Saturday, November 30, 2024
Virtual Heart Care
Telehealth 

Rapid Increase in Telemental Health Within the Department of Veterans Affairs During the COVID-19 Pandemic

Editor


Introduction

Telemental health via videoconferencing (TMH-V) can provide mental health (MH) care in real time directly to patients’ homes. Its use has become critical during the Coronavirus 2019 (COVID-19) pandemic due to large-scale restriction of nonurgent in-person appointments.1 Availability of MH care is especially important given increased psychological distress related to COVID-19 (e.g., illness, deaths of loved ones, isolation, disruption of daily routines, and economic hardship2). MH care is uniquely well suited for conversion to telehealth as it typically does not require physical examination, and TMH-V has demonstrated effectiveness comparable with in-person care.3

The Department of Veterans Affairs (VA) is the nation’s largest health care system, providing MH services to 1.7 million Veterans in 2019. In March and April 2020, VA issued national memoranda directing in-person MH visits to be converted to TMH-V sessions whenever possible and promoting MH providers’ ability to conduct TMH-V visits from home.4 We characterize here VA’s rapid increase in TMH-V due to COVID-19, including the extent of its use relative to telephone and in-person appointments during this time period.

Methods

Data were obtained from the VA Corporate Data Warehouse. We defined TMH-V encounters as having an MH outpatient primary stop code and a telehealth secondary stop code (videoconferencing to a non-VA location, e.g., patient’s home). Encounters with an MH telephone primary stop code were classified as telephone appointments, and all other outpatient MH encounters were classified as in-person appointments. COVID-19 changes were captured during the 6 weeks after the World Health Organization’s pandemic declaration (March 11–April 22, 2020). Pre-COVID-19 TMH-V encounters were assessed from October 1, 2017 (rollout of VA’s current TMH-V platform, VA Video Connect) to March 10, 2020. Analyses were conducted using SAS version 9.4 (SAS Institute) and were approved by the VA Boston Institutional Review Board.

Results

Daily TMH-V encounters rose from 1,739 on March 11 to 11,406 on April 22 (556% growth, 222,349 total encounters; Fig. 1). Daily TMH-V encounters doubled in four business days (3,673 daily encounters on March 17) and doubled again in nine business days (7,352 daily encounters on March 30). Between March 11 and April 22, 114,714 patients were seen via TMH-V (Fig. 2). Eighty-eight thousand nine hundred eight (77.5%) were first-time TMH-V users. The number of new TMH-V patients during this 6-week period is roughly equivalent to the total number of unique patients seen via TMH-V during the 127-week period between October 1, 2017 and March 10, 2020 (n = 89,229). Twelve thousand three hundred forty-two MH providers completed a TMH-V appointment between March 11 and April 22 (Fig. 2); 4,281 (34.7%) were first-time TMH-V users. Daily telephone encounters rose from 6,348 on March 11 to 34,396 on April 22 (442% growth). Daily in-person encounters fell from 57,296 on March 11 to 10,931 on April 22 (81% decrease; Fig. 3).

Fig. 1.

Fig. 1. Cumulative increase in VA TMH-V encounters after the COVID-19 pandemic declaration. Expected increase represents the cumulative number of encounters if daily encounters held constant at 1,564 (the average number of daily TMH-V encounters during the week before the COVID-19 pandemic declaration, March 4–March 10). Weekend days are not graphed, but weekend encounters are included in the total number of cumulative encounters. COVID-19, Coronavirus 2019; TMH-V, telemental health via videoconferencing.

Fig. 2.

Fig. 2. Cumulative increase in unique VA patients and providers using TMH-V after COVID-19 pandemic declaration. Weekend days are not graphed but are included in cumulative totals of unique patients and providers. VA, Veterans Affairs.

Fig. 3.

Fig. 3. Daily TMH-V, telephone, and in-person encounters after the COVID-19 pandemic declaration. Weekend days are not graphed.

Discussion

In the days after the COVID-19 pandemic declaration, VA demonstrated dramatic growth in TMH-V use. The speed of this increase is in part attributable to VA’s pre-existing telehealth infrastructure, including a long-standing contract with its telehealth platform developer; VA had been successfully utilizing a federally compliant encrypted platform, VA Video Connect, before COVID-19. In the wake of the pandemic, platform developers rapidly worked to increase capacity, and national and regional telehealth leadership implemented provider and scheduler consultation sessions and increased technology help desk availability. Locally, facility-level telehealth coordinators and clinical champions quickly trained and mobilized staff. Of note, VA had been prioritizing telehealth use among MH providers before COVID-19; for instance, VA set national goals of 45% of MH providers completing at least one TMH-V encounter by the end of fiscal year 2019 and 60% completing an encounter by the end of 2020, which may partly explain the smaller percentage of new TMH-V providers as compared with patients after the pandemic declaration.

