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.