Exploring Reinforcement Learning for Fluid Transitions Between Clinical Mental Healthcare and Everyday Wellness Support

Reinforcement learning (RL) in healthcare has had mixed results, with reward sparsity, unreliable off-policy evaluation, and deployment-simulation gap as recurring failure modes. We argue that chronic disease management is structurally a more tractable RL setting than the acute-care problems the field has primarily studied, but only if the problem is formalized to exploit chronic care's properties. We propose such a formalization. The agent's objective is to compress time-to-control (TTC) under a tiered reward calibrated to the CMS ACCESS Model. Two quantities from our companion preference-learning paper [Singh et al. 2026] enter as load-bearing structural elements: the execution intensity εbounds action availability under a constrained Markov Decision Process, and the clinician capability κweights offline-data transitions during RL training. Together they couple preference learning and RL into a two-loop architecture. We present simulation results on synthetic state machines for hypertension and type 2 diabetes. Capability-weighted offline RL outperforms uniform-weighted offline RL and the behavior policy by 15 percentage points on T2D TTC; the uniform-weighted formulation (the standard in existing healthcare RL) underperforms even the heterogeneous behavior policy. \Epsilon-aware policies generalize across deployment regimes while ε-naive policies do not.

Medical treatment recommendation poses several challenges to reinforcement learning (RL): patient physiology evolves in continuous time, measurements and interventions are performed at irregular intervals, and treatment effects vary substantially across individuals. Existing RL formulations and simulated environments, however, are based on discrete-time MDP or POMDP abstractions with fixed or pre-specified decision intervals. Thus, it remains difficult to evaluate whether RL methods can handle time-interval-dependent disease progression, personalized treatment response, and safety between consecutive measurement points. To address this gap, we introduce MedGym, a benchmark environment for dynamic treatment recommendation. MedGym models longitudinal patient evolution in a continuous-time framework and constructs a configurable medical RL benchmark from clinical data by using Physics-Informed Neural Networks. The resulting benchmark supports both offline and online RL, and enables direct comparison between discrete-time and continuous-time methods under irregular treatment timing and patient-specific dynamics. Besides, MedGym supports evaluation from clinically important perspectives, including personalization, trajectory-level safety, and the performance gap between model-based offline learning and online deployment. By providing a standardized and configurable benchmark for continuous-time dynamic treatment, MedGym aims to facilitate more realistic and informative evaluation of medical RL methods.

Clinical protocol-execution tasks -- checking a lab value, applying a threshold, placing a correctly structured FHIR order -- are natural candidates for RL from world feedback: once clinical SMEs encode decision logic into a verifier, that verifier grades unlimited rollouts without per-episode annotation. But applying RL requires a sound feedback channel and sufficient base capability. We audit MedAgentBench v1/v2, find a 41.7% silent-finish ceiling that makes inaction the RL dominant strategy, and construct \textbf{MedAgentBench-v3 (MAB-v3)} (508 tasks, 8.9% ceiling). Training Qwen3-8B exposes two structural barriers: a \emph{capability ceiling} (10/20 task types have 0% base performance, zero gradient) and a \emph{format-knowledge barrier} (3/20 types require exact clinical codes undiscoverable by exploration). Pure RL reaches 18.2% pass@1 vs.\ 34.1% for rule-based SFT; the 15.9~pp gap is attributable entirely to these barriers. A decision/format-knowledge/lookup taxonomy predicts RL learnability and prescribes the fix: SFT to inject codes, RL to learn conditionals.