The Transition of Academic Mental Health Clinics to Telehealth During the COVID-19 Pandemic

At the federal level in the United States, multiple legal, regulatory, and reimbursement changes facilitated shifts in health care service delivery. The Office for Civil Rights (OCR) of the Department of Health and Human Services announced that it would “exercise its enforcement discretion” and “not impose penalties for noncompliance with the regulatory requirements” under the Health Insurance and Portability Accountability Act (HIPAA).United States Department of Health and Human Services
Health Insurance Portability and Accountability Act of 1996. August 21, 1996.,United States Department of Health and Human Services
Notification of enforcement discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. This flexibility covered health care providers in connection with the good faith provision of telehealth (ie, real-time, interactive services delivered directly to patients through telephone and/or videoconferencing) specifically during the pandemic.United States Department of Health and Human Services
Notification of enforcement discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. The OCR indicated, under this notice, that health care providers could use non−public facing popular applications that allow for videoconferencing to provide telehealth services without risk of the OCR seeking to impose a penalty for noncompliance with the HIPAA Rules. The Drug Enforcement Administration (DEA) adopted policies during the pandemic allowing DEA-registered providers to prescribe controlled substances without an in-person examination.Drug Enforcement Administration Diversion Control Division
How to prescribe controlled substances to patients during the COVID-19 public health emergency. Most states modified their licensure requirements during the crisis, with significant state-by-state variability.Federation of State Medical Boards. U.S. states and territories modifying licensure requirements for physicians in response to COVID-19. The Centers for Medicare and Medicaid Services (CMS) expanded telehealth reimbursement during the pandemic, including expanding coverage for psychotherapy, assessment, and intervention, as well as other behavioral health services to be delivered via telephone.Centers for Medicare and Medicaid Services
COVID-19 emergency declaration blanket waivers for health care providers. August 20, 2020.Discussion

To our knowledge, this is the first description of the experience of a consortium of academic child and adolescent psychiatry outpatient programs in rapidly pivoting from traditional in-person services to home-based telehealth services during the COVID-19 pandemic, or any other crisis. Our aims were to describe telehealth service delivery before and during the early stages of the COVID-19 pandemic with respect to telehealth practices, service use, and barriers to telehealth service delivery. Based on the data and experiences of the consortium, we provide recommendations to inform and support future development and evaluation of telehealth services.

COVID-19 was a “disrupter” of child and adolescent psychiatric practice. Programs rapidly pivoted to home-based telehealth practice to continue providing care for their patients, while following site and state/province recommendations to shelter at home at the start of the pandemic. This rapid transition created new stressors for providers and families,Doan B.T. Yang Y.B. Romanchych E. et al.From pandemic to progression: an educational framework for the implementation of virtual mental health care for children and youth as a response to COVID-19. including coping with stressors related to sheltering at home, managing home schooling, and, for some individuals, sharing devices and Internet bandwidth. Each program paved its own way to delivering home-based telehealth services in the context of local regulatory requirements, reimbursement environment, hospital resources, patient clinical needs, and patient and provider receptivity. As evidenced by our use data, all programs transitioned to providing home-based telehealth services, noting a decrease in some barriers (eg, billing, reimbursement, technology support) and persistence of others (eg, liability, cost of equipment, discomfort with technology, cultural concerns).

Each program’s experience transitioning from in-person to telehealth service delivery varied in part because of differences in site and state/province telehealth practices pre−COVID-19. In order for some programs to offer home-based telehealth services, regulations had to change first. Most of the participating sites provided some telehealth services prior to the pandemic, but there were differences related to the amount offered, allowable locations for providers and patients, number of providers experienced with the modality, and the established infrastructure to support telehealth services. These differences likely contributed to how easily sites transitioned to home-based telehealth.

After the COVID-19 pandemic began, all sites moved to offering predominately home-based telehealth, rather than in-person, services. The majority of sites were able to bill, had specific documentation requirements, and trained their staff with regard to telehealth services and safety protocols. Not only did programs have to modify their existing practices, but many individual providers experienced abrupt changes, as many were naive to telehealth and had to learn a new skill set not only for use of the technology but also for tasks such as billing (ie, per Current Procedural Terminology [CPT]),American Medical Association
CPT (Current Procedural Terminology). documentation, safety, and secure service delivery. Regarding safety, consortium sites anecdotally noted that their providers encountered new clinical challenges in transitioning to home-based telehealth practice because of lack of familiarity with the privacy and safety of the home and the resources in the community.

