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(Updated April 27, 2020)
Health providers working in emergency rooms, intensive care units, and primary care clinics are on the front lines of battling the COVID-19 crisis. But behavioral health workers are also playing a key role in managing the stress and behavioral health challenges resulting from the social and economic fallout of the pandemic, in addition to continuing to meet ongoing behavioral health needs. The purpose of this page is to (1) bring attention to implications of the COVID-19 pandemic for the behavioral health workforce, and (2) summarize emerging information about resources that are available to mitigate the impact of COVID-19 on behavioral health services. The content of this document will be updated regularly and as needed, should key policy updates emerge. Please check the referenced websites and links for the latest information.
As you browse below, you will find that information organized into the following categories: Key Updates, Funding to Support Increased Mental Health and Substance Use Disorder Needs, Hotline and Warmline Resources, Licensure, Supervision and Pro Bono Work, Small Business Administration Loan Programs, Other Business Relief, Protecting Patient Privacy and Confidentiality, Protecting the Safety and Wellness of the Behavioral Healthcare Workforce and Telehealth Billing, Funding and Technology.
Certain private non-profit organizations are eligible to apply for funding through the Federal Emergency Management Association under the emergency declaration for COVID-19. The funding was announced April 2, 2020. No deadline was stated in the FEMA press release. Non-profits must own or operate a facility that provides an eligible service, including utilities, medical, custodial care, and other essential social services. More information here. (link)
The Substance Abuse and Mental Health Services Administration (SAMHSA) issued a funding opportunity (Emergency Grants to Address Mental and Substance Use Disorders During COVID-19) for states, territories and tribes to address the increased mental health and substance use disorder needs that will result from the COVID-19 crisis. The application process for those funds closed on April 10. Total available funding is $110 million, with 60 awards anticipated.[1] This grant program focuses on meeting the needs of people with less severe mental health disorders, notably “those in the healthcare profession.” By explicitly including people in the healthcare profession, SAMHSA shows that it is aware of this group’s risk for increased depression, anxiety, and other issues as a result of the intense daily toll the pandemic is having on them. The Substance Abuse and Mental Health Services Administration (SAMSHA) is also allowing its grantees who are experiencing a loss of operational capacity or increased costs due to COVID-19 to allocate 25% of their current budgets, or $250,000, whichever is less, to cover these costs. The agency is also providing $250 million for the Certified Community Behavioral Health Clinics Expansion Grant program and $50 million in funds for suicide prevention programs.[2] The Certified Community Behavioral Health Clinics demonstration has been extended through November 30, 2020, for the demonstration’s original eight states and has been expanded to two new states, which will be selected within the next six months.[3]
With funding provided by the CARES Act, the U.S. Department of Health and Human Services (HHS) has awarded $1.3 billion through the Health Resources and Services Administration (HRSA) to 1,387 health centers across the nation, including $16.2 million to 21 organizations in Oklahoma.[4] This latest round of HRSA awards provides funding to help communities detect the coronavirus; prevent, diagnose and treat COVID-19; and maintain or increase health care capacity and staffing levels to address the public health emergency. The grant recipients include two Tulsa awardees: Community Health Connection, Inc ($958,175) and Morton Comprehensive Health Services, Inc. ($901,250); both list behavioral health care among the services they offer. Although it is not clear from the press releases on HRSA’s website, these awards appear to be in addition to the $100 million HRSA grants announced March 24 that were awarded to 1,381 HRSA-funded health centers across the nation to be used for screening and testing needs, acquiring medical and personal protective equipment supplies, and increasing telehealth capacity. Those HRSA awards provided $1,356,077 to Oklahoma HRSA-funded health centers, including Community Health Connection, Inc. ($78,096) and Morton Comprehensive Health Services, Inc. ($72,864).[5]
Individual hotlines across the country are reporting increases in call volume during the pandemic as people grapple with isolation, anxiety and depression.[1], [2] A center serving North Dakota and Minnesota reported that its call volume was up 300%,[3] and in Massachusetts an organization reported that it was receiving approximately 350 calls per day—up from 250 to 275 calls per day before the coronavirus pandemic.[4] Even lines that are not seeing an increase in callers considering suicide are reporting growing numbers of callers who are deeply distressed about the virus’ impact on their families’ health and economic standing.[5], [6] The increase in call volumes results in longer wait times to speak to a counselor, and staff are sometimes taking double shifts to meet the increased demand.[7]
SAMHSA offers a Disaster Distress Helpline at 1.800.985.5990 (people may also text “TalkWithUs” to 66746). This national resource is available 24 hours a day and offers immediate crisis counseling for people who are experiencing distress related to natural or manmade disasters.[8] The National Suicide Prevention Lifeline (the Lifeline) can be reached at 800.273.8255. In 2019, the Federal Communications Commission approved a 988 suicide crisis line—similar to 911—that will be routed to the Lifeline.[9] The tentative rollout for 988 is late in 2021.[10]
