Use of Tele–Mental Health in Conjunction With In-Person Care: A Qualitative Exploration of Implementation Models
Abstract
Objective:
Although use of tele–mental health services is growing, there is limited research on how tele–mental health is deployed. This project aimed to describe how health centers use tele–mental health in conjunction with in-person care.
Methods:
The 2018 Substance Abuse and Mental Health Services Administration Behavioral Health Treatment Services Locator database was used to identify community mental health centers and federally qualified health centers with telehealth capabilities. Maximum diversity sampling was applied to recruit health center leaders to participate in semistructured interviews. Inductive and deductive approaches were used to develop site summaries, and a matrix analysis was conducted to identify and refine themes.
Results:
Twenty health centers in 14 states participated. All health centers used telepsychiatry for diagnostic assessment and medication prescribing, and 10 also offered therapy via telehealth. Some health centers used their own staff to provide tele–mental health services, whereas others contracted with external providers. In most health centers, tele–mental health was used as an adjunct to in-person care. In choosing between tele–mental health and in-person care, health centers often considered patient preference, patient acuity, and insurance status or payer. Although most health centers planned to continue offering tele–mental health, participants noted drawbacks, including less patient engagement, challenges sharing information within the care team, and greater inefficiency.
Conclusions:
Tele–mental health is generally used as an adjunct to in-person care. The results of this study can inform policy makers and clinicians regarding the various delivery models that incorporate tele–mental health.
HIGHLIGHTS
•
Health centers offered a range of tele–mental health services; however, diagnostic assessment and medication prescribing were the most common.
•
Tele–mental health was an adjunct to in-person care.
•
In choosing between tele–mental health and in-person care, health centers often considered patient acuity.
•
Drawbacks to tele–mental health—including less patient engagement, challenges sharing information within the care team, and greater inefficiency—may be partially mitigated by providing tele–mental health services alongside in-person services and by providing a mix of telehealth and in-person services to the same patient.
Despite the high burden of mental illness in the United States, many patients lack access to specialty mental health providers. According to data from 2018, 115 million Americans live in a mental health professional shortage area (1).
Tele–mental health, in the form of interactive videoconferencing between a patient and provider, can increase access to specialty mental health services. Research suggests that tele–mental health and in-person care are equivalent in terms of quality and that tele–mental health can expand the mental health workforce by making it easier for retirees and part-time workers to provide care (2, 3).
The use of tele–mental health is growing rapidly (4, 5). In 2016, 38% of federally qualified health centers (FQHCs) reported offering telehealth, with tele–mental health as a common application (6). A 2017 survey of 329 U.S. behavioral health organizations found that 48% used tele–mental health for a range of services, including medication management, individual and group counseling, assessment, consultation, and crisis services (7).
Despite this growth, there is limited research on how tele–mental health is deployed and how it is used in conjunction with in-person care (8). Prior research has focused primarily on identifying barriers to establishing and sustaining tele-mental health or assessing provider and patient satisfaction, typically within the context of select programs (9–14). Health care providers lack practical examples and guidance on how and why to use tele–mental health rather than in-person care for certain services and patient populations. To address this gap, we interviewed representatives from community mental health centers (CMHCs) and FQHCs that use tele–mental health. The goal was to understand how various tele–mental health services are used, both in isolation and in combination; the role of tele–mental health versus in-person services; and the patient factors that affect the decision to offer tele–mental health services rather than in-person care. Our goal is to inform policy makers and clinicians regarding the various delivery models that incorporate tele–mental health.
Methods
Study Participants and Sampling Strategy
The Substance Abuse and Mental Health Services Administration (SAMHSA) tracks organizations providing behavioral health services in the United States, including information such as location, facility type, service setting, treatment approaches, and provision of telehealth services (yes/no). To develop a sampling frame, we identified the CMHCs and FQHCs in the 2018 SAMHSA Behavioral Health Treatment Services Locator database (https://findtreatment.samhsa.gov/) with telehealth capabilities (N=1,319 of 2,748 such clinics; 48%). We focused on CMHCs and FQHCs because of their critical role in serving vulnerable populations.
