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Virtual Care for Behavioral Health Conditions

Published:October 19, 2022DOI:https://doi.org/10.1016/j.pop.2022.04.008

      Keywords

      Key points

      • The COVID-19 pandemic continues to highlight the immense need for more behavioral health care services, particularly services embedded in the primary care setting whereby many patients present first and solely for their mental health needs.
      • Virtual care provides opportunities for prompt and improved access to behavioral health services.
      • Virtual behavioral health is helping to support reducing health care disparities, particularly among rural and at-risk populations.

      Introduction

      The COVID-19 pandemic has highlighted the urgent need for behavioral health care services.
      • Panchal N.
      • Kamal R.
      • Cox C.
      • et al.
      At the same time, the pandemic thrust virtual care forward out of necessity. A substantial portion of mental health care transitioned to virtual care during the COVID-19 pandemic, remains virtual today, and may persist in the future.
      Mental health conditions are very common affecting about 20% of adults.
      National Institute of Mental Health
      Mental illness.
      They include a wide array of disorders that cause changes in emotion or behavior, and these can cause problems with the quality of life, relationships, and school or job function. There are many challenges and barriers to high-quality and accessible mental health care, and primary care providers (PCPs) often take on the management of mental health conditions.
      • Xierali I.M.
      • Tong S.T.
      • Petterson S.M.
      • et al.
      Family physicians are essential for mental health care delivery.
      Before the COVID-19 pandemic, there were known benefits to virtual behavioral health. Studies had shown that it was effective for managing and treating mental health conditions, with similar or better outcomes compared with in-person care. Studies had also demonstrated that telehealth could increase access for people, particularly in rural locations. Importantly, patients were satisfied with virtual health and were found to still be able to create a therapeutic relationship with their provider.
      • Hilty D.M.
      • Ferrer D.C.
      • Parish M.B.
      • et al.
      The effectiveness of telemental health: a 2013 review.
      Yet, telehealth for mental health had not seen significant uptake, until the rapid shift to virtual care with the COVID-19 pandemic.
      • Knierim K.
      • Palmer C.
      • Kramer E.S.
      • et al.
      Lessons learned during COVID-19 that can move telehealth in primary care forward.
      Virtual visits for behavioral health increased significantly, while there was also an increased need for behavioral health care.
      • Moreno C.
      • Wykes T.
      • Galderisi S.
      • et al.
      How mental health care should change as a consequence of the COVID-19 pandemic.
      Data around the benefits of telehealth for mental health at the system, provider, and patient level became clear. There were also evident barriers and challenges to virtual behavioral health care, highlighting areas to research and continue to improve.
      As mental health needs continue to increase, access to timely evaluation from mental health providers decreases, and PCPs manage more complex behavioral health needs, there is an opportunity for the growth of effective, accessible, and affordable virtual integration of behavioral health services. In addition, payors are increasingly providing telehealth coverage for mental health services making it an option for more people. Here, we review the current state and future directions of behavioral health care via telehealth.

      State of Virtual Behavioral Health Before COVID-19

      Synchronous virtual delivery of behavioral health care was a rarity before the COVID-19 pandemic. Despite providing time savings, increased patient access, high user satisfaction, and comparable therapeutic alliance and clinical effectiveness to face-to-face visits across varied clinical populations and psychotherapies,
      • Backhaus A.
      • Agha Z.
      • Maglione M.L.
      • et al.
      Videoconferencing psychotherapy: a systematic review.
      ,
      • Langarizadeh M.
      • Tabatabaei M.S.
      • Tavakol K.
      • et al.
      Telemental health care, an effective alternative to conventional mental care: a systematic review.
      just 7% of prepandemic clinical work performed by psychologists was virtual.
      • Pierce B.S.
      • Perrin P.B.
      • Tyler C.M.
      • et al.
      The COVID-19 telepsychology revolution: a national study of pandemic-based changes in U.S. mental health care delivery.
      Factors accounting for this slow rate of adoption can be distilled into 3 domains including provider factors, patient factors, and policy/reimbursement barriers. In a pre–COVID-19 study of 1400 US-based psychologists, the most frequently cited deterrents to virtual behavioral health use were insufficient proficiency or knowledge to use virtual behavioral health in their practice (28.4% of respondents), client safety/crisis concerns (28%), privacy/HIPAA concerns (27%), and legality/inter-jurisdictional practice concerns (25.1%).
      • Pierce B.S.
      • Perrin P.B.
      • McDonald S.D.
      Pre-COVID-19 deterrents to practicing with videoconferencing telepsychology among psychologists who didn't.
      From the patient perspective, barriers to virtual behavioral health include those related to access issues (eg, need for reliable Internet, phones with cameras and data, private spaces) and difficulties using virtual technologies (eg, among older adults and individuals with certain disabilities, such as those with visual, hearing, or severe attentional difficulties) as well as concerns surrounding trust, privacy, and security.
      • Young K.S.
      An empirical examination of client attitudes towards online counseling.
      ,
      • Zhai Y.
      A call for addressing barriers to telemedicine: health disparities during the COVID-19 pandemic.
      Importantly, many of these patient-related barriers remain, particularly among those that are underserved,
      • Ramsetty A.
      • Adams C.
      Impact of the digital divide in the age of COVID-19.
      despite burgeoning acceptance of virtual behavioral health by providers, organizations, and the psychotherapy-seeking population as a whole.
      Finally, policy and reimbursement barriers precluded widespread adoption of virtual behavioral health before the COVID-19 pandemic. Such barriers included restrictions based on geographic location, mode of delivery of services (eg, telephone vs video), and licensure qualifications of behavioral health providers. However, even before COVID-19, some advances expanded coverage and reimbursement for virtual behavioral health. For example, a 2018 federal ruling allowed veterans to access telehealth services including behavioral health visits, across states.
      United States Veterans Affairs
      VA expands telehealth by allowing health care providers to treat patients across state lines.
      Before COVID-19, Medicare coverage of virtual behavioral health visits was permitted but was limited to patients residing in designated rural areas and visits conducted from an approved originating site, such as a clinic, hospital, or certain medical facilities.
      • Centers for Medicare & Medicaid Services
      Medicare telemedicine health care provider fact sheet.
      Availability of virtual behavioral health services for patients with Medicare was expanded in 2019 to the treatment of substance use disorders and cooccurring mental illnesses regardless of the rural status of the patient.
      National Association of Behavioral Healthcare
      CMS expands medicare telehealth coverage for mental health and addiction treatment services.
      Although individual states and health insurances continue to differ in terms of their coverage for virtual behavioral health services,
      Health Resources & Services Administration
      Best practice guide: telehealth for behavioral health care.
      the COVID-19 pandemic ushered in a new era of virtual behavioral health associated with expanded access and increased acceptance by patients, providers, and organizations.

