ReflectionsontheDisrupterExperienceofCOVID-19
RachelM.Talley,MD,*† MaryF.Brunette,MD,*‡ DavidA.Adler,MD,*§LisaB.Dixon,MD,MPH,*|| JeffreyBerlant,MD,PhD,*¶#MatthewD.Erlich,MD,*||BethGoldman,MD,MPH,* MichaelB.First,MD,*||SteveKoh,MD,MPH,MBA,*** DavidW.Oslin,MD,*††† andSamuelG.Siris,MD*‡‡
Abstract: Thenovelcoronaviruspandemicandtheresultingexpandeduseof telemedicinehavetemporarilytransformedcommunity-basedcareforindividualswithseriousmentalillness(SMI),challengingtraditionaltreatmentparadigms.Wereviewtherapidregulatoryandpracticeshiftsthatfacilitatedbroad useoftelemedicine,theliteratureontheuseoftelehealthandtelemedicinefor individualswithSMIsupportingthefeasibility/acceptabilityofmobileinterventions,andthemorelimitedevidence-basedtelemedicinepracticesforthispopulation.Weprovideanecdotalreflectionsontheopportunitiesandchallengesfor telemedicinedrawnfromourdailyexperiencesprovidingservicesandoverseeingsystemsforthispopulationduringthepandemic.Weconcludebyproposing thatacontinued,moreprominentrolefortelemedicineinthecareofindividuals withSMIbesustainedinthepost-coronaviruslandscape,offeringfuturedirections forpolicy,technicalassistance,training,andresearchtobringaboutthischange.
KeyWords: Servicedeliveryincommunity-basedcare,expansionoftelemedicine use,practiceadaptationstotheCOVID-19pandemic
(JNervMentDis 2020;00:00 00)
Theemergenceofthesevereacuterespiratorysyndromecoronavirus 2(SARS-CoV-2,whichcausesthediseaseCOVID-19)andthe resultingpublichealthcrisisforcedmentalhealthproviderstorapidly suspendthemajorityofin-personcontactandtransitiontotelemedicine servicestobothpreventthespreadofinfectionandmaintainaccessto care.Giventhetraditionalrelianceuponin-personinterventionsfor peoplewithseriousmentalillness(SMI),suchchangespresentaunique paradigmshiftforcommunityandpublicsectorprovidersworkingwith thispopulation.Howdidtheadaptationsneededforthisnewpractice environmentimpacttheclinicalcareexperienceforindividualswith SMIandtheirproviders?Hastelemedicineimpactedoutcomesfor thoseserved?Theanswersarenotreadilyprovidedbytheexistingresearchontheuseoftelemedicineinevidence-basedpracticesforindividualswithSMI.Here,wereviewcurrentresearchandprovide reflectionsonthepatientandprovidertelemedicineexperiencefrom
*GroupforAdvancementofPsychiatry,NewYork,NewYork; †DepartmentofPsychiatry,PerelmanSchoolofMedicine,UniversityofPennsylvania,Philadelphia, Pennsylvania; ‡DepartmentofPsychiatry,GeiselSchoolofMedicineatDartmouth, Lebanon,NewHampshire;§DepartmentofPsychiatry,TuftsMedicalCenterand TuftsUniversitySchoolofMedicine,Boston,Massachusetts;||Departmentof Psychiatry,NewYorkStatePsychiatricInstitute/ColumbiaUniversityVagelos CollegeofPhysiciansandSurgeonsandNewYorkPresbyterian,NewYork, NewYork;¶OptumIdaho,Boise,Idaho;#CanyonManorMentalHealthRehabilitation,Novato,California;**DepartmentofPsychiatry,UniversityofCalifornia SanDiego,SanDiego,California; ††CorporalMichaelJ.CrescenzVeteransAdministrationMedicalCenter,Philadelphia,Pennsylvania;and ‡‡DepartmentofPsychiatry,Donna andBarbaraZuckerSchoolofMedicineatHofstra/Northwell,NewYork,NewYork.