To represent the diversity of experiences with tele–mental health among participating organizations, we used maximum-variation sampling. First, we selected 20 states that varied with respect to region, percentage of rural population, and state tele–mental health policy and focused our recruiting on CMHCs and FQHCs in those states (15). We then randomly selected organizations to participate until we reached thematic saturation, defined as the point at which new interviews uncovered no new themes.
Interviews
We invited health center leaders to participate in a 60-minute telephone interview. Interviewees were given a $50 gift card and provided verbal informed consent. From February to April 2019, we completed a total of 20 semistructured interviews.
Interviews followed a semistructured protocol informed by the Consolidated Framework for Implementation Research (16, 17). Topics included history of the tele–mental health program, current tele–mental health services, relationships between originating and distant sites, tele–mental health program goals, the role of tele–mental health in the context of in-person care, and how providers decide whether to offer tele–mental health to specific patients. Interviews were recorded and transcribed. Harvard University’s institutional review board approved this study.
Analysis
Interview transcripts were uploaded into Dedoose (2019), a cloud-based, qualitative-analysis program. We employed an inductive and deductive approach to develop a site summary template for each health center. The summary covered codes mapped to key research questions addressed within the interview protocol as well as codes that emerged during the interviews. We then conducted a supplemental matrix analysis, listing health centers as rows and listing salient categories that we developed from codes included in the site summaries as columns (18). To facilitate cross-site comparisons, the matrix allowed us to interpret each participant’s remarks in the context of the health center’s particular tele–mental health services and models. (Additional details on our analyses can be found in the online supplement .)
Results
A total of 20 health centers (nine FQHCs and 11 CMHCs) from 14 different states participated (Figure 1). Thirteen health centers are located in rural areas only, and six have locations in both rural and urban areas (Table 1). Health center staff who participated in interviews included chief operating officers or presidents (N=6), chief operating officers (N=3), executive directors (N=3), clinical directors (N=3), and other staff (N=5).
FIGURE 1. States represented in a sample of 20 health centers with a tele–mental health programa
aFQHC, federally qualified health center; CMHC, community mental health center.
| Characteristic | N | % |
|---|---|---|
| Region | ||
| Northeast | 3 | 15 |
| West | 7 | 35 |
| South | 8 | 40 |
| Midwest | 2 | 10 |
| N of clinic sites | ||
| 2–5 | 7 | 35 |
| 7–10 | 10 | 50 |
| ≥11 | 3 | 15 |
| Location of clinic sites | ||
| Rural only | 13 | 65 |
| Urban only | 1 | 5 |
| Mix of rural and urban | 6 | 30 |
| Percentage of patients with Medicaid | ||
| ≤50 | 8 | 40 |
| 51–69 | 8 | 40 |
| ≥70 | 4 | 20 |
How Tele–mental Health Is Used
Participants distinguished between tele–mental health services provided at the health center and services provided by health center staff to patients in the community who receive care at other sites. All health centers in our sample offered tele–mental health services to their own patients, but only some provided tele–mental health services for other organizations.
Services for health center patients.
All of the health centers offered telepsychiatry for diagnostic assessment and medication prescribing. These were the only tele–mental health services offered at six health centers (two CMHCs and four FQHCs). Ten health centers (six CMHCs and four FQHCs) also offered therapy via videoconferencing, typically through individual therapy, although several health centers offered group therapy via videoconferencing. Six health centers provided telehealth services for substance use disorders, including assessment, counseling, and prescribing (Table 2).
