The Transition to Telehealth during the First Months of the COVID-19 Pandemic: Evidence from a National Sample of Patients

What Explains Inequalities in Telehealth Utilization Among North Carolina Medicaid Beneficiaries?

Background: Increased availability of telehealth can improve access to health care. However, there is evidence of persistent disparities in telehealth usage, as well as among people from minoritized racial and ethnic groups and rural residents. The objective of our work was to explore the degree to which disparities in telehealth use for behavioral health (BH) and musculoskeletal (MSK) related services during the COVID-19 pandemic are explained by observed beneficiary- and area-level characteristics. Methods: Using North Carolina Medicaid claims data of Medicaid beneficiaries with BH or MSK conditions, we apply nonlinear regression-based decomposition analysis-based models developed by Kitagawa, Oaxaca, and Blinder to determine which observed variables are associated with racial, ethnic, and rural inequalities in telehealth usage. Results: In the BH cohort, we found statistically significant differences in telehealth usage by race in the adult population, and by race, Hispanic ethnicity, and rurality in the pediatric population. In the MSK cohort, we found significant inequities by Hispanic ethnicity and rurality among adults, and by race and rurality among children. Inequalities in telehealth use between groups were small, ranging from 0.7 percentage points between urban and rural adults with MSK conditions to 3.8 percentage points between white adults and people of color among those with BH conditions. Overall, we found that racial and ethnic inequalities in telehealth use are not well explained by the observed variables in our data. Rural disparities in telehealth use are better explained by observed variables, particularly area-level broadband internet use. Conclusions: For inequalities between rural and urban residents, our analysis provides observational evidence that infrastructure such as broadband internet access is an important driver of differences in telehealth use. For racial and ethnic inequalities, the pathways may be more complex and difficult to measure, particularly when relying on administrative data sources in place of more detailed data on individual-level socioeconomic factors.

"Like One Long Battle:" Employee Perspectives of the Simultaneous Impact of COVID-19 and an Electronic Health Record Transition

BACKGROUND

Healthcare organizations regularly manage external stressors that threaten patient care, but experiences handling concurrent stressors are not well characterized.

OBJECTIVE

To evaluate the experience of Veterans Affairs (VA) clinicians and staff navigating simultaneous organizational stressors-an electronic health record (EHR) transition and the COVID-19 pandemic-and identify potential strategies to optimize management of co-occurring stressors.

DESIGN

Qualitative case study describing employee experiences at VA's initial EHR transition site.

PARTICIPANTS

Clinicians, nurses, allied health professionals, and local leaders at VA's initial EHR transition site.

APPROACH

We collected longitudinal qualitative interview data between July 2020 and November 2021 once before and 2-4 times after the date on which the health system transitioned; this timing corresponded with local surges of COVID-19 cases. Interviewers conducted coding and analysis of interview transcripts. For this study, we focused on quotes related to COVID-19 and performed content analysis to describe recurring themes describing the simultaneous impact of COVID-19 and an EHR transition.

KEY RESULTS

We identified five themes related to participants' experiences: (1) efforts to mitigate COVID-19 transmission led to insufficient access to EHR training and support, (2) clinical practice changes in response to the pandemic impacted EHR workflows in unexpected ways, (3) lack of clear communication and inconsistent enforcement of COVID-19 policies intensified pre-existing frustrations with the EHR, (4) managing concurrent organizational stressors increased work dissatisfaction and feelings of burnout, and (5) participants had limited bandwidth to manage competing demands that arose from concurrent organizational stressors.

CONCLUSION

The expected challenges of an EHR transition were compounded by co-occurrence of the COVID-19 pandemic, which had negative impacts on clinician experience and patient care. During simultaneous organizational stressors, health care facilities should be prepared to address the complex interplay of two stressors on employee experience.

The impact of the COVID-19 pandemic on the health and working conditions of nurses and its implications for policies: a cross-sectional study in Slovakia

BACKGROUND

Increased workload and of the health workforce (HW) strained the capacity to maintain essential health services (EHS) during the Coronavirus Disease 2019 (COVID-19) pandemic, while putting them at increased risk of COVID-19 and other consequences to their health. The aim of this study was to assess the impact of COVID-19 on the health, wellbeing, and working conditions of nurses in Slovakia and to identify gaps in policies to be addressed to increase preparedness of the HW for future emergencies.

