How North Carolina’s Behavioral Health and Intellectual and Developmental Disabilities System Is Responding to COVID-19

The emergence and rapid spread of COVID-19 has prompted an unprecedented response by governments at all levels. This includes dramatic shifts in the way health care, including behavioral health and intellectual and developmental disabilities (IDD) services, are being delivered. In North Carolina, the behavioral health and IDD response falls into three major streams of work:

• maintaining and sustaining community behavioral health services,
• safeguarding our most vulnerable populations in state health care facilities, and
• responding to emerging behavioral health needs while building resiliency.

The goal of these efforts is to reduce the need for emergency department visits and any hospitalization in order to free up those limited resources for a potential surge in COVID-19 patients. In addition, we at the North Carolina Department of Health and Human Services (NCDHHS) aim to ensure behavioral health and IDD services continue for existing patients and for those newly in need of help.

Maintain and sustain community behavioral health services

To sustain and bolster the behavioral health and IDD systems during the COVID-19 emergency, NCDHHS worked quickly with federal, state, and local partners to create regulatory latitude. The most notable adjustment was broadly expanding providers’ ability to receive Medicaid and state funds for services delivered through telehealth and telephonic methods. Telehealth policy in North Carolina moved forward 10 years in a matter of 10 days.

Our agency also took actions to assist the seven Local Management Entities/Managed Care Organizations (LME/MCOs) that manage the care of beneficiaries who receive services for mental health, developmental disabilities, or substance use disorders. Following the implementation of stay-at-home orders, many providers experienced a sudden drop in demand for their traditionally delivered services, resulting in financial hardship for these small businesses. While many of these providers worked to quickly adopt telehealth strategies to both continue care and sustain their businesses, they also faced costs associated with adopting systems to support telehealth and electronic records. Inpatient providers faced even greater challenges as they navigated how to maintain staffing levels and adapt operations to minimize the spread of COVID-19, sustain services, and keep unneeded pressure off local hospitals.

To ensure all these organizations had the resources to support robust networks of behavioral health and IDD providers, the state immediately released the remainder of state funds allocated for the rest of the fiscal year and increased rate ceilings for many services so providers could be paid more. Each of the LME/MCOs carry a self-insured risk reserve to be used in catastrophic events. The state authorized use of up to 15% of their risk reserves—freeing up millions in additional, flexible funding to meet immediate needs during the crisis.

Safeguard our most vulnerable populations

North Carolina’s state-operated health care facilities, encompassing 14 facilities and approximately 2,700 patients and residents, provide compassionate care to individuals with the most complex physical and behavioral health issues in the state. With so many high-risk individuals as patients, these facilities began taking protective measures before the first case was confirmed in the state. Specifics steps taken to prevent the spread of the virus and plan for potential infection of staff and patients include screening employees and residents; closing to all visitors; developing alternative programming to ensure that patients/residents and, where possible, staff from different units do not comingle; and more.

The state facilities have also been working to secure the necessary personal protective equipment that has been in short supply globally, including employing home-grown solutions such as creating masks on site for use in certain circumstances.

Responding to behavioral health needs and building resiliency

North Carolina is no stranger to disasters given our experience with natural disasters like hurricanes. While these lessons and disaster-related infrastructure are helpful now, the COVID-19 pandemic has created new challenges.

During previous disasters, we have observed the need for behavioral health services peak around six months after the event. The COVID-19 pandemic is a prolonged event that is still in the disaster phase; it’s difficult for many to even imagine what the recovery will look like. While NCDHHS is working with partners to ready providers for the likely lasting impact of this pandemic, we are also repurposing and augmenting our disaster infrastructure to meet individuals’ immediate needs and build resiliency.

To meet immediate behavioral health and IDD needs, and transition individuals to appropriate care, NCDHHS has established two mental health resources to support North Carolinians through the COVID-19 crisis. The Hope4NC Helpline is now available 24 hours per day, seven days a week, in all of North Carolina’s 100 counties. It has proven invaluable as part of the state’s recent hurricane recovery efforts. The second resource, Hope4Healers, is a new initiative in partnership with the North Carolina Psychological Foundation that will provide mental health and resilience supports for health care professionals on the COVID-19 front lines and their families.

Looking Ahead

While it can be hard to have clear perspective on what actions are making an impact as a crisis is still unfolding, we are gaining some initial insight as this emergency persists. Repurposing and leveraging existing infrastructure, networks, and institutions to address new challenges posed by this crisis has been key to shortening response times. Additionally, as a crisis is cresting, providing stability is paramount—whether that’s providing additional supports for staff at health care facilities like hazard pay or free child care to facilitate sufficient staffing levels, or offering financial supports to organizations and providers who key to an effective response.

Providing flexibility across the system must also be a priority, coupled with clearly and frequently communicating those flexibilities. Weeks into this event, we are now are in the process of identifying metrics and gathering information to evaluate what temporary flexibilities and waivers may need to be phased out, and others whose value could live beyond the pandemic in some form. As we’ve done in our overall response to COVID-19, we will rely on data to guide our decision-making and justifications for what to sunset and what to keep.

This emergency has also highlighted some key challenges in the behavioral health system and underscored the need to address them. This includes long-term funding challenges, a deficit of providers, not having the necessary technology infrastructure to support telehealth, and too many North Carolinians facing difficulty accessing care due to a lack of insurance. However, the COVID-19 pandemic has demonstrated the importance of behavioral health and IDD services. And since every one of us has been impacted by this pandemic, we at NCDHHS may have a window in which to build on public empathy and bust the stigma associated with needing, seeking out, and receiving these services. We indeed are all in this together, and we’ll work to sustain this momentum and commitment to each other in the months to come.

Kody H. Kinsley is the deputy secretary for behavioral health and intellectual and developmental disabilities at the North Carolina Department of Health and Human Services.