Unlike hotlines, which serve people in immediate crises, “warmlines” offer resources and support to intervene early and prevent a crisis. These lines typically offer free, confidential peer support services that may be staffed by volunteers or paid employees (who usually have personal experience with mental health issues and systems). Warmlines can reduce wait times to reach counselors on crisis lines and cut costs of emergency service calls and emergency department visits. Warmlines can help callers who may be unsure of where to access care, who to seek out, or what level of care may best serve them.[11]
Locally, the Community Outreach Psychiatric Emergency Services (COPES) COVID Emotional Support Line (918.744.4800)—administered by Family & Children’s Services (FCS)—is staffed 24 hours a day, seven days a week by mental health professionals who provide support to people in Tulsa County who feel they need help coping with the pandemic. The COVID line is an expansion of the COPES free mobile crisis program and takes advantage of existing staff and infrastructure to support additional community needs. People may also place non-COVID calls for crisis intervention and support; COPES serves and responds to both adults and children.[12] A COPES representative reports that although the call volume for the support line has not increased, the call topics have changed. Pre-COVID, there were frequent calls about school issues (placed by both faculty/staff and students), but now the COPES line is receiving calls related to the virus. Previously, a typical COPES callers had undiagnosed mental health conditions and the line’s responders helped to stabilize and then coordinate care. Currently, callers are seeking support for issues such as anxiety and shorter-term concerns. The staff have been offering guidance on identifying natural support networks, navigating systems, filing for unemployment and applying for benefits. COPES has had to adapt its staffing patterns to accommodate need, but that need is still being met.[13]
Any licensed medical professional whose credentials have been issued by any state that is party to the Emergency Management Compact, and thus meets the qualifications for practicing certain medical services, will be deemed licensed to practice in Oklahoma during the time the Amended Executive Order 2020-07 is in effect. Any medical professional intending to practice in the state must receive approval from the appropriate board; it is the responsibility of each board to verify the license or other credentials of applicants.[1], [2]
For Medicare services requiring direct supervision by a physician or other practitioner, physician supervision can be provided virtually using real-time audio/video technology.
Under the Coronavirus Aid, Relief, and Economic Security Act (CARES) Act, Congress has provided liability protection to volunteer health care professionals who are providing health care services during the current public health emergency. The services being provided must be within the scope of the provider’s license. Specifically, the CARES Act exempts volunteer health care professionals from liability under federal or state law for any harm caused by an act or omission, unless the harm was caused by willful or criminal misconduct, gross negligence, reckless misconduct, conscious flagrant indifference or under the influence of alcohol or intoxicating drugs, in providing health care services during the public health emergency with respect to the coronavirus. This provision preempts state or local laws that provide such volunteers with lesser protection from liability.[3], [4]
UPDATE (4/24/20): The Paycheck Protection Program will soon be replenished with $320 billion, but it will have some additional guidelines to remediate challenges with the first round of funding, including reducing the likelihood that publicly-traded companies will receive funds.[1] Because there is a large backlog of applications from the first round, few new applicants may receive the loans.[2] The new round of funding will allocate portions of the funding to smaller financial institutions, which are more likely to offer smaller loans, serve smaller businesses, and be more geographically disbursed.[3] The Small Business Administration has posted an FAQ document. (link)
Some behavioral healthcare provider organizations with less than 500 employees may be eligible to apply for CARES Act funding that is being administered by the U.S. Small Business Administration. Sole proprietorships, independent contracts, people who are self-employed, 501(c)(19) veterans organizations and private non-profit organizations are eligible for the Paycheck Protection Program, which was designed to provide incentives to small businesses to keep employees on their payrolls.[4] The Small Business Administration will forgive the Paycheck Protection Program loans if all employees are retained on the payroll for eight weeks and funds are utilized to cover payroll, rent, mortgage interest, or utilities. The Small Business Administration did not list a range or maximum amount for the loans. Applications are being accepted through June 30, 2020.[5] Organizations can apply through any existing Small Business Administration lender, any federally insured depository institution or credit union, and any participating Farm Credit System institution. Other regulated lenders will be able to make these loans once they are approved and enrolled in the program. Organizations can start the application here. (link)
The COVID-19 Economic Injury Disaster Loan Emergency Advance provides funds of up to $10,000 for organizations currently experiencing a temporary loss of revenue. This loan advance does not have to be repaid. The emergency advance application can be accessed at https://covid19relief.sba.gov/#/. The application website indicates that the estimated time for completing the application is two hours and ten minutes.
