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Covid as Catalyst

Published November 2nd, 2020

How Mental Health Strains Amid the Pandemic Make The Case for In-Home Care


One of the benefits of being a nurse practitioner is the “nurse” component puts me in a profession deemed “most trusted” for 18 years in a row. I like to think that allows people to open up to me more freely. This transparency provides the information I need for a good assessment, and subsequently, a good plan. Since February, the stories people have shared with me have changed. Amid the pandemic, conversations have gone from initial irritation over canceled plans and lack of toilet paper, to stress and anxiety over an unknown future and expressions of loss for what was once “normal.”

It seems that the pandemic has served a two-fold blow to the state of mental wellbeing, both causing problems and worsening them. While approximately 1 in 5 adults report experiencing mental illness every year, more than 1 in 3 have reported experiencing symptoms of anxiety or depressive disorder during this pandemic. A Kaiser Family Foundation poll in mid-July showed that 53% of adults in the United States reported that the pandemic has had a negative impact on their mental health, and many reported they have had difficulty eating and sleeping. Concern over catching the virus isn’t the only strain on mental wellbeing: social isolation, job insecurity, and loss of income all contribute as well.


How does mental health fit in?

Mental health is more than just “feeling sad” or “feeling happy.” It encompasses emotional, psychological, and social wellbeing, and impacts how we think and act, as well as how we feel. Mental states are the product of the interplay of individual, environmental, economic, and sociocultural components (substantial overlap with determinants of physical health), and any change in one of these factors can impact an individual’s mental state. While, historically, western medicine has long separated the mind from the body in treatment, with the approach being to specialize in treating one or the other, mental and physical health have a reciprocal relationship. People with poor mental health are at risk of developing chronic physical conditions, and people with chronic physical conditions are at risk of developing poor mental health. The relationship extends into health economics, with adults who experience behavioral health issues having higher physical health expenditures than those who don’t experience behavioral health issues.


A vicious cycle

To say that this year has brought change in all aspects of day-to-day life is an understatement. Such sudden, major change has had a ripple effect, and prompted a change in health-related behavior as well. Notably, almost 50% of Americans are delaying care out of concern for the pandemic. The delay in seeking care prompted concerns from healthcare professionals around worsening conditions, and both hospitals and payers have started campaigns urging people to stop “medical distancing” while continuing with social distancing.

The fear that medical distancing is worsening conditions such as cancer, stroke, and cardiac events is an easy one to understand. It seems logical that problems with identifiable physical causes, if left unaddressed, will worsen a patient’s physical condition — and could even result in death. What is becoming increasingly apparent is how this plays a role in mental wellbeing. As the pandemic increases the number of people experiencing symptoms of anxiety and depression, anxiety and depression then link to delayed medical care. The process continues, as delaying care can worsen both mental and physical health conditions.


Rethinking how we deliver care

The pandemic is pushing us to rethink how we deliver care, and the future of healthcare needs a solution which considers this physical-mental health relationship proactively in every model. The number of new coronavirus cases continues to remain high, and the US is entering a time of year when there’s already a high community infection baseline. We can anticipate that people will continue to hesitate when it comes to seeking care in traditional clinic and hospital settings out of concern for infection, and that social distancing guidelines are here to stay. This means that people will continue to experience the isolation and symptoms of anxiety and depression that accompany a pandemic. Healthcare cannot wait for a “return to normal;” healthcare has to create new models by which people can receive care.


Meet people where they are

In what is perhaps an unprecedented industry experience, healthcare has rapidly transitioned to telehealth during this pandemic. Virtual visits can help address both physical and mental health, and patients want to continue this technology-based care going forward. Leveraging technology both during and after the pandemic should be the norm in healthcare, and many are already reimagining the future of healthcare with telehealth as a key component.

But telehealth isn’t the solution for everyone. It’s estimated that 13 million older adults in the US have trouble accessing telehealth services. This is a population that also has a significant need for access to care, especially during the pandemic. 80% of older adults have at least one chronic disease, one in four experience some mental disorder, and nearly one-fourth of adults over age 65 are considered socially isolated. And despite the widespread reach of the internet, there are still more than 14 million people in the US without any internet access, and 25 million without broadband access.

So, while telehealth is integral to both the current state and the future of healthcare, it is insufficient to meet the needs of everyone who is delaying care right now. Any solution for the present need and the future ideal state has to include more than just telehealth and facility-based care. A solution which honors both the physical and mental impact of the pandemic is one which also includes meeting people where they are: in their homes. In a sense, if those who need care can’t, or won’t, come to us, we need to go to them.


Visiting patients in their homes

Reimagining healthcare and creating an actual system that works is not an easy undertaking. There are no quick answers, and the scenarios for which the industry tries to design a model are as numerous as the people who need the care. But recognizing that there is no “one-size-fits-all” solution is a great place to start. Removing a mindset that only envisions certain care in certain settings lifts arbitrary constraints, and allows for a more agile approach to meeting people’s needs.

Instead of a dichotomy of “inpatient” or “outpatient”, imagine a spectrum of offerings, so that there would be no reason for almost 50% of people to delay seeking care. An array that includes telehealth, in-home lab draws, physical and occupational therapy both remotely and in-person, and a return of the housecall when needed. For an even higher level of care, incorporate hospital-at-home models and couple with medication delivery.

There will always be the need for traditional hospital- and clinic-based care, but they wouldn’t be the default options. A model that incorporates so many settings has the opportunity to meet people where they are as well as mitigate situations such as isolation and delaying care due to fear and anxiety. From a consumer (i.e. patient) standpoint, this makes perfect sense: provide options, recognize that not everyone is ready for certain approaches, and engage with people where they feel both physically and mentally comfortable. Such an approach allows healthcare to meet people where they are, both literally and figuratively.


Going forward

Despite the losses that we continue to experience with the pandemic, there is useful information to be gleaned. With more and more people experiencing symptoms of anxiety and depression as well as delaying care, this is an opportunity to craft a proactive approach that truly meets people where they are to provide better care than even pre-pandemic. Doing so recognizes that there needs to be a shift not only in how care is practiced, but where as well.