Implementation of telehealth during COVID-19: Implications for providing behavioral health services to pediatric patients

It takes a village: A pilot study of a group telehealth intervention for support persons affected by opioid use disorder

INTRODUCTION

Opioid use disorder (OUD) has devastating effects on individuals, families, and communities. The Community Reinforcement and Family Training (CRAFT) is a Support Person (SP)-focused intervention that aims to increase SPs' communication strategies, positive reinforcement/rewards, and social support. This pilot study, called eINSPIRE (INtegrating Support Persons Into REcovery), adapted CRAFT for delivery via group telehealth. The aims were to evaluate the feasibility, acceptability, and preliminary effectiveness of this intervention on patient buprenorphine retention and SP mental health.

METHODS

The study recruited patients receiving buprenorphine treatment in a primary care setting across five community health centers with their SP (N = 100 dyads). SP participants were randomly assigned to receive usual care (UC) or the eINSPIRE intervention. We interviewed Patients and SPs at baseline and three months later. The study collected patient buprenorphine retention data from the electronic medical record three months post-baseline.

RESULTS

About 88 % (656/742) of potentially eligible patients were able to nominate a SP and 69 % (100/145) of nominated SPs were eligible and consented to the study. eINSPIRE groups had low reach (25 % of SPs attended), but high exposure (M = 7 of 10 sessions attended) and acceptability (classes helped them with their patient's OUD). The proportion of eINSPIRE patients (68 %) and UC patients (53 %) retained on buprenorphine at follow-up were similar (p = 0.203). SPs in both conditions reported similar reductions in their depression, anxiety, and impairment symptoms.

CONCLUSIONS

Preliminary data suggest that eINSPIRE groups may not be feasible in primary care without further adaptations for this population. A future study with a larger sample size is needed to elucidate the observed distribution differences in buprenorphine retention. Future research should also explore methods to reduce barriers to SP session attendance to improve the reach of this evidence-based intervention.

Management of High Acuity Patients in Pediatric Medical Settings: The Role of Consultation/Liaison Psychologists During the Growing Mental Health Crisis

Since the onset of the COVID-19 pandemic, consultation/liaison (C/L) psychologists had to drastically shift their practices to care for psychiatrically acute pediatric patients admitted to medical settings. The aim of the current study was to provide an updated state of the field surrounding these changes and their implications for clinical practice. Psychologists and psychology post-doctoral fellows completed an anonymous, 51-item survey distributed via a national professional organization listserv. The results review responses, by percentages, about C/L team composition and practice patterns, as they relate to suicide risk assessments, transfers to inpatient psychiatric and other levels of care, intervention for boarding patients, and disposition and safety planning. Thematically coded qualitative responses regarding impact and management of high acuity patients are also summarized. The state of the field outlined by this survey suggests an increase in C/L assessments and interventions delivered to pediatric patients with acute psychiatric needs, as well as a reverberating effects on provider wellness. Ensuring providers establish competency for this subset of patients is vital to the continued provision of optimal patient care and to sustained provider wellness. Considerations for the field are explored.

Modality and terminology changes for behavioral health service delivery during the COVID-19 pandemic: a systematic review

Introduction

The COVID-19 pandemic prompted healthcare professionals to implement service delivery adaptations to remain in compliance with safety regulations. Though many adaptations in service delivery were reported throughout the literature, a wide variety of terminology and definitions were used.

Methods

To address this, we conducted a PRISMA review to identify service delivery adaptations across behavioral healthcare services in the United States from March 2020 to May 2022 and to identify variations in terminology used to describe these adaptations. We identified 445 initial articles for our review across eight databases using predetermined keywords. Using a two-round screening process, authors used a team approach to identify the most appropriate articles for this review.

Results

Our results suggested that a total of 14 different terms were used to describe service modality changes, with the most frequent term being telehealth (63%). Each term found in our review and the frequency of use across identified articles is described in detail.

Discussion

Implications of this review such as understanding modality changes during the COVID-19 pandemic and beyond are discussed. Our findings illustrate the importance of standardizing terminology to enhance communication and understanding among professionals.

