No abstract

In March 2020, at the beginning of the COVID-19 pandemic, state-funded community mental health service programs (CMHSP) in Michigan, organized into 10 regions known as a "Prepaid Inpatient Health Plan" (PIHP), grappled with the task of developing a modified plan of operations, while complying with mitigation and social distancing guidelines. With the premise that psychiatric care is essential healthcare, a panel of physician and non-physician leaders representing Region 5, met and developed recommendations, and feedback iteratively, using an adaptive modified Delphi methodology. This facilitated the development of a service and patient prioritization document to triage and to deliver behavioral health services in 21 counties which comprised Region 5 PIHP. Our procedures were organized around the principles of mitigation and contingency management, like physical health service delivery paradigms. The purpose of this manuscript is to share region 5 PIHP's response; a process which has allowed continuity of care during these unprecedented times.

Polypharmacy in older nursing home patients is a well-documented concern. Several large studies have demonstrated an association between treatment with antipsychotics and increased morbidity and mortality in people with dementia, and the economic impact of polypharmacy is also substantial, with annual medicationrelated issues costing $7.6 billion in nursing facilities alone. We chose to use the Assess, Review, Minimize, Optimize, Reassess (ARMOR) protocol for our team-based intervention to address inappropriate prescribing in older residents. A reduction in the use of psychotropic medications was associated with an improvement in activities of daily living and fewer reports of depression but was also linked to an increase in the rate of falls and reports of pain. The lower use of antipsychotics also appears to unmask untreated anxiety, expressed in the results as the increased rate of antianxiety medications.