SendreprintrequeststoRachelM.Talley,MD,DepartmentofPsychiatry,Perelman SchoolofMedicine,UniversityofPennsylvania,3535MarketSt,Philadelphia, PA19104.E mail:Rachel.Talley@pennmedicine.upenn.edu.
Copyright©2020WoltersKluwerHealth,Inc.Allrightsreserved.
ISSN:0022-3018/20/0000 0000 DOI:10.1097/NMD.0000000000001254
cliniciansandadministratorsacrossthecountryinsettingsservingindividualswithSMIduringthepandemic.Weofferrecommendations drawnfromlessonslearnedthroughthisexperience.Wespecificallyfocusoncommunity-basedandoutpatientservices,acknowledgingthat experienceswiththeparalleltransformationinuseoftelemedicinefor inpatient,consultation-liaison,andemergencydepartmentpsychiatric carealsomustbeaddressed(Kalinetal.,2020).
TheHealthResourcesServicesAdministrationdefinestelehealth astheprovisionofabroadarrayofclinicalandnonclinicalhealth-related activitiesthroughtelecommunicationandelectronicmeans(e.g.,provider training,administrativemeetings,etc.),andmorenarrowlydefinestelemedicineastheremotedeliveryofclinicalservices(Departmentof HealthandHumanServices,2019).Telemedicinehastypicallyincorporatedbothaudioandvisualcommunications,asrequiredbyregulations.Telemedicineisalsodifferentiatedfromtelework,whichrefers toprovidersworkingfromhome,andencompassesallservicesand thechallengesprovidersfacewhenworkingremotelyduringapandemic orotherwise.
Beforethepandemic,thepromiseoftelemedicinehadnotbeen fullyrealized,althoughequipmentandcommunicationshadbecome cheaperandwidelyavailableinofficesandhomes,supportedbyInternettechnologyanddatasecuritythathadadvancedenoughtogain broadtrustfromthepublic.Telemedicinehadbeenpartiallysupported bytheMedicare,Medicaid,andSCHIPBenefitsImprovementandProtectionActof2000,whichintendedtoexpandaccesstocareforrural Americaviatelemedicine.Itallowedtelemedicinevisitsbetweenclinical sitestobepaidtheusualMedicareratefortheservice(notablyrequiringapatienttotraveltoaclinicalsitefortheserviceandaprovidertobe inanofficesetting).AlthoughtheHealthInsurancePortabilityandAccountabilityAct(HIPAA)of1996wasintendedtoensuredatasecurity forsensitivemedicalinformation,technicalandlegalrequirementsimpededtelemedicineuntilrecently.By2019,telemedicinecertainlyhad thepromisetobeeasilyandcheaplyutilized;indeed,somehealthcare sectors,mostnotablytheVeteransHealthAdministration,haveexperiencedrapidgrowthinuseoftelemedicine(Darkins,2014).Yet,before theCOVID-19pandemic,useoftelemedicine,particularlyamong Medicaidrecipients,wasextremelylow(Douglasetal.,2017).Arecent comparisonofbehavioralhealthtelemedicineMedicaidclaimsinrural versusnonruralsettingsfrom2012to2017foundlowratesofusein bothsettings,althoughuseincreasedovertime;substanceusedisorder treatmentinparticulardidnotexceed3%foreithertimepointorgeographicsetting(Creedonetal.,2020).
