Development and Implementation of a Virtual Clinical Skills Examination in General Psychiatry.

OBJECTIVE: During the COVID-19 pandemic, psychiatry programs have administered the Clinical Skills Evaluation (CSE) through videoconferencing. The authors evaluated the feasibility and appropriateness of administering virtual CSEs. METHODS: Virtual CSEs were administered to 11 general psychiatry residents on March 16, 2021. Teleconference software was used to connect faculty at work sites, residents at a simulation center, and volunteer patients at home. Before and after the CSE, residents and faculty were surveyed with Likert scale questions to evaluate their perceptions and experience. RESULTS: All virtual CSEs were completed successfully. Nine residents (82%) and 12 faculty (92%) responded to both surveys. Most participants (range, 67-83%) indicated that the virtual CSE was appropriate for assessing patient health and resident skills. Most participants (range, 56-100%) reported that the opening and closing of the interview, informational and affective cues, and rapport were adequately assessed. All participants agreed that suicidal and homicidal risks could be adequately assessed. Most faculty and residents (76%) believed that unique skills were required for telehealth interviews. Before the CSE, more faculty than residents believed that they received adequate training for the virtual CSE (P=.02); afterward, most participants thought that training was adequate (P=.46). More faculty than residents reported increased convenience with virtual assessments (both surveys, P<.01). CONCLUSION: Virtual CSEs were deemed feasible and appropriate. Further research is needed to identify the specific skills required to perform a virtual CSE and to clarify the potential limitations and benefits of this format.

Chapter 17 - A look forward to digital therapeutics in 2040 and how clinicians and institutions get there

Widespread use of telehealth, mobile health, and remote patient monitoring during the COVID-19 pandemic has given users a vision of what is possible in future healthcare worldwide. Artificial intelligence and predictive modeling capitalize on in-time, continuous data collection, and analytics to support patient and clinician decision-making. The necessary shift in health technology adoption during the pandemic has also highlighted a shift toward digital, health, and cultural literacy and the need for clinician and institutional competencies in order to maximize technology adoption and improve health outcomes. Healthcare providers and entire systems must consider necessary adjustments to financing, reimbursement, policy, training, and infrastructure. Propelled by the needs caused by the pandemic, there exists an opportunity to build on lessons learned and to create a new vision for the future of healthcare. Research is needed in the areas of user-centered design, implementation and effectiveness approach, models of care, human–computer interaction, ethical and legal issues, and economic cost analyses.

Flipping a Single Lecture in a Survey Course to Active Learning: Do the Benefits Justify the Costs?

Health education has seen a surge of interest in active learning strategies like the flipped classroom. In response to the need for physical distancing in the age of COVID-19, schools are rapidly shifting to web-based and video technology, sometimes without being able to predict the outcomes of this change. The objectives of this pilot experiment were to (1) compare active learning (AL) methods versus traditional lecture for transmitting and retaining knowledge in the introductory pre-clinical medical school curriculum and (2) weigh whether the costs required to flip instruction were justified by learning gains. The authors took a 2 h lecture for first-year medical students and converted half of it into an AL format. In-person lecture and active learning groups were compared in terms of student knowledge at pre-intervention, immediately post-intervention, and 6 months post-intervention. Costs for first-time delivery and anticipated costs for repeat delivery of each format were calculated. Students' gains in knowledge increased in both groups, though more by lecture (control) than via AL. Delivering a single hour of new AL costs 3.4 times that of a new lecture. Repeat offerings of the AL intervention were estimated to cost 5.4 times that of the repeat lecture. The 1 h AL session was less effective than the 1 h lecture for knowledge acquisition and retention at 6-month follow-up. The AL was more expensive to produce and to repeat. Future research needs to evaluate the impact of AL with a larger N, control group, structured faculty/resident procedures, and assessment of gaining and applying attitudes and skills in addition to knowledge.

CTiBS and Clinical Social Work: Telebehavioral Health Competencies for LCSWs in the Age of COVID-19.

Licensed Clinical Social Workers (LCSWs) have been integrating technology into psychotherapy practice for at least two decades, but the COVID-19 pandemic dramatically shifted the primary method of service delivery for diagnostic assessment and therapy to telebehavioral health. By developing telebehavioral health competencies, the 250,000 + LCSWs in the US can ensure and enhance the quality of care both during and after the COVID public health emergency (PHE). This article applies an evidence- and consensus-based, interprofessional telebehavioral health (TBH) competency framework to the field of social work. This framework was developed by the Coalition for Technology in Behavioral Science (CTiBS), initially published in 2017. It has seven competency domains: (1) clinical evaluation and care; (2) virtual environment and telepresence; (3) technology; (4) legal and regulatory issues; (5) evidence-based and ethical practice (comprised of Standards and Guidelines and Social Media); (6) mobile health and apps; and (7) telepractice development. The framework outlines three competency levels (novice, proficient, and authority) covering 49 specific objectives and 146 measurable competencies or practices. The TBH competencies support existing in-person clinical practices and are intended for trainees and practitioners who are implementing TBH in practice. This competency framework can also be used to integrate clinical social work professional development, research, and training. Additionally, considerations for other behavioral health professions regarding licensure, certification, and policy may apply to clinical social work. Future research is needed on implementation and evaluation of the competencies.

