Since social distancing became a part of the defense against the COVID-19 pandemic, many health care providers have closed their doors and deferred procedures to protect patients from COVID-19 infection (1–3), significantly altering how care is delivered. However, continued management of chronic diseases that increase COVID-19 risk, such as diabetes mellitus and hypertension, remains a crucial part of response to the pandemic. Because of a combination of comorbid conditions and adverse social determinants of health (e.g., housing instability, economic hardship, and social isolation), people with serious mental illness may be at particular risk for increased COVID-19–associated morbidity and mortality and for the adverse social and psychological effects of the pandemic (4). In many states, mental health providers responded to the COVID-19 emergency with rapid and widespread transition to telehealth, supported by relief from many regulatory and legislative barriers established before COVID-19 (5).

Many people with severe mental illness require complex multidisciplinary care management with frequent engagement to help them recover, maintain a degree of independence, and avoid hospitalization (6, 7). For individuals served by teams of mental health professionals, such as in assertive community treatment (ACT) or supported housing, these teams may be the greatest potential source of COVID-19 transmission risk. Transition of these treatment models to telehealth became essential during the pandemic but faced unique barriers.

A growing body of evidence supports the notion that with regard to outcomes and patient satisfaction, telepsychiatry is comparable to face-to-face psychiatry in clinical settings (8–10). A subset of evidence has examined telepsychiatry for the management of serious mental illness, finding that most clients appreciate these services (6, 11–14). Social isolation is a common problem among people with serious mental illness, sometimes compounded by paranoid ideation or negative symptoms (15–25). It is possible that being able to connect with mental health professionals without leaving the home or receiving visitors may offer some relief.

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Available studies most frequently involve telepsychiatry offered through videoconferencing or smartphone technology augmenting primarily face-to-face treatment. However, low computer literacy and limited access to Internet technology are prevalent among individuals with serious mental illness and represent barriers to telehealth access. Older individuals may experience even greater issues with telehealth access because of difficulties with hearing, speech, vision, and cognitive impairment (21). When New York State expanded regulations to allow its licensed programs to bill Medicaid for telehealth visits in March 2020 in response to the COVID-19 pandemic, telephone-based interventions were permitted to address technology barriers. Little is known about client preferences and experiences regarding telephone-based services, particularly among people with serious mental illness.

In this study, we examined the acceptability and feasibility of telehealth service provision shortly after its introduction in a community behavioral health agency. In particular, we examined client subjective experience, preferences, and satisfaction with services across behavioral health program types, and we compared their responses with those from a 2018 sample. We also examined utilization patterns for these behavioral health services and for emergency and hospital services.

Methods

Population

We invited individuals receiving services from May 8 to 18, 2020, in programs that had introduced telehealth services during the COVID-19 pandemic at a New York City community behavioral health agency. The total census of these programs was 6,546, which included 2,668 individuals in treatment programs (mental health clinics, ACT, Intensive Mobile Treatment [IMT] program, and Personal Recovery Oriented Services [PROS] day program), 2,540 in outreach programs (including care coordination and several small program types), and 1,796 in housing programs (including Treatment Apartment Program [TAP] and supported housing). Some individuals were enrolled in more than one program. For the 6,546 individuals served by these programs, most had a diagnosis of serious mental illness, with 39% (N=2,553) diagnosed as having a psychotic disorder and 41% (N=2,684) diagnosed as having mood disorders. Most participants identified as Black (60%, N=3,929), with 22% (N=1,440) identifying as Hispanic, 14% (N=916) identifying as White, 3% (N=196) identifying as multiracial, and 1% (N=65) identifying as Asian. Participants had a mean±SD age of 45±17 years (range 5–93). For 233 minors among the individuals served, their guardians were asked to take the survey on their behalf. This study was performed as part of routine agency performance improvement. Institutional review was not required.

