Telehealth and the Community SMI Population by articles

ORIGINAL ARTICLE

Telehealth and the Community SMI Population Reflections on the Disrupter Experience of COVID-19 Rachel M. Talley, MD,*† Mary F. Brunette, MD,*‡ David A. Adler, MD,*§ Lisa B. Dixon, MD, MPH,*|| Jeffrey Berlant, MD, PhD,*¶# Matthew D. Erlich, MD,*|| Beth Goldman, MD, MPH,* Michael B. First, MD,*|| Steve Koh, MD, MPH, MBA,*** David W. Oslin, MD,*††† and Samuel G. Siris, MD*‡‡

Abstract: The novel coronavirus pandemic and the resulting expanded use of telemedicine have temporarily transformed community-based care for individuals with serious mental illness (SMI), challenging traditional treatment paradigms. We review the rapid regulatory and practice shifts that facilitated broad use of telemedicine, the literature on the use of telehealth and telemedicine for individuals with SMI supporting the feasibility/acceptability of mobile interventions, and the more limited evidence-based telemedicine practices for this population. We provide anecdotal reflections on the opportunities and challenges for telemedicine drawn from our daily experiences providing services and overseeing systems for this population during the pandemic. We conclude by proposing that a continued, more prominent role for telemedicine in the care of individuals with SMI be sustained in the post-coronavirus landscape, offering future directions for policy, technical assistance, training, and research to bring about this change. Key Words: Service delivery in community-based care, expansion of telemedicine use, practice adaptations to the COVID-19 pandemic (J Nerv Ment Dis 2020;00: 00–00)

he emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, which causes the disease COVID-19) and the resulting public health crisis forced mental health providers to rapidly suspend the majority of in-person contact and transition to telemedicine services to both prevent the spread of infection and maintain access to care. Given the traditional reliance upon in-person interventions for people with serious mental illness (SMI), such changes present a unique paradigm shift for community and public sector providers working with this population. How did the adaptations needed for this new practice environment impact the clinical care experience for individuals with SMI and their providers? Has telemedicine impacted outcomes for those served? The answers are not readily provided by the existing research on the use of telemedicine in evidence-based practices for individuals with SMI. Here, we review current research and provide reflections on the patient and provider telemedicine experience from *Group for Advancement of Psychiatry, New York, New York; †Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ‡Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; §Department of Psychiatry, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts; ||Department of Psychiatry, New York State Psychiatric Institute/Columbia University Vagelos College of Physicians and Surgeons and New York Presbyterian, New York, New York; ¶Optum Idaho, Boise, Idaho; #Canyon Manor Mental Health Rehabilitation, Novato, California; **Department of Psychiatry, University of California San Diego, San Diego, California; ††Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, Pennsylvania; and ‡‡Department of Psychiatry, Donna and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York. Send reprint requests to Rachel M. Talley, MD, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market St, Philadelphia, PA 19104. E‐mail: Rachel.Talley@pennmedicine.upenn.edu. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/20/0000–0000 DOI: 10.1097/NMD.0000000000001254

clinicians and administrators across the country in settings serving individuals with SMI during the pandemic. We offer recommendations drawn from lessons learned through this experience. We specifically focus on community-based and outpatient services, acknowledging that experiences with the parallel transformation in use of telemedicine for inpatient, consultation-liaison, and emergency department psychiatric care also must be addressed (Kalin et al., 2020). The Health Resources Services Administration defines telehealth as the provision of a broad array of clinical and nonclinical health-related activities through telecommunication and electronic means (e.g., provider training, administrative meetings, etc.), and more narrowly defines telemedicine as the remote delivery of clinical services (Department of Health and Human Services, 2019). Telemedicine has typically incorporated both audio and visual communications, as required by regulations. Telemedicine is also differentiated from telework, which refers to providers working from home, and encompasses all services and the challenges providers face when working remotely during a pandemic or otherwise. Before the pandemic, the promise of telemedicine had not been fully realized, although equipment and communications had become cheaper and widely available in offices and homes, supported by Internet technology and data security that had advanced enough to gain broad trust from the public. Telemedicine had been partially supported by the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, which intended to expand access to care for rural America via telemedicine. It allowed telemedicine visits between clinical sites to be paid the usual Medicare rate for the service (notably requiring a patient to travel to a clinical site for the service and a provider to be in an office setting). Although the Health Insurance Portability and Accountability Act (HIPAA) of 1996 was intended to ensure data security for sensitive medical information, technical and legal requirements impeded