Clinician Satisfaction with Rapid Adoption and Implementation of Telehealth Services During the COVID-19 Pandemic.

Background: To examine clinician perspectives on the acceptability, appropriateness/suitability, and feasibility of video telehealth as a way to deliver mental health services during the COVID-19 pandemic. Materials and Methods: Mental health clinicians were surveyed with 27 Likert questions, using previously validated measures, on satisfaction and implementation experience with video telehealth visits between March and June 2020. Results: A total of 112 of 193 clinicians completed the survey (58.0%), including psychiatrists, psychologists, trainees (i.e., residents and fellows), advanced practice providers, and licensed mental health counselors. Clinicians reported high levels of acceptability, feasibility, and appropriateness of video telehealth; they also reported high levels of satisfaction with video telehealth visits. Seventy-nine and a half (79.5%) reported that their patients seemed highly satisfied with video telehealth visits, and 107 (95.5%) of clinicians responded that they would like video telehealth visits to represent at least 25% of their practice in the future. Discussion: Mental health clinicians showed positive attitudes toward the implementation of video telehealth visits, high levels of satisfaction with this care, and indicated strong interest in continuing this modality as a significant portion of clinical practice. Conclusions: This study demonstrates the ability of mental health clinicians to embrace new technology to expand access to care during the COVID-19 pandemic. Results indicate that telemental health is likely to be an integral part of clinic practice in the future.

Flipping a Single Lecture in a Survey Course to Active Learning: Do the Benefits Justify the Costs?

Health education has seen a surge of interest in active learning strategies like the flipped classroom. In response to the need for physical distancing in the age of COVID-19, schools are rapidly shifting to web-based and video technology, sometimes without being able to predict the outcomes of this change. The objectives of this pilot experiment were to (1) compare active learning (AL) methods versus traditional lecture for transmitting and retaining knowledge in the introductory pre-clinical medical school curriculum and (2) weigh whether the costs required to flip instruction were justified by learning gains. The authors took a 2 h lecture for first-year medical students and converted half of it into an AL format. In-person lecture and active learning groups were compared in terms of student knowledge at pre-intervention, immediately post-intervention, and 6 months post-intervention. Costs for first-time delivery and anticipated costs for repeat delivery of each format were calculated. Students’ gains in knowledge increased in both groups, though more by lecture (control) than via AL. Delivering a single hour of new AL costs 3.4 times that of a new lecture. Repeat offerings of the AL intervention were estimated to cost 5.4 times that of the repeat lecture. The 1 h AL session was less effective than the 1 h lecture for knowledge acquisition and retention at 6-month follow-up. The AL was more expensive to produce and to repeat. Future research needs to evaluate the impact of AL with a larger N, control group, structured faculty/resident procedures, and assessment of gaining and applying attitudes and skills in addition to knowledge.

A Survey of Residents/Fellows, Program Directors, and Faculty About Telepsychiatry: Clinical Experience, Interest, and Views/Concerns.

The effectiveness of telepsychiatry video for clinical care is well established, and clinician and psychiatry resident interest in it is growing-particularly in light of the COVID-19 impact. Still, few residency programs in the United States have core curricula, rotations/electives available, and competencies, and many faculty have no experience. A survey was sent via national organization listserves for residents, fellows, faculty, and program directors to complete. The survey queried demographics, clinical experience and interest, and views/concerns, using Likert-like and yes/no questions. Descriptive statistics and other analyses compared the groups to assess impact of clinical experience on interest and views/concerns. Respondents (N = 270) have limited clinical experience with telepsychiatry (46% none), with trainees having less than others, and yet, most were very interested or interested in it (68%). Trainees (N = 123) have concerns about being prepared for future practice. Clinical experience with video in the range of 6-20 h appears to dramatically increase interest and reduce concerns, though less time has a positive effect. Respondents have concerns about connectivity, medico-legal issues, and clinical effectiveness (e.g., diverse populations, psychosis, and emergencies) with telepsychiatry. More research is needed to assess current clinical and curricular experience, interest, and concerns. Additional curricular interventions during residency and fellowship training could build skills and confidence, if this is feasible, and the benefits outweigh the costs.

Health Care Providers' Perceptions of Quality, Acceptance, and Satisfaction With Telebehavioral Health Services During the COVID-19 Pandemic: Survey-Based Study.