Schoenfelder Gonzalez E, Myers K, Thompson EE, King DA, Glass AM, Penfold RB. Developing home-based telemental health services for youth: practices from the SUAY Study. J Telemed Telecare. July 2019 [ePub]. Accessed April 18, 2020. https://doi.org/10.1177/1357633X19863208

,Luxton D.D. O’Brien K. McCann R.A. Mishkind M.C. Home-based telemental health care safety planning: what you need to know. Each program developed its own approach, ranging from screening for suicidality with a rating scale, to sending explanatory letters to families regarding the technology and clinical processes, to a protocol assessing the availability of a private space as well as safety risks with documentation of community resources in case of potential harm. Going forward, safety protocols are needed to ensure a standard of care comparable to that of clinic-based telehealth, as well as to traditional in-person care.American Academy of Child and Adolescent Psychiatry Committee on Telepsychiatry and the Committee on Quality Issues
Clinical Update for Telepsychiatry with Children and Adolescents. Programs would benefit from retaining and consistently updating telehealth practices and provider training, as this will allow for more nimble shifts between in-person and telehealth services as needed. Ongoing training of providers to master technology-mediated clinical service and to implement safety protocols should increase competence and reduce provider stress in delivering telehealth services. Safety protocols will help providers to be prepared for possible adverse events such as suicidality, aggression, or family emergencies,

Schoenfelder Gonzalez E, Myers K, Thompson EE, King DA, Glass AM, Penfold RB. Developing home-based telemental health services for youth: practices from the SUAY Study. J Telemed Telecare. July 2019 [ePub]. Accessed April 18, 2020. https://doi.org/10.1177/1357633X19863208

,Luxton D.D. O’Brien K. McCann R.A. Mishkind M.C. Home-based telemental health care safety planning: what you need to know. as well as “zoombombing” (ie, intrusion of uninvited individuals into sessions). In the future, telehealth experiences should ideally start during training (eg, residency and fellowship) so that new providers are ready to integrate telehealth into their practices, not only for crisis services but for routine care that diversifies their practice options and promotes access for families.

Despite the programs’ differences, all pivoted their follow-up services from in-person to home-based telehealth on the same timeline. Service use was likely underreported by sites who were not able to fully capture the amount of telephony provided because of limitations with billing codes and EMR encounter tracking. While accommodating for program-specific telehealth ramp-up considerations (eg, credentialing, training, software licensing, technology support, prescription regulations), the current study shows that sites generally prioritized transitioning established patients’ care first and had to delay enrolling new patients; about half of the sites achieved pre-pandemic intake levels within a month. No-show rates for telehealth in 2020 varied across sites but were not dramatically different from 2019 rates for traditional in-person care; this was of interest because colloquially it was perceived that telehealth no-show rates were lower.

Use data also revealed that all programs experienced a lag in establishing tele-group interventions. Establishing tele-group services requires considerable extra administrative coordination. For example, although videoconferencing platforms integrated with the EMR facilitate access to individual appointments, additional steps outside of the EMR may be required to access group appointments. Time is also required to adapt clinical interventions to the virtual modality, and some group interventions may be more adaptable to telehealth than others (eg, parent-training programs versus children’s group anxiety programs).

Sasser T, Rutter T, Gurtovenko K, et al. Rapid adaptation and acceptability of telegroup delivery of evidence-based treatments for youth during COVID-19. Poster presented at the American Academy of Child and Adolescent Psychiatry Annual Meeting (Virtual), October 12−24, 2020.

No site reached pre-pandemic rates of group therapy within the study window.

Based on the Consortium’s experience and use data, we recommend that programs planning to use telehealth in the future develop sustainable data collection systems for tracking telehealth service use. Programs should build visit types in the EMR that distinguish in-clinic versus home-based videoconferencing and telephony services, as well as telephony services from nonbillable telephone encounters. These data are critical to health equity and understanding differences in the populations served (or not served) by the various types of telehealth or in-person services. In addition, we recommend developing processes to track clinical outcomes to monitor the quality and effectiveness of care provided through telehealth, to determine whether care delivered via telehealth is comparable to in-person care. This information can also clarify which patients (eg, age groups, diagnoses) and therapeutic interventions are most appropriate for telehealth service delivery. Tracking clinical outcomes is directly linked to ensuring financial sustainability. The Congressional Budget Office has often assigned telehealth legislation low scores, noting that this is due to insufficient quantitative outcomes documenting the effectiveness of telehealth interventions. An evidence base is needed to help make the case for the quality and cost-effectiveness of telehealth.

