Integrating Behavioral Health and Serious Illness Care in a Post–COVID-19 Environment

Serious illness care (SIC) entails care for patients with life-threatening medical illnesses, such as cancer, chronic obstructive pulmonary disease, and heart failure. SIC includes interdisciplinary specialist care (e.g., cardiology, oncology) and palliative and hospice care delivered across settings. In contrast to primary care or chronic illness care, SIC is framed around life-threatening medical illness with significant functional impairment.

Over the past several decades, the burden of serious illnesses has increased with the aging of the population and improved capacity to extend life medically. This trend has prompted expansion of SIC services such as hospice and palliative care. Individuals with serious medical illness are at high risk of comorbid behavioral health (BH) conditions, including mood and anxiety disorders, serious mental illness, and neuropsychiatric disorders (1). Such comorbid conditions include both exacerbations of long-standing BH conditions (e.g., an individual with schizophrenia who develops lung cancer) and de novo BH conditions developed in the setting of serious medical illness (e.g., an individual with worsening heart failure who develops new major depression). Individuals with serious illness and BH comorbid conditions are at risk of poor outcomes and disparities, including differential access to specialist care, loss of access to preexisting BH services, and increased acute care utilization at end of life (2).

Despite the burden of BH issues among individuals with serious medical illness, BH and SIC remain siloed. Enormous progress has been made in the integration of BH into primary and chronic illness care. Unfortunately, this progress has not translated into SIC (with the exception of the psycho-oncology paradigm specific to cancer care), possibly because the needs of patients with SIC differ from those of patients in the primary care setting. SIC often entails progressive illness with unpredictable medical and BH needs. SIC is delivered across a wide variety of settings (inpatient, outpatient, other care settings), sometimes over short periods. Moreover, serious illness includes unique BH stressors, including the psychosocial challenges of contending with life-threatening illness and the challenges of difficult treatment regimens. For example, a patient with chronic obstructive pulmonary disease may be stable from a medical and BH perspective for some time; they then may experience an acute decline in pulmonary function prompting transition from home to inpatient care, initiation of high-dose steroids, and new severe anxiety. Many existing models of BH integration are predicated on a greater degree of longitudinal stability, for instance, the presumption that patients will be obtaining care in an outpatient setting. It is particularly noteworthy that essentially no operationalized models of BH integration have been incorporated into hospice and palliative care even though more than half of Medicare decedents die under hospice care and that formalized palliative care quality criteria recognize the need for BH services (3).

In response to the high BH burden in SIC, the deleterious impact of BH comorbidity on SIC outcomes, and the lack of models to guide BH-SIC integration, we created the BH-SIC model. This conceptual framework identifies components of BH-SIC integration across five broad components comprising 15 domains to provide a roadmap and continuum for implementation and quality improvement (Box 1) (1). The BH-SIC model is applicable across the diverse settings and stakeholders that make up SIC and has a companion workforce development schema (4). The premise of the BH-SIC model is to improve the following care principles for individuals with BH-SIC comorbid conditions: person- and family-oriented care, interdisciplinary and team-based care, coordinated and integrated care, value-based and accountable care, and equitable care.

The initial iteration of the BH-SIC model was developed before the COVID-19 pandemic. Since the model’s publication, COVID-19 has amplified existing challenges in BH-SIC integration. SIC services have had to pivot from working with patients affected by chronic illness, such as cancer, toward acutely ill patients with COVID-19. SIC services have also had to negotiate ongoing care for individuals with non–COVID-19, life-threatening medical illnesses.

BH services have had to innovate to provide high-quality care to vulnerable patients through novel mechanisms, such as telehealth. These shifts risk excluding patients with certain BH problems (e.g., anxiety, especially related to issues with technology and executive function) and patients with limited means (poor Internet access, restricted phone plans, etc.). BH services have also had to adapt to the needs of clinicians, caregivers, and the general population in response to the pandemic.

In one sense, the goal of BH-SIC integration seems more distant than before the pandemic. However, COVID-19 has prompted innovations in health care delivery, a focus on health equity, and adaptations in workforce that are applicable to BH-SIC integration. The pandemic may provide an opportunity to reconfigure BH-SIC in ways that align with, and may inform the evolution of, the BH-SIC model. We next describe the impact of several of these factors on the model.

Workforce: Developing Models of Adaptation and Support

In the original BH-SIC model, we determined that BH clinicians receive little exposure to SIC and vice versa. Despite long-standing mandates for BH-SIC cross-training, the BH and SIC workforces are largely siloed (4).

COVID-19 has demanded workforce adaptations that may inform the evolution of BH-SIC models. National COVID-19 surges have been characterized by high volumes of critically ill individuals in settings with limited resources such as mechanical ventilators. To that end, the need for conversations related to high-volume, high-urgency serious illness, such as goals-of-care discussions, has been unprecedented. To meet these demands, BH providers such as psychiatrists and psychologists have been asked to step into palliative care roles, performing clinical duties that have traditionally been the purview of SIC clinicians, such as advance care planning (5). Workforce adaptations instituted during the pandemic have demonstrated that BH clinicians are capable of participating in many components of SIC with limited additional training and relatively low-resource, just-in-time supervision under real-world conditions (5).

