Telebehavioral Health: Workforce, Access, and Future Implications.

Even before the COVID-19 pandemic, telebehavioral health (TBH) was proving itself to be a valuable, effective tool for service delivery. The widespread adoption of its use over the past 2 years for continuity of care should be considered one of the silver linings of the pandemic. It has the potential to be a particularly powerful tool for providing more equitable access to care for those in rural communities if barriers to broadband access can be addressed. In addition to providing an attractive, flexible method of service delivery for patients and families, TBH holds appeal to the workforce as well.

Rapid Development of a Telehealth Patient Satisfaction Survey Using a Multi-Stakeholder Approach.

Introduction: The COVID-19 pandemic has hastened the adoption of telehealth and the drastic shift to an unfamiliar process may impose significant impact to the quality-of-care delivery. Many providers are interested in understanding the quality of their telehealth services from the patients' experience. Materials and Methods: A telehealth patient satisfaction survey (TPSS) was developed by using an iterative stakeholder-centered design approach, incorporating elements from validated telemedicine and customer service survey instruments, and meeting the operational needs and constraints. A cross-sectional study design was employed to collect survey responses from patients and families of a large pediatric hospital. Finally, we performed exploratory factor analysis (EFA) to extract latent constructs and factor loadings of the survey items to further explain relationships. Results: A 22-item TPSS closely matched the existing in-person patient satisfaction survey and mapped to a revised SERVPERF conceptual model that was proposed by the interdisciplinary committee. Survey was implemented in the HIPAA-compliant online platform REDCap® with survey link embedded in an automated Epic MyChart (Verona, WI) visit follow-up message. In total, 2,394 survey responses were collected between July 7, 2020, and September 2, 2020. EFA revealed three constructs (with factor loadings >0.30): admission process, perceived quality of services, and telehealth satisfaction. Conclusions: We reported the development of TPSS that met the operational needs of compatibility with existing data and possible comparison to in-person survey. The survey is short and yet covers both the clinical experience and telehealth usability, with acceptable survey validity.

The Impact of COVID-19 on Pediatric Telepsychiatry Training in Child and Adolescent Psychiatry Fellowships.

OBJECTIVE: This report summarizes findings from a 2020 survey of US child and adolescent psychiatry training programs that explored the impact of the COVID-19 pandemic on pediatric telepsychiatry training. The authors hypothesized that telepsychiatry training significantly increased during the pandemic, in part due to legal and regulatory waivers during the COVID-19 public health emergency. METHODS: In August 2020, an anonymous, 28-question online survey was emailed to all (138) accredited child psychiatry fellowships on the Accreditation Council for Graduate Medical Education website. Forty-nine programs responded (36%). This analysis focuses on three of the 28 questions relevant to the hypotheses: characteristics of the program's training in telepsychiatry; perceived impediments to clinical training; and perceived impediments to didactic training pre-COVID onset vs. post-COVID onset, respectively. Total scores were created to investigate differences in training programs and impediments to including telepsychiatry pre- and post-COVID onset. Paired sample t-tests were used to compare means pre- and post-COVID onset. RESULTS: Results provided support for significant differences between training components related to telepsychiatry pre- and post-COVID onset, with participants reporting more training components post-COVID onset (M = 5.69) than pre-COVID onset (M = 1.80); t(48) = 9.33, p < .001. Participants also reported significantly fewer barriers to providing clinical experiences in pediatric telepsychiatry post-COVID onset (M = 2.65) than pre-COVID onset (M = 4.90); t(48) = - 4.20, p < .001. CONCLUSIONS: During the COVID-19 pandemic, pediatric telepsychiatry training in child psychiatry fellowships increased significantly. Perceived barriers to providing clinical, but not didactic, training decreased significantly.

Home-Based Telemental Health: A Proposed Privacy and Safety Protocol and Tool.

Objectives: To describe the development of a protocol and practical tool for the safe delivery of telemental health (TMH) services to the home. The COVID-19 pandemic forced providers to rapidly transition their outpatient practices to home-based TMH (HB-TMH) without existing protocols or tools to guide them. This experience underscored the need for a standardized privacy and safety tool as HB-TMH is expected to continue as a resource during future crises as well as to become a component of the routine mental health care landscape. Methods: The authors represent a subset of the Child and Adolescent Psychiatry Telemental Health Consortium. They met weekly through videoconferencing to review published safety standards of care, existing TMH guidelines for clinic-based and home-based services, and their own institutional protocols. They agreed on three domains foundational to the delivery of HB-TMH: environmental safety, clinical safety, and disposition planning. Through multiple iterations, they agreed upon a final Privacy and Safety Protocol for HB-TMH. The protocol was then operationalized into the Privacy and Safety Assessment Tool (PSA Tool) based on two keystone medical safety constructs: the World Health Organization (WHO) Surgical Safety Checklist/Time-Out and the Checklist Manifesto.Results: The PSA Tool comprised four modules: (1) Screening for Safety for HB-TMH; (2) Assessment for Safety During the HB-TMH Initial Visit; (3) End of the Initial Visit and Disposition Planning; and (4) the TMH Time-Out and Reassessment during subsequent visits. A sample workflow guides implementation. Conclusions: The Privacy and Safety Protocol and PSA Tool aim to prepare providers for the private and safe delivery of HB-TMH. Its modular format can be adapted to each site's resources. Going forward, the PSA Tool should help to facilitate the integration of HB-TMH into the routine mental health care landscape.