      Efficacy of Virtual Mental Health Services

      While not a new method of delivering behavioral health care, virtual mental health service delivery was not widely used, and certainly not at the rate it has been used currently, before the COVID-19 pandemic. One reason for this has been provider preference or the belief that in-person behavioral health care is superior in quality and achieving improvements in functioning or reduction in symptomatology.
      Multiple systematic reviews have examined the literature to determine if this belief is supported by research. In 2013, Hilty and colleagues
      • Hilty D.M.
      • Ferrer D.C.
      • Parish M.B.
      • et al.
      The effectiveness of telemental health: a 2013 review.
      reviewed 70 studies researching the effectiveness of interventions comparing telehealth and in-person care. Findings from this review support telehealth as effective for multiple populations (eg, geriatric, adult, pediatric, underserved, rural, and ethnically diverse) in producing the same outcomes as in-person care (eg, reduction in depression, panic symptoms, reduced hospitalization, improved adherence, high satisfaction).
      In some cases, telehealth was reported as superior to in-person care in its ability to allow for non-English speaking patients to connect with off-site bilingual providers as well as its acceptability in primary care settings for the collaboration of care.
      • Hilty D.M.
      • Ferrer D.C.
      • Parish M.B.
      • et al.
      The effectiveness of telemental health: a 2013 review.
      Additional systematic reviews and meta-analyses have reported that telehealth yields comparable results to in-person care for the treatment of depression and anxiety and posttraumatic stress disorder (PTSD), particularly when cognitive behavioral therapy is used.
      • Hilty D.M.
      • Ferrer D.C.
      • Parish M.B.
      • et al.
      The effectiveness of telemental health: a 2013 review.
      ,
      • Berryhill M.B.
      • Culmer N.
      • Williams N.
      • et al.
      Videoconferencing psychotherapy and depression: a systematic review.
      ,
      • Fernandez E.
      • Woldgabreal Y.
      • Day A.
      • et al.
      Live psychotherapy by video versus in-person: a meta-analysis of efficacy and its relationship to types and targets of treatment.
      Randomized controlled trials have also found telehealth to be as effective as in-person behavioral health care for the treatment of PTSD,
      • Frueh B.C.
      • Monnier J.
      • Yim E.
      • et al.
      A randomized trial of telepsychiatry for post-traumatic stress disorder.
      bulimia,
      • Mitchell J.E.
      • Crosby R.D.
      • Wonderlich S.A.
      • et al.
      Randomized trial comparing the efficacy of cognitive-behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face.
      and even anger management.
      • Morland L.A.
      • Greene C.J.
      • Rosen C.S.
      • et al.
      Telemedicine for anger management therapy in a rural population of combat veterans with posttraumatic stress disorder: a randomized noninferiority trial.
      Additional concerns that have potentially hindered the uptake of telehealth for behavioral health treatment are beliefs that telehealth negatively impacts the therapeutic alliance or the degree to which clinicians can effectively build rapport with their patients, and that patients would not want to engage in this type of treatment. Concerns have been cited that detecting nonverbal cues such as fidgeting, crying, poor hygiene, or signs of intoxication may be more challenging through telehealth and that maintaining eye contact and experiencing disruptions to conversation flow due to technology would be detrimental to care.
      • Connolly S.L.
      • Miller C.J.
      • Lindsay J.A.
      • et al.
      A systematic review of providers' attitudes toward telemental health via videoconferencing.
      Systematic reviews have consistently reported overall high patient satisfaction with interventions delivered via telehealth.
      • Hilty D.M.
      • Ferrer D.C.
      • Parish M.B.
      • et al.
      The effectiveness of telemental health: a 2013 review.
      ,
      • Richardson L.K.
      • Frueh B.C.
      • Grubaugh A.L.
      • et al.
      Current directions in videoconferencing tele-mental health research.
      ,
      • Jenkins-Guarnieri M.A.
      • Pruitt L.D.
      • Luxton D.D.
      • et al.
      Patient perceptions of telemental health: systematic review of direct comparisons to in-person psychotherapeutic treatments.
      High patient satisfaction with individual telehealth for behavioral health care has continued to be reported now that it has become the nearly exclusive method of delivering behavioral health care since the COVID-19 pandemic.
      • Sugarman D.E.
      • Busch A.B.
      • McHugh R.K.
      • et al.
      Patients' perceptions of telehealth services for outpatient treatment of substance use disorders during the COVID-19 pandemic.
      ,
      • Guinart D.
      • Marcy P.
      • Hauser M.
      • et al.
      Patient attitudes toward telepsychiatry during the COVID-19 pandemic: a nationwide, multisite survey.
      Comparable therapeutic alliance has also been reported when comparing in-person vs. telemental health care.
      • Stiles-Shields C.
      • Kwasny M.J.
      • Cai X.
      • et al.
      Therapeutic alliance in face-to-face and telephone-administered cognitive behavioral therapy.
      Further, systematic reviews have found additional support that therapeutic alliances are equally strong when care is delivered via telehealth as compared with in-person psychotherapy.
      • Jenkins-Guarnieri M.A.
      • Pruitt L.D.
      • Luxton D.D.
      • et al.
      Patient perceptions of telemental health: systematic review of direct comparisons to in-person psychotherapeutic treatments.
      ,
      • Sucala M.
      • Schnur J.B.
      • Constantino M.J.
      • et al.
      The therapeutic relationship in e-therapy for mental health: a systematic review.
      An interesting new factor to consider in the delivery of in-person behavioral health care is the impact that mask-wearing may have on the therapeutic alliance. Future research will help determine any potential differences in the therapeutic alliance between mask-wearing during in-person visits compared with telehealth for behavioral health.