| State and facility type | Telepsychiatry | Therapy via telehealth | Other telehealth services |
|---|---|---|---|
| Arizona | |||
| CMHC | PNP employed by health center (but located out of state) provides medication management | LCSWs employed by health center (who also see patients in person) conduct therapy at understaffed clinic locations | Substance use disorder services by PNP |
| CMHC | Contracts with telemedicine vendor for PNP for medication management | None | None |
| Arkansas | |||
| CMHC | Contracts with independent child psychiatrist for medication management, initial psychiatric evaluations, and update evaluations | None | None |
| California | |||
| FQHC | Contracts with telemedicine vendor for psychiatrists for medication management | LCSWs employed by health center (who also see patients in-person) conduct therapy at understaffed clinic locations | None |
| FQHC | Psychiatrists employed by health center provide medication management to understaffed clinic sites | None | None |
| Georgia | |||
| CMHC | Contracts with a telemedicine vendor for medication management by PNPs | None | None |
| Indiana | |||
| CMHC | Contracts with independent psychiatrist and PNP for medication management; PNP employed by health center (who also sees patients in person) is available on an emergency basis for understaffed clinic sites | None | Substance use disorder services by PNP and psychiatrist |
| Kansas | |||
| CMHC | Contracts with a telemedicine vendor for child psychiatrist and midlevel general provider; psychiatrist employed by health center. All provide medication management | Staff employed by health center conduct therapy (small program in case-by-case basis) | None |
| Louisiana | |||
| FQHC | Contracts with academic medical center for second opinion by child and adult psychiatrists on complex cases and uses PNP employed by health center (who also sees patients in person) for medication management | None | None |
| Maine | |||
| CMHC | Contracts with telemedicine vendor for medication management by psychiatrists | LCSWs employed by health center conduct therapy with Medicare patients; group therapy for sexual assault program conducted by staff employed by health center | None |
| Montana | |||
| CMHC | PNPs employed by health center (who also see patients in person) provide medication management to understaffed clinic sites | LCSWs employed by health center conduct therapy with Medicare patients | None |
| New York | |||
| FQHC | Contracts with independent psychiatrist for medication management | None | None |
| FQHC | Contracts with adult and child psychiatrists and neurologists at academic medical center and another FQHC (all within their in-person referral networks) for medication management | Contracts with staff member at another FQHC for bilingual counseling services; LMHCs and LCSWs employed by health center conduct therapy | Substance use disorder services by primary care providers and peer counselors after an initial in-person visit |
| Oregon | |||
| CMHC | Contracts with a telemedicine vendor for medication management by PNP and child psychiatrist | None | None |
| CMHC | Contracts with telemedicine vendor and uses own (off site) staff psychiatrists and PNPs for medication management and psychiatric screening | Staff employed by health center conduct individual therapy, family therapy, and peer counseling | Offers substance use disorder services by psychiatrists and NPs to complement in-person substance use disorder treatment. Patients in school-based clinic receive counseling and prescribing services via video |
| Tennessee | |||
| FQHC | Contracts with telemedicine vendor for medication management by child psychiatrist | None | Substance use disorder services with LCSW |
| Texas | |||
| CMHC | PNPs and psychiatrists employed by health center (who also see patients in person) provide medication management to understaffed clinic sites | Staff employed by health center conduct therapy (small program in case-by-case basis) | Intakes at all understaffed rural sites conducted via video by LPCs or LCSWs employed by health center; crisis-service coverage for 48-hour extended observation |
| CMHC | Contracts with health center cooperative for psychiatrists and uses own staff for intakes and medication management | None | Psychiatrists employed by health center provide crisis assessments to facilities in their network |
| CMHC | Contracts with telemedicine vendor for double-boarded psychiatrists and uses own staff PNPs and psychiatrists (some who also see patients in person and others who are exclusively telehealth providers) | Multiple types of providers conduct cognitive-behavioral therapy, cognitive processing therapy, rehabilitation skills training, and group therapy | None |
| West Virginia | |||
| FQHC | Contracts with independent psychiatrist (former employee) for medication management | Contracts with independent LCSW (former employee) for individual and group therapy | Substance use disorder services with LCSW |
a
CMHC, community mental health center; FQHC, federally qualified health center; LCSW, licensed clinical social worker; LPC, licensed professional counselor; NP, nurse practitioner; PNP, psychiatric nurse practitioner.
