patients.
“Many case managers are struggling,” Signorelli shares. “They want to do what’s best for their patients and residents, and yet there are so many barriers to doing that, so it’s inherently stressful. Not to mention, they are the people who get lashed out at by patients or families, and sometimes the hospital system itself is asking, ‘We need discharges, what are you doing?’ It’s very challenging, many are feeling the pressure, and some can’t get what they need for their patients.”
Another factor is that while case managers work to serve the needs of patients, they also are experiencing the personal effects of COVID-19. “They may have been ill, or have family members or friends who have, or have suffered losses,” Signorelli says. “Yet, they are still showing up and dedicated to meeting the needs of others.”
Still, it is important for case managers to meet the challenge head-on and pay particular attention to rooting out the truth of patient wellness, especially concerning mental health.
Conduct Assessments and Prepare Plan
Key to helping identify and assist patients who may be suffering from mental health issues is what Signorelli calls a “comprehensive, fast, and deep assessment” of a patient. She suggests case managers look at the patient “holistically, with a practiced eye, to determine what the person truly needs for optimal success.”
Case management departments are tasked with conducting these assessments under CMS rules. But, depending on the organization, these assessments can run the spectrum from light to more robust. Still, asking the right questions is important to uncovering mental health issues that might otherwise go unnoticed, and therefore untreated. It is important to include evidence-based assessments for anxiety, depression, mental health and addiction, and social determinants of health (e.g., safety, food, housing, health literacy), in addition to the more typical core functional and medical standard assessments used in healthcare settings.
“The more robust assessments do take more time up front, but they also help frontload and identify what this patient, in the context of their family and friends system, will need,” Signorelli explains. “This helps care managers to be more proactive and efficient. I know many case managers can often get caught between ‘get them out the door’ and the optimal outcome, but there is a sweet spot. When you do that deep but quick assessment, it becomes a valuable tool that reflects what you need to do next.”
Another benefit to performing early, quick assessments is the ability to then look at the patient as a whole person, and not as “just cardiac or diabetes or what have you,” Signorelli says. “By understanding the mental health piece, the case manager will really be able to help reach positive outcomes.”
This is especially true for patients with mental health or substance abuse issues, as these can compound medical recovery and achievement of optimal outcomes. It is critical to understand how the patient was functioning before entering the hospital or facility to understand and attend to any barriers or challenges that need to be considered when formulating a plan.
“It could be that a patient’s history of drug addiction has burned bridges for any hope of home health and help in dealing with their issues,” Signorelli says. “Their options may be very different than someone not in that situation, and it’s good to know that when heading into planning for discharge. This is the kind of thing that is good to remember when you feel like sometimes you don’t have time to do an assessment. But really, you don’t have time not to.”
A clear and comprehensive discharge plan should be the robust goal of this assessment. It is important to see and involve the patient and the family or caregiver, when possible, to engage them in the plan.
Without this direct engagement, Signorelli explains, case managers “could be shocked by what you actually see [when visiting with the patient]. The patient may look very different on paper than in person.”
When Beds Are Scarce
At the start of the COVID-19 crisis, when mental health issues were rampant and hospitals were quite full, the problem was made worse when no beds were available for people in need. Signorelli saw how this played out with residents in a long-term care facility who needed attention due to their mental health, but could not get help due to overwhelmed hospitals.
“We had residents who were really escalating with mental health behaviors way beyond what a nursing home would typically deal with,” she explains. “They waited weeks in an ER with no bed available, only for the nursing home to be told they have to take them back because there are no beds.”
These kinds of situations have been mitigated by creative approaches like telehealth, she says. The hope is that telehealth is here to stay, which is a positive as it has improved access for some people. Case managers should consider options for patients who might not otherwise have access to care due to bed shortages or other barriers.
Resources and Data
Similarly, case managers who are attuned to mental health issues “need to have a real [understanding] about what community resources are available, and the key point people to contact,” Signorelli says. Keeping those contacts and resources up to date can save time and effort later, when it matters the most.
Signorelli also encourages case managers to avoid “doing the same three and four referrals,” but rather to broaden their connections with community partners. Sticking with the same referrals can lead to “missing out on something that could open up a whole world,” she added.
Another benefit to connecting with community partners is the opportunity to work together to fill gaps in care options in the community. “If there are no facilities, for example, that take people with dementia with behavioral disturbances, your ER and hospital will back up with people because there is just nowhere else for them to go,” Signorelli notes. “But if you can identify needs — and this is critically important — and also keep statistics on barriers and outcomes, down to granular level, you can work with community partners to develop something that doesn’t yet exist. Data can tell us, ‘If I send patients routinely to two home cares, and two-thirds of patients come back to the hospital from one home care and with the other only one-third are readmitted, I can more easily ask what that is.’”
Collaborating Brings Clarity
The final piece to ensuring mental health needs do not go unnoticed and unaddressed in the hospital setting is making time for nurses, physicians, social workers, and case managers, as well as other allied health professionals, to come together and address patient needs, risks, complexities, and potential options. This does not need to take long, but it is a critical component to ensuring nothing about a particular patient that will prevent a positive outcome is overlooked.
“It’s a team sport, and everyone’s input is important,” Signorelli says. “The team should briefly go over every patient on a daily basis, if possible. It’s best if they are face-to-face, or even virtual face-to-face, with a standard script to ensure they cover everything, including mental health needs.”
Since mental health is such an important aspect of human life, and case managers are there during a person’s most vulnerable moments, it is crucial to consider the patient as a whole person, body, and mind. Since mental health has been shown to affect physical health, it is a worthwhile practice to keep an eye on each patient’s mental health status — especially during a time of crisis or pandemic, when depression and anxiety are on the rise.
“We don’t only want to deal with problems or crisis, but rather support the overall health and well-being of a patient,” Signorelli notes. “Sometimes, that gets lost in the shuffle, but by being attentive, encouraging people, and reinforcing their attempts at healthy habit adoption, case managers can do a lot to help.”
Social work case managers in particular, due to their mental health background and ability to conduct behavioral assessments and interventions, can help patients meet their goals through addressing mental health needs and planning to support a patient’s overall medical and behavioral well-being.
- Czeisler M, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep 2020;69: 1049-1057.