METHODS

A nation-wide cross-sectional study was conducted among nurses during November-December 2021, referring to the period of January 2021 to November 2021. To assess the differences between impact on HW on various levels of care, respondents were grouped by type of facility: hospital-COVID-19 wards; Hospital-non-covid ward; Outpatient or ER; Other care facilities.

RESULTS

1170 nurses participated, about 1/3 of them tested positive for COVID-19 by November 2021, mostly developing mild disease. Almost 2/3 reported long-covid symptoms and about 13% reported that they do not plan to get vaccinated against COVID-19. The median of the score of the impact of workload on health was 2.8 (56% of the maximum 5), the median score of mental health-wellbeing was 1.9 (63% of a maximum of 3). The studied impacts in all domains were highest in nurses working in COVID-19 hospital wards. Significant disruptions of health care were reported, with relatively high use of telemedicine to mitigate them. Overall, about 70% of the respondents thought of leaving their job, mostly due to working stress or inadequate pay.

CONCLUSIONS

Our study showed that the COVID-19 pandemic poses a substantial burden on the health, wellbeing and working conditions of nurses in Slovakia and that a large proportion of nurses considered leaving their jobs because of work overload or low salaries. Human resource strategies should be adopted to attract, retain and continuously invest in HW development including in emergency preparedness and response. Such an approach may improve the resilience and preparedness of the health system in Slovakia for future emergencies.

Telehealth Implementation, Treatment Attendance, and Socioeconomic Disparities in Treatment Utilization in a Community Mental Health Setting During the COVID-19 Pandemic: A Retrospective Analysis of Electronic Health Record Data

Background

Previous studies have found that the widespread implementation of telehealth for outpatient mental health treatment during the COVID-19 pandemic has been associated with reduced no-show rates and increases in total number of appointments. However, it is unclear to what degree this is due to increased accessibility provided by telehealth, rather than to increased consumer demand for services fueled by the pandemic-related exacerbation of mental health needs. To shed light on this question, the present analysis examined changes in attendance rates for outpatient, home-, and school-based programs at a community mental health center in southeastern Michigan. Disparities in treatment utilization associated with socioeconomic status were also examined.

Methods

Two-proportion z-tests were conducted to examine changes in attendance rates, and Pearson correlations were calculated using the median income level and attendance rate by zip code to examine disparities in utilization associated with socioeconomic status.

Results

The proportion of appointments kept after telehealth implementation was statistically significantly higher for all outpatient programs, but not for any home-based programs. Specifically, absolute increases in the proportion of appointments kept ranged from 0.05 to 0.18 for outpatient programs, representing relative increases of 9.2% to 30.2%. Furthermore, before telehealth implementation, there was a strong positive correlation between income and attendance rate for all outpatient programs (ranging from r = 0.50 to 0.56). After telehealth implementation, there were no longer any significant correlations.

Discussion

Results highlight the utility of telehealth in increasing treatment attendance and mitigating disparities in treatment utilization associated with socioeconomic status. These findings are highly relevant to ongoing discussions surrounding the long-term fate of evolving insurance and regulatory guidelines pertaining to telehealth.

A longitudinal study of predictors of serious psychological distress during COVID-19 pandemic

BACKGROUND

The prevalence of serious psychological distress (SPD) was elevated during the COVID-19 pandemic in the USA, but the relationships of SPD during the pandemic with pre-pandemic SPD, pre-pandemic socioeconomic status, and pandemic-related social stressors remain unexamined.

METHODS

A probability-based sample (N = 1751) of the US population age 20 and over was followed prospectively from February 2019 (T1), with subsequent interviews in May 2020 (T2) and August 2020 (T3). Multinomial logistic regression was used to assess prospective relationships between T1 SPD with experiences of disruption of employment, health care, and childcare at T2. Binary logistic regression was then used to assess relationships of T1 SPD, and socioeconomic status and T2 pandemic-related stressors with T3 SPD.

