Telemental Health Response to the COVID-19 Pandemic: Virtualization of Outpatient Care Now as a Pathway to the Future

The COVID-19 pandemic has precipitated transformations across societies and health care systems through social and physical distancing, and deployment of suppression and mitigation strategies.¹ Although many sectors of the health care system saw patient visits drop, the mental health community adapted quickly to these changes. Telemental health (TMH), or the use of communication technologies to deliver mental health services, allowed for the continued delivery of clinical services, often from clinician homes into patient homes.^2,3 With a broad evidence base demonstrating efficacy across a range of mental health concerns developed over decades, TMH was uniquely positioned for success during this global crisis.^4,5 This opinion is designed to introduce two articles further detailing the virtualization process for two outpatient clinics at the University of Colorado Anschutz Medical Campus (AMC) and suggest a future state where current lessons learned are applied to foster flexibility and appropriately blend the strengths of in-person and TMH care into hybrid in-person/TMH clinical relationships.

TMH as a system of care originated in providing services from one clinically supported setting (e.g., hospital or clinic) to another.⁶ Care delivered into clinically unsupported settings (such as patient homes) has often been considered “nontraditional,” with many systems, insurers, and health care providers reluctant to pay for or deliver services to these locations despite evidence demonstrating that they can be effective sites of care and feasible alternatives to both in-person and more traditional clinic-based TMH.⁷ The Johnson Depression Center (JDC) and Steven A. Cohen Military Family Clinic (Cohen-AMC) at the University of Colorado AMC, like many health care systems around the country and globally, identified in-home services as a solution to maintaining mental health care and virtualized outpatient services in response to COVID-19 suppression and mitigation strategies.

The JDC and Cohen-AMC had been providing direct in-home TMH services for >2 years. Previous experience with TMH fostered the transition to 100% virtual outpatient mental health services, and both clinics were able to make the transition within 2 business days by focusing on key interdependent but separate tasks: (1) expanding or initiating provider home-to-patient home services, (2) virtualizing workforce administrative operations to manage these organizations remotely, and (3) expanding or developing virtual supportive groups and mental health education programs. The lifting of many federal and state regulatory barriers to telehealth, even temporarily, along with clinic leadership support, provider flexibility, and patient demand, further facilitated this rapid virtual transformation. This rapid virtualization provides important lessons for the TMH field with emphasis on how to continue to adapt to the current COVID-19 situation. An overview of these lessons is provided hereunder and further elucidated in related articles led separately by Steidtmann and Mishkind.

The key lesson that applies across both clinics was the strong organizational willingness and commitment to take the timely actions necessary to virtualize. Communication, training, and trust, from leadership to frontline staff, and working from established best practices facilitated the rapid transition. Employing staff and providers already experienced in TMH and managing a virtual workforce further benefited these collective efforts, and how these past experiences positively impacted virtualization success should not be underappreciated. The willingness to engage and capacity for rapid learning were equally important. Feedback loops, open communication between clinical and administrative staff, and leadership teams including virtual staff meetings and regular e-mail and phone updates were critical to identifying challenges and developing collective solutions. Although patient and provider experience does vary, current data and anecdotal evidence suggest widespread adoption, reduced no-show rates, and robust satisfaction levels.

Key principles for virtualization of operations have been “keep calm and carry on,” KISS (“keep it simple, stupid”), and “go slow to go fast.” These translate to a thoughtful, strategic, and measured approach to modifying only what is necessary to engage in TMH services and telework operations while leaving many aspects of standard operating procedures unchanged. Other important principles include clearly defining needs for each service, communicating team member roles and responsibilities (noting changes from in-person workflow), and delineating both the communication pathways (who communicates with whom and when), and the technologies to be used for each pathway (phone, video, and e-mail).⁸ Other services including community- and workplace-based mental health training and education programs, and subclinical support groups were virtualized in response to COVID-19 mitigation efforts. The virtualization of these services produced additional lessons learned about how to effectively engaged individuals in public, and large group, forums while maintaining the integrity of the group and participant safety (e.g., mitigating disruptive behavior).

Our mental health systems will be transformed when we emerge from the current pandemic and we expect much wider use and acceptance of TMH, virtual work, and other virtualized services. We expect this transformation to be most notable in how health care providers and systems reconceptualize how, when, and where services are provided, and how patients respond to these changes. We further anticipate it is unlikely that outpatient mental health services will return to a predominant focus on in-person care, but rather will be focused on hybrid (i.e., in-person and TMH) services moving forward due to convenience, acceptability, and equivalent quality. Although this pandemic was not asked for and global responses could not have been predicted, the current data are supportive of continued TMH integration^2,3,9,10 and those in the mental health profession must continue to openly discuss and advocate for the most effective provision of services or risk losing the opportunity to help shape a future focused on hybrid in-person/TMH clinical relationships. The following are some important issues for continued discussion.

• Regulations. The declaration of public health emergencies led to the lifting, temporarily for some, of regulations on telehealth such as geographic and physical location and audio-only limitations for Medicare reimbursement, and some state licensure requirements. The temporary restrictions have benefited patients in their ability to access clinicians, and clinicians benefited by receiving reimbursement for their services, and reverting back to pre-COVID-19 limitations will likely have negative impact on some patient populations.

• Technology. Some patients still need training to use TMH systems and others do not have appropriate devices or network connections. Test calls before initial sessions can help evaluate whether a patient has the necessary understanding of and technology for the service, and clinical judgment should be used when a decision between access and technological adequacy is debated. More focus must be placed on ensuring technology and bandwidth access across populations for TMH to fully expand.

• Economics. TMH services can reduce overall system cost when use of personal devices, lost work time, commute cost, and other efficiencies are factored. The low rates of mental health reimbursement in general, the lack of true TMH parity in many states, and the inability to capture facility fees and other aspects of the full cost of care must be addressed as they may have a negative longer term impact on clinician or institution willingness to maintain TMH services.

• Therapeutic appropriateness. Most TMH services show on-par outcomes to traditional in-person care. For some, the lack of behavioral activation associated with traveling to a clinic may have longer term consequences. Rather than focus on in-person services or associate TMH with a one-size fits all approach, the mental health field must develop a more robust understanding of when and where to use the flexibility of care approaches to promote hybrid episodes of care.

The experience of the JDC and Cohen-AMC clinics demonstrates how full conversion to virtual care can be successful especially with proper planning. Although the change to fully virtualized services may be temporary, the range of systems now promoting TMH solutions in varied settings makes it unlikely that we will return to strict boundaries on settings of care delivery, with a future focus on developing hybrid in-person/TMH care relationships between clinicians and patients. It is uncertain how hybrid outpatient mental health services will ultimately be organized. Our opinion is that a call must be put out to the mental health field to implement now these lessons learned to prepare for future potential emergencies, to help develop a health care system with TMH as a recognized standard of care, and to more fully define hybrid in-person/TMH care.

Disclosure Statement

Dr. Shore works with AccessCare a provider of telebehavioral health services and has received royalties from American Psychiatric Association Publishing and Springer Press. The remaining authors have nothing to disclose.

Funding Information

No external funding was received for this work.