During this time of rapid transition to telehealth, participating programs noted that some barriers to care decreased whereas others persisted or became even more apparent (Figure 3). Although troubleshooting and infrastructure support for providers improved during the initial stages of the pandemic, respondents noted ongoing barriers related to patient access, comfort, and support for the use of technology. If home-based telehealth is to be accessible and equitable for patients, continued work is needed to reduce the “digital chasm” by considering how to provide families with devices and Internet resources. An Executive Order was issued on August 3, 2020, requiring the Secretary of Health and Human Services and the Secretary of Agriculture to develop and implement, within 30 days, “a strategy to improve rural health by improving the physical and communications health care infrastructure available to rural Americans.”Executive order on improving rural health and telehealth access. August 3, 2020. This will hopefully improve connectivity, although as telehealth expands, more bandwidth is needed across the nation, not just in rural communities. The “digital chasm” is an increasingly important social determinant of health. As programs are likely to offer hybrid services (eg, part in-person and part home-based telehealth) in the future, academic child and adolescent psychiatry programs should advocate for strategies to ensure universal connectivity and devices that reach underserved populations.Telephony was crucial to our programs’ ability to sustain care and outreach to families at the start of the pivot from in-person to home-based telehealth services until videoconferencing was available, and to continuing care for families who never had videoconferencing access. The value of telephony is emphasized by another crisis, namely, Hurricane Maria in Puerto Rico. Satellite telephone and cellular lines were reinstated much more quickly than videoconferencing capacity.Emergency preparedness and Hurricane Maria: the experience of a regional academic medical center in southwest Puerto Rico. The CMS’s relaxation of policies during the COVID-19 pandemic to allow billing for psychotherapy and Evaluation and Management codes for services conducted through telephonyCenters for Medicare and Medicaid Services
COVID-19 emergency declaration blanket waivers for health care providers. August 20, 2020. helped programs to continue providing services to families while recouping some revenue. Telephony continues to be the primary telehealth approach for patients with limited technology or Internet access (eg, unhoused individuals), low technological literacy, and other barriers faced by disenfranchised communities. Given that community health centers and public hospitals serve a disproportionate share of low-income, racial and ethnic minoritized, and immigrant populations—those hardest hit by the COVID-19 pandemic—disruptions to mental health care services have risked exacerbating these inequities.Vahidy F.S. Nicolas J.C. Meeks J.R. et al.Racial and ethnic disparities in SARS-CoV-2 pandemic: analysis of a COVID-19 observational registry for a diverse US metropolitan population.,Fortuna L.R. Tolou-Shams M. Robles-Ramamurthy B. Porche M.V. Inequity and the disproportionate impact of COVID-19 on communities of color in the United States: the need for a trauma-informed social justice response.

In addition to ensuring families have access to technology, the ongoing development of infrastructure and systems to guide patients and families in technology-facilitated protocols is necessary to optimize experience and satisfaction with telehealth services. Different approaches to training are possible. Informational sheets with written instructions or how-to-videos in the patient’s preferred language can efficiently convey information. A follow-up telephone call or test run of the video connection by support staff can be helpful for families struggling with technology. Providers should also be given tips to support patients “on the fly.”

Prior to the pandemic, all sites reported that inability to bill for services and regulatory limitations were barriers to telehealth service delivery. The COVID-19 pandemic prompted temporary regulatory and billing changes, allowing sites to provide telehealth in the context of the ongoing crisis. If telehealth is to be a feasible and sustainable service model, it will be crucial to establish a business model for financial stability for sufficient revenue to pay providers, to maintain technologies (eg, videoconferencing platforms, electronic prescribing software), and to support clinic operations; this requires alignment across states and among Medicare, Medicaid, and private insurers (ie, parity across all payers). Regulations that were modified during the pandemic to decrease barriers to telehealth care, such as the changes related to prescribing of controlled substances (eg, stimulants), will need to be reviewed once the public health crisis is over. In Canada, sustainability will depend on individual provincial health plans continuing to fund telehealth services via multiple videoconferencing platforms. Advocacy should continue to emphasize the value that telehealth brings to patients and families so that it can be used not only during crises.