RESULTS

At T1, SPD was associated with age, race/ethnicity, and household income. SPD at T1 predicted disruption of employment (OR 4.5, 95% CI 1.4-3.8) and health care (OR 3.2, 95% CI 1.4-7.1) at T2. SPD at T1 (OR 10.2, 95% CI 4.5-23.3), low household income at T1 (OR 2.6, 95% CI 1.1-6.4), disruption of employment at T2 (OR 3.2, 95% CI 1.4-7.6), and disruption of healthcare at T2 (OR 3.3, 95% CI 1.5-7.2) were all significantly associated with elevated risk for SPD at T3.

CONCLUSIONS

Elevated risk for SPD during the COVID-19 pandemic is related to multiple psychological and social pathways that are likely to interact over the life course. Policies and interventions that target individuals with pre-existing mental health conditions as well as those experiencing persistent unemployment should be high priorities in the mental health response to the pandemic.

Mental Health Service Utilization Rates Among Commercially Insured Adults in the US During the First Year of the COVID-19 Pandemic

Importance

The COVID-19 pandemic has been associated with an elevated prevalence of mental health conditions and disrupted mental health care throughout the US.

Objective

To examine mental health service use among US adults from January through December 2020.

Design, Setting, and Participants

This cohort study used county-level service utilization data from a national US database of commercial medical claims from adults (age >18 years) from January 5 to December 21, 2020. All analyses were conducted in April and May 2021.

Main Outcomes and Measures

Per-week use of mental health services per 10 000 beneficiaries was calculated for 5 psychiatric diagnostic categories: major depressive disorder (MDD), anxiety disorders, bipolar disorder, adjustment disorders, and posttraumatic stress disorder (PTSD). Changes in service utilization rates following the declaration of a national public health emergency on March 13, 2020, were examined overall and by service modality (in-person vs telehealth), diagnostic category, patient sex, and age group.

Results

The study included 5 142 577 commercially insured adults. The COVID-19 pandemic was associated with more than a 50% decline in in-person mental health care service utilization rates. At baseline, there was a mean (SD) of 11.66 (118.00) weekly beneficiaries receiving services for MDD per 10 000 enrollees; this declined by 6.44 weekly beneficiaries per 10 000 enrollees (β, -6.44; 95% CI, -8.33 to -4.54). For other disorders, these rates were as follows: anxiety disorders (mean [SD] baseline, 12.24 [129.40] beneficiaries per 10 000 enrollees; β, -5.28; 95% CI, -7.50 to -3.05), bipolar disorder (mean [SD] baseline, 3.32 [60.39] beneficiaries per 10 000 enrollees; β, -1.81; 95% CI, -2.75 to -0.87), adjustment disorders (mean [SD] baseline, 12.14 [129.94] beneficiaries per 10 000 enrollees; β, -6.78; 95% CI, -8.51 to -5.04), and PTSD (mean [SD] baseline, 4.93 [114.23] beneficiaries per 10 000 enrollees; β, -2.00; 95% CI, -3.98 to -0.02). Over the same period, there was a 16- to 20-fold increase in telehealth service utilization; the rate of increase was lowest for bipolar disorder (mean [SD] baseline, 0.13 [16.72] beneficiaries per 10 000 enrollees; β, 1.40; 95% CI, 1.04-1.76) and highest for anxiety disorders (mean [SD] baseline, 0.20 [9.28] beneficiaries per 10 000 enrollees; β, 9.12; 95% CI, 7.32-10.92). When combining in-person and telehealth service utilization rates, an overall increase in care for MDD, anxiety, and adjustment disorders was observed over the period.

Conclusions and Relevance

In this cohort study of US adults, we found that the COVID-19 pandemic was associated with a rapid increase in telehealth services for mental health conditions, offsetting a sharp decline in in-person care and generating overall higher service utilization rates for several mental health conditions compared with prepandemic levels.

