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Recommendations from County Behavioral Health and Developmental Disability Directors

April 08, 2020
Ron Manderscheid
By Ron Manderscheid, President and CEO, NACBHDD and NARMH
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The opinions expressed by Psychiatry & Behavioral Health Learning Network bloggers and those providing comments are theirs alone and are not meant to reflect the opinions of the publication.

On March 25 and April 1, the National Association of County Behavioral Health & Developmental Disability Directors (NACBHDD) held town hall meetings with members. The purpose of these meetings was to understand the impact of the coronavirus crisis on behavioral healthcare and to identify the urgent needs of the behavioral health field that must be placed before Congress as it considers additional coronavirus legislation.

The key recommendations to Congress are as follows:

Systemic changes

  • Challenge: County response to the coronavirus crisis has not yet been organized. Action: Provide resources and technical assistance to organize a core leadership group in each county to include, at minimum, representatives of the county health, behavioral health, public health and corrections programs, as well as representatives of the private sector.
  • Challenge: State Medicaid response is unduly slow. Action: Develop a mechanism whereby the federal government can override aspects of individual state Medicaid rules and waivers to implement consistent rules across states during times of a national emergency, without states needing to complete separate waiver requests for the change. For example, the ability to provide Medicaid services via telephone is essential during the COVID-19 epidemic.
  • Challenge: States and/or managed care organizations must be more responsive in enabling providers to utilize new telehealth/telephone care codes. The provider workload hasn’t gone down. It has just shifted to codes that are difficult to bill through existing systems. Michigan for example, gives verbal ability to use the telehealth waiver code retroactive to March 1 but has not released any written procedures. Action: States/bureaucracies must offer written procedures for using new billing codes. Also, permit use of telephones for care delivery under Medicare.
  • Challenge: There’s a need for accelerated implementation of the 988 suicide prevention/crisis/mental health lines in taking the burden off of overloaded 911 emergency circuits. Action: Accelerate nationwide implementation of 988 crisis lines.
  • Challenge: If the House proposes an additional $10 billion for federally qualified health centers—then certified community behavioral health clinics, community mental health centers, and CSUCs must get added funding too. Action: Ensure parity federal aid to county mental health, substance use, and intellectual/developmental disability programs.

Short-term actions

  • Challenge: Behavioral health is not generally considered part of the health system. It’s at low priority relative to physical health. Providers can’t get any access to PPE available for other staff who are working face-to-face. Many additional resources are flowing to medical, nothing to behavioral health. This must be fixed. Action: Get behavioral health recognition and priority for essential protection resources for interpersonal healthcare delivery.
  • Challenge: Behavioral health and I/DD providers are at risk of losing essential staff. They need the flexibility to reassign/redeploy staff who aren’t busy/who aren’t needed for closed programs into other appropriate tasks. Action: Get providers flexibility to redeploy rather than lose staff.
  • Challenge: There’s rising concern about the status of residential programs, recovery houses and other congregate living circumstances. These locations house a lot of sick people and operate on low margins, and there are staffing, funding and other challenges. How do we assist these people? How do we keep them safe from coronavirus? How do we keep them fed? How do we ensure that staff are on hand? Action: Stabilize congregate living situations to keep people healthy.
  • Challenge: Inconsistent reimbursement practices across public and private insurance payers within a state: Action: Require standardized reimbursement practices.

Short-term funding

  • Challenge: Low-income clients have inadequate prepaid phone plans—calling in uses up minutes quickly. Action: Get prepaid phone users extra minutes for care.
  • Challenge: Some providers don’t have the steady-state funding to keep their payrolls up and their doors open. Some county boards have been adding funding to assist providers whose stream of work and billable revenues are disrupted. Some states, including Oregon and Pennsylvania, say they are approving provider payments based on history of monthly billings. Action: Get core funds to stabilize provider operations.
  • Challenge: Behavioral health and I/DD provider personnel working at home often lack the organizational tools/access/infrastructure to do their jobs effectively. Action: Provide resources for appropriate technical assistance.
  • Challenge: School-based counselors in Ohio have been reaching out to parents and children to assess situations and offer assistance, but not getting huge response. Teachers, however, have been calling in to counselors to report children who are struggling with isolation, remote learning or other problems. So, children are having problems and teachers are a resource to help. Action: Provide resources for clinical outreach to teachers and students.

Urgent future needs

  • Challenge: Now is the time to share existing crisis response plans or work on new contingency plans, networks and partnerships for future crises. Sept. 11 gave rise to county emergency response resources. What resources are now needed to help counties to plan for and meet future crises? Action: Pursue planning grant funds for development of future county crisis response plans and requirements.

An urgent need exists to address each of these problems. Self-correction through delay is not an option. The consensus expectation is that sheltering in place, business closures and virtual behavioral healthcare will persist for several months longer, if not even into the latter summer months.

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