Interview Procedures

The survey was administered by clinicians and case managers during scheduled or routine meetings with participants via the telephone, by videoconferencing call, or in person during the study period. Clinicians and case managers were provided with a script to introduce the survey, which explicitly stated that the survey was voluntary. The survey took approximately 5 minutes to complete, and the clinicians and case managers recorded the survey responses in SurveyMonkey.

Measures

The agency developed a brief survey to measure participants’ experience with telehealth services. The first three survey items measured perceived level of connection and support experienced before the pandemic compared with the present. The next four items were extracted from the agency’s annual consumer satisfaction survey to allow for historical data comparison. The next item asked whether the individual would like to continue receiving services remotely after the pandemic ended. If the response was yes, the individual was asked whether they would prefer all telehealth or a mixture of telehealth and in-person service. The next item asked what type of device was used to engage in telehealth (e.g., phone or laptop). The clinician or case manager was then asked to rate their perception of the individual’s level of distress related to the COVID-19 pandemic.

Monthly aggregate service utilization data for Medicaid-reimbursable programs, including clinics, ACT, PROS, and TAP, were extracted from electronic health records to examine changes in client access to and engagement in telehealth and face-to-face services during the period immediately before and after the beginning of the pandemic (February 1–April 30, 2020). Self-reported emergency and inpatient utilization data were obtained from the electronic health record’s Healthy Living Questionnaire, administered quarterly or semiannually in all participating programs other than IMT and care coordination (for the periods January–April 2019 and January–April 2020), to enable comparison.

Data Analysis

All collected data were coded and recorded into a computer data file and analyzed with IBM SPSS Statistics, version 26. Data were aggregated by program type (treatment, outreach, and housing), and ordinal logistic regressions were used to test for differences among program types on responses to the 5-point, Likert-rated survey questions (1, a lot less than before; 2, a little less than before; 3, the same as before; 4, a little more than before; 5, a lot more than before). Ordinal logistic regressions were used to identify differences between historical responses to the client satisfaction survey items in 2018 and responses during the study period in 2020. Ordinal logistic regressions were also used to determine whether provider-rated client distress due to the pandemic was correlated with experience of services and satisfaction. Results were considered statistically significant at p<0.01 to account for multiple testing. Service use frequency data were summarized in graphs.

Results

Survey Participation

In total, 1,482 individuals responded, including 363 (25%) in treatment programs, 225 (15%) in outreach programs, and 894 (60%) in housing programs and representing 38% (N=3,933) of individuals scheduled for visits during the study period. (Estimated survey participation rates by program type can be found in an online supplement to this article, with a higher participation rate in housing programs than in other programs.)

Comparison of Responses by Program Type

Survey responses are detailed in Table 1 and separated by program type. For the overall sample, most participants responded that their ability to connect to staff (85%, N=1,260), get support when needed (90%, N=1,334), and get an appointment when wanted (82%, N=1,215) was the same as or more than before the pandemic.

	Treatment		Housing		Outreach
Survey item and responses	N	%	N	%	N	%
I feel connected to my care teama
A lot less	14	4	26	3	10	4
A little less	49	14	90	10	33	15
The same	186	51	517	58	125	56
A little more	56	16	164	18	31	14
A lot more	57	16	95	11	26	12
I can get support when I need it
A lot less	12	3	17	2	2	1
A little less	23	6	62	7	34	15
The same	214	59	543	61	125	56
A little more	55	15	181	20	41	18
A lot more	56	16	90	10	23	10
I can get an appointment when I want
A lot less	11	3	42	5	11	5
A little less	24	7	118	13	58	26
The same	233	65	560	63	122	54
A little more	41	12	110	12	12	5
A lot more	49	14	63	7	22	10
I feel comfortable asking about treatment and medications
A lot less	3	1	8	1	2	1
A little less	8	2	15	2	4	2
The same	24	7	66	7	23	10
A little more	183	51	537	60	129	58
A lot more	140	39	268	30	66	30
Staff talk to me about specific goals for my health
A lot less	3	1	3	<1	1	<1
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