Adapting these newly implemented models of BH-inclusive SIC may provide important benefits outside the COVID-19 context. Engagement of BH clinicians in SIC may reduce disparities for individuals with comorbid BH conditions. For example, an unfounded, but common, perception exists that people with serious mental illness are unable to participate in conversations about serious illness, such as discussions of goals of care. BH providers may improve equity by dispelling such incorrect beliefs and, more generally, by advocating against stigma toward individuals with comorbid BH conditions. BH clinicians who have worked in SIC during the COVID-19 pandemic have demonstrated value by training colleagues in key BH skills, including management of delirium, BH crisis management, and decisional capacity evaluation. Ultimately, integration of BH-SIC clinicians allows for natural collaboration for both SIC and BH clinicians that promotes further workforce integration.

Although COVID-19 has prompted models of BH-SIC workforce integration, it has also brought the high-pressure environment of health care into stark focus. Both BH and SIC clinicians are exposed to emotionally challenging and, at times, physically dangerous clinical situations. In the context of COVID-19, recognition has increased about the consequences of high-intensity, high-risk clinical work. Clinicians working at the BH-SIC interface assume the challenges and risks of each domain of practice and may prove to be at particular risk for sequelae such as burnout, trauma-related disorders, and depression. In recognition of the vulnerabilities of frontline clinical staff during the pandemic, innovative models of workforce support have been realized. These models focus on providing confidential, easily accessible care to clinicians across a spectrum of formats, including individual care, group support, and town halls (6). Organizational support of these programs after the pandemic will be key in supporting the integrated BH-SIC workforce given the challenges of working at this interface.

Making Equity a Priority: Focusing on Social Determinants of Health

The COVID-19 pandemic has exacerbated long-standing health inequities. Disparities in the care provided to racial-ethnic minority groups, individuals with BH disorders, individuals with disabilities, and many others have been perpetuated in dramatic fashion in COVID-19 outcomes. Given the inextricable link of BH comorbidity with social determinants of health and health disparities, BH-SIC linkage represents an important element of equity in SIC. This claim is supported by data across SIC showing worsened outcomes among individuals with comorbid BH conditions, including during the current pandemic; moreover, recent evidence suggests that serious mental illness is associated with mortality risk in the context of COVID-19 (7). Furthermore, those vulnerable to health care disparities, such as members of racial-ethnic minority groups, have been more likely to experience BH complications during the COVID-19 pandemic and may be more likely to have concurrent BH-SIC needs (8).

The impact of BH comorbidity on vulnerability to health care disparities and the impact of disparities on the development of BH conditions speak to the impossibility of achieving BH-SIC integration without a focus on disparities. To that end, we have adapted the model to highlight equity as one of the guiding principles shaping the model’s domains.

Our aim is to provide appropriate care and services to people with serious illness and BH issues, regardless of race-ethnicity or socioeconomic or health status. A significant component of providing such care in a manner that promotes equity involves leveraging social services, ranging from programs providing housing and food services, to community centers, to legal advocacy. Such organizations have long operated with only limited connections to institutionalized health care. In addition, many such programs have been destabilized and interrupted because of the COVID-19 pandemic.

The burden of unmet needs for social care among people with serious illness is high (9). Individuals with BH-SIC needs are at especially high risk of housing and food insecurity, loneliness, and other forms of disenfranchisement by virtue of both their BH and serious illness diagnoses. The preexisting siloes between organizations addressing social determinants of health and health care systems have a largely disproportional impact on this population; moreover, these siloes have worsened during this pandemic.

Despite these challenges, COVID-19 may ultimately accelerate partnership between clinical and social service providers in the interest of improving care for high-need patients. Increased partnerships spearheaded by health systems could support these efforts (10). Such partnerships could also enhance food pantries to mitigate food insecurity or continue funding local organizations and their efforts to meet the socioeconomic needs of vulnerable members of their communities.

Conclusions

Patients with comorbid BH-SIC needs are among the most vulnerable patients in the health care system. BH comorbidity overlaid on serious illness is associated with other psychosocial vulnerabilities and affects BH and SIC outcomes. Unfortunately, the U.S. health care system is poorly prepared to provide equitable, integrated care to patients with BH-SIC needs. Our model represents one of the only conceptual frameworks of BH-SIC integration. COVID-19 has challenged many of the assumptions that have gone into the creation of the BH-SIC model. Although these challenges have been disheartening, they have also opened paths to improvements in the model, ranging from innovative workforce solutions to recognition of the profound inequities tied into the fabric of the U.S. health care system that disproportionately affect patients with BH-SIC needs.

Realization of the BH-SIC model in the brave new world of post–COVID-19 health care will depend on infrastructures of accountability and measurement. Such infrastructures have the potential to incentivize movement of clinical programs toward the ideals of the model. Indeed, the movement toward BH-SIC integration may depend on separate assessment of health care quality for people with BH conditions, particularly serious mental illness, to help understand and target issues of inequitable health outcomes for patients with BH-SIC needs. The National Consensus Project for Quality Palliative Care (NCP) has established guidelines that provide a foundation for high-quality palliative care across clinical domains; these guidelines have been honed for more than a decade to better reflect the delivery of palliative care across diverse settings to diverse patients (3). The NCP guidelines reflect the importance of social and psychological aspects of palliative care as two discrete domains of palliative care delivery. However, as of yet, the NCP guidelines have not distinctly laid out measurement metrics for evaluating programmatic integration of BH aspects of SIC. The lack of suitable quality measures (structure, process, and outcomes) at the BH-SIC interface poses challenges not only to the delivery of integrated care services but also to the ability to pay for these kinds of services. COVID-19 has demonstrated the urgency to move from concept to practice in the care provided to individuals with BH-SIC comorbid conditions, and our model is providing an adaptable framework to do so.