Staffing models for telepsychiatry varied across sites. Some health centers used their own on-site and off-site behavioral health staff, including psychiatric nurse practitioners (PNPs) and psychiatrists, to serve understaffed locations within their own network. Others contracted with telemedicine vendors or independent providers. Health centers used PNPs for medication management services as often as they use psychiatrists and typically serve both adults and children. In contrast, most telehealth services for various forms of therapy were provided by health center staff rather than by contracted providers.
Most health centers require patients to receive tele–mental health services at a physical clinic site. A few health centers provided tele–mental health in patients’ homes. One Oregon CMHC described a small-scale program in which patients receive most mental health services from home via videoconferencing after completing an initial, in-person intake.
Services at community sites.
In addition to hosting patients receiving tele–mental health, five health centers (4 CMHCs and 1 FQHC) provided tele–mental health services to various community organizations that host patients. At the FQHC, providers with a waiver to prescribe buprenorphine offered medications for opioid use disorder to patients at a freestanding substance abuse counseling center. The four CMHCs reported providing crisis screening, mental health assessment, counseling, and medication management with various community organizations, including detention centers, law enforcement offices, schools, hospitals, jails, and other CMHCs. Two CMHCs used tele–mental health to conduct crisis screening at local hospitals, eliminating the need for providers to travel to the hospital.
Tele–mental health and in-person care.
In most health centers, patients receiving tele–mental health services also received in-person care. In-person services usually included psychotherapy and case management and less commonly included skills training, supported employment, supportive housing, and peer support. A few health centers require that all initial mental health assessments be conducted in person with on-site clinicians. Patients are then referred to telepsychiatry if the assessment suggests a need for medication initiation and management. Several interview participants believed that patient engagement is better when tele–mental health is combined with in-person touchpoints.
Goals and Benefits of Tele–mental Health
Interviewees described numerous reasons for why their clinics started and maintain a telehealth program. Most reasons focused on improving access, including reducing wait times or offering specific services (e.g., medication management, child psychiatry). Often the decision to establish tele–mental health was precipitated by the inability to recruit or maintain in-person providers. In several cases, health centers started offering tele–mental health services to address a vacancy caused by the departure of a provider or to continue working with a provider who moved out of state (Table 3).
| Theme | Illustrative quote |
|---|---|
| By offering tele–mental health, health centers can introduce a care model that can be reimbursed | “We [CMHC in Maine] added therapy with LCSWs to our existing tele–mental health services because although several types of licensed providers were providing in-person therapy here, psychotherapy services by providers other than LCSWs and psychologists were not reimbursed by Medicare. Providing therapy through telehealth allowed Medicare patients at any location in our network to receive billable services even if their specific clinic location did not have in-person LCSWs.” |
| Patient engagement is better when tele–mental health is combined with in-person touchpoints | “It's a mix. Yeah. Nobody's receiving everything [via telehealth]. . . . I don't know that this is valid, statistically, or have any kind of data, I haven't seen anything, but it's engagement. I mean, you need to look the guy in the eyes and have a conversation with him. It's not the same via video.” |
| Teletherapy is not equivalent to in-person therapy with respect to quality | “But, I think it’s [therapy with telehealth] different than telepsychiatry and that I think you would lose more, because therapy is relationship-based, and that making that connection, I think that's harder to do over a screen versus asking face to face, ‘How are your medications working… how is your sleep?’ ” |
| Confidentiality and safety concerns prevent some health centers from offering tele–mental health in patients’ homes | “[Tele-mental health in the home] was something that we discussed and that decision was based on the lack of confidentiality at the patient's home. For instance, we have problems with domestic violence. We didn't feel like it was a good idea to encourage patients to have a conversation with a therapist where they open up about everything, including the people in their lives, and leave their confidentiality up to them, when they might not even understand the risk.” |