In addition to federal and other funding programs, contract language and insurance coverage may provide additional opportunities for businesses to mitigate losses. Force majeure provisions in contracts may excuse or delay contractual obligations and business interruption insurance may also provide relief. This advice was shared on a recent College for Behavioral Health Leadership webinar by attorney Greg Moore.[1] Many insurance companies are pushing back on covering losses attributed to the pandemic, but Mr. Moore encouraged businesses to file regardless.[2]
Some behavioral health care agencies are asking about the availability of funding for hazard pay for staff who have direct contact with COVID-19 patients These agencies cite the need for pay increases because of the higher level of risk these staff face. They are also considering strategies to retain staff during and after the COVID-19 pandemic. There is bipartisan movement toward funding hazard pay for health care workers, though it was not included in the second round of CARES Act funding.[3] If this funding materializes, it is unclear, and may be unlikely, that any behavioral health care providers would be included as essential workers. One bill being introduced includes, “…salary additions for healthcare workers, but excludes categories of employees who are not directly treating COVID-19 patients, such as veterinarians or chiropractors.”[4] Some behavioral health workers work in hospitals or residential settings, where they may have contact with COVID-19 patients. Another proposal from senate democrats (The COVID-19 “Heroes Fund”) notes that, “the definition of essential frontline workers for purposes of both the premium pay increase and the recruitment–retention incentive will be the subject of debate.”[5]
It appears that time is of the essence since retrospective pay increases will not motivate behavioral health workers who are worried about catching the virus to come into work now; prospective pay increases are needed to accomplish that. Some crisis services providers are already paying higher wages, with whatever reserves are available, to keep their sites staffed, but this may eventually affect the financial viability of these organizations. It is unclear if any of the federal funds available through various sources such as HRSA, FEMA or SAMSHA may be used for hazard pay.
The Substance Abuse and Mental Health Services Administration (SAMHSA) recognizes that in the midst of the pandemic, providers may not be able to obtain written patient consent for disclosure of substance use disorder records. SAMHSA has released guidance on relaxing enforcement of 42 CFR Part 2 during the pandemic. When disclosure is needed but a consent is not obtainable, a provider may determine that a medical emergency exits for the purpose of providing needed treatment. In this case, the prohibitions on use and disclosure of patient identifying information under 42 CRF Part 2 would not apply. Providers must make their own determination that a medical emergency exists for providing treatment. SAMHSA notes that programs are required to document certain information in the patient record after a disclosure for a medical emergency is made. The full SAMHSA brief can be found here. (link)
In Tulsa, the Tulsa City-County Health Department (THD) has worked with Ascension Indigent Healthcare to create a system for all personal protective equipment (PPE) requests from providers to go through. If any behavioral health providers need PPE, they will need to submit this survey: https://arcg.is/aKi1T. Behavioral health providers can call Amy Wenham, EMSA, at (918) 500-1115 if they need help completing the survey.
Also, the Chief Resiliency Officer at the City of Tulsa is coordinating donated PPE items for distribution as a part of the Resilient Tulsa initiative. PPE requests can be emailed to Covid19donations@cityoftulsa.org.
The Occupational Safety and Health Administration, OSHA, has been at the forefront of helping providers/organizations understand how to use their PPE for optimum safety and prolonged use. As a part of this effort, OSHA produced guidance on preparing workplaces for COVID-19, which includes outlining PPE use. It describes basic steps that every employer can take to reduce the risk of worker exposure to SARS-CoV-2, the virus that causes COVID-19 in their workplace. Later sections of this guidance—including those focusing on jobs classified as having low, medium, high, and very high exposure risks— provide specific recommendations for employers and workers within specific risk categories.