Long-standing barriers to TMH-V implementation (e.g., provider hesitance5) were lessened in the context of a pandemic, during which nonurgent in-person MH care was drastically reduced and VA providers were urged to become telehealth and telework capable by national VA leadership.4,6 This increased the relative advantage of TMH-V by allowing for continuity of virtual “face-to-face” care, while preventing COVID-19 spread. More broadly, TMH-V use during COVID-19 has been facilitated by loosening of national restrictions regarding telehealth reimbursement, controlled substance prescribing, and use of HIPAA-compliant telehealth platforms.7

Telephone appointments made up a significantly greater share of virtual care after the COVID-19 pandemic declaration as compared with TMH-V. This is not surprising in that care delivered via telephone is less complex and has considerably fewer barriers to use as compared with TMH-V, which requires the patient and provider to have camera-enabled devices, adequate connectivity for streaming video, and comfort navigating a telehealth platform. In addition, in the early stages of the pandemic, telephone appointments were encouraged via national VA policy memos while platform developers worked to increase capacity to accommodate the exponential rise in telehealth use; these recommendations deferred to providers’ clinical judgment and were lifted once platform enhancements were in place. Despite this combination of factors, TMH-V demonstrated greater percentage growth than telephone encounters in the weeks after the pandemic declaration. Rates of TMH-V use had more room to grow during this time; at the beginning of the analysis period on March 11, 2020 there were a total of 1,739 daily TMH-V appointments, as compared with 6,348 telephone appointments.

Moving forward, future study will be needed to understand the extent to which COVID-19-related changes in TMH-V use may permanently impact the MH care provision landscape. Specifically, employing implementation science frameworks (e.g., CFIR,8 i-PARIHS9) to understand barriers and facilitators at the patient, provider, health care system, insurer, and legislative levels will be critical in informing the long-term growth and sustainability of TMH-V.

Disclaimer

Content is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. Department of Veterans Affairs or the U.S. Government.

Disclosure Statement

No competing financial interests exist.

Funding Information

The research reported in this study was supported by the Department of Veterans Affairs, Veterans Health Administration, VISN 1 Career Development Award to S.L.C.

References

  • 1. CDC. Outpatient and Ambulatory Care Settings: Responding to Community Transmission of COVID-19 in the United States. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ambulatory-care-settings.html (last accessed April 7, 2020). Google Scholar
  • 2. Whaibeh E, Mahmoud H, Naal H. Telemental health in the context of a pandemic: The COVID-19 experience. Curr Treat Options Psychiatry 2020;7:198–202. Crossref, Google Scholar
  • 3. Fletcher TL, Hogan JB, Keegan F, et al. Recent advances in delivering mental health treatment via video to home. Curr Psychiatry Rep 2018;20:56. Crossref, Medline, Google Scholar
  • 4. Heyworth L, Kirsh S, Zulman D, Ferguson JM, Kizer KW. Expanding access through virtual care: The VA’s early experience with Covid-19. NEJM Catal 2020 [Epub ahead of print]; DOI: 10.1056/CAT.20.0327. Google Scholar
  • 5. Cowan KE, McKean AJ, Gentry MT, Hilty DM. Barriers to use of telepsychiatry: Clinicians as gatekeepers. Mayo Clin Proc 2019;94:2510–2523. Crossref, Medline, Google Scholar
  • 6. Wind TR, Rijkeboer M, Andersson G, Riper H. The COVID-19 pandemic: The ‘black swan’ for mental health care and a turning point for e-health. Internet Interv 2020 [Epub ahead of print]; DOI: 10.1016/j.invent.2020.100317. Crossref, Medline, Google Scholar
  • 7. Kannarkat J, Smith NN, McLeod-Bryant SA. Mobilization of telepsychiatry in response to COVID-19—Moving toward 21st century access to care. Adm Policy Ment Health 2020;47:489–491. Crossref, Medline, Google Scholar
  • 8. Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the consolidated framework for implementation research. Implement Sci 2016;11:72. Crossref, Medline, Google Scholar
  • 9. Harvey G, Kitson A. PARIHS revisited: From heuristic to integrated framework for the successful implementation of knowledge into practice. Implement Sci 2016;11:33. Crossref, Medline, Google Scholar





Source link