InresponsetotheacutedisruptionresultingfromCOVID-19, regulatorsimplementeddramaticbuttemporarychangesinavariety offederalandstatetelemedicineregulationstofacilitatecontinuedaccess tocareandpaymentforservices(Goldmanetal.,2020).Stay-at-home orderswereimplementedinmanystates,yetpeoplewithSMIneeded ongoingservices.Theservicedeliverysystemrequiredadramaticoverhaultoenablesocialdistancingandinfectioncontrol,whileenabling providerstocontinuetoprovideservicesforthispopulation.Thus,
policiesandprocedureswereputintoplaceonthelocal,state,and federallevelstoallowtelemedicinetoaddresspotentialgapsinservice.ChangesonthefederallevelincludedsuspensionofMedicarerequirementsonphysicallocationofpatientandprovider,flexibility aroundcost-sharingrequirementsundertheauspicesofthe1135EmergencyWaiver,thetemporarywaiverofrestrictionsoncontrolledsubstanceprescriptionviatelemedicinepreviouslyinplacethroughthe RyanHaightAct(CentersforMedicare&MedicaidServices,2020), andeasedrequirementsoflaboratorymonitoringfortheClozapine RiskEvaluationandManagementStrategyProgram.AllowabletelemedicineservicesunderMedicarewereexpanded,includingaudio-only services;penaltiesfortheuseofnon-HIPAA compliantvideoconference technologyweresuspended(AmericanPsychiatricAssociation,2020). StateshavebeenpermittedbroadlatitudetoexpandtherangeoftelemedicineservicescoveredunderMedicaidaswellasformsofpermissibletelemedicinecommunication(NationalCouncilforBehavioral Health,2020).Notably,theseregulatorychangesarealltemporarilyauthorizedunderfederalandstateemergencydeclarations.Although thereisaconcertedeffortunderway,itisyetunknowntowhatdegree thesechangeswillrevertbacktotheirformerstatusuponexpiration ofthesedeclarations.
TELEHEALTH/TELEMEDICINEANDTHESMIPOPULATION
Inresponsetothepandemic,communitymentalhealthproviders rapidlyadaptedtheirpracticestructuresandprocedures,ofteninclose partnershipwithstate,county,and/orcitymentalhealthauthorities. Forexample,NewHampshirecommunitymentalhealthorganizations workedcloselywiththestatementalhealthauthority,thegovernor,and thelegislaturetoadjustproceduresandregulationstoenablecontinued mentalhealthserviceprovisionacrossthestate,includingforthosewith SMI.Theseeffortswereremarkablysuccessful:byweek4ofNew Hampshire'sstateofemergency,91%ofpeoplewithSMIhadreceived atleastoneserviceviatelemedicine.Further,inthefirst2monthsof NewHampshire'sdeclaration,thevolumeofserviceprovisiontoindividualswithSMIandchildrenwithseriousemotionaldisturbancewascomparabletothesameperiodin2019(unpublisheddata).Arecently publishedaccountfromNorthernCaliforniasimilarlydescribesatransitiontofullyvirtualoperationswithinamatterofdays,withpositivefeedbackfrombothpatientsandprovidersdespitesomeadaptationchallenges (Yellowleesetal.,2020).Inanotherexample,NewYorkStatesimilarly waivedsectionsofregulationstoallowfortherapiddeliveryoftelemedicineservicesincommunitysettings,toensuretheequivalentreimbursementfortelemedicineservices,and,importantly,toallowfor initialevaluationstobeconductedviatelemedicine.MedaliaandcolleaguesofferperspectiveonthefrontlineNewYorkexperienceadapting tothesechanges,particularlytheuniquedifficultiesofproviding group-basedinterventionsbyvideoconference(Medaliaetal.,2020). Theyencounteredissuesaroundvideoetiquette,patienttrainingneeds, andmanagementofgroupprocessandcontent.Despitetheseissues, theirpatientsofferedpositivequalitativefeedback,andtheyachieved an84%attendancerate2weeksafterthevideoconferenceconversion ascomparedwith94%beforetheshelter-in-placeorder.