BACKGROUND: Due to rapidly increasing rates of COVID-19 across the country, system-wide changes were needed to protect the health and safety of health care providers and consumers alike. Technology-based care has received buy-in from all participants, and the need for technological assistance has been prioritized. OBJECTIVE: The objective of this study was to determine the initial perceptions and experiences of interprofessional behavioral health providers about shifting from traditional face-to-face care to virtual technologies (telephonic and televideo) during the COVID-19 pandemic. METHODS: A survey-based study was performed at a large, integrated medical health care system in West-Central Florida that rapidly implemented primary care provision via telephone and televideo as of March 18, 2020. A 23-item anonymous survey based on a 7-point Likert scale was developed to determine health care providers' perceptions about telephonic and televideo care. The survey took 10 minutes to complete and was administered to 280 professionals between April 27 and May 11, 2020. RESULTS: In all, 170 respondents completed the survey in entirety, among which 78.8% (134/170) of the respondents were female and primarily aged 36-55 years (89/170, 52.4%). A majority of the respondents were outpatient-based providers (159/170, 93.5%), including psychiatrists, therapists, counselors, and advanced practice nurses. Most of them (144/170, 84.7%) had used televideo for less than 1 year; they felt comfortable and satisfied with either telephonic or televideo mode and that they were able to meet the patients' needs. CONCLUSIONS: Our survey findings suggest that health care providers valued televideo visits equally or preferred them more than telephonic visits in the domains of quality of care, technology performance, satisfaction of technology, and user acceptance.

Changes in telepsychiatry regulations during the COVID-19 pandemic: 17 countries and regions' approaches to an evolving healthcare landscape.

BACKGROUND: During the COVID-19 pandemic, the use of telemedicine as a way to reduce COVID-19 infections was noted and consequently deregulated. However, the degree of telemedicine regulation varies from country to country, which may alter the widespread use of telemedicine. This study aimed to clarify the telepsychiatry regulations for each collaborating country/region before and during the COVID-19 pandemic. METHODS: We used snowball sampling within a global network of international telepsychiatry experts. Thirty collaborators from 17 different countries/regions responded to a questionnaire on barriers to the use and implementation of telepsychiatric care, including policy factors such as regulations and reimbursement at the end of 2019 and as of May 2020. RESULTS: Thirteen of 17 regions reported a relaxation of regulations due to the pandemic; consequently, all regions surveyed stated that telepsychiatry was now possible within their public healthcare systems. In some regions, restrictions on prescription medications allowed via telepsychiatry were eased, but in 11 of the 17 regions, there were still restrictions on prescribing medications via telepsychiatry. Lower insurance reimbursement amounts for telepsychiatry consultations v. in-person consultations were reevaluated in four regions, and consequently, in 15 regions telepsychiatry services were reimbursed at the same rate (or higher) than in-person consultations during the COVID-19 pandemic. CONCLUSIONS: Our results confirm that, due to COVID-19, the majority of countries surveyed are altering telemedicine regulations that had previously restricted the spread of telemedicine. These findings provide information that could guide future policy and regulatory decisions, which facilitate greater scale and spread of telepsychiatry globally.

COVID-19 Transmission in a Psychiatric Long-Term Care Rehabilitation Facility: An Observational Study.

OBJECTIVE: To report the clinical characteristics and transmission rate of coronavirus disease 2019 (COVID-19) in a community inpatient long-term care psychiatric rehabilitation facility designed for persons with serious mental illness to provide insight into transmission and symptom patterns and emerging testing protocols, as well as medical complications and prognosis. METHODS: This study examined a cohort of 54 residents of a long-term care psychiatric rehabilitation program from March to April 2020. Baseline demographics, clinical diagnoses, and vital signs were examined to look for statistical differences between positive versus negative severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) groups. During the early phase of the pandemic, the facility closely followed the local shelter-in-place order (starting March 19, 2020) and symptom-based testing. RESULTS: Of the residents, the primary psychiatric diagnoses were schizoaffective disorder: 28 (51.9%), schizophrenia: 21 (38.9%), bipolar I disorder: 3 (5.5%), and unspecified psychotic disorder: 2 (3.7%). Forty (74%) of 54 residents tested positive for SARS-COV-2, with a doubling time of 3.9 days. There were no statistical differences between the positive SARS-COV-2 versus negative groups for age or race/ethnicity. Psychiatric and medical conditions were not significantly associated with contracting SARS-COV-2, with the exception of obesity (n = 17 [43%] positive vs n = 12 [86%] negative, P = .01). Medical monitoring of vital signs and symptoms did not lead to earlier detection. All of the residents completely recovered, with the last resident no longer showing any symptoms 24 days from the index case. CONCLUSION: Research is needed to determine optimal strategies for long-term care mental health settings that incorporate frequent testing and personal protective equipment use to prevent rapid transmission of SARS-COV-2.