      Behavioral Health Conditions Addressed in Primary Care

      PCPs are in a unique position to provide better mental health care and in fact, are one of the main sources of mental health care.
      • Xierali I.M.
      • Tong S.T.
      • Petterson S.M.
      • et al.
      Family physicians are essential for mental health care delivery.
      Up to 70% of primary care visits are related to a mental health condition.
      • Hunter C.L.
      • Goodie J.L.
      • Oordt M.S.
      • et al.
      Integrated behavioral health in primary care: step-by-step guidance for assessment and intervention.
      PCPs manage many acute and chronic behavioral health conditions including depressive disorders, anxiety disorders, panic attacks, stress disorders, bipolar disorders, attention deficit hyperactivity disorder, and substance abuse.
      Mental health needs have increased during the COVID-19 pandemic, particularly in vulnerable populations.
      • Han B.
      • Compton W.M.
      • Blanco C.
      • et al.
      Prevalence, treatment, and unmet treatment needs of us adults with mental health and substance use disorders.
      ,
      • Diaz A.
      • Baweja R.
      • Bonatakis J.K.
      • et al.
      Global health disparities in vulnerable populations of psychiatric patients during the COVID-19 pandemic.
      Pandemic-related stress has resulted in poorer sleep and eating habits, more difficulties managing chronic conditions, isolation, depression, anxiety, and substance use, and with that increased barriers to care, which could result in an estimated 75,000 additional deaths by suicide and alcohol or drug misuse if we cannot address the behavioral health impact of the pandemic.
      • Czeisler M.E.
      • Lane R.I.
      • Petrosky E.
      • et al.
      Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020.
      According to the CDC, specifically, younger adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers reported having experienced disproportionately worse mental health outcomes, increased substance use, and elevated suicidal ideation:
      • 13.3% reported starting or increasing the use of substances
        • Czeisler M.E.
        • Lane R.I.
        • Petrosky E.
        • et al.
        Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020.
      • 40.9% reported at least one adverse mental or behavioral health condition
        • Czeisler M.E.
        • Lane R.I.
        • Petrosky E.
        • et al.
        Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020.
      • 30.9% reported symptoms of anxiety or depression
        • Czeisler M.E.
        • Lane R.I.
        • Petrosky E.
        • et al.
        Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020.
      • 26.3% reported trauma- and stressor-related symptoms related to the pandemic
        • Czeisler M.E.
        • Lane R.I.
        • Petrosky E.
        • et al.
        Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020.
      • 10.7% reported seriously considering suicide 30 days before completing the survey
        • Czeisler M.E.
        • Lane R.I.
        • Petrosky E.
        • et al.
        Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020.
      Of these respondents, symptom rates were significantly higher among respondents:
      • Aged 18 to 24 years: 25.5%
      • Hispanic respondents: 18.6%
      • Non-Hispanic black respondents: 15.1%
      • Self-reported unpaid caregivers for adults: 30.7%
      • Essential workers: 21.7%
        • Czeisler M.E.
        • Lane R.I.
        • Petrosky E.
        • et al.
        Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020.
        ,
        • Substance Abuse and Mental Health Services Administration
        Key substance use and mental health indicators in the United States: results from the 2019 national survey on drug use and health.
      Since the pandemic began, an estimated 1.5 million children lost a caregiver, and many more have suffered similar traumatic experiences. There have been a greater number of caregivers lost to COVID-19 in Black, Indigenous, People of Color (BIPOC) communities, and it was recently published that “Black children are disproportionately affected, comprising only 14% of children in the United States but 20% of those losing a parent to COVID-19.”
      • Kidman R.
      • Margolis R.
      • Smith-Greenaway E.
      • et al.
      Estimates and Projections of COVID-19 and Parental Death in the US.
      The need for behavioral health services is growing, and when primary care integrates behavioral health services for in-person, virtual, and telephonic care, there is a pathway for increased access promptly; this expands the behavioral health services PCPs can provide their patients.