The United States Department of Agriculture has announced a second application window for its Distance Learning and Telemedicine grants. The filing window opened April 14, 2020, and closes July 13, 2020. The Distance Learning and Telemedicine program will fund audiovisual equipment, computer hardware and software, inside wiring, and technical assistance and instruction for students, teachers, medical professionals and rural residents who will be using eligible equipment. The grants are intended to increase rural access to education, training, and healthcare resources that would otherwise be limited or unavailable. Eligible applicants include most entities that provide healthcare or education through telecommunications.[1] For a specific list of eligible applicants and an explanation of the use of funding, see the funding opportunity announcement here. (link)
The Centers for Medicare and Medicaid Services (CMS) specifically lists psychological and neuropsychological testing codes as covered telehealth services under the Temporary Addition for the Public Health Emergency for the COVID-19 pandemic. Additional guidelines state that services provided by licensed clinical social workers and clinical psychologists can be paid for as Medicare telehealth services; [2] Medicare does not allow payment for services provided by licensed professional counselors or licensed marriage and family therapists. CMS has provided this additional information about virtual check-ins and e-visits: [3]
The Oklahoma Health Care Authority (OHCA) has declared that during the national COVID-19 emergency, services rendered by behavioral health providers via telephone will use the HCPC/CPT codes listed in the rates and codes sheets applicable to their provider type, using the GT modifier and indicating that the service was delivered via telemedicine. OHCA states that services should only be delivered via telephone (not face-to-face) when “SoonerCare members do not have access to telehealth equipment, the service is necessary to the health and safety of the member, and the service can be safely and effectively provided over the telephone.” OHCA is encouraging providers to create internal policies and procedures regarding the use of telehealth so that all staff understand its appropriate use during this time.[4] OHCA held a webinar for behavioral health providers on April 9. A recorded session of the webinar and a Q&A report can be found at https://www.okhca.org/covid19/#webinars.[5]
The Federal Communications Commission’s (FCC) COVID-19 Telehealth Program will provide $200 million in funding, appropriated by Congress as part of the Coronavirus Aid, Relief and Economic Security (CARES) Act.[6], [7] This funding will provide support to eligible health care providers responding to the COVID-19 pandemic by fully funding their telecommunications services, information services, and devices necessary to provide critical connected care services until the program’s funds have been expended or the COVID-19 pandemic has ended. In addition to this new telehealth initiative, the FCC is starting the Connected Care Pilot Program, a three-year, $100 million effort to expand telehealth for underserved populations, particularly low-income residents and veterans.
Interested health care providers must complete several steps prior to applying for funding through the COVID-19 Telehealth Program: (1) obtain an eligibility determination from the Universal Service Administrative Company (USAC), (2) obtain an FCC Registration Number (FRN) and (3) register with System for Award Management. Additional information is available at https://www.fcc.gov/keep-americans-connected. Applications are now being accepted. (link)
Health care providers in both rural and non-rural areas are eligible for the COVID-19 Telehealth Program. Specifically, the program is limited to eligible nonprofit and public health care providers that fall within the health care providers categories in section 254(h)(7)(B) of the 1996 Act, including community mental health centers, medical schools and teaching hospitals, community health centers and migrant care centers, local health agencies and departments, not-for-profit hospitals, rural health clinics, and skilled nursing facilities. Because of the direct allocation from Congress, the funds have fewer constraints and can be used for a wide variety of services and equipment, and recipients will not have to abide by competitive bidding requirements. The FCC reports that the application is streamlined. In order to ensure as many applicants as possible receive available funding, the FCC does not anticipate awarding more than $1 million to any single applicant. Funds can be used to pay for 100% of costs incurred.[8], [9], [10]
Examples of services and devices that COVID-19 Telehealth Program applicants may seek funding for include:
Eligible health care providers that purchased telecommunications services, information services, and/or devices in response to the COVID-19 pandemic after March 13, 2020, may apply to receive funding support through the COVID-19 Telehealth Program for eligible services that were purchased.
Healthy Minds is not endorsing or recommending any specific technology, software or applications. Choosing a software or video chat application should be informed by an organization’s risk analysis.
Zoom has a HIPAA-compliant add-on in the form of a business associate agreement (see https://zoom.us/healthcare). It does not appear that obtaining the “HIPAA Compliant” add-on for Zoom increased its “security” or encryption; rather, the business associate agreement offers the provision that Zoom will take on the responsibility for keeping patient information secure and reporting security breaches. It would be important to clarify this issue for whichever application that is selected.
Doxy.com is an internet resource created to help clinicians use HIPAA-compliant telemedicine websites (see https://doxy.me/). Information about other applications are available here. (link)
[6] CARES Act, Pub. L. No 116-136, 134 Stat. 281 (2020). The CARES Act appropriates $200 million to the Commission “to support efforts of health care providers to address coronavirus by providing telecommunications services, information services, and devices necessary to enable the provision of telehealth services” during the pendency of the COVID-19 pandemic