Even before the COVID pandemic crashed through the doors at The University of New Mexico’s Sandoval Regional Medical Center, Dr. Poonè Haghani Tehrani could see that psychiatric services needed to be more efficient.
In a state with a big need but a small workforce for mental and behavioral health, Tehrani saw resources across the hospital stretched thin, including the closure in 2016 of a geriatric unit at the center after mill levy funding expired.
“So that right there basically brought to my attention the shortage of workforce and reinforcements in psychiatry and the fact that we have to be very efficient with how we utilize our resources including workforce,” said Tehrani, a psychiatrist who at the time was working in a consult-liaison capacity at the hospital.
She decided to implement a new approach.
“It was obvious that it was very important to take that proactive approach to medicine and try to minimize the need for in-patient care as much as possible,” she said. Tehrani originally was hired to start integrated psychiatry at SRMC Family Practice clinic and provide consult liaison services to the hospital but was called on to temporarily step into a role directing the geriatric unit before it closed.
Her goal was to develop integrated psychiatry within the limits of existing resources while she continued to be the hospital’s psychiatric consult liaison. This allowed her to provide care for as many patients as possible. In integrated care, services are built into primary care clinics. The model means providers such as psychiatrists work hand in hand with family medicine providers and often are co-located in the same offices.
With buy-in from hospital officials, Tehrani spent time from 2017 to 2019 creating a system of integrated care at the center. She also used the opportunity to develop a curriculum for training psychiatry residents in this approach, which is gaining in popularity worldwide, she said.
Integration seemed to be working, and psychiatric services were reaching more patients than before. Tehrani had stepped back into the work she had been hired to perform.
And then, as the story goes, the pandemic hit.
"There was no integration in COVID, there was no clinic. I was just locked up in an office for a few months – almost a year – seeing all my patients on the phone, and then after that, when things improved, I started seeing my patients on Zoom and some patients still on the phone.” – Dr. Poonè Haghani Tehrani
Suddenly, instead of seeing patients and co-workers in person, Tehrani – the only psychiatrist based at the hospital – was marooned in her office, trying to reach those in distress through a screen or a phone line. It was harrowing at times.
“There was no integration in COVID, there was no clinic. I was just locked up in an office for a few months – almost a year – seeing all my patients on the phone, and then after that, when things improved, I started seeing my patients on Zoom and some patients still on the phone.”
Her list of patients, it turned out, was growing. And, left isolated physically and emotionally, many were urgently in need of help.
“At some point I remember that it felt very, very deeply dark in terms of patient care,” she said. “Depression was outrageous. A lot of patients who had already suffered from depression were having suicidal ideations.”
By some estimates, as much as 40 percent of the U.S. population reported experiencing depression or anxiety during the pandemic.
People who hadn’t had time to think about past traumas, relationships gone wrong or feelings of inadequacy or shame suddenly had empty hours. Without the distractions and escapes of the gym, the mall, the movie theater, or restaurants, patients needed to talk.
Tehrani did the best she could, going to her office at the hospital in person so that she had separation from home and work, even as she used remote technology to do her job. The other doctors in the hospital were on another floor, and the interactions they used to share seemed a world away.
“Reflecting back, I would admit it was not easy to kind of live COVID and be there for people who were impacted by COVID to a greater degree than I was,” said Tehrani, an associate professor of psychiatry.
Yet the work was rewarding and connected her back to her life’s mission.
“It definitely gave me a sense of focus and purpose through those difficult times,” Tehrani said.
Working during the crisis made her realize what a privilege it is to care for others.
“I feel like it’s an honor for me,” she said of the journey she goes on alongside her patients, “when they have hit the bottom and are ready to rise up.”
These days, Tehrani is finishing research on data she collected about the beginnings of the integration program at the medical center in hopes that a curriculum she developed as part of the process can be used in other places, too.
“There is not a whole lot of training or teaching curriculum nationwide or worldwide for training residents in these models,” she said.
Already, she has two manuscripts drafted that look at the outcome of the curriculum and the effectiveness of the curriculum from the learners’ perspective.
Her work on integrated care earned Tehrani a new title of the Medical Director of the SRMC Psychiatry Primary Care Integration. It also has earned her accolades from co-workers.
“With Dr. Poonè Tehrani in her new role… patients can feel confident that behavioral care in their medical home at SRMC will be overseen by one of our expert UNM psychiatrists,” said Dr. Davin Quinn, vice chair of Adult Clinical Services in the Department of Psychiatry and Behavioral Sciences at the UNM School of Medicine.
“Dr. Tehrani will collaborate closely with our medical providers to implement screening for anxiety and depression, support best practices around choice of treatments and monitoring for outcomes, and provide direct psychiatric assessment and treatment when needed,” said Quinn, Chief of the Division of Behavioral Health Consultation and Integration at the school.
As the world emerges from the most awful parts of the pandemic, Tehrani is focused on the bright spots.
Although it was clunky and less than desirable for many patients, telemedicine stands out as something that Tehrani and her colleagues are glad to have and will continue to use, especially for low-income patients and those in the remote reaches of New Mexico.
“This is kind of like one great thing that has come out of it,” she said, adding that for severely disabled patients in particular it’s a great resource that UNM has invested in and improved.
The telemedicine system and the integrated care approach come in handy as the number of psychiatric patients grows.
COVID “has pushed a larger number of people than pre-COVID to need mental health care, both psychiatry and counseling and psychotherapy…so this basically makes it even more important than before to be efficient with resources and with our workforce,” Tehrani said.
Patients in need of care include those whose troubles bubbled to the surface during COVID – and those with new challenges caused by the confusion and anguish of the public health crisis. Some patients with anxiety and depression found their conditions triggered by social isolation, while others found themselves panicked over the possibility of getting the coronavirus.
“Psychiatry is becoming more and more competitive and popular, so I look forward to the workforce growing, but I still think it’s not going to be at the pace that would eliminate the need for us to be very efficient with our resources.” – Dr. Poonè Haghani Tehrani
The evolving integrated approach means more patients should be able to receive psychiatric services from Tehrani as well as from trainees who rotate through her department.
Patients also might be more likely to stick with their long-term care plans because the approach involves less stigma for many.
Due to the co-location of psychiatric services in clinic offices, some patients are less self-conscious about what others might think of their visits.
“Showing up to the same location where they see their primary care provider and sitting in that lobby, nobody knows why they are there.”
It can also be comforting to patients to seek mental or behavioral health services in a familiar place with staff they know, she said, making them more likely to return.
“It makes a huge difference, and that’s part of the reason people are more likely to show up,” she said.
Currently, the statistics for how many patients follow through with referrals for mental and behavioral health care aren’t good. Tehrani said about half of the patients don’t go to such visits and can get lost in the system.
As more patients continue their care, the workforce conundrum, however, remains.
Right now, Tehrani is working on adopting some other models of integrated care that could increase the system’s capacity even more, something she said has to be one of the steps moving forward.
With the implementation of the integrated system, Tehrani is now seeing patients with psychiatric needs of nine or 10 providers, which is a lot more than the number of patients she could see in a specialized psychiatric clinic.
That means the days are full, and she must be mindful of her own capacity, something she learned from COVID. She’s still processing the burnout from those days.
“It was a process for me to be able to kind of find a way to replace my own resources so I could continue to replenish my soul so that I could continue to be there for people as they figured out their process of recovery. At the beginning it was challenging.”
Tehrani hopes to have more psychiatry colleagues to work with in the future.
“Psychiatry is becoming more and more competitive and popular, so I look forward to the workforce growing, but I still think it’s not going to be at the pace that would eliminate the need for us to be very efficient with our resources.”