Interprofessional Medication Error Disclosure Training Using a Telehealth Consultation Simulation

Objective. Health professions students must develop collaborative skills to disclose errors effectively and improve patient safety. We proposed that an interprofessional simulation using telehealth technology would provide medical and pharmacy students the opportunity to practice, develop, and grow in their confidence and skills of working collaboratively and disclosing medication errors.Methods. A three-phase interprofessional student simulation was developed. Phase 1 included individual student preparation. An interprofessional telehealth consultation encounter occurred in phase 2 for the error disclosure between the pharmacy and medical students. Phase 3 included faculty-led interprofessional debrief sessions. A pre- and postsimulation survey assessed students' experiences regarding their confidence in error disclosure, use of telehealth technology, and the role of the community pharmacist. Faculty evaluated pharmacy student performance using a 12-point rubric.Results. Presimulation survey responses (n=173) were compared to postsimulation survey responses (n=140). Significant changes were seen for all students' confidence in error disclosure and use of telehealth technology. No significant change was noted in the students' understanding of the community pharmacists' role on the interprofessional team. Pharmacy student performance-based rubric data (n=148) revealed a median score of seven out of 12 for error disclosure and interprofessional communication items.Conclusion. Medical and pharmacy students perceived their confidence improved in interprofessional error disclosure and use of telehealth consultation technology through this interprofessional simulation. Pharmacy students' error disclosure and interprofessional communication skill development were assessed through this simulation.

Brief Report: Telehealth Satisfaction Among Caregivers of Pediatric and Adult Psychology and Psychiatry Patients with Intellectual and Developmental Disability in the Wake of Covid-19

Telehealth has been shown to be both acceptable and effective in many areas of healthcare, yet it was not widely adopted prior to the SARS-CoV-2 (COVID-19) pandemic. Additionally, previous evaluations of telehealth for autism spectrum condition (ASC) and intellectual and developmental disability (IDD) populations are limited in both number and scope. Here, we investigated satisfaction amongst Psychology and Psychiatry patient caregivers at Cincinnati Children’s Hospital Medical Center (CCHMC) after the onset of the COVID-19 pandemic. Results (640 responses) showed high rates of satisfaction across departments, appointment types, and diagnoses, with 92% indicating overall satisfaction with their appointment. There were, however, notable decreases in satisfaction among Group Therapy respondents, and those whose diagnosis was classified as Other.

Inequities in Telehealth Use Associated with Payer Type During the COVID-19 Pandemic

Introduction: The COVID-19 pandemic has prompted a shift in health care delivery and compelled a heavier reliance on telehealth. The objective of this study was to determine if differences in coverage policies by payer type resulted in differential telehealth use during the first 3 months of the COVID-19 pandemic. In this population-based cohort study of low-income Arkansans, Medicaid beneficiaries enrolled in the traditional Primary Care Case Management (PCCM) program were compared with Medicaid beneficiaries covered through premium assistance in private Qualified Health Plans (QHPs). Methods: A retrospective review was conducted of insurance claims records from June 1, 2019, to June 30, 2020, for synchronous telehealth and mobile health (m-health) visits, as well as other forms of telehealth. To establish the baseline equivalence of enrollees in the two groups, propensity score matching design was used on demographic and geographic characteristics, Charlson Comorbidity Index, broadband availability, and prior service utilization. Results: Compared with enrollees in the PCCM program, Medicaid expansion enrollees in QHPs had higher odds of having had at least one telehealth visit (adjusted odds ratio [aOR] = 1.35, 95% confidence interval [CI]: 1.29-1.42) during the early phase of the COVID-19 pandemic. Categorizing utilizations by domain, QHP enrollees were more likely to use synchronous telehealth (aOR = 1.31; 95% CI: 1.25-1.37) and m-health (aOR = 5.91; 95% CI: 4.25-8.21). A higher proportion of QHP enrollees also had at least one mental or behavioral health telehealth session (aOR = 1.13; 95% CI: 1.07-1.19). Conclusions: Our study demonstrated that within low-income populations, payer type was associated with inequitable access to telehealth during the early phase of the COVID-19 pandemic.

Psychological differences in adults with and without a COVID-19 diagnosis

BACKGROUND

Substantial evidence is emerging regarding the broad societal and psychological impacts of the COVID-19 pandemic, but little is known about whether infected individuals are differently affected.

