The COVID-19 pandemic has had significant and harmful effects on people’s mental health. Individuals with serious mental illness (SMI) — such as schizophrenia, bipolar disorder, and major depressive disorder — are especially susceptible to these challenges. The physical distancing measures used to mitigate the spread of infection have reduced the formal and informal supports that are often vital to people with SMI in managing their conditions. This loss of support, combined with the novel stress of the pandemic, may lead to worsening behavioral health symptoms. For people with SMI who are dually eligible for Medicare and Medicaid, these issues amplify existing difficulties stemming from the fragmentation and lack of service delivery coordination between the two programs.

With support from Arnold Ventures, the Center for Health Care Strategies (CHCS) is producing a blog series that explores the impact of COVID-19 on different sub-populations of dually eligible individuals. To better understand the pandemic’s impact on dually eligible individuals with SMI, CHCS spoke with several experts: Xavior Robinson, MHA, chief operating officer at Pathways to Housing PA; Jennifer Mathis, JD, director of policy and legal advocacy at the Bazelon Center for Mental Health Law; and Ellen LaSalvia, MSW, senior director of long-term services and supports/home and community-based services at Buckeye Health Plan.

Challenges for Dually Eligible Individuals with SMI amid COVID-19

While COVID-19 is impacting the health of people with SMI across the U.S., dually eligible individuals with SMI face some unique challenges during the pandemic, including:

• Heightened Risk of Infection Due to Multiple Chronic and Comorbid Conditions. Nearly one-third of dually eligible individuals have been diagnosed with SMI, a rate that is nearly three times higher than non-dually eligible Medicare beneficiaries. This population also tends to have high rates of physical health comorbidities that make them more vulnerable to infection, including chronic conditions such as cardiovascular and respiratory disease, hypertension, and diabetes. Not only do these conditions require ongoing medical management that is more difficult to access during the pandemic, but these chronic issues can also raise the risk of severe complications or death from COVID-19 infection. Dually eligible individuals who have co-occurring mental health and substance use disorders may also be more likely to relapse in this environment due to isolation and emotional distress, increasing their risk for overdose, hospitalization, or suicide attempts.
• Reduced Access to Already Tenuous Supports. Without coordination across physical and behavioral health care services, which dually eligible individuals with SMI often already lack, it can be difficult for health plans and providers to effectively mitigate the impact of COVID-19 for this population. Managing a person’s SMI, chronic medical conditions, and/or substance use disorders requires frequent interactions with care providers to optimize health outcomes. COVID-19, however, has reduced access to routine medical care, maintenance treatments, and community mental health services — such as assertive community treatment (ACT), crisis intervention, and psychosocial supports like clubhouses. While some services have adapted to a virtual environment, telehealth may not meet the needs of some people with SMI who benefit from face-to-face interaction — and the informal nuances that come with it — to build trusting relationships and engage in care. These barriers to accessing care and interruptions to home- and community-based services can exacerbate behavioral health symptoms for dually eligible individuals with SMI, leading to adverse outcomes, including avoidable hospitalizations and lapses in chronic care management.
• Increased Housing Instability and Homelessness. COVID-19 has also worsened challenges faced by people with SMI in finding safe, supportive, and affordable housing, a problem that already existed prior to the pandemic, as reflected in the high rate of homelessness among this population. While organizations like Pathways to Housing PA are using innovative, integrated approaches to address both housing instability and health needs, homelessness across much of the U.S. remains common among dually eligible individuals with SMI. Housing instability can increase the risk of infection and make it more difficult for people to safely shelter-in-place. It also creates additional hurdles to care delivery and management, such as making it more difficult to reach members. This long-standing problem among dually eligible individuals with SMI creates further barriers to care and services at a time when monitoring, screening, potential treatment, and follow-up are paramount.
• Disparate Impacts on Communities of Color. The dually eligible population, which is more racially and ethnically diverse than the Medicare population as a whole, is more susceptible to COVID-19 infection. Black individuals are more than three-and-a-half times likely to be hospitalized with COVID-19 and almost three times more likely to die than white individuals. While Black individuals may be more likely to become infected, compared to white individuals, they can also be more reluctant to seek care due to potential experiences of discrimination. This perspective is echoed by some of the people that Pathways to Housing PA serves. Four of their ACT teams work with people who have SMI, most of whom are Black and older and report instances of traumatizing medical racism.

Benefits of Integrated Care for Dually Eligible Individuals with SMI

Integrated Medicare-Medicaid programs can help alleviate the impacts of service fragmentation — made worse by the pandemic — and better meet the needs of this population by:

• Enabling Responsive, Trusting Relationships. By aligning Medicare and Medicaid benefits in a single entity, health plans and providers can be more responsive to an individual’s needs. Robust care management is critical for dually eligible members given the challenges of navigating across the Medicare and Medicaid systems. Building trusting relationships with a care manager can be particularly beneficial for people with SMI and help engage them in care.

• Establishing Clearer Clinical Profiles. Dually eligible individuals with SMI often see multiple providers to manage a range of physical and behavioral health conditions. With access to both Medicare and Medicaid data, integrated care programs are well-positioned to understand the clinical profile of their members as well as their social risk factors. These data are useful not just to practitioners, but also to care managers who coordinate care across providers and ensure access to wraparound services, which is critical to people with SMI during the COVID-19 pandemic.
• Responding to Care Needs More Rapidly. Because integrated programs are designed to serve members with complex needs, they can quickly ramp up to fill gaps brought on by the pandemic. For example, Buckeye Health Plan’s existing behavioral health crisis line and peer support services became invaluable during COVID-19. Buckeye Community Connect, the plan’s platform for locating local resources and services, has always been useful for the plan’s care managers but took on new importance during the pandemic in finding food banks that would deliver to members isolating at home. Furthermore, Pathways to Housing PA’s Federally Qualified Health Center, with its co-located primary care and behavioral health services, streamlines care and makes it easier for patients to see all of their providers at a single location.

The Importance of Integration Moving Forward

Dually eligible individuals with SMI often need a range of physical and behavioral health services and must navigate multiple systems and providers to meet their full care needs. COVID-19 has intensified existing issues related to system fragmentation and health disparities, creating new challenges by reducing access to community-based supports and regular communications with trusted providers. The pandemic environment is highlighting the benefits of service integration and comprehensive care management for this population. Integrating both Medicare and Medicaid services, as well as physical and behavioral health care, may help address the needs of dually eligible individuals with SMI during the pandemic and into the future.