This study had several limitations. The Consortium was a nonrandom sample of child and adolescent psychiatry programs at academic medical centers in the United States and Canada serving predominantly urban and suburban communities. As such, the experiences of our sites may not be representative of the experiences of all sites, particularly those serving rural communities. Another limitation was related to the inability to gather data prospectively during a crisis. All data were obtained retrospectively using data extracted from EMR visit types and billing codes, which are subject to error. Not all visit types were comparably recorded across EMRs, and some sites did not have distinct codes to differentiate videoconferencing and telephony encounter types. Data were collected in aggregate form and not from individual patient charts, preventing disaggregation of the use data by patient demographic characteristics (eg, race/ethnicity). Future studies could also include qualitative patient impressions (eg, patient-level barriers to telehealth services) or clinical patient outcomes, as such information would add to understanding the value-added benefit of home-based telehealth to the mental health care landscape for children and adolescents.

The pandemic has transformed our mental health care delivery system. The Consortium’s experiences highlight the considerable variation and rapid transformation of telehealth practices among sites in the context of changing laws and regulations. We recommend ongoing efforts to document the successes and barriers to telehealth practice to promote equitable and sustainable telehealth service delivery in the future.

The authors wish to acknowledge Douglas K. Novins, MD, at the University of Colorado Anschutz Medical Campus, for introducing consortium members, serving as a scientific advisor, and assistance with data collection. The authors would like to thank Matthew Biel, MD, MSc, at Georgetown University, for data collection and manuscript editing; James Murphy, MD, MBA, at the University of Colorado School of Medicine, for manuscript editing; and Marina Tolou-Shams, PhD, at the University of California, San Francisco, for data collection and scientific collaboration. The authors would like to thank the following individuals for their contribution to data collection: Marie Augustine, MS and Kathy Brewer, MS, at Seattle Children’s Hospital; David A. Axelson, MD, with Nationwide Children’s Hospital and The Ohio State University; Terrilyn Chow and Hiba Michael, BA, at The Hospital for Sick Children; Reena Carmen, LCSW, at Northwell Health; Claudine Higdon, MD, at Northwell Health and Zucker School of Medicine; Glenn Hirsch, MD and William Moitoza, MEd, at NYU Langone Health; Aaron Reliford, MD, at NYU Langone Health and Family Health Centers at NYU Langone; Barbara Krishna Stuart, PhD, at the University of California, San Francisco; and Giuseppa M. King, MBA, at Children’s Hospital Colorado.

Article InfoPublication History

Published online: June 09, 2021

Accepted: June 3, 2021

Publication stageIn Press Journal Pre-ProofFootnotes

Drs. Folk and Schiel are co−first authors of this article. Drs. Fortuna and Myers are co−senior authors of this article.

The authors have reported no funding for this work.

This study was presented as an abstract at the American Academy of Child and Adolescent Psychiatry 67th Annual Meeting, October 12−24, 2020, virtual.

Dr. Oblath served as the statistical expert for this research.

Author Contributions

Conceptualization: Folk, Schiel, Feuer, Sharma, Khan, Doan, Kulkarni, Ramtekkar, Hawks, Fornari, Fortuna, Myers

Data curation: Folk, Oblath, Feuer

Formal analysis: Oblath

Project administration: Schiel

Visualization: Folk, Schiel, Oblath

Writing – original draft: Folk, Schiel, Oblath, Feuer, Sharma, Khan, Doan, Kulkarni, Ramtekkar, Hawks, Fornari, Fortuna, Myers

Writing – review and editing: Folk, Schiel, Oblath, Feuer, Sharma, Khan, Doan, Kulkarni, Ramtekkar, Hawks, Fornari, Fortuna, Myers

Disclosure: Dr. Folk has received salary support from the National Institute of Mental Health ( T32MH018261 ) and the National Institute on Drug Abuse ( K23DA050798 ). Dr. Schiel has served on the Behavioral Health Steering Board for Epic. Drs. Feuer, Fornari, and Fortuna have received salary support from the Patient-Centered Outcomes Research Institute (PCORI). Drs. Oblath, Sharma, Khan, Kulkarni, Ramtekkar, Hawks, Myers and Ms. Doan have reported no biomedical financial interests or potential conflicts of interest.

Identification

DOI: https://doi.org/10.1016/j.jaac.2021.06.003

Copyright

©2021 Published by Elsevier Inc. on behalf of the American Academy of Child and Adolescent Psychiatry.

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