      Behavioral Health Home Monitoring Tools

      At the start of the pandemic, the world focused on physical health. Due to safety concerns, practitioners encouraged patients to track physical health using at-home monitoring tools (eg, pulse oximeters, at-home COVID-19 tests, and so forth). It has become apparent that mental health home-monitoring tools are comparably important. At-home behavioral health monitoring measures facilitate the observation of progress in terms of treatment goals. These tools can also inform the patient about their progress as well as any impact on treatment expectations. For example, by completing a bi-weekly patient health questionnaire
      • Kroenke K.
      • Spitzer R.L.
      • Williams J.B.
      The PHQ-9: validity of a brief depression severity measure.
      patients and practitioners can determine progress around alleviating depressive symptomology. Below are some ways to monitor mental health from home:
      • Evidence-based measures sent and completed via the electronic health record For example, practitioners may send PHQ-9 forms to patients through an EHR to be completed before the session, which may allow the practitioner to understand the patient’s current symptoms, thus informing the focus of the telehealth meeting.
      • Patient-driven device applications (Goldberg and colleagues, 2022)
        • There are a variety of free and paid apps that can help patients monitor:
          • Mood
          • Drug and alcohol use
          • Meditation sessions
          • Food intake/nutrition
          • Sleep
          • Thoughts
      • Wearable fitness trackers
        • Fitness tracker information can support the facilitation of treatment goals
      While results are generally mixed on the effectiveness of apps in promoting health behavior, reducing health-risk behavior, and improving mood, apps are still a viable home monitoring tool for patients if electronic tracking is their preferred method, as opposed to worksheet tracking.
      • Milne-Ives M.
      • Lam C.
      • De Cock C.
      • et al.
      Mobile apps for health behavior change in physical activity, diet, drug and alcohol use, and mental health: systematic review.
      Milne-Ives et. al, 2020 analyzed 52 randomized, controlled trials measuring patient perception and behavioral change based on the use of applications. They found that, while patient perceptions were generally positive, these applications overall did not contribute to significant behavioral changes or improved health outcomes. Despite this, applications can be helpful tools for patient engagement and tracking progress via telehealth.

      Benefits of Virtual Behavioral Health

      There are multiple benefits to using telehealth for behavioral health concerns in the primary care setting at the system level, the provider level, as well as at the individual patient level.

      Benefits of telehealth for behavioral health at the system level

      At the system level, there is a potential for overall cost-effectiveness in both increasing capacity to provide more care to patients and reducing expenditures necessary for in-person care (eg, transportation, work hours lost).
      • Hilty D.M.
      • Ferrer D.C.
      • Parish M.B.
      • et al.
      The effectiveness of telemental health: a 2013 review.
      Telemental health services have also been associated with long-term cost savings including reduced psychiatric hospitalizations, reduced days spent in the hospital, and improved treatment compliance and outcomes.
      • Godleski L.
      • Darkins A.
      • Peters J.
      Outcomes of 98,609 U.S. department of veterans affairs patients enrolled in telemental health services, 2006-2010.
      Offering telehealth to patients maintains a healthy workforce to be able to continue providing care during a much-needed time. Maintaining social distancing during the COVID-19 pandemic and reducing the risk of transmission allows for a safe environment in which behavioral health clinicians can practice.
      • Madigan S.
      • Racine N.
      • Cooke J.E.
      • et al.
      COVID-19 and telemental health: benefits, challenges, and future directions.
      Behavioral health visits typically last longer than primary care visits, and due to the nature of these visits, it is not uncommon for patients to become tearful, take off their mask to blow their nose, have an ill-fitting mask, or have symptoms of COVID-19 that would prevent them from being seen in the clinic.
      The flexibility of telehealth delivery can also support the expansion of the behavioral health workforce within primary care, where space is not a concern and providers can flex their schedules to provide overlapping in-person and remote availability. Due to the ability to engage in virtual behavioral health visits wherever a patient may be, decreased no-shows and cancelations also provide additional access to patient care and revenue for practices.
      • Mishkind M.C.
      • Shore J.H.
      • Bishop K.
      • et al.
      Rapid conversion to telemental health services in response to COVID-19: experiences of two outpatient mental health clinics.

      Benefits of telehealth for behavioral health at the provider level

      An initial review of the literature examining provider benefits of a transition to telehealth for behavioral health services indicates several factors that providers appreciate. This includes greater work-life balance for individuals who prefer the opportunity to work remotely or need to for childcare reasons. These providers now have the flexibility of continuing to see patients virtually rather than having to cancel and reschedule,
      • Yellowlees P.
      • Nakagawa K.
      • Pakyurek M.
      • et al.
      Rapid conversion of an outpatient psychiatric clinic to a 100% virtual telepsychiatry clinic in response to COVID-19.
      have increased schedule flexibility,
      • Siegel A.
      • Zuo Y.
      • Moghaddamcharkari N.
      • et al.
      Barriers, benefits and interventions for improving the delivery of telemental health services during the coronavirus disease 2019 pandemic: a systematic review.
      lack a commute,
      • Steidtmann D.
      • McBride S.
      • Mishkind M.C.
      Experiences of mental health clinicians and staff in rapidly converting to full-time telemental health and work from home during the COVID-19 pandemic.
      and have reduced burnout.
      • Gardner J.S.
      • Plaven B.E.
      • Yellowlees P.
      • et al.
      Remote telepsychiatry workforce: a solution to psychiatry's workforce issues.
      Telehealth with patients in their homes also offers additional contextual data that can enhance care. This may include having access to the home environment to get a better sense of patients’ struggles, be it their sleep environment to address sleep hygiene concerns, whereby medications are stored and how they are organized to promote treatment adherence, opportunities to engage within vivo exposure in the home environment whereby patients are coming in to contact with potentially anxiety-provoking stimuli, engaging in safety planning with family support who may also be available in the home, or observing pets or toys as a means to connect and build rapport.
      • Pruitt L.D.
      • Luxton D.D.
      • Shore P.
      Additional clinical benefits of home-based telemental health treatments.