Transgender and gender diverse youths' experiences of healthcare: A systematic review of qualitative studies

Transgender and gender-diverse (TGD) populations are identified as high-risk for negative healthcare outcomes. Limited data exists on experiences of TGD youths in healthcare. The review aim is to systematically review literature on healthcare experiences of TGD youths. Seven electronic databases were systematically searched for relevant studies. Pre-determined eligibility criteria were used for inclusion with a double-screening approach. Sixteen studies were included. Studies included were quality appraised, data were extracted, and findings were synthesized narratively. Four narratives were identified including experiences of: accessing care, healthcare settings and services, healthcare providers, and healthcare interventions. Long waiting times, lack of competent providers, and fear were reported as challenges to accessing gender-affirming care. Negative experiences occurred in mental health services and primary care, while school counseling and gender clinics were affirming. Puberty blockers and hormone-replacement therapy were identified as protective factors. TGD youths are at risk of negative health outcomes due to an under resourced healthcare system. Further research is needed to assess interventions implemented to improve TGD youth's experiences.

Telehealth Use Across Time and Regional Medical Resources During the COVID-19 Pandemic: Evidence from China

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has created lots of difficulties for individuals to seek medical help offline. Telehealth is considered as a potential approach to solve this issue. During the COVID-19 pandemic, although the use of telehealth has increased in the short term, it still remains unknown whether the use of telehealth can maintain a high level of development in the long term. The purpose of this article is to investigate the impact of COVID-19 pandemic on telehealth use across time and regional medical resources. Materials and Methods: Our research used the Internet search index from Baidu Index Platform in 31 provinces of China as the proxy of telehealth use. A total of 2,119,486 times of searching behaviors from January 2018 to December 2021 are included in our dataset. Changing plots, the method of analysis of variance and empirical models are applied to reveal the relationship between COVID-19 pandemic and telehealth use. Results: Baidu Index counts increased (p < 0.01) at the beginning of COVID-19 pandemic (2020) but started to decline (p < 0.01) during the period of regular epidemic prevention and control (2021). Moreover, the counts of Baidu Index in regions with rich medical resources are higher than those in other regions in 2020. Comparing Baidu Index counts in 2020, the COVID-19 pandemic has higher positive effects on telehealth use during the period of 2021 in regions with average and poor medical resources. Conclusions: COVID-19 pandemic has a positive effect on telehealth use in 2020 but has a negative effect in 2021. During the epidemic, telehealth use differs in regions with rich, average, and poor medical resources. Our findings indicate that the use of telehealth should be promoted with different measures in regions with different medical resources, thereby contributing its healthy development in the long term.

Assumptions, Perceptions, and Experiences of Behavioral Health Providers Using Telemedicine: Qualitative Study

BACKGROUND

The urgent and reactive implementation of telemedicine during the pandemic does not represent a long-term, strategic, and proactive approach to optimizing this technology. The assumptions, perceptions, and experiences of the behavioral health providers using telemedicine can inform system-wide and institutional-level strategies to promote longitudinal maintenance of care delivery, which can reduce the use of high-cost care due to new symptom onset and symptom exacerbation related to service interruptions.

OBJECTIVE

We aim to identify the assumptions, perspectives, and experiences of behavioral health clinicians and providers using telemedicine to inform the development of an optimized, sustainable approach to telemedicine implementation.

METHODS

This qualitative study applies the domains of the Consolidated Framework for Implementation Research (CFIR) to structure data collection and analysis from behavioral health providers using telemedicine via an audiovisual connection in the New England region. In total, 12 providers across levels of care were recruited for a 60-minute interview, developed from the CFIR interview guide. Atlas Ti Qualitative Software (version 23; ATLAS.ti Scientific Software Development GmbH) was used to coordinate and facilitate coding among 3 reviewers. Deductive coding was provided from the CFIR interview guide, allowing for data to be categorized by domain and construct. Constructs were analyzed for descriptive themes and tabulated for response frequency. Uncoded data were reviewed and coded in vivo to explore variables contributing to participant perceptions of experience with telemedicine use. Descriptive themes, then analytical themes, were identified. Analytical themes and tabulated frequency of response data were summarized. Finally, a sentiment analysis was completed to derive tone and meaning from the data.

RESULTS

Results are reported within the CFIR domains: intervention characteristic, outer setting, inner setting, characteristics of individuals, and process. The findings with ≥90% agreement include "best practice standards were not known"; "telemedicine was believed to be efficient and time-saving for the patient and provider, maximizing productivity and thus increasing access to care"; "telemedicine provided an additional option for patients to access services, promoting sustained continuity and timeliness of care"; "participants did not identify any clear goals related to telemedicine use"; "demonstrated positive affective responses to telemedicine use"; "expressed high efficacy with telemedicine utilization"; and "strong leadership support."

