Clinicians' Perceptions of Rapid Scale-up of Telehealth Services in Outpatient Mental Health Treatment.

Background: Little is known about specialty mental health and/or substance use disorder (MH/SUD) clinicians' experiences transitioning from in-person to telehealth care, to treat a diagnostically diverse population during the COVID-19 pandemic. Methods: Survey of outpatient MH/SUD clinicians (psychiatrists, nurse practitioners, psychologists, and licensed clinical social workers; N = 107) at a psychiatric hospital. Clinician satisfaction and experiences using telehealth across a variety of services (individual, group or family therapy, initial assessments, evaluation and management, and neuropsychological assessment) were assessed using a mixed-methods approach. Results: Across services, a majority agreed/strongly agreed that telehealth provided an opportunity to build rapport with patients (67-88%) and they could treat their patients' needs well (71-88%). The interest in continuing to use telehealth when in-person visits resume varied by type of service provided (50-71%). Group therapy and initial assessment were lowest (50% and 51%, respectively). Clinicians noted telehealth improved access to care for patients with logistical barriers, competing demands, mobility difficulties, and medical concerns; but was more challenging to care for patients with certain psychiatric characteristics (e.g., psychosis, paranoia, catatonia, high distractibility, and avoidance), high symptom severity, or who needed to improve social skills. Telehealth influenced the therapeutic process (e.g., observations of family dynamic, increased patient/clinician therapeutic alliance). Discussion and Conclusions: MH/SUD clinicians who quickly transitioned to telehealth care during the pandemic were largely satisfied with telehealth, but also identified challenges related to specific patient characteristics, or types of MH/SUD services. These observations warrant additional study to better delineate the role for an expanded use of telehealth postpandemic.

Impact of a quality improvement program on care and outcomes for children with asthma.

OBJECTIVE: To test a quality improvement intervention, a learning collaborative based on the Institute for Healthcare Improvement's Breakthrough Series methodology, specifically intended to improve care and outcomes for patients with childhood asthma. DESIGN: Randomized trial in primary care practices. SETTING: Practices in greater Boston, Mass, and greater Detroit, Mich. PARTICIPANTS: Forty-three practices, with 13 878 pediatric patients with asthma, randomized to intervention and control groups. Intervention Participation in a learning collaborative project based on the Breakthrough Series methodology of continuous quality improvement. MAIN OUTCOME MEASURES: Change from baseline in the proportion of children with persistent asthma who received appropriate medication therapy for asthma, and in the proportion of children whose parent received a written management plan for their child's asthma, as determined by telephone interviews with parents of 631 children. RESULTS: After adjusting for state, practice size, child age, sex, and within-practice clustering, no overall effect of the intervention was found. CONCLUSIONS: This methodologically rigorous assessment of a widely used quality improvement technique did not demonstrate a significant effect on processes or outcomes of care for children with asthma. Potential deficiencies in program implementation, project duration, sample selection, and data sources preclude making the general inference that this type of improvement program is ineffective. Additional rigorous studies should be undertaken under more optimal settings to assess the efficacy of this method for improving care.

Improving care for children with attention deficit hyperactivity disorder: assessing the impact of self-assessment and targeted training on practice performance.

OBJECTIVES: Major gaps exist between usual clinical practice and evidence-based recommendations for care. Many interventions to improve care are costly and time intensive. This study sought to determine whether a clinician's self-assessment of their practice performance for the diagnosis and management of children with attention deficit hyperactivity disorder (ADHD) followed by attendance at a 2-day conference focused on system change would result in improvement in care. DESIGN: Quasi-experimental-before and after with external controls. PARTICIPANTS: Clinician attendees compared with convenience sample of nonattendees. OUTCOMES: Consistency with 10 specific recommendations from the American Academy of Pediatrics Guidelines concerning ADHD. ANALYSIS: Logistic regression, with use of generalized estimating equations to account for clustering of subjects within clinician practices. RESULTS: Widespread deficiencies in care were present prior to the intervention. Practice improved significantly more among conference attendees in 2 of the 10 performance measures (evaluation for coexisting conditions and offering treatment options), with positive trends in most of the other indicators. CONCLUSIONS: Practice assessment and system-based training may be a cost-effective strategy to improve practice performance.