      Benefits of telehealth for behavioral health at the patient level

      Multiple benefits of telehealth are reported at the patient level. Increased access, affordability by way of reducing expenditures to attend an in-person appointment, (eg, not needing to take time away from work to drive to and from an appointment, not needing to facilitate childcare coverage), and transportation barriers are commonly mentioned in the literature.
      • Waugh M.
      • Voyles D.
      • Thomas M.R.
      Telepsychiatry: benefits and costs in a changing health-care environment.
      During the COVID-19 pandemic, patients with comorbid physical health and mental health concerns may prefer to be seen virtually to avoid possible exposure to illness. Telehealth also has the advantages to reach individuals in rural areas who may otherwise have limited access to providers
      • Benavides-Vaello S.
      • Strode A.
      • Sheeran B.C.
      Using technology in the delivery of mental health and substance abuse treatment in rural communities: a review.
      as well as providing support to those feeling isolated in their homes. Telehealth may also help to reduce stigma for individuals who have been hesitant to come to in-person behavioral health services.
      • Olden M.
      • Cukor J.
      • Rizzo A.S.
      • et al.
      House calls revisited: leveraging technology to overcome obstacles to veteran psychiatric care and improve treatment outcomes.
      Patient satisfaction with telehealth for behavioral health services has been consistently reported as high across multiple populations including perinatal patients, older adults, children, and general adult populations.
      • Guinart D.
      • Marcy P.
      • Hauser M.
      • et al.
      Patient attitudes toward telepsychiatry during the COVID-19 pandemic: a nationwide, multisite survey.
      ,
      • Ackerman M.
      • Greenwald E.
      • Noulas P.
      • et al.
      Patient satisfaction with and use of telemental health services in the perinatal period: a survey study.
      • Hantke N.
      • Lajoy M.
      • Gould C.E.
      • et al.
      Patient satisfaction with geriatric psychiatry services via video teleconference.
      • Mayworm A.M.
      • Lever N.
      • Gloff N.
      • et al.
      School-based telepsychiatry in an urban setting: efficiency and satisfaction with care.

      Barriers to Virtual Behavioral Health Care

      There are also many barriers to using telehealth for behavioral health concerns in the primary care setting at the system level, the provider level, as well as at the individual patient level.

      Barriers to telehealth for behavioral health at the system level

      The utilization of telehealth services had been incorporated slowly into medical systems before the pandemic despite literature suggesting the potential benefit of administering care in this manner.
      • Waugh M.
      • Voyles D.
      • Thomas M.R.
      Telepsychiatry: benefits and costs in a changing health-care environment.
      From a systems level, some of the slow integration of telehealth services have been attributed to reimbursement concerns, policy regulations, and the cost of telehealth infrastructure.
      Parity is needed to ensure that providers will receive comparable reimbursement for telehealth encounters as they would in-person visits as well as ensure that coverage would be guaranteed for telehealth services. Before the COVID-19 pandemic, only a handful of states had telehealth parity laws making telehealth services a much less desirable and feasible investment to make.
      • Warren J.C.
      • Smalley B.K.
      Using telehealth to meet mental health needs during the covid-19 crisis. To the Point (blog).
      To further complicate the picture, no 2 states have the same definition or regulation of telehealth services, which can narrow accessibility to these visits depending on who the service provider is, which insurance coverage is used, the type of electronic service provided, and the patient’s location when receiving the service.
      • Center for Connected Health Policy
      State telehealth laws and Medicaid program policies.
      Inconsistent and inadequate reimbursement for telehealth services continues to plague efforts by institutions, organizations, and systems to implement the delivery of telemedicine to patients.
      • Waugh M.
      • Voyles D.
      • Thomas M.R.
      Telepsychiatry: benefits and costs in a changing health-care environment.
      Regarding policy regulations, the COVID-19 pandemic prompted policymakers and insurers to make telehealth services rapidly available; however, it remains to be seen what future policy, concerning telehealth services, will look like.
      • Cantor J.H.
      • McBain R.K.
      • Pera M.F.
      • et al.
      Who is (and is not) receiving telemedicine care during the COVID-19 pandemic.
      ,
      • Lucia K.
      • Blumberg L.J.
      • Curran E.
      The COVID-19 pandemic − insurer insights into challenges, implications, and lessons learned.
      The financial costs of implementing telehealth infrastructure also play a role in the uptake of services. Waugh, Voyles, and Thomas
      • Waugh M.
      • Voyles D.
      • Thomas M.R.
      Telepsychiatry: benefits and costs in a changing health-care environment.
      referenced several cost types including fixed (videoconferencing technology), variable (connectivity, hardware, clinic space, personnel), opportunity (possibility for disagreement between a provider’s service hours and billable hours), and reimbursable (dependent on payer source and service type), highlighting the complexity of implementing telehealth on a large scale.
      It is clear that there are several system-level barriers to implementing telehealth services, and while systems are attempting to improve the availability and equity of health care services via telehealth platforms, researchers have also stressed the importance of ensuring telehealth services are provided in an equitable and accessible manner given that there is a real risk of further contributing to the “digital divide in which populations that have poorer health outcomes continue to have poorer health outcomes despite technological improvements” (p. 1).
      • Saeed S.A.
      • Masters R.M.
      Disparities in health care and the digital divide.
      Ensuring that the implementation of telehealth services does not exacerbate or perpetuate poor health outcomes and inequities in health care need to be considered carefully when designing and executing a largely new method of patient care.
      • Cantor J.H.
      • McBain R.K.
      • Pera M.F.
      • et al.
      Who is (and is not) receiving telemedicine care during the COVID-19 pandemic.
      ,
      • Saeed S.A.
      • Masters R.M.
      Disparities in health care and the digital divide.
      ,
      • Chunara R.
      • Zhao Y.
      • Chen J.
      • et al.
      Telemedicine and healthcare disparities: a cohort study in a large healthcare system in New York City during COVID-19.