| Patients feel less connected to tele–mental providers because of limitations of a video encounter | “It seems to be very difficult for the prescriber to pick up on humor when somebody is trying to be funny about something, so there tends to be miscommunication.; “When we move telepsychiatry into a clinic, we see our no-show rates increasing. So the people who vote by filling out the [patient satisfaction] survey are fine with it, but the people who vote with their feet are not coming in for visits.” |
| Tele–mental health hampers information sharing among members of the care team | “Building a team around services when one of the key providers is not co-located is a challenge. . . . Just in terms of sharing information . . . like in one site we have somebody go to the state hospital and then later get discharged and re-enter services, and nobody had told the nurse practitioner [who provides medication management via telehealth].” |
| Patients are given the option to see a provider in person or via telemedicine. | “Whatever the patient wants. We always offer it, so if a patient looks at us like we're nuts when we say, ‘Hey do you want to see your counselor by video?’ And if they say, ‘No, I'm not interested,’ well then that ends that discussion. We're very up front with patients and say, ‘We use telehealth to provide you more access. You have more options if you're willing to use the program with telehealth.’ ” |
a
LCSW, licensed clinical social worker.
Reasons for Not Offering Specific Tele–mental Health Services
Several health center representatives mentioned that they do not offer psychotherapy as a telehealth service because of lower perceived need for providers; these health centers were able to recruit and retain therapists to provide in-person services. Also, several interviewees mentioned perceptions that the quality of psychotherapy provided through telehealth was inferior to that of in-person psychotherapy. Other, less common reasons for not offering teletherapy included limited bandwidth (“not good to have someone come in for a therapy appointment, ready to pour out their heart or share all their struggles, and then you have a bad Internet connection, or [there are] glitches”); concerns that no-show rates would be too high; and belief that therapy is a “gateway” service that should be offered in person. A handful of participants noted that they did not offer tele–mental health in patients’ homes because of lack of reimbursement and concerns about maintaining confidentiality and safety.
Drawbacks of Implemented Models Of Tele–mental Health
Several health center staff believed patients felt less connected to tele–mental health providers because of limitations of a video encounter. They argued that video technology can be “a bit of a barrier to the patient-provider relationship,” making it more challenging to establish rapport. Second, several interview participants mentioned that tele–mental health hampers information sharing and communication among members of the care team. Third, several health center staff believed that tele–mental health is less efficient than in-person services, given that it requires extra staff and new steps in the workflow. Fourth, a couple participants mentioned that tele–mental health providers cannot perform certain aspects of the mental status exam, such as an assessment of the patient’s hygiene. Finally, several FQHC representatives observed that tele–mental health seems less well-suited to providing same-day “warm hand-offs” between primary care and mental health providers, which are crucial to integrated mental health services. Tele–mental health may be less conducive to warm hand-offs because primary care providers prefer to do hand-offs with in-person providers, setting up telehealth equipment can be time consuming, and the availability of tele–mental health providers is limited.
Decision to Offer Tele–mental Health Rather Than In-person Services
At many health centers, certain services were available only through a video connection. When services could be provided in person or via video, a number of factors influenced the decision to offer tele–mental health. Leading considerations included patient preference in the context of wait times and patient acuity. Representatives of several health centers explained that they offer both options to patients. To be responsive to patient’s preferences, these centers provide patients with information on wait times for in-person and telehealth services and allow patients to choose between the two.
Acuity also influenced the decision to offer tele–mental health to individual patients. At a CMHC in Montana, PNPs prescribed medication in person at the urban clinic locations and via videoconferencing in the clinic’s smaller, rural locations. Health center leaders preferred that higher acuity patients in the rural locations be seen in person if the PNP is able to travel to those sites. At a West Virginia FQHC, therapy was not offered via videoconference to high-risk patients, including those with suicidal or homicidal ideation. In contrast, the in-person providers in several health centers, were midlevel providers, and the remote providers were psychiatrists. At these centers, tele–mental health was reserved for higher acuity patients with more complex histories.
