Experiences of Mental Health Clinicians and Staff in Rapidly Converting to Full-Time Telemental Health and Work from Home During the COVID-19 Pandemic

Introduction

The suppression and mitigation strategies designed to reduce morbidity and mortality of the COVID-19 pandemic have dramatically changed how health care services are delivered. Telemental health (TMH), which is the use of technology to provide mental health care at a geographic or temporal distance, has a growing evidence base and is a demonstrated viable alternative to in-person services.^1–3 The use of TMH was increasing before the COVID-19 pandemic because it offers solutions to the growing need for mental health services, provider shortages, and patient obstacles (e.g., geography, mobility, and stigma to care access).⁴ Although TMH has historically included providing services from one health care setting to another and required significant resources to be used effectively,⁵ revolutions in technology and consumer devices have reduced infrastructure needs and expanded TMH locations to include patient and clinician homes. A growing body of research has demonstrated both the clinical efficacy and feasibility of in-home TMH, as evaluated by treatment adherence, patient and provider satisfaction, cost-effectiveness, safety, and other clinical considerations.^6–11

The established efficacy of in-home TMH favorably positioned mental health systems to readily convert to use of clinician-home to patient-home TMH care in the face of the COVID-19 pandemic. Indeed, the push to rapidly implement social distancing to control COVID-19 in combination with concerns about the impact of that distancing on mental health¹² motivated many individual clinicians and health care systems to rapidly virtualize all mental health services. Even health care providers and patients who were previously reluctant to use TMH were encouraged to use it during the pandemic and TMH was made less burdensome through temporary regulatory changes (e.g., lifting of certain restrictions by the Centers for Medicare and Medicaid Services). This rapid and widespread adoption of TMH during the pandemic is likely to have broad ranging and long-term impacts on the delivery of mental health care. These factors present an opportunity to re-envision how the work of mental health care is delivered and provide a real-time laboratory to examine best practices for increasing access and satisfaction for patients, improving job satisfaction for providers, and understanding how TMH services are best configured to incorporate work-from-home (WFH) considerations.

Recent literature has described the processes involved in rapid transition to TMH and identified challenges as well as factors that enabled successful transition.^13–15 However, very little is known about clinician perspectives of rapid virtualization. Even less is known about administrative staff perceptions with TMH and rapid virtualization. Understanding the experiences of mental health clinicians and staff through rapid implementation of full-time TMH and WFH can inform how to best manage any subsequent waves of the pandemic, and how mental health care delivery may be beneficially restructured more broadly. In this article, we describe the results of a survey to assess mental health clinician and administrative staff experiences when rapidly converting to full-time synchronous TMH and WFH during the COVID-19 pandemic.

Methods

DESIGN

This study describes the results of a mixed-methods anonymous online survey administered to clinical and administrative staff at two outpatient mental health clinics, the Johnson Depression Center (JDC) and the Steven A. Cohen Military Family Clinic (Cohen–AMC), at the University of Colorado Anschutz Medical Campus. The survey was determined to be quality improvement by the applicable Institutional Review Board and was thus exempt from human subjects’ review. The JDC was established in 2009 as a clinic specializing in the treatment of mood, anxiety, and related disorders in an outpatient setting. The Cohen–AMC provides outpatient mental health services to post-9/11 Veterans and their families as part of the national Cohen Veterans Network and was established in 2018 through a partnership with the JDC. Both clinics were providing between 10% and 30% of services via TMH before the COVID-19 pandemic.

Participants were informed of the survey’s purpose, reminded that responses were voluntary and anonymous, and informed that results would be used to assess the process of rapid transition to full TMH and WFH to identify areas for improvement. Surveys were administered and completed between 7 and 10 weeks after the transition to full-time TMH and WFH.

PARTICIPANTS

Thirty-one clinicians and administrative staff at the JDC and Cohen–AMC (excepting two authors of this article) were invited to participate via e-mail. Staff at both clinics included prescribing clinicians (either psychiatrists or psychiatric mental health nurse practitioners), therapists (psychologists, social workers, and licensed professional counselors), and administrative support staff.

