The soaring incidence of mental health problems triggered by COVID-19 and the resulting precipitous economic downturn, combined with the social distancing required to curb the coronavirus’ spread, have thrust telemental health into the spotlight.
When the pandemic hit, hospitals and health systems had to move within days or weeks to a virtual model to continue psychotherapy and psychiatric management for patients and reduce the risk of suicide attempts, ED visits and hospitalizations. Now that many organizations have made the transition, early signs are that this option will last.
An encouraging example can be seen at CHI Health Immanuel, Mercy and Lasting Hope Recovery Center, Omaha, part of a 14-hospital network serving Nebraska and southwestern Iowa. It saw virtual behavioral health visits during the first month of the pandemic rise to 85% (from 2%) of encounters and the no-show rate drop to less than 10% (from 23%).
“We hope the temporary regulatory changes ensuring telehealth access due to COVID-19 will remain in place,” says Ann M. Schumacher, RN, FACHE, president, CHI Health Immanuel and Lasting Hope Recovery Center, and CHI Mercy Council Bluffs, Iowa. “Behavioral health translates well to the virtual platform and eliminates many of the barriers, including stigma, that may stop patients from following up with treatment. Patients appreciate their ability to access timely and safe services.”
Not surprisingly, telehealth, already on the rise in many specialties, has shown value as a delivery tool for emerging behavioral health models. It offers convenience for patients, brings services to people in remote areas or for whom travel is difficult, and allows clinicians to transport themselves remotely, on demand, to emergency rooms and inpatient units for consultations.
“When it comes to integrating behavioral health into service offerings, telehealth also provides a pathway for organizations that want to develop more robust behavioral health programs but lack the staff to do so,” says Howard J. Gershon, LFACHE, founding principal of New Heights Group, Santa Fe., N.M. “Telehealth allows organizations to expand their treatment capacity.”
Jay H. Shore, MD, director of telemedicine at the Helen and Arthur E. Johnson Depression Center, University of Colorado Anschutz Medical Campus, and chair of the American Psychiatric Association’s Committee on Telepsychiatry, notes that, “like anything in medicine, there are complexities involved in implementing telepsychiatry, but as a field, it has matured, and especially since COVID, it is coming to the mainstream. My assumption is that we’ll have more virtual options once COVID ends—hybrid care that will include in-person visits as well as videoconferencing, phone, patient portal and email communication. We’ll see more technology in care going forward, and each system and practitioner will go through their own process of figuring out the optimal blend.”
A silver lining with COVID-19 is the fact that mental health is receiving heightened attention, Gershon observes. “People are learning that telesolutions in mental health services are readily available and work well. This shot in the arm will help us use these options to treat more people,” he says.
Following are profiles of three organizations that have used virtual technology to broaden their behavioral health services in some innovative ways, both before and during the pandemic.
Providence St. Joseph Health: Optimizing Resources With Telecare
With 51 hospitals in seven states, and as the parent organization for 100,000 caregivers, Providence St. Joseph Health is large. But it faces the same high demand for mental health services and shortage of psychiatrists seen across the U.S. The system has responded with a model built around the judicious use of psychiatrists as members of a collaborative care team that is integrated into primary care practices. Virtual visits are the foundational mode of delivery.
Telebehavioral health was introduced as an option 10 years ago at a handful of the system’s suburban and rural hospitals, where need was greatest. Since 2016, the system has been offering virtual services at 35 hospitals, and further expansion is planned.
“We’ve headed decidedly away from a traditional one doctor, one patient relationship to a multidisciplinary approach that includes on-demand service with a counselor or nurse practitioner with psychiatrist backup,” says Todd Czartoski, MD, chief medical technology officer for telehealth. “We use social workers and other allied health professionals to spread the expertise. The important part is connecting patients to the ecosystem so that if someone does need a psychiatrist, we can seamlessly make that referral.”
Embedding psychiatrists into primary care practices via virtual care works well because “primary care is where most behavioral healthcare really occurs,” Czartoski notes. “The best ER visit for a mental health issue is the one that never happens. It’s the one you can prevent by seeing people before they go into crisis.”
Layered in with these ambulatory offerings are self-service digital tools that help patients monitor their condition. The apps drive additional cost efficiencies. “We’re not eliminating psychiatrists; we’re adding digital resources to free psychiatrists to care for larger populations,” Czartoski says.
A second major initiative at Providence St. Joseph is a service for employees and their families called Behavioral Health Concierge, an on-demand help line with a record of responding quickly to employees’ needs since its rollout a year ago. Czartoski reports that 65% of people are seen within 24 hours.
Developed partly in response to some physician suicides within the organization, the service sees 400 individuals monthly and continues to fill a vital need during the pandemic. “Physicians are notoriously reticent to ask for help, but 21% of the people using the concierge are physicians,” he says.
Czartoski says virtual visits enhance the patient experience rather than detract from it. He reports that patient satisfaction scores at Providence St. Joseph for telemental health have consistently been higher than in-person visits.
Virtual care has been particularly meaningful during the pandemic. “For patients in a COVID isolation unit who haven’t seen a person with an unmasked face in 10 days, a remote visit with a psychiatrist during which masks are not required can be a more intimate experience than if the psychiatrist were in the room,” Czartoski says.