A National Pediatric Telepsychiatry Curriculum for Graduate Medical Education and Continuing Medical Education.

Objectives: Our goal was to develop an open access nationally disseminated online curriculum for use in graduate and continuing medical education on the topic of pediatric telepsychiatry to enhance the uptake of telepsychiatry among child psychiatry training programs and improve access to mental health care for youth and families. Methods: Following Kern's 6-stage model of curriculum development, we identified a core problem, conducted a needs assessment, developed broad goals and measurable objectives in a competency-based model, and developed educational content and methods. The curriculum was reviewed by experts and feedback incorporated. Given the urgent need for such a curriculum due to the COVID-19 pandemic, the curriculum was immediately posted on the American Academy of Child and Adolescent Psychiatry and American Association of Directors of Psychiatric Residency Training websites. Further evaluation will be conducted over the next year. Results: The curriculum covers the six areas of core competence adapted for pediatric telepsychiatry and includes teaching content and resources, evaluation tools, and information about other resources. Conclusion: This online curriculum is available online and provides an important resource and set of standards for pediatric telepsychiatry training. Its online format allows for ongoing revision as the telepsychiatry landscape changes.

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

OBJECTIVE: A consortium of 8 academic child and adolescent psychiatry programs in the United States and Canada examined their pivot from in-person, clinic-based services to home-based telehealth during the COVID-19 pandemic. The aims were to document the transition across diverse sites and to present recommendations for future telehealth service planning. METHOD: Consortium sites completed a Qualtrics survey assessing site characteristics, telehealth practices, service use, and barriers to and facilitators of telehealth service delivery prior to (pre) and during the early stages of (post) the COVID-19 pandemic. The design is descriptive. RESULTS: All sites pivoted from in-person services to home-based telehealth within 2 weeks. Some sites experienced delays in conducting new intakes, and most experienced delays establishing tele-group therapy. No-show rates and use of telephony versus videoconferencing varied by site. Changes in telehealth practices (eg, documentation requirements, safety protocols) and perceived barriers to telehealth service delivery (eg, regulatory limitations, inability to bill) occurred pre-/post-COVID-19. CONCLUSION: A rapid pivot from in-person services to home-based telehealth occurred at 8 diverse academic programs in the context of a global health crisis. To promote ongoing use of home-based telehealth during future crises and usual care, academic programs should continue documenting the successes and barriers to telehealth practice to promote equitable and sustainable telehealth service delivery in the future.

Documented Reasons of Cancellation and Rescheduling of Telehealth Appointments During the Pandemic.

Background and Objective: The COVID-19 pandemic increased the use of telehealth around the world. The aim is to minimize health care service disruption as well as reducing COVID-19 exposure. However, one of the major operational concerns is cancellations and rescheduling (C/Rs). C/Rs may create additional burden and cost to the patient, provider, and the health system. Our aim is to understand the reasons for C/Rs of the telehealth session after the scheduled start time. Materials and Methods: We reviewed electronic health records (EHRs) to identify the C/R reasons for behavioral health and speech language pathology departments. Documented C/Rs in the medical charts were identified from EHR by using a keyword-based and Natural Language Processing (NLP)-supported EHR search engine. From the search results, we randomly selected 200 notes and conducted a thematic analysis. Results: We identified four themes explaining C/R reasons. Most frequent theme was "technicality" (47, 36%), followed by "engagement" (34, 25%), "scheduling" (31, 24%), and "unspecified" (20, 15%). The findings showed that technical reasons are the leading cause of C/Rs, constituting 36% of the cases (95% confidence interval [CI]: 29-43%). Notably, "engagement" constituted a sizeable 25% (95% CI: 19-31%) of C/Rs, as a result of the inability to engage a patient to complete the telehealth session. Conclusions: The study shows that engagement is one of the new challenges to the pediatric telehealth visits. Future studies of new engagement models are needed for the success of telehealth. Our findings will help fill the literature gaps and may help with enhancing the digital experience for both caregivers and providers, reducing wasted time and resources due to preventable C/Rs, improving clinical operation efficiency, and treatment adherence.

Readiness for voice assistants to support healthcare delivery during a health crisis and pandemic.

To prevent the spread of COVID-19 and to continue responding to healthcare needs, hospitals are rapidly adopting telehealth and other digital health tools to deliver care remotely. Intelligent conversational agents and virtual assistants, such as chatbots and voice assistants, have been utilized to augment health service capacity to screen symptoms, deliver healthcare information, and reduce exposure. In this commentary, we examined the state of voice assistants (e.g., Google Assistant, Apple Siri, Amazon Alexa) as an emerging tool for remote healthcare delivery service and discussed the readiness of the health system and technology providers to adapt voice assistants as an alternative healthcare delivery modality during a health crisis and pandemic.

Pediatric Telebehavioral Health: A Transformational Shift in Care Delivery in the Era of COVID-19.

The use of telebehavioral health has been expanding in the past decade to improve access to psychiatric care and address critical shortages in the psychiatric workforce. The coronavirus (COVID-19) pandemic forced a sudden shift from traditional in-person visits to alternative modalities. There are key factors associated with successful transitional and large-scale implementation of telehealth with existing resources. We describe the experience of a large health care system using telehealth technology, and we identify strategies and discuss considerations for long-term sustainability after the pandemic.