AIM

We evaluated psychological differences between individuals who do vs. do not report testing positive for COVID-19.

METHODS

An online survey was offered to adults (≥18 years) who were diagnosed with COVID-19 by a provider within a large integrated-delivery healthcare system, enrolled in COVID-19-related clinical trials at the healthcare system, or responded to targeted local distribution. Measures assessed included the 8-item Patient Health Questionnaire depression scale, Generalized Anxiety Disorder 7-item Scale, and Posttraumatic Diagnostic Scale for DSM-5.

RESULTS

Of 487 respondents, 43% reported testing positive for COVID-19, including 11% requiring hospitalization. Overall rates of general anxiety disorder and posttraumatic stress were 34% and 16%, respectively, with no significant differences between groups. Prevalence of depression was higher among respondents reporting a positive COVID-19 test (52% vs. 31%). This difference persisted after controlling for respondent characteristics (odds ratio = 3.7, p < 0.01).

CONCLUSIONS

People who report testing positive for COVID-19, even those not requiring hospitalization, have increased risk for depression. Mental health care screening and services should be offered to individuals testing positive, facilitating early intervention.

Lessons for psychiatrists from the COVID pandemic: the need for expanded roles and additional competencies

The disaster of the COVID-19 pandemic has fundamentally changed the norms of psychiatric practice: from its methods of care delivery to its methods of practice. Traditional methods of care delivery using in-person visits became impractical or unsafe. Meanwhile, the pandemic has resulted in an increased demand for services. The resulting pivot to telepsychiatry required a skillset that was not a part of traditional psychiatry training. To meet the demand for services, many providers needed to join collaborative models of care to help scale their expertise. Although many innovative collaborative models of care exist, providers remain in their traditional consultative roles within many of those models. In a disaster, when there is an expanding mental health care need in the population, psychiatrists need to adapt their practice to meet expanded roles that naturally build on their usual ones. We explore the expanded roles that psychiatrists will need to fill based on what is known about the field of disaster mental health and principles from Psychological First Aid (PFA). In preparation for a new normal, in what George Everly describes as a 'disaster of uncertainty,' we propose evolutions in the way psychiatrists are trained. Specific training on telepsychiatry best practices will prepare psychiatrists to use this method most effectively and appropriately. Additional training should focus on the core competencies of disaster psychiatry: effective crisis leadership and strategic planning, disaster surveillance, knowledge of benign vs. concerning symptoms, psychological triage, implementation of crisis interventions, resource facilitation, crisis communication, and self and peer care. Developing and integrating these competencies into psychiatry training programs will best prepare psychiatrists for the expanding mental health care needs of the community in this ongoing disaster and future ones.

Assessment of Patient Preferences for Telehealth in Post-COVID-19 Pandemic Health Care

Importance

Telehealth use greatly increased in 2020 during the first year of the COVID-19 pandemic. Patient preferences for telehealth or in-person care are an important factor in defining the role of telehealth in the postpandemic world.

Objective

To ascertain patient preferences for video visits after the ongoing COVID-19 public health emergency and to identify patient perceptions of the value of video visits and the role of out-of-pocket cost in changing patient preference for each visit modality.

Design, Setting, and Participants

This survey study was conducted using a nationally representative sample of adult members of the RAND American Life Panel. The data were obtained from the American Life Panel Omnibus Survey, which was fielded between March 8 and 19, 2021.

Main Outcomes and Measures

Preferences for video visits vs in-person care were analyzed in the survey. The first question was about participants' baseline preference for an in-person or a video visit for a nonemergency health issue. The second question entailed choosing between the preferred visit modality with a cost of $30 and another modality with a cost of $10. Questions also involved demographic characteristics, experience with video visits, willingness to use video visits, and preferences for the amount of telehealth use after the COVID-19 pandemic.

Results

A total of 2080 of 3391 sampled panel members completed the survey (participation rate, 61.3%). Participants in the weighted sample had a mean (SE) age of 51.1 (0.67) years and were primarily women (1079 [51.9%]). Most participants (66.5%) preferred at least some video visits in the future, but when faced with a choice between an in-person or a video visit for a health care encounter that could be conducted either way, more than half of respondents (53.0%) preferred an in-person visit. Among those who initially preferred an in-person visit when out-of-pocket costs were not a factor, 49.8% still preferred in-person care and 23.5% switched to a video visit when confronted with higher relative costs for in-person care. In contrast, among those who initially preferred a video visit, only 18.9% still preferred a video visit and 61.7% switched to in-person visit when confronted with higher relative costs for video visits.

Conclusions and Relevance

This survey study found that participants were generally willing to use video visits but preferred in-person care, and those who preferred video visits were more sensitive to paying out-of-pocket cost. These results suggest that understanding patient preferences will help identify telehealth's role in future health care delivery.

Clinical leadership during the COVID-19 pandemic: Reflections and lessons learned

COVID-19 has, and continues to, wreak havoc worldwide, and the healthcare system has been particularly challenged with personnel shortages, resource insecurity, mixed messages, and fear to name a few. At the outset, it was thought the pandemic would be short-lived, resulting in the enactment of disaster plans in hospitals. Such autocratic approaches are not always effective in the long-term; a servant leadership approach is more conducive to engaging teams, and this dyad structure supports effective leadership during challenging times. While there is not one right approach to leading through a pandemic, lessons learned from this pandemic are applicable when, not if, the next pandemic occurs.

A longitudinal study of predictors of serious psychological distress during COVID-19 pandemic

BACKGROUND

The prevalence of serious psychological distress (SPD) was elevated during the COVID-19 pandemic in the USA, but the relationships of SPD during the pandemic with pre-pandemic SPD, pre-pandemic socioeconomic status, and pandemic-related social stressors remain unexamined.

METHODS

A probability-based sample (N = 1751) of the US population age 20 and over was followed prospectively from February 2019 (T1), with subsequent interviews in May 2020 (T2) and August 2020 (T3). Multinomial logistic regression was used to assess prospective relationships between T1 SPD with experiences of disruption of employment, health care, and childcare at T2. Binary logistic regression was then used to assess relationships of T1 SPD, and socioeconomic status and T2 pandemic-related stressors with T3 SPD.

RESULTS

At T1, SPD was associated with age, race/ethnicity, and household income. SPD at T1 predicted disruption of employment (OR 4.5, 95% CI 1.4-3.8) and health care (OR 3.2, 95% CI 1.4-7.1) at T2. SPD at T1 (OR 10.2, 95% CI 4.5-23.3), low household income at T1 (OR 2.6, 95% CI 1.1-6.4), disruption of employment at T2 (OR 3.2, 95% CI 1.4-7.6), and disruption of healthcare at T2 (OR 3.3, 95% CI 1.5-7.2) were all significantly associated with elevated risk for SPD at T3.

CONCLUSIONS

Elevated risk for SPD during the COVID-19 pandemic is related to multiple psychological and social pathways that are likely to interact over the life course. Policies and interventions that target individuals with pre-existing mental health conditions as well as those experiencing persistent unemployment should be high priorities in the mental health response to the pandemic.

Veterans Hospital Administration Telehealth Utilization for Recreation and Creative Arts Therapies: A Brief Report

Background:

A brief query was fielded to Veterans Health Administration (VHA) facilities across the United States to provide an initial assessment of recreation therapy (RT) and creative arts therapy (CAT) telehealth utilization.

Methods:

To develop an understanding of barriers and identify potential solutions for better delivery of services, a cross-sectional survey was deployed to points of contact at 136 VHA facilities. The survey included questions across five areas: staff, infrastructure, barriers to use, training, and interventions being deployed. Descriptive statistics were calculated, and a thematic analysis of qualitative responses was conducted.

Results:

The most frequent themes from aggregated responses indicated a need for hands-on training, reliable telehealth equipment, and accessible training and tools for Veteran patients who want to use telehealth services.

Conclusion:

Telehealth delivery of RT/CAT has increased services to Veteran patient populations; however, equipment and training are needed to expand consistent delivery to enhance patient reach across a national health care system.