APA’s District Branches Take Lead in Helping Psychiatrists Adjust to New Way of Working

APA’s district branches (DBs) lost no time in mobilizing to help their members care for their patients and respond to community needs as the grip of the COVID-19 pandemic tightened throughout the country. Their efforts complement the advocacy and support that APA is providing at the national level.

Adjusting to a new world of social distancing (or perhaps more accurately, “physical distancing”) was a major first step. Patient engagement is the central tool in psychiatry, which traditionally has depended on face-to-face encounters between psychiatrists and patients. Federal and state regulations and insurers are allowing use of phone, video, or online contacts with patients under loosened restrictions.

The North Carolina Psychiatric Association (NCPA), for instance, successfully urged the state’s governor and health secretary to relax restrictions and require insurance companies to expand access to mental health care through telepsychiatry, NCPA President Jennie Byrne, M.D., Ph.D., told Psychiatric News. One unsolved problem: Payment rates for telephone psychiatry services were still in flux at press time.

The NCPA has set up a website to inform members about the rapidly changing professional landscape, said Byrne. “Our goal is to keep up to date and be a single source of truth to members.”

The Ohio Psychiatric Physicians Association developed a two-hour telemedicine webinar that covers how to bill for telepsychiatry services; what to bill; the necessary coding; and policies expected from Medicaid, Medicare, and private insurers.

The New York County Psychiatric Association, which includes Manhattan, paired with the Colorado Psychiatric Association to organize several psychiatric summits. The summits are virtual conferences during which members can communicate with each other and then break out into separate chat rooms to discuss areas of interest such as consultation-liaison psychiatry, palliative care, private practice issues, and working on COVID-19 units, said DB President David Roane, M.D., chief of psychiatry at Lenox Hill Hospital.

Patients appear to have accepted telepsychiatry well, perhaps because of their familiarity with personal technology. One consequence of telepsychiatry appointments is that no-show rates have decreased dramatically, according to some psychiatrists, possibly because transportation issues or other impediments to access have been eliminated.

However, the shift may create other obstacles, reported Byrne’s colleague Constance Olatidoye, M.D. Some of her more severely ill patients in rural Rose Hill, N.C., don’t have an internet connection or even access to a phone.

Changes in other regulations are easing access to medication for patients with opioid use disorder, said Northern California Psychiatric Society President Smita Das, M.D., Ph.D., M.P.H., an addiction specialist and a clinical assistant professor of psychiatry and behavioral sciences at Stanford University School of Medicine.

“The Substance Abuse and Mental Health Services Administration now allows us to use our clinical judgment and prescribe two to four weeks of take-home methadone to help patients shelter in place and authorized buprenorphine health care professionals can prescribe without an in-person visit,” said Das. “The main psychiatric concerns about our patient population are anxiety and the effects of isolation on mood.”

Other shifts in practice may help open hospital slots for COVID-19 patients.

“We are putting together a list of psychiatrists and mental health professionals and clinics who are accepting new patients by telemedicine,” said Dan Bristow, M.D., president of the Oregon Psychiatric Physicians Association. “The hope is to get the list to crisis lines and emergency departments around Oregon in order to divert patients who are lower risk from emergency departments and free up space for COVID-19 patients.”

New York State’s Office of Mental Health made a similar request, said New York County’s Roane. That has meant a shift away from face-to-face encounters for first evaluations.

“Our clinicians must take more time to do an initial evaluation remotely,” he said, “but it’s an adjustment that seems to be working out.”

The Maine Association of Psychiatric Physicians is preparing psychiatrists to work with people in specific job categories, like police, hospital workers, and emergency medical technicians, said Ed Pontius, M.D., the legislative affairs chair for the DB.

DBs are also lobbying state legislators and health officials over treatment concerns caught up in the sudden eruption of new rules. The Washington State Psychiatric Association pushed to keep ECT as an essential procedure rather than an “elective” one. So did the NCPA, arguing that while avoiding nonurgent procedures in hospitals was a worthy goal, ECT was indeed essential to avoid “rapid, severe deterioration” in some patients, “based on the individual’s psychiatric history and assessment.”

The same two states were wrestling with rule makers over involuntary commitment. North Carolina ordinarily demands a notarized document, not easy to obtain since state agencies have been closed, said Allan Chrisman, M.D., disaster chair of the NCPA and an associate professor emeritus of psychiatry at Duke University. In larger cities, other individuals have been designated to perform that function, but they are less available in rural areas. Washington state’s problem was more complex, said WSPA President Joshua Bess, M.D.

“The involuntary commitment procedures are quite adversarial here,” said Bess in an interview. “The defense attorneys’ organization [wanted] to immediately dismiss involuntary commitment cases and release the patients if hospitals did not provide full protective equipment for attorneys visiting their clients at the hospital.”

The issue remained unsettled as the legislative session ended, said Bess.

Several DBs also pushed for clarification about switching users from long-acting injectable antipsychotic medications to oral forms to reduce clinic trips by patients and viral exposure to clinicians who still lacked protective equipment.

Some patient populations require added attention, said Chrisman. “People with chronic mental illness and substance use disorders are among those at the highest risk for infection and are likeliest to relapse. Also, vulnerable populations like children, the poor, and racial minorities may require additional outreach efforts.”

Between their own efforts, an exchange of information between DBs, and the work of APA staff, psychiatrists across the country are pivoting to a new way of working.

“I really appreciate APA’s taking swift action to provide guidance and support to members,” said Northern California’s Das. “The Association is making sure that psychiatrists are protected and can deliver safe care.” ■