TMH AND WFH IMPLEMENTATION

Less than 1 week before the TMH/WFH implementation date, staff began making plans to convert to full telehealth in anticipation of the escalating precautions due to COVID-19. All staff were required to WFH on March 16, 2020, and were informed the day prior. Outcome monitoring was suspended at one clinic because the vendor used for online outcome monitoring prohibited use with patients when they were not physically located in a health care setting. Most staff utilized home office and technology equipment. Personal cell phones were utilized by most staff who were advised to restrict their phone numbers and main clinic phone numbers were forwarded to prepaid cell phones so administrative staff could respond to clinic calls from their homes. Staff later used mobile phone apps that were compliant with the Health Insurance Portability and Accountability Act (HIPAA) and cloaked personal phone numbers with office phone numbers. TMH services were provided by HIPAA-compliant videoconferencing software that had previously been in place for TMH services in both clinics. Virtualization was operational across both clinics within 48 h. In the early weeks of virtualization, clinic administration had regular direct contact with the billing department, and billing information was frequently communicated to all team members during staff meetings to increase the likelihood that TMH services were appropriately coded and eligible for reimbursement.

MEASURES

The surveys were self-designed online questionnaires that included questions about experience with TMH before COVID-19, expectations and experiences in converting to full-time TMH, impressions and experiences of patient care provided by TMH and experiences in working full-time from home during the pandemic. Administrative staff received a different version of the questionnaire than clinical staff to account for workflow differences (e.g., only clinicians were asked about the amount of time spent providing clinical services; only administrative staff were asked about experiences answering clinic phones). The clinician survey was 43 items. This included 17 multiple-choice items to which participants could also add free-text comments on certain items, 14 items that asked participants to rate personal satisfaction or estimate patient satisfaction in various areas on a Likert scale, and 11 items where participants could respond with free-text. The administrative staff survey was 37 items. This included 12 multiple-choice items to which participants could also add free-text comments on some items, 14 items that asked participants to rate personal satisfaction or estimate patient satisfaction in various areas on a Likert scale, and 11 items where participants could respond with free-text.

Results

PARTICIPANT CHARACTERISTICS

Twenty-five of 31 invited participants responded to the survey (80.6% response rate), including 14 clinicians (56.0% of sample and 73.7% response rate) and 11 administrative staff (44.0% of sample and 92.0% response rate). Respondents included 17 of 19 invited participants from the JDC clinic (89.5%) and 8 of 12 invited participants from the Cohen–AMC clinic (66.7%). Six psychiatrists (42.9%), three psychiatric nurse practitioners (21.4%), four psychologists (28.6%), and one social worker (7.1%) completed the clinician survey.

STAFF IMPRESSIONS OF PATIENT EXPERIENCES WITH TMH

Twenty-two out of 23 respondents with direct patient contact (95.6%) reported an impression that patients were satisfied or very satisfied with the experience of TMH during COVID-19 and estimated that more than 80% of established patients had elected to continue services by TMH rather than wait for in-person services to resume. Specific patient feedback as relayed by staff appears in Table 1. Of note, four clinicians identified that they had not received any negative feedback from patients about TMH sessions.

CLINICIAN EXPERIENCES WITH TMH

Clinicians had varied expectations upon learning of the plan to rapidly virtualize services. Eight clinicians (57.2%) reported they initially felt very positive or positive about the plan, three clinicians (21.4%) felt neutral, and three clinicians (21.4%) felt negative or very negative. However, upon reflection of how the actual experience compared with initial expectations, 12 clinicians (85.7%) found the process to be somewhat better or much better than they had expected; only 1 clinician (7.1%) reported the process to be somewhat worse than expected. Clinicians were generally satisfied with the experience of performing specific tasks in providing TMH and identified more positive experiences than negative experiences. Likert-rated clinician TMH satisfaction for specific tasks appears in Table 2, and free-text responses regarding experiences appear in Table 3. Five clinicians (35.7%) reported that satisfaction with TMH was different for new patient visits versus follow-up visits with free-text comments suggesting some clinicians were less comfortable conducting initial visits by TMH. However, eight clinicians (57.1%) indicated that their TMH satisfaction was equal for new visits and follow-up appointments.

ADMINISTRATIVE STAFF EXPERIENCES WITH TMH

Administrative staff were also generally satisfied with experiences in performing specific tasks related to TMH and offered few free-text responses regarding the process. Likert-rated TMH satisfaction for specific tasks appears in Table 4, and free-text responses appear in Table 5.

