Background
The COVID-19 pandemic created the opportunity to leverage collaborative care model (CCM) best practices (Unützer, 2012) and a rapidly evolving knowledge base to serve patients with post-infection neuropsychiatric symptoms (Taquet, 2020). Expanding the team-based framework of the CCM to incorporate neuropsychology, health psychology, and proactive screening can help psychiatrists meet the neuropsychiatric needs of COVID-19 survivors in primary care.
Methods
In April 2020, we designed a new CCM intervention through an institutional patient care innovation grant to address the anticipated neuropsychiatric needs of patients impacted by COVID-19. We implemented a modified CCM framework in academic general internal medicine clinics featuring social work care management, psychiatric consultation, and collaborating health psychologists and neuropsychologists. We established additional screening and referral pathways from a post-COVID recovery clinic, COVID-19 test follow-up telephone calls, and post-hospital transition of care encounters.
Results
The investigators screened 3557 post-hospital discharge patients between December 1, 2020 and September 30, 2021. 100 patients screened positive for depression or anxiety symptoms. 38 declined enrollment, 3 were already established with services, and 23 were referred to other services. In total, 25 patients referred from all sources were enrolled in the CCM intervention. Of these 25 patients, 23 had prior COVID-19 infection and 19 had prior history of depression or anxiety. Average time between COVID-19 diagnosis to enrollment was 98.8 days. The most commonly identified disorders were depressive (21) and anxiety disorders (19) followed by cognitive complaints (6) and PTSD (2). 18 patients received medication management and 9 received psychotherapy through the CCM. Among 9 patients with complete symptom measurement data, average PHQ-9 decreased from 13.2 to 6.7 during intervention, and average GAD-7 decreased from 13.4 to 6.0. 3 patients completed neuropsychological testing, and 1 demonstrated objective cognitive impairment.
Discussion
The CCM can be adapted to address the needs of patients with post-COVID neuropsychiatric needs. Exacerbation of pre-existing depressive and anxiety disorders was common whereas cognitive problems and PTSD were less common in our cohort. On average, patients were enrolled more than 3 months after their COVID-19 diagnosis. Serial screenings following initial COVID-19 diagnosis and screening patients who required ICU care may identify more symptomatic patients. Adoption of CCM practice among primary care providers was slower than expected, and rapid transition to telehealth complicated completion of symptom measurement instruments.
Conclusion/Implications
COVID-19 survivors will need consistent care access to manage chronic behavioral health and cognitive needs as they arise over time and across treatment settings. This interdisciplinary program based upon the CCM highlights the model’s ability to flexibly leverage limited behavioral health resources to meet the needs of rapidly evolving populations. More targeted screening protocols, more reliable remote symptom measurement, and outreach to primary care providers can help build more effective CCM interventions.