Tanner Health System: Virtual Continuity Lowers Recidivism
Before COVID-19, Carrollton, Ga.-based Tanner Health System’s involvement in telepsychiatry revolved around the use of a third-party service to cover the nonprofit five-hospital system’s EDs and floors. The behavioral health division at Willowbrooke at Tanner, the system’s inpatient behavioral health facility, provided telepsychiatry for the system’s more remote campuses.
When COVID-19 hit, Willowbrooke moved its psychiatrists from in-person inpatient care to daily teleporting from home. The reduced “windshield time” afforded by the shift allowed the psychiatrists to assume responsibility for the consult service that was being handled by the outside vendor, reports Wayne Senfeld, EdS, senior vice president for behavioral health.
While the use of telepsychiatry during the COVID-19 crisis “hasn’t been optimal for every patient, it has provided a very good alternative and enabled us to manage our patients effectively,” he says.
Senfeld, who chairs the Psychiatry Committee of the Georgia Hospital Association, notes that Willowbrooke is the only behavioral health hospital in the state he knows of that continued providing both inpatient and outpatient services without interruption during COVID-19 using telehealth.
The wider utilization of virtual care catalyzed by COVID-19 has also had the unanticipated benefit of allowing the same psychiatrist that treated a patient remotely during their in-patient stay to continue seeing that patient remotely after discharge without a break in continuity of care, notes Kenneth Genova, MD, Willowbrooke’s executive medical director.
Because the hospital serves as a behavioral health services provider for a large swathe of Georgia, including a sizeable share of the state’s indigent people, some of whom might live two or more hours away, it hadn’t been practical for the same providers who’d treated a patient during their hospitalization to continue seeing them for outpatient care.
That changed with the pandemic. “Until the world gets to a calm place where local psychiatric services can be accessed more readily, we’re taking care of everybody that we see from the moment they hit the ERs all the way back to their communities,” Genova says. “The change to virtual delivery during COVID has reduced recidivism by enabling our inpatient level of care to be extended to more patients on an outpatient basis.”
Though Willowbrooke’s practitioners all transitioned successfully to telehealth, some adapted exceptionally well. Their ease with virtual medicine will be tapped to help the hospital build a full-scale tele-psychiatry service, Genova says.
Genova sees potential for organizations that eliminated their behavioral health programs years ago to begin offering mental health services again through telepsychiatry. “What’s to stop an established, well-staffed behavioral health program from tele-porting practitioners to a smaller or even a larger hospital that doesn’t have the same depth of expertise?” he says.
Genesis PrimeCare: Remote Therapy for Underserved Populations
Genesis PrimeCare, Marshall, Texas, a seven-site network of primary and specialty care clinics, is among the 82 healthcare organizations that have received funding so far under the Federal Communications Commission’s COVID-19 Telehealth Program.
The program is distributing $200 million appropriated under the Coronavirus Aid, Relief, and Economic Security Act to help nonprofit and public eligible healthcare providers address care access issues related to the pandemic by developing new or expanded telehealth capabilities. As of mid-May 2020, when Genesis PrimeCare was announced as a recipient along with 32 other organizations, the program had distributed $33 million in funding.
Genesis PrimeCare received $990,000 to expand telehealth and remote patient monitoring services for primary, pediatric and behavioral healthcare for low-income and underserved communities in rural northeast Texas.
In the behavioral health space, that funding has been used to support the organization’s journey from all on-site therapy and counseling services to an environment in which 90% of visits are now done remotely.
“While we’re eager to get some patients back into the clinic when it is safe for certain types of therapy that are more conducive to being on-site—such as eye movement desensitization and reprocessing therapy for post-traumatic stress disorder—our patients love the televisits, and our providers feel they’re able to meet their patients’ needs,” says Carla Roadcap, CEO.
The organization faced some challenges during the transition. Many of the behavioral health patients were initially uncomfortable with the idea of not being in the same room with their therapist. To gently raise their comfort level, the practitioners began by having educational conversations with the patients, followed by brief teletalks—informal chats, not therapy sessions—so patients could get a taste of videoconferencing. “All of our patients were pleased with this option once they tried it,” Roadcap says. “And their transportation issues are gone.”
Patients whose children were a distraction during therapy appointments were encouraged to let their children watch a movie or engage in an activity to free their parents to focus on their session. “Many patients have indicated they would like to continue with virtual therapy because they no longer have to arrange and pay for childcare for their appointments,” Roadcap says.
Dedicated patient service representatives at three of Genesis PrimeCare’s locations handle telehealth appointment scheduling and help patients work through any technical glitches before their therapy sessions begin. The organization’s IT department steps in occasionally to assist some patients who lack sufficient internet connectivity.
Despite some patients’ initial hesitation, “the virtual visits have helped many people feel less isolated during the pandemic,” says Roadcap. “Telehealth allows us to continue encouraging patients to practice their healthy coping mechanisms. It’s working.”
Susan Birk is a Chicago-based freelance writer specializing in healthcare. Lea Radick, writer, Healthcare Executive, contributed to this article.