CONCLUSIONS

These findings support the development of interstate compacts advancing licensure across state lines; payment parity across modalities of care to ensure the financial vitality of behavioral health services; improved dissemination of telehealth training and resources, and telehealth training in academic programs of the health professions; seamless, dynamic workflows to accommodate the changing needs of patient and care continuity; emergency response protocols; and community partnerships to provide private spaces needed for a therapeutic encounter. Future research exploring the patient's experience with telemedicine is needed for all stakeholders to be represented in developing a sustainable, integrated system.

Children and adolescents' mental health in pandemics and confinement: A scoping review of vulnerability factors and repercussions

Children and adolescents are a population at particular risk of experiencing adverse mental health repercussions related to pandemics. To understand vulnerability factors and repercussions of pandemics and related sanitary measures on children and adolescents' mental health, we performed a scoping review to examine and synthesize literature. In total, 66 articles were included. Results present: (1) factors that increase vulnerability to adverse mental health repercussions (e.g., having a pre-existing mental health condition, social isolation, low socio-economic status, parental distress, and overexposure to media content) and (2) specific mental health repercussions (e.g., anxiety, fear, depression, and externalizing behaviors). Addressing concerns underlined in this review could contribute to preventing further negative mental health repercussions of pandemics for children and adolescents and better prepare governments and professionals to address these highly challenging situations. Recommendations for practice include enhancing healthcare professionals' awareness about possible detrimental repercussions pandemics and sanitary measures have on children and adolescents' mental health, assessing changes for those with pre-existing mental health conditions, allocating funding for telehealth research, and providing greater support to healthcare providers.

Patient and provider perspectives of the implementation of remote consultations for community-dwelling people with mental health conditions: A systematic mixed studies review

Remote, or tele-, consultations became a necessary form of mental healthcare provision during the COVID-19 pandemic. As the prevalence of mental health problems rises, they may have a role in future mental health services. We aimed to review the literature on patient and provider perspectives on factors influencing the implementation of remote consultations for community-dwelling people with mental health conditions. We searched five electronic databases (PubMed, EMBASE, Web of Science, CINAHL, and PsycINFO) for empirical research up to July 13th, 2022. Only studies of synchronous, interactive remote consultations conducted via video, phone, or live-messaging between patients and providers were included. Two reviewers independently assessed the quality of included studies using the Mixed Methods Appraisal Tool. We integrated qualitative and quantitative data from 39 studies into a single mixed-methods synthesis. We mapped reported factors to the domains of the Consolidated Framework for Implementation Research (CFIR). Acceptability was generally high among participants, despite concerns about the quality of care and the perceived impeded therapeutic relationship. A prominent facilitator was the increased accessibility and convenience of remote consultations, while lack of appropriate infrastructure and low patient comfort and competence were among the most prevalent barriers. This review highlights the importance of patient preferences and provider buy-in to the future of remote consultations.

Telehealth in a paediatric developmental metropolitan assessment clinic: Perspectives and experiences of families and clinicians

Background

The application of telehealth in the paediatric setting is growing, and yet, limited research has focused on using telehealth in developmental diagnostic assessment and the consumers' perceptions of their telehealth experience. This study explored parents'/carers' and staff experiences of using telehealth as part of the developmental diagnostic assessment.

Methods

Parents/carers who attended an assessment between June 2020 and July 2021 that incorporated a telehealth component within a hybrid service delivery model were invited to provide feedback about their experience of telehealth appointments at a multidisciplinary developmental assessment service. All parents were invited to complete an online survey, with a sample of families being offered a telephone interview. Staff members were invited to a focus group to explore their experiences of delivering services via telehealth. Data obtained were analysed descriptively and thematically using a mixed method of analysis. Codes were categorized, enabling facilitators and barriers to be explored.

Results

The use of telehealth in the diagnostic assessment of complex developmental disorders received high levels of acceptance from parents/carers and staff, despite having limitations such as technical issues, difficulties building rapport between families/clinicians and limited direct observations of the child. Telehealth services are perceived to reduce costs and increase flexibility, including increased ability to accommodate family needs.