      Barriers to telehealth for behavioral health at the provider level

      Before the COVID-19 pandemic, the proportion of behavioral health services administered via telehealth was small.
      • Comer J.S.
      Rebooting mental health care delivery for the COVID-19 pandemic (and beyond): guiding cautions as telehealth enters the clinical mainstream.
      However, the adoption of telehealth services by psychologists increased rapidly at the beginning of the COVID-19 crisis.
      • Sammons M.T.
      • VandenBos G.R.
      • Martin J.N.
      • et al.
      Psychological practice at six months of COVID-19: a follow-up to the first national survey of psychologists during the pandemic.
      Given that providing telehealth services was uncommon prepandemic, formal training on telehealth practices had not been included in accreditation standards for mental health providers meaning that individual clinicians might not be adequately prepared to deliver culturally sensitive and in-person equivalent standards of care.
      • Comer J.S.
      Rebooting mental health care delivery for the COVID-19 pandemic (and beyond): guiding cautions as telehealth enters the clinical mainstream.
      An overall lack of formal training for providers administering telehealth services can be a limiting factor in providing this type of treatment. Prior research suggests clinicians’ technological skillset is an important element in providing this type of care from a patient’s perspective.
      • Henry B.W.
      • Block D.E.
      • Ciesla J.R.
      • et al.
      Clinician behaviors in telehealth care delivery: a systematic review.
      When behavioral health services rapidly shifted to being conducted mainly electronically, the boundaries and norms of care also changed. One important example of the changing therapeutic landscape involved informed consent. Informed consent ensures the patient participates in treatment with the knowledge and awareness of the risks/benefits, nature, and course of care (American Psychological Association Standard 3.01, Standard 10.01).
      American Psychological Association
      Ethical principles of psychologists and code of conduct.
      In the realm of telehealth, special attention to the changes in the informed consent process need to be considered including clinicians being able to verify a patient’s identity, the potential privacy concerns of conducting treatment on virtual platforms and in less confidential locations as well as the potential interruptions with technical glitches or failures.

      Barriers to telehealth for behavioral health at the patient level

      To respond to the COVID-19 pandemic, behavioral health providers promptly began providing telehealth services to both new and existing patients. In Colorado, legislation was enacted that did not permit carriers offering telehealth services to impose additional training or certifications on providers delivering this method of service as a condition of reimbursement, require there to be an established relationship among a patient and provider, or require the use of specific HIPAA-compliant technologies to deliver these services (see Senate Bill 20–212). This meant that patients were quickly able to access behavioral health services at a time when patients were unable or unwilling to obtain care through in-person settings. While expanding the availability of telehealth provided increased access and continuity of care, it also has the potential to negatively impact health equity for patients.
      • Cantor J.H.
      • McBain R.K.
      • Pera M.F.
      • et al.
      Who is (and is not) receiving telemedicine care during the COVID-19 pandemic.
      ,
      • Saeed S.A.
      • Masters R.M.
      Disparities in health care and the digital divide.
      ,
      • Chunara R.
      • Zhao Y.
      • Chen J.
      • et al.
      Telemedicine and healthcare disparities: a cohort study in a large healthcare system in New York City during COVID-19.
      For instance, since 2019, home broadband subscriptions and Smartphone possession have both increased. However, even with the increased growth of technology, 30% of adults report Internet connectivity issues either often or sometimes, and for individuals without access to broadband home Internet, financial constraints are cited as a primary reason they do not have this service.
      Comfort with using telehealth platforms should be individually assessed since each patient will likely differ in his or her ability or proficiency with telehealth platforms. For instance, adaptive devices for patients with disabilities and interpretation services for nonnative speakers could provide significant barriers to receiving telehealth care. In addition to connectivity and access concerns, there are concerns regarding patient privacy.
      • Comer J.S.
      Rebooting mental health care delivery for the COVID-19 pandemic (and beyond): guiding cautions as telehealth enters the clinical mainstream.
      ,
      • Crockett J.L.
      • Becraft J.L.
      • Phillips S.T.
      • et al.
      Rapid conversion from clinic to telehealth behavioral services during the COVID-19 pandemic.
      For example, behavioral health services have the potential to include a discussion of more personal and sensitive topics that require a private location/space to conduct a visit, which can be challenging for some patients. For patients attending video sessions in the privacy of their homes or personal spaces, it is also important for providers to ensure patients feel comfortable and capable with this method of service provision.
      • Comer J.S.
      Rebooting mental health care delivery for the COVID-19 pandemic (and beyond): guiding cautions as telehealth enters the clinical mainstream.