STAFF EXPERIENCES WORKING FROM HOME DURING A PANDEMIC

Thirteen staff (52.0%) reported they were “very satisfied” with WFH and seven (28.0%) were “satisfied.” Four staff (16.0%) reported they were “neither satisfied nor dissatisfied” and only one respondent (4.0%) reported being “dissatisfied” with WFH. Free-text responses regarding experiences working from home appear in Table 6, with lack of commute being the most commonly identified positive aspect of WFH, and various issues related to communication and feeling disconnected from colleagues being the most commonly mentioned challenge. Reported levels of burnout, vicarious trauma, and/or compassion fatigue compared with pre-COVID-19 were variable and appear in Figure 1. Twenty-two staff (88.0%) reported that their current WFH arrangements would be comfortable to maintain for 3 or more months. When asked what would extend the length of time staff could comfortably WFH, the most common free-text response was adjustments to computer equipment or furniture (n = 5; 20.0%). In free-text responses, the most frequently mentioned factor to enable a successful transition back to in-office work was to feel safe with respect to COVID-19 exposure (n = 8; 32.0%). Preference ratings for ideal schedules in the future appear in Figure 2. Of note, all respondents indicated a preference to maintain some level of WFH in the future. A subset of administrative staff indicated a preference to maintain 100% WFH in contrast to clinicians who all preferred a mix of in-office work and WFH.

Table 6. Staff Experiences Working Full-Time from Home

POSITIVE EXPERIENCES	FREQUENCY	CHALLENGES	FREQUENCY
Lack of commute	10 (40.0%)	Missing as-needed consultation	4 (16.0%)
Spending more time with family and pets	8 (32.0%)	Feeling isolated/missing the team	4 (16.0%)
Opportunities for self-care	5 (20.0%)	Difficulty separating work and nonwork responsibilities	3 (12.0%)
Schedule flexibility	2 (8.0%)	Tasks taking more time	2 (8.0%)
		Uncertainty about if/when return to work will occur	1 (4.0%)
		Working with children at home	1 (4.0%)
		Difficulties in connecting with community partners	1 (4.0%)

Discussion

Mental health staff in this survey reported that the process of rapid conversion to TMH and WFH during COVID-19 was smooth and well-accepted. Regarding TMH, both clinicians and administrative staff reported generally positive experiences and the impression that patients were satisfied with the process and experience. In particular, staff mentioned positive impressions about the ability to maintain continuity of care and having increased schedule flexibility. Challenge areas included difficulties with technology and outcome monitoring, virtual meeting fatigue, difficulty providing TMH care to very young patients, and a subset of clinicians who were less comfortable doing new visits (vs. follow-ups) by TMH. Regarding WFH, participants cited lack of commute, opportunities for time with family and for self-care, and schedule flexibility as significant benefits. Difficulties in maintaining team cohesion while working remotely, less preferable office equipment, and difficulty shifting between work and other responsibilities were commonly described challenges with WFH. Overall, findings suggest good acceptability among staff for continuing to rely on WFH in the future. In fact, all respondents indicated a preference to continue some WFH in the future with almost 1/3 of administrative staff indicating a preference to maintain full WFH. Interestingly, experiences with burnout, compassion fatigue, and vicarious trauma were mixed. Free-text comments suggest this may be due to the varying impacts of TMH and WFH, as well as the larger collective impact of pandemic stress.

Prior research has shown the benefits and acceptability of TMH,¹⁶ and current findings suggest that many of those benefits persist under the suboptimal conditions of rapid implementation during a pandemic. Findings are reassuring regarding the ability to respond to any subsequent resurgence of COVID-19, and suggest areas of opportunity for future TMH operations. Future implementation may be improved by ensuring ability to administer clinical forms remotely, paying extra attention to facilitating team cohesion while working remotely, developing creative strategies for engaging young children by TMH, and developing clear policies about the potential for using office equipment from home.

Current findings should be interpreted with several limitations in mind. This was a survey administered to a small sample as part of a clinical quality improvement effort. Thus, results cannot be considered generalizable and should primarily be used to identify promising directions for future research. In addition, the survey was administered shortly after TMH and WFH implementation and impressions may change over time. For example, a sense of rallying together as a team in a relatively early phase of the pandemic, a phenomenon coined the “honeymoon” phase in disaster recovery,¹⁷ may have applied and inflated positive responses. Regular reassessment of staff experiences at various phases of the pandemic will be informative in this regard.

The generally positive response to providing full-time TMH and WFH, even under suboptimal conditions of a global pandemic, suggests that mental health staff view TMH and WFH as viable responses to public health emergencies. This is important as it provides a previously underevaluated perspective on the perception and sustainability of virtual mental health operations. Although the long-term sustainability of in-home TMH will be largely dependent on whether payers maintain TMH benefits postpandemic, these findings are suggestive of multiple benefits in doing so. Findings also suggest that TMH and WFH are high-priority areas for research and innovation in mental health care delivery. Ultimately, the COVID-19 pandemic may catalyze change toward a “better normal” that re-envisions how and where the work of mental health care is done.

Disclosure Statement

No competing financial interests exist.

Funding Information

No specific funding was received for this work.

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