Psychiatric Rehabilitation & Counseling Professions
Rutgers Biomedical and Health Sciences
Research Tower
675 Hoes Lane West, 8th Floor
Piscataway, NJ 08854

April 8, 2020

Rutgers School of Health Professions conducted an open-ended, online survey to identify the key challenges facing NJ mental healthcare providers due to the COVID-19 pandemic, from Wednesday, March 26^th, and closed Sunday, April 6^th. Forty-eight responses from thirty-nine organizations were received. Each respondent reported at least one, top-priority challenge due to COVID-19 as well as several additional challenges. Those most frequently cited top-priority challenges included:

• Safety (66%) – lack of personal protective equipment was cited by 25% of respondents.
• Transitioning to telehealth (56%) – lack of consumer access to technology was raised by 19%. Reliability, regulations, and privacy were less frequently mentioned.
• Having to continue to provide face to face services (21%).
• Staffing concerns (19%) – at time of survey, only 6% reported absenteeism as a problem.
• Immediate Funding concerns (18%) – one organization has already required lay-offs.

Numerous other concerns were also raised including increased unemployment among service recipients, medical adherence challenges, fear/anxiety/depression among both staff and service recipients, inability to provide group services, communication challenges, central administration and office logistical challenges, and billing.

Although telehealth and related approaches are being quickly and widely applied with varying degrees of success, numerous practical and regulatory challenges remain. One of the most significant challenges is that many organizations, their staff, and clientele do not have the infrastructure of software and technology and therefore are not able to avail themselves of these services due to restricted access. Even when remote approaches are implemented there are technical challenges, “attentional” challenges on the part of participants, and difficulty adapting technology to address group formats. Organizations are also concerned about regulatory, billing, and privacy requirements. While both the federal and state agencies are providing some regulatory relief and increasing guidance about existing regulations, more is needed. When face to face services are needed due to the lack of resources or the nature of the service (e.g., residential services, inpatient treatment, some outreach, services that require home visits like ICMS, PACT, homeless outreach, and family services), personal protective equipment (PPE) is required but, in large part, has often been unavailable consistent with the known increased demands and shortages. Training in its proper use is also desired. Funding challenges have already arisen due to increased equipment and supply costs, staff over time, part-time temporary staff (if available), outside experts, PPE, increased cleaning services and other unforeseen expenses.

In summary, regulatory clarity and guidance is required in terms of privacy laws, billing, and reimbursement regarding both formal telehealth and other related approaches. Also required is regulatory flexibility on definition of services and requirements, relief from applicable regulations that may be impractical to adhere to at this time. Clarity on how organizations will be reimbursed given interruption of Medicaid and other billing disruption, partial “suspension of fee for service” approach, and decreased billable services. Reimbursement by state and federal sources for unforeseen expenses in categories of spending that were not expected, specifically communication-related technology, PPE, and special services. Organizations may require ongoing PPE and guidance requiring opening for facilities ongoing remediation in treatment and residential environments

The Department of Psychiatric Rehabilitation and Counseling Professions, conducted an open-ended, online survey to identify the key challenges facing NJ mental healthcare providers due to the COVID-19 pandemic, and the operational adaptations providers are making to address those challenges. The survey *(see Annex 1) was opened on Wednesday, March 26^th, and closed Sunday, April 6^th.

Forty-eight responses from thirty-nine organizations were received. Each respondent reported at least one, top-priority challenge due to COVID-19 as well as several additional challenges. Those most frequently cited top-priority challenges included:

• Safety (66%) – lack of personal protective equipment was cited by 25% of respondents.
• Transitioning to telehealth (56%) – lack of consumer access to technology was raised by 19%. Reliability, regulations, and privacy were less frequently mentioned.
• Having to continue to provide face to face services (21%).
• Staffing concerns (19%) – at time of survey, only 6% reported absenteeism as a problem.
• Immediate Funding concerns (18%) – one organization has already required lay-offs.

Numerous other concerns were also raised including increased unemployment among service recipients, medical adherence challenges, fear/anxiety/depression among both staff and service recipients, inability to provide group services, communication challenges, central administration and office logistical challenges, and billing. All the original responses are summarized in Table 1.

Adaptations

Respondents reported 149 operational adaptations that have already been implemented, 41 adaptations still in the planning stage, and 39 desirable adaptations that providers are unable to implement. Adaptations already implemented are summarized in three tables: general safety and operational adaptations (Table 2), adaptations in relation to telehealth and other use of remote or distance technology to deliver services and supports (Table 3), and specific adaptations by individual service modalities (Table 4).

Although telehealth and related approaches are being quickly and widely applied with varying degrees of success, numerous practical and regulatory challenges remain. One of the most significant challenges is that many organizations, their staff, and clientele do not have the infrastructure of software and technology and therefore are not able to avail themselves of these services due to restricted access. Even when remote approaches are implemented there are technical challenges, “attentional” challenges on the part of participants, and difficulty adapting technology to address group formats. Organizations are also concerned about regulatory, billing, and privacy requirements. While both the federal and state agencies are providing some regulatory relief and increasing guidance about existing regulations, more is needed.

When face to face services are needed due to the lack of resources or the nature of the service (e.g., residential services, inpatient treatment, some outreach, services that require home visits like ICMS, PACT, homeless outreach, and family services), personal protective equipment (PPE) is required but, in large part, has often been unavailable consistent with the known increased demands and shortages. Training in its proper use is also desired.

Funding challenges have already arisen due to increased equipment and supply costs, staff over time, part-time temporary staff (if available), outside experts, PPE, increased cleaning services and other unforeseen expenses. Some organizations have an immediate need; others are concerned about sustaining increased costs. The variety of adaptations desired, yet to be made, partially implemented or that could not be implemented are summarized in Table 5.

Potential Advocacy Issues

• Regulatory clarity and guidance is required in terms of privacy laws, billing, and reimbursement regarding both formal telehealth and other related approaches.
• Regulatory flexibility on definition of services and requirements.
• Relief from applicable regulations that may be impractical to adhere to at this time.
• Clarity on how organizations will be reimbursed given interruption of Medicaid and other billing disruption, partial “suspension of fee for service” approach, and decreased billable services.
• Reimbursement for unforeseen expenses in categories of spending that were not expected, specifically communication-related technology, PPE, and special services.
• Availability of PPE, and guidance on re-open building and services.

Survey Respondents and their Services

The forty-eight respondents were comprised of 12 Presidents/CEOs, six senior executives, 19 directors, three managers, two clinicians, and six others, representing 39 agencies. The median completion time was 10 minutes. Of the responding agencies, 100% reported significant challenges. Among the respondents, 56% provide outpatient programs, 44% provide co-occurring mental health/substance use treatment (including both medication-assisted and not) and 35% offer Community Support Services. These organizations also provide residential services (29%), homeless services (29%), partial care and/or partial hospitalization programs (29%), and justice involved services (21%). Only one type of NJ DMHAS-related program element, Deaf Enhanced Short Term Care Facilities, was not addressed by any respondent. The types of program represented are summarized in Table 6.

Below are the tables referenced above. They are intended to provide an assessment of the current challenges, adaptations, and desired changes due to the impact of the pandemic on New Jersey’s mental health organizations that participated in the survey.

Prepared by:

Aaron Levitt, Ph.D.

levittaj@shp.rutgers.edu

Kenneth J, Gill, Ph.D.

kgill@rutgers.edu

*For the complete study, please contact the study authors.