      Best Practices for Virtual Behavioral Health Care

      Virtual behavioral health care provides an opportunity to integrate behavioral health services immediately into primary care practices. This allows the behavioral health team to be present without requiring them to be physically present in the practice. It also allows the PCP, behavioral health provider, and patient to be in different locations while joined together virtually. Immediate warm hand-offs, connecting a patient to behavioral health practitioners in real-time, can happen anytime regardless of physical location. The behavioral health provider can also receive warm hand-offs from multiple different clinical sites, improving access to care.
      The PCP may identify the need for behavioral health care at multiple points in the visit, including:
      • The reason for the visit may be a new or uncontrolled mental health issue
      • Screening and intake forms including social history documentation, the PHQ screening, or Edinburgh Postnatal Depression Scale, may identify a need for behavioral health care such as new depression or anxiety, a substance use disorder, or acute stressor
      • The discussion between the PCP and patient may reveal an acute mental health crisis or need for better control of chronic mental health conditions
      A virtual warm hand-off allows the provider to immediately introduce the patient to the behavioral health team. This can be conducted before the office visit if a need is known, during the office visit (eg, through secure text-based communication, joining a visit virtually, or a phone call), or after the office visit once the PCP has finished the appointment.
      • Kanzler K.E.
      • Ogbeide S.
      Addressing trauma and stress in the COVID-19 pandemic: challenges and the promise of integrated primary care.
      It is important to recognize that some patients may not be suitable candidates for virtual behavioral health. This may include if the patient:
      • Is having an acute psychotic episode
      • Is actively suicidal or homicidal
      • Does not feel comfortable with virtual communication
      • Does not have access to broadband services
      • Has a disability limiting virtual health capability
      • Has a language barrier, and no translator is available
      • Does not have access to a confidential space
      • Is a victim of abuse with the potential for the abuser to be present
      Alternatively, virtual behavioral health can greatly increase access for individuals who:
      • Are responsible for caretaking for young children or elderly
        • Fiks A.G.
        • Jenssen B.P.
        • Ray K.N.
        A defining moment for pediatric primary care telehealth.
      • May be immunocompromised
      • Struggle with lack of transportation
      • Have busy schedules and cannot afford to take time to travel to the clinic, park, and meet with a psychologist for a full session
      • Struggle with agoraphobia or other behavioral health concerns that make travel difficult
      • Struggle with a disability or other physical health concerns that make travel difficult
      Best practices for integrating virtual behavioral health care into primary care practices include:
      • HIPAA-compliant technology
      • Process for virtual warm hand-offs (secure chat, phone, and so forth)
      • Handling unsafe situations such as suicidal patients
      • Building a team of therapists to provide access to the care needed
      Once a patient’s behavioral health needs have been identified by a PCP, the PCP should reach out to the behavioral health provider. The behavioral health provider and PCP connect using a variety of methods. These include texting, telephone calls, using the “chat” function on medical health record software, or using other HIPAA compliant applications/platforms.
      Once the PCP and behavioral health provider connect, they briefly discuss the patient’s key behavioral health concerns and create a preliminary course of care. The behavioral health provider then connects directly with the patient and PCP. This connection can take place via various HIPAA-compliant platforms, including through the organization’s electronic health record and compatible apps/websites. At this time, a warm handoff is performed, wherein the PCP introduces the patient and behavioral health provider in real-time. There are several options for in vivo behavioral health care once the behavioral health provider and patient connect. Warm handoffs can be nonbillable, focused on an introduction to available services and/or behavioral health triage, or they can be billable, focused on using a specific intervention to address the patient’s behavioral health needs in vivo.
      For example, if a patient is struggling with primary insomnia, the behavioral health provider may implement psychoeducation, or provide education and support to a patient around psychological factors. Psychoeducation around how to enact sleep hygiene techniques and assisting the patient in identifying behavioral changes she can make to develop sleep hygiene skills would be appropriate warm hand-off interventions. Alternatively, in a nonbillable warm handoff, the behavioral health provider may triage the patient, assisting her with connecting to a community-based long-term therapist who specializes in the patient’s main behavioral health concerns. Warm handoffs can also be facilitated by other medical staff, including medical assistants and nurses if the PCP must move on to the next patient. The behavioral health provider then closes the loop by reporting the outcome of the warm handoff to the PCP. Again, this can be achieved via several online/virtual platforms. Well-staffed clinics may be able to provide patient warm handoffs with behavioral health providers as well as psychiatrists, care managers, social workers, and trainees at all levels.
      • Raney L.
      • Bergman D.
      • Torous J.
      • et al.
      Digitally driven integrated primary care and behavioral health: how technology can expand access to effective treatment.
      In response to the fast-changing landscape of behavioral health service delivery via telehealth platforms, scientific and professional organizations representing psychology, psychiatry, and telemedicine could be used as valuable guides for best practices in telehealth.
      American Psychological Association
      Guidelines for the practice of telepsychology.
      ,
      American Psychiatric Association
      Best practices in videoconferencing-based telemental health.
      The guidelines of the American Psychological Association are informed by psychological theory, evidence-based practice, and multicultural guidelines and considerations. The guidelines apply to the use of all technologies to deliver behavioral health services. Both the psychologists’ knowledge and telepsychology competency, as well as the patients’ understanding of the increased security and confidentiality risks, should be prioritized. Additionally, the guidelines highlight the importance of inter-jurisdictional practice and encourage psychologists to learn and comply with laws and regulations on inter-jurisdictional and international practice. Table 1 lists each of the guidelines, their rationale, and examples of how they may be applied.
      Table 1APA’s telepsychology guidelines, rationale, and examples of how they may be applied
      Data from American Psychological Association (APA). 2013. Guidelines for the Practice of Telepsychology. Accessed December 14, 2021. https://www.apa.org/practice/guidelines/telepsychology.
      GuidelineRationaleSpecific Example(s) of Application
      (1) Competence of the PsychologistAs telepsychology is an emerging area, psychologists must continuously assess their own competency and risk management practices.Psychologists should assess and develop their technical competence in addition to their regular professional practice competence.

      Be familiar with local emergency services and prepare a written plan and instructions for patients in case of risk.
      (2) Standards of Care in the Delivery of Telepsychology ServicesThe same ethical and professional standards of care for in-person services must be upheld for telepsychology services. Assessment of the appropriateness of telepsychology technologies is encouraged.Conduct a risk-benefit analysis of telepsychology services with the consideration of patient’s unique characteristics and communicate those with the patient.

      Consider the efficacy, privacy, and safety of the chosen telepsychology intervention and technology/platform.
      (3) Informed ConsentObtain informed consent by including a thorough description of telepsychology services, policies, and procedures. Also consider implementing additional security measures and inform patients about them.Obtain and document written informed consent that is specific to the type of services provided.

      Include boundaries and procedures in the use of technologies.

      Include billing documentation and fees as part of informed consent as it pertains to specific telepsychology services (eg, video chat, texting fees, and so forth).
      (4) ConfidentialityPsychologists must familiarize themselves with risks to confidentiality unique to telepsychology and consult technology experts when needed. Further, psychologists must be thoughtful about boundary issues that may arise from participation in social networking sites.Consider the risks and benefits of searching patients on the Internet before and during services.

      Set and maintain appropriate boundaries.

      Understand the risks to privacy and confidentiality when using electronic communication.
      (5) Security and Transmission of Data and InformationPsychologists must be mindful of security threats (eg, hackers, theft, viruses, and so forth) and take steps to protect themselves and patients against them.Conduct an analysis of security risk - and consult experts when necessary—to ensure data are accessible only by authorized entities and/or individuals.

      When documenting, specify the types of telecommunications used.
      (6) Disposal of Data and Information and TechnologiesPsychologists must ensure the secure destruction of patient information, particularly electronic data and information and the technologies involved in maintaining that data.Understand means of storage and disposal of patient data specific to telepsychology technologies (eg, videoconferencing file storage).

      Document the procedures followed for both storage, transmission, and disposal of data.
      (7) Testing and AssessmentPsychologists must consider the suitability of assessments created for in-person use when applying them in telepsychology services. Further, they should maintain the integrity of the original assessment as much as possible.Maintain the integrity of the original assessment as much as possible. Make and document modifications to testing when needed.

      Consider all types of possible distractions during assessment (eg, smell, sound, and so forth), and interpret assessment results accordingly.

      Be aware of special considerations when working with diverse populations (eg, age, physical/sensory impairment, and so forth), and enlist an on-site proctor to facilitate the assessment if needed.
      (8) Interjurisdictional PracticePsychologists must inform themselves of laws and regulations that govern the provision of telepsychology as described by their organizational system, state, province, territory, and country.When practicing in jurisdictions without laws and regulations in place, search for statements and regulations in relevant governing bodies and nearby jurisdictions to guide telepsychology service delivery.

      Stay informed of the changes in laws, regulations, and the credentialing of telepsychology as this mode of delivery evolves.
      The American Psychiatric Association and American Telemedicine Association similarly outline their best practices
      American Psychiatric Association
      Best practices in videoconferencing-based telemental health.
      and include many of the same guidelines as the American Psychological Association. Additional considerations by these governing institutions are provided as well. Suggestions are outlined to behavioral health care providers related to program development and administration, communication with patients, and guidelines specific to patient populations and types of providers.
      Additional guidelines related to program development and administration include encouragement to providers to obtain malpractice insurance that covers telehealth practices if that coverage is not already included in the current insurance package. Providers should conduct a program development analysis before delivering telehealth services, during which needs related to training, space, types of services, and other administrative considerations are assessed. Additionally, the APA asserts that organizations providing telemental health services should create Standard Operating Procedures that include components such as a quality improvement plan and a method for documenting provider credentials.
      American Psychiatric Association
      Best practices in videoconferencing-based telemental health.
      The APA offers several directives regarding patient and provider communication, as well. For example, they suggest developing a standard way of identifying both the patient and the telemental health providers(s) present. To do so, the provider might state their name, credentials, and contact information and request that the patient provides their name, location, and contact information at the start of the session.
      American Psychiatric Association
      Best practices in videoconferencing-based telemental health.
      Further, it would be prudent to discuss continued means of communication and emergency management between appointments.
      American Psychiatric Association
      Best practices in videoconferencing-based telemental health.
      The provider should encourage each patient to choose a consistent location whereby they can receive telehealth services to manage risk and maintain an appropriate plan for emergencies.
      American Psychiatric Association
      Best practices in videoconferencing-based telemental health.
      Behavioral health care providers might also assess the patient to determine if an in-person physical examination is needed. If so, the provider must assist the patient in arranging an onsite appointment.
      American Psychiatric Association
      Best practices in videoconferencing-based telemental health.
      Finally, providers are instructed to maintain open communication regarding the wellbeing of the patient with other health care providers as indicated and allowed by local and federal law and privacy guidelines.
      American Psychiatric Association
      Best practices in videoconferencing-based telemental health.

      Summary

      The COVID-19 pandemic has highlighted the growing need for more behavioral health care services, particularly those integrated into the primary care setting whereby many patients first present with mental health needs. We continue to learn more about the barriers and challenges to virtual behavioral health care, while also seeing more data supporting virtual behavioral health care to successfully increase access to mental health services in a timely and effective manner.

      Clinics care points

      • When considering if a behavioral health visit should occur via telehealth versus in-person, with a few notable exceptions, this can be driven largely by patient preference, as telehealth is as effective as in-person care in delivering high-quality behavioral health services.
      • When providing behavioral health care via telehealth, providers should consult the American Psychological Association and American Psychiatric Association standards of care to ensure they are providing ethical, quality care via this rapidly evolving mode of delivery.

      Acknowledgments

      The authors would like to thank Elizabeth W. Staton, MSTC from the University of Colorado Department of Family Medicine who helped with editing and formatting the article.

      Disclosure

      The authors have nothing to disclose.

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