A handful of interviewees mentioned the role of insurance in deciding who is offered tele–mental health. Two health centers excluded Medicare patients from tele–mental health services because Medicare would not reimburse the patients’ care with that particular delivery model. Medicare requires that therapy services (both in person or via video) be delivered by certain types of health care providers, including licensed clinical social workers (LCSWs), and if a health center uses other types of staff in its telehealth therapy model, it cannot be reimbursed for the video-enabled visit. Furthermore, a few health centers arrange for Medicare patients to receive therapy services via telehealth with LCSWs because the services are eligible for reimbursement, even though such services would typically be provided in person with other types of providers.
Future Plans for Tele–mental Health
Nearly all interview participants felt that tele–mental health services were a permanent solution to workforce shortages. Whether viewed as a “necessary evil” or—more optimistically—as “Plan B,” tele–mental health services were considered a required service because of difficulty recruiting or retaining in-person providers. Many health centers described future plans to actively expand tele–mental health services by providing video-enabled psychotherapy and group therapy and by offering services in patients’ homes. Participants also discussed becoming distant-site providers and serving schools, jails, and emergency rooms.
Discussion
Health centers offer a range of tele–mental health services. Diagnostic assessment and medication prescribing were the most commonly provided. Consistent with our prior quantitative work, we found that at most health centers, patients who received tele–mental health services also received some in-person care (4).
Although a handful of studies have described the tele–mental health services offered by community health centers (7, 19, 20), ours is the first to describe how the various delivery models are integrated with in-person care. We hope these results, in combination with related quantitative analyses (4, 5, 21), can inform other health centers on the various options for structuring tele–mental health programs and how to decide when to offer tele–mental health rather than in-person care. Future research should continue to characterize different emerging models and explore the impact of various delivery models on patients’ experience and outcomes.
Although many health centers employ behavioral health staff, only a subset of health centers in our study deployed behavioral health staff to provide tele–mental health to community organizations that host patients. This is a rational policy if all existing staff are working at their highest capacity, but when there is some excess capacity, health centers can both help patients in need and benefit financially by deploying salaried staff to serve community partners.
The drawbacks to tele–mental health identified here may be partially mitigated when tele–mental health services coexist alongside in-person services and when health center providers provide a mix of telehealth and in-person services to the same patient. For example, perhaps the therapeutic alliance would be strengthened if health center therapists required occasional in-person visits. Also, no-show rates may be improved if tele–mental health visits included some time for patients to interact in person with other health center staff. Health centers have employed a number of these types of strategies to increase patient engagement with tele–mental health (e.g., requiring all intake interviews to be conducted in person prior to referral to telehealth), but few have been formally tested.
A key limitation of this research was that the sample included only CMHCs and FQHCs. As such, the themes we identified may not apply to other behavioral health organizations. Also, we interviewed different types of health centers leaders, including clinicians and nonclinicians, who may have different perspectives, and could not compare the characteristics of urban versus rural telehealth programs because of sample size.
Conclusions
CMHCs and FQHCs deploy tele–mental health to complement in-person care. Although most health center representatives consider tele–mental health to have drawbacks compared with in-person care, most concede that these services are a permanent feature in the delivery of mental health services to underserved populations. If carefully designed and implemented, tele–mental health can help make care more integrated, patient centered, and accessible.
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Information & Authors
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History
Received: 29 July 2019
Revision received: 11 October 2019
Accepted: 15 November 2019
Published online: 30 January 2020
Published in print: May 01, 2020
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Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
National Institute of Mental Healthhttp://dx.doi.org/10.13039/100000025: RO1 MH112829
This project was supported by the National Institute of Mental Health (RO1 MH112829).Metrics & Citations
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