Theimplicationsofthisshiftinserviceprovisioncannotbereadilypredicted.Studieshavedemonstratedthegrowingavailabilityof mobilephonesandacceptabilityofreceivingremotehealthinterventionsamongindividualswithSMI(Biagiantietal.,2018;Firthetal., 2016;Naslundetal.,2016;Santesteban-Echarrietal.,2020).PriorresearchontheuseoftelehealthintheSMIpopulationhasmostlyevaluatedcomputerandWeb-basedapplications,remotemonitoring,and textnotificationprocessesratherthanuseoftelemedicineforcorecomponentsofcareforpeoplewithSMI(Ben-Zeevetal.,2019;LawesWickwaretal.,2018;Naslundetal.,2015;vanderKriekeetal., 2014;Williamsetal.,2019).AliteraturereviewbyNaslundandcolleaguesnotedrobustsupportforthefeasibilityandacceptabilityofmobile
technologiesforself-management,medicationadherence,psychoeducation, andsymptommonitoringbuthesitatedtodrawconclusionsonclinical outcomesgiventhemixedresultsfromthisresearch.Inanotherreview, vanderKriekeandcolleaguesobservedsuperiorityofthesetechnologiestousualcareinsupportingmedicationmanagement,psychoeducation, andshareddecisionmaking;however,thisfindingwastemperedbythe limitationofinconsistenciesincontrolconditionsofstudies.Themajority ofstudiesidentifiedbyLawes-Wickwarandcolleaguesassessed computer-assistedcognitiveremediation,includingself-directedcomputerbasedapplicationswithaliveclinician/trainerassistingthe clientratherthan remotedeliveryofservices.Takentogether,thisresearchindicatesthatmany mobileandcomputerizedinterventionsarefeasibleandacceptable,but furtherresearchisneededtoassesstheefficacyofotherformsof telehealthinterventionforpeoplewithSMI,includingtelemedicine.
Littlecontrolledresearchhasspecificallyevaluatedthesubstitutionoftelemedicineforin-personclinicalencountersforpeoplewith SMI,bothinevidence-basedmodelsoftreatmentandinothercommon interventionsforindividualswithSMI.Itisimportanttonotethattelemedicinecouldsubstituteforsomein-personofficevisitsaswellas community-basedvisitsinprogramsthatprovideservicesoutsidethe office.Thesedifferentialsubstitutionsarenotgenerallydiscussed.Nationalsurveydataindicatethattheuseoftelemedicineserviceshas growninfacilitiesprovidingassertivecommunitytreatment(ACT)at arateproportionaltoitsgrowthinallmentalhealthfacilities(Spivak etal.,2019).However,researchontheincorporationoftelemedicine modalitiesintoACTislimited.Severalrecentpilotstudieshavedescribedblendingtheuseofin-personwitheithervideoconferenceor telephonevisitsbyACTstaff(Blankersetal.,2016;Hulsboschetal., 2017;Stefancicetal.,2013;SwansonandTrestman,2018).ThesestudieshaveeithernotmeasuredoutcomedataspecifictotheACTinterventionorproducedmixedresults.Evaluationoftheincorporationof telemedicineintoIllnessManagementandRecovery(IMR)interventionsissimilarlylimited.Aclusterrandomizedcontrolledtrialexamininge-IMR,whichincludessomee-mailcorrespondencebetweenuser andprovideraspartofanapplicationmeanttosupplementstandard IMR,waslargelyinconclusiveduetoconfoundingandlowuseofthe e-IMRapplicationintheinterventiongroup(Beentjesetal.,2018). Wearenotawareofexamplesintheliteratureoftelephonicorvideoconferencebeingsubstitutedforin-personinteractionsinsupported employmentinterventions.
Outsideoftheseevidence-basedpractices,telephonicnursing supportformedicationadherenceinSMIpopulationswasassociated withreducedsymptomsseverity,reducedinpatientstays,andimproved medicationadherence(forreview,seeLawes-Wickwaretal.,2018). Anotherreviewoftelephone-onlypsychologicalinterventionsforrelapseprevention,medicationadherence,andhealthriskfactormanagementyieldedsomeresultsfavoringtelephone-onlyinterventions, althoughtheauthorsnotedtheneedformoremethodologicallyrigorousstudy(Bakeretal.,2018).Asmallobservationalstudyofuseof videophonesforthedeliveryofclinicalservicesinanintensivecase managementteamresultedinpositiveself-reportedsatisfactionfrom patients(Nievesetal.,2009).Intermsofproviderperspectives,arecent qualitativestudyofFederallyQualifiedHealthCenterandCommunity MentalHealthCenterleaderssuggestedamixedview,withproviders notingbothpositivesanddrawbacksofprovidingpsychiatricevaluation,medicationmanagement,andpsychotherapyviatelemedicine (Uscher-Pinesetal.,2020)
PATIENTANDPROVIDERPERSPECTIVESONCOVID-19 ANDTELEMEDICINE
Box1and2highlightthekeythemeswehaveexperiencedand observedregardingthepositivesandchallengesforbothpatientswith SMIandtheirprovidersusingtelemedicineduringtheCOVID-19pandemic.Patientthemes(Box1)aredrawnfromexplicitfeedbackwe
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Box1. AnecdotalSMIPatients’ PerspectivesonTelemedicine duringCOVID-19
Positives
• Reducedlogisticalandfinancialbarrierstocare
○
Moreconvenientandacceptabletomost,includinglesswaittime
○ Lesscostincludingtransportationtoparticipateincare
○ Easingoftravelchallengesforthosewithmobilitylimitationsor medicalfrailty
○ Lesstimedemandforthosewi themploymentandparenting obligations
• Reducedpersonalbarrierstocare
○
Physicalcomfortandconvenienceofbeinginone'sownsetting ratherthanunfamiliarclinicsetting
○
Additionalanonymityofthetelephoneovervideoconferencing, althoughmostarecomfortablewithcommunicatingviavideo
○ Reducedanxietyforpatientschallengedbysocialconnection (e.g.,extremesocialanxiety)
Challenges
• Logisticalbarriers
○
Lackofaprivatelocationinthehomesetting
○
Difficultyidentifyingaprivatemeetingspacefortheunstably housed
○
Limitationsinaccesstophoneservices,minutes,and/orInternet forsmartphones
○
VariabilityinqualityandconsistencyofInternetconnectivityfor thepatientandtheproviderwhoisteleworking
• Engagementanduserissues
○ Distractionsfromtheexternalenvironment
○
Psychiatricsymptoms,includingparanoia,and/orcognitiveimpairmentsimpedinguseofdevices
○ Concernsaboutsessionprivacyorbeingrecorded
○ Generaldislikeofvideomedium,includingaversiontoseeing oneselfonvideo
○
Limitationsforthosewithvisualorhearingimpairments
• Servicelimitation
○ Lossofcommunityintegration
○
Barrierstoconcreteserviceneeds(e.g.,supportininstrumental activitiesofdailyliving)
○ Barrierstorapid,hands-oninterventionwhenneeded(e.g.,crisis intervention)
○
Lackofengagementwithpeersingroupsorintheclinicalsetting
○ Inabilitytodropinorstopbyproviders
SMIhaveexpressedreceptivitytotelemedicinetreatment,possibly relatedtopreviousroutinetelephonecontact(e.g.,casemanagement), whereasothershavestruggledwithemotionalandlogisticalbarriers, thelatteroftenrelatedtolimitationsinfinancialmeans.Providerssimilarly havehadmixedreactionstodisruptionsoftheir “wayofconductingbusiness” andhaveexpressedconcernsregardingwhatthefuturewillhold.
Box2. AnecdotalSMIProviders’ PerspectiveonTelemedicine duringCOVID-19
Positives
• Reductionoflogisticalbarriers
○
Convenienceandefficiencyincludinglesstransitiontimeand greatereasewithdocumentation
○
Amenableandadaptabletomultipleservicetypesandlevelsofcare, fromAssertiveCommunityTreatmenttostandardofficeservice
• Clinicallyacceptable
○
Potentialreductioninnoshowandlateshowratesduetoconvenienceforpatients
○
Preservedobservationofpatientsandmonitoringofnonverbal communicationthroughvideoconference
○ Containmentofrisktoclinicianthroughphysicalseparation
○ Increasedcontroloverstartandstoptimes
○ Observingpatientsintheirownenvironmentsimilartoahomevisit
○ Increasedeaseofconnectingwithfamilyandothercollateralcontactpresentinthehome
Challenges
• Resistancetoadoption
○ Difficultyadaptingtonewtechnology
○
Generaldislikeoftelemedicinemedia,includingaversionto viewingoneselfonvideoanddifficultyengagingpatients
○ Fatiguefromextendeduseoftelemedicinemedia
• Processesneededforchangesinworkflow
○ Abilitytohavesimultaneouscapacitytodocumentwhileprovidingservice
○ Managingthelossofthespontaneousandinformalcontacts (“hallwayconversations”)betweenstaffwhosupportandimprovecare
○ Obtainingpresessionconsentsorassessmentsandusingtools (e.g.,handouts)
○
Maintainingprivacyincludingspecificplatformswithprocedurestomaintainprotectionofproviderpersonalinformation andcontentofthesession
Proceduresandworkflowsforremotecarecoordination
○
• Needforneworadditionalskills
○
havereceivedfrompatientsaswellasourexperienceswithhowpatientshaveorhavenotengagedwithtelemedicine,whereasprovider themes(Box2)aredrawnfromourownexperiencesandobservationsofpeers.
Thepatientandproviderresponsestotheshifttowardtelemedicinemustbeconsideredinthecontextofthesimultaneousimposition ofstay-at-homeorders,theshifttoteleworkformanyoftheclinicians, andotherchangesthathaveoccurredinthisperiod.Providersofalldisciplineshavefoundthemselveslivingintheworldoftelework,whereas patientsandprovidersalikehaveexperiencedsignificantlimitationsin theirtypicaldailyactivities,pursuits,andinteractions.Thishasledtoa numberofresponsesamongbothpatientsandproviders,includinganxiety,dysphoria,boredom,loneliness,sleepdifficulty,andsoon.Inaddition,utilizingtelemedicineinandofitselfhasrequiredsignificant adjustmentforprovidersandpatientsalike.Manyindividualswith
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•
○
Unique,activeclinicalstyleforengagementandrapport-building viavideoconferenceandtelephone
Learninghowtofacilitatepatients'psychologicaladjustmentto telemedicine
○ Cliniciantimemanagementandwork/nonworkboundarieswhen workingfromhome
Clinicallimitations
○
Lossofsomecomponentsofevaluation observingambulationand hygiene,obtainingvitals,laboratorytesting,andassessingsafety,particularlychallengingingeriatricandneuropsychiatricpatients
○
Lackofin-personconnection(i.e.,shakingahand,offeringatissue,reviewingaform)
○ Difficultyinassessingphysicalcuesand/orbodylanguage
○ Postponementordisconnectfromcareinpatientsuncomfortable withthemedia
○
Limitationstoencouragingsocialengagementinpatientsforwhom thismightbeatherapeuticintervention(e.g.,extremesocialanxiety)
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WhatRoleWillTelemedicinePlayinCommunity-Based TreatmentofPatientsWithSMIAfterthePandemic?
Inmostsituations,in-personservicesareanecessary,corecomponentofcommunity-basedcareforpeoplewithSMI.Yet,real-world experienceduringthepandemicsuggeststhattelemedicinehasmany advantagesandthereforeshouldcontinuetobeanoptionasonemethod fordeliveryofthiscare.Telemedicinecanenableprovidersandorganizationstoaccesshard-to-hireworkers,suchaspsychiatrists,whomaynot beabletobephysicallypresentinclinicsprovidingin-personcare. Telemedicineexpansionmaynotfullysolveworkforceshortages andmaysimplycreatecompetingjobopportunitiesthatreducethe in-personcommunitypsychiatricworkforceratherthanrecruitingnew talent.Still,telemedicinemayaddressscope-of-practiceissuesinsettings wheretherehasbeenadearthofonsitepsychiatrists.Inaddition,telemedicineenablesclinicianstohaveenhancedflexibilityinreaching patientswhoareunableorunwillingtomeetinpersonatallorasfrequentlyasneededtoaddresstheirneeds.
Althoughmostpatientsappreciatetheconvenienceoftelemedicinevisits,theyalsovalueseeingcliniciansinpersonatleastsomeof thetime.Theclinicalandfunctionalneedsofsomeindividualswith SMI,includingelementsofclinicalassessmentandgoalsofcommunityintegrationandsocialization,arechallengingorinsomecasesimpossibletomeetthroughtelemedicine.Thus,weenvisiontelemedicine notasareplacementforin-personcommunitymentalhealthcarebutas animportanttooltoincreaseaccesswhenin-personcareisnotfeasible ornecessary.Wecouldenvisionahybridsystem,inwhichtelemedicine andin-personcarearebothavailable,offeringflexibilityinservicesto patientsandproviders.Yet,researchisurgentlyneededtoclarifytheefficacyandharmsoftelemedicineforpeoplewithSMI.
CHALLENGESTHATWILLNEEDTOBEADDRESSEDIN ORDERTOMAINTAINTELEMEDICINEFORPEOPLE WITHSMIPOSTPANDEMIC
Research
Researchisneededtoestablishhowtelephoneand/orvideoconferencetelemedicineinteractionscanbemosteffectivelyutilizedasa replacementfororadjunctiveinterventionwithin-persontreatmentof individualswithSMI.Whichservicescanbeeffectivelydeliveredvia telemedicine?Forwhom,howoften,andinwhatsettings?Whatis thebestmixtureofin-personandtelemedicineservices?Aretheredifferencesintheacceptabilityofvideoconferenceversustelephone-only? Howbesttoadaptgroup-basedinterventions,suchasthoseneededfor psychosocialrehabilitation?Thenaturalexperimentofdeliveringservices viatelemedicineduringthepandemiccanproviderapidinformationtoanswersomeofthesequestions.Prospectivecomparativeeffectivenessstudieswillalsobeneeded.
CareDeliveryModels
WithfurtherresearchprovidingguidanceonwhatkindsoftelemedicinecanbeeffectiveforpeoplewithSMI,integrationofevidencebasedtelemedicineintocommunitymentalhealthservicesisexpected toleadtochangesinmodelsofcaredelivery,includinghowwerun clinicaloperations,manageatreatmentteam,coordinatehandoffsand dischargeplanningbetweencaresettings,andoverseeclinicalstaff.It mayalsoshiftthevolumeofpatientsagiventeamofcliniciansiscapableofseeinginagivenweek.Fromcheck-inprocesstopostvisitprocess,caredeliverymodelsthatincludetelemedicinemustattendto theoverallpatientandproviderexperience.Theclinicaldeliverymodel mustalsoaddresshowtodelivertelemedicineservicesinconcertwith in-personwork.Forexample,giventheimportanceofgroup-based
interventionsinrecovery-orientedandrehabilitativeservices,should someofthesecontinueutilizingtelemedicine,trainingandlogistical needswillneedattentiontomaintainqualityofservices.Webelievea hybridmodeltobetheapproachtoservethewidestrangeofpatients whoneedservicesforSMI.Creatingthiskindofintegrativecaredeliverymodelwillbeimportantinthecontextoftheinevitablechangesto financialandpolicyofmentalhealthdelivery.
Payment
Telemedicinecannotcontinueunlessthefinancialincentivesto dosoremaininplace.Overallpaymentequityfortheseservicesis needed(Shacharetal.,2020).Underpaymentequity,telemedicineservicesshouldbereimbursedtocovercostofcare.Thecostofproviding atelemedicinevisitislikelysimilartobutmaybesomewhatlessthan in-personvisits,astelemedicinevisitstendtobeshorterandtoinclude fewercomplexdiagnosticmeasures.Thus,paymentsmaybesomewhat lowerunderapaymentequitymodel,butmuchhigherthantheywere beforethepandemicinmostsystems.Inaddition,paymentfortelephonebasedcareshouldcontinuetoensureaccessforindividualswithout thecapacitytousevideoconferenceaswellasthemostvulnerablepatientswhoaretheleastlikelytohavethepersonalandfinancialresourcestousevideotelemedicine.Maintainingthechangestopayment willrequirelegislationatthefederallevelaswellasregulatorychanges withinMedicare,stateMedicaidprograms,andtheprivateinsurance industry.Importantly,inorderfortelemedicinetotrulyovercomedistancebarriers,itwillneedtobereconceptualizedtoreflectactualdeliverymodels,inwhichthe “originatingandreceivingsites” describedin federalregulationnowincludehomeofficesandpatient'shomes.
Privacy
Werecommendcautionregardingmaintainingtheflexibilityin HIPAAenforcementintroducedduringtheCOVID-19crisis,given theimportanceofpreservingpatientconfidentiality.Areturntotheenforcementofcertainsafeguardsmaybewarranted.However,giventhat telemedicinehasbecomeapriorityforcommunitymentalhealth,regulationsregardingprivacycouldadoptthestancethatproperconsent tousethetelephoneandvideoconferencingforcare,withclarityon limitationstoprivacy,issufficient.
Access
Inorderforaccesstobeequitable,peoplewithSMImayneed financialsupporttoobtainandmaintaindevicesthatenabletelemedicine,suchastheSafeLinkWirelesstelephoneprograms,toaccessphones andphoneminutes.Medicaidprogramsmaywishtofurthersupportpatients'phoneplans.SomepeoplewithSMIwillalsoneedtechnicalsupportsuchastrainingonbasicskillsforusingadevicefortelephoneor videoconferencevisits.Forexample,adigitalnavigatororclinicaltechnologyspecialist(Ben-Zeevetal.,2015)canassesspatientneedsfor usingtelephoneandvideoconference,andsupportpatientsindevelopingtheskillsneededtousetheirdevicestosupportclinicalcare.
WorkforceTrainingandSupervision
Toharnessthecapacityfortelemedicinetoimproveaccessand maintainqualityincommunitymentalhealthcare,workerswillneed trainingonhowtousetelemedicineeffectively.Asresearchestablishes whenandhowtoconductandusetelemedicine,educationalprograms willneedtoincorporatethisinformation.Inaddition,trainingprograms andclinicalserviceleaderswillneedtoestablishbestpracticesfor monitoringqualityintelemedicinecare.Theabilityofdevicesandtelemedicineplatformstoincludesupervisorsandtorecordsessionsmay actuallyimprovecapacitiesforsupervisionandqualitymonitoring.
©2020WoltersKluwerHealth,Inc.Allrightsreserved.
CONCLUSIONS
AmidstthechallengesanduncertaintyofCOVID-19,weshare theemergingviewthatthisunexpectedexperimentofdramaticallyincreasedprovisionoftelemedicineservicestoindividualswithSMIisan opportuneturningpoint(Ben-Zeev,2020).Acknowledgingtheanecdotalnatureoftheobservationsnotedhere,weurgeimplementation ofresearchtofurtherstudytelemedicineforpeoplewithSMI.Inaddition,weurgestakeholdersincommunitymentalhealthtocarefullyconsiderhowtelemedicine'sflexibilityandaccessibilityfurthersthevision ofpatient-centered,recovery-orientedcare.
Ourfocushasbeenonevidenceandreflectionsrelatedtooutpatientorcommunity-basedinterventionsforindividualswithSMI,where mostoftheircaretakesplace.Thisisnottosuggestthatinpatient, consultation-liaison,andemergencydepartmentserviceshavenotonly experiencedupheavalandtransitioninresponsetothepandemicbut alsonecessitatedtelemedicineservices(Lietal.,2020);however,telemedicineintheseservicesisbeyondthescopeofthisdiscussion.
Aswehavenoted,somepitfallsareapparentintelemedicinecare forpeoplewithSMI,andtheuniquepowerofin-personinteractionsto fosterconnectionandcommunityintegrationshouldnotbediscounted. Assuch,wedonotadvocateforpolicyorpracticeshiftsthatwould promptthefullreplacementofin-personinteractionswithtelemedicine forindividualswithSMI.Rather,weencourageproviders,administrators, regulators,andpolicymakerstoconsiderleveragingtelemedicinetocomplimentin-personcareandextendservicedelivery,maximizingaccess,efficacy,andappealofservicesforourmostvulnerablepatientswithSMI.
DISCLOSURE
DavidA.Adler,MD,isaco-founderofHealthandProductivity Scienceswhohasnoassetsandhasbeenaninvestigatoronresearch grantsfromJanssenPharmaceuticals.Theremainingauthorsdeclare noconflictofinterest.
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