Conclusions

Results demonstrated that telehealth is a highly acceptable mode of service in a developmental assessment service. The current study informs the development of a hybrid service delivery model by enhancing facilitators and reducing barriers commonly reported by consumers and provides direction for future research.

Patient or Public Contribution

Parents or carers of children who attended a tertiary paediatric assessment unit for a diagnostic developmental assessment completed the online survey and were interviewed.

Preliminary Practice Recommendations for Telehealth Direct Applied Behavior Analysis Services with Children with Autism

This article provides preliminary practice recommendations for telehealth direct applied behavior analysis (ABA) services for children with autism. In the face of COVID-19, there is an immediate need for discussion on how to implement various ABA procedures via telehealth for ABA practitioners. Alongside emerging scientific evidence on the effectiveness of telehealth direct service as well as various service-related guidelines, we provide preliminary practice recommendations that are based on the existing literature on in-person and telehealth ABA procedures. We also discuss these recommendations with case studies of two boys with autism. Social validity measures indicated that families were satisfied with telehealth direct services. Even after the COVID-19 pandemic has resolved itself, telehealth direct ABA service will still be a valuable option for remote and international locations where direct ABA service is limited, and thus, practice recommendations continue to be relevant for all practitioners that use telehealth direct service.

Teaching Adults with Neurodevelopmental Disabilities to Interact Successfully with Others in a Virtual Format

As a result of the COVID-19 pandemic, individuals with neurodevelopmental disabilities (NDD) are engaging more with others in virtual group formats for social, educational, and professional reasons. This study extends prior research by evaluating the efficacy of common behavioral interventions, including behavioral skills training, provided via group video conferencing to teach skills that are important when interacting with others in a virtual format. Four adults with NDD were taught to use their cameras and microphones appropriately and to make encouraging statements to one another while discussing current events and social skills-based lessons via Zoom™. Two of the three skills increased and maintained for all participants even after the experimenter faded the contingencies for appropriate responding. The third skill maintained after the experimenter arranged for the response to produce natural consequences. Tests for generalization across group leads and activities yielded promising results. Findings suggest that adults with NDD benefit from group-based telehealth services to improve skills needed to interact successfully with others in a virtual format.

Modified Training Experiences for Psychology Interns and Fellows During COVID-19: Use of Telepsychology and Telesupervision by Child and Adolescent Training Programs

Coronavirus (COVID-19) has affected opportunities available to psychology interns and postdoctoral fellows completing capstone training experiences during culminating training years. While research supports COVID-19 has increased the use of telepsychology services amongst psychologists, there is a paucity of research regarding how COVID-19 has altered training and use of telepsychology by psychology trainees. The current study includes survey responses from 59 psychology training directors and 58 psychology internship and postdoctoral fellowship trainees at pediatric sites throughout the United States. Results support changes in telepsychology training provided during COVID-19, including increased use of telepsychology for clinical service delivery and increased use of telesupervision for training. As expected, findings suggest novel training experiences in telepsychology for trainees within the last two years as a result of COVID-19. Given ongoing need for telepsychology services to assure access to psychological care during the pandemic and beyond, results provide support for graduate and advanced training programs to provide formal training in best-practices for utilization of telepsychology and telesupervision.

Transitioning to Telehealth Services in a Pediatric Diabetes Clinic During COVID-19: An Interdisciplinary Quality Improvement Initiative

COVID-19 necessitated a rapid shift to telehealth for psychologists offering consultation-liaison services in pediatric medical settings. However, little is known about how psychologists providing these services adapted to using telehealth service delivery formats. This report details how our interdisciplinary team identified declining psychosocial screener completion and psychology consultation rates as primary challenges following a shift to telehealth within a pediatric diabetes clinic. We utilized the Plan-Do-Study-Act (PDSA) quality improvement framework to improve screening and consultation rates, which initially declined during the telehealth transition. Screening and consultation rates dropped initially, but recovered to nearly pre-pandemic levels following three PDSA intervention cycles. During implementation, challenges arose related to the feasibility of patient interactions, interdisciplinary collaboration, patient engagement, and ethical issues. Clinics shifting psychology consultation-liaison services to telehealth should prioritize interdisciplinary communication, elicit perspectives from all clinic professionals, leverage the electronic health record, and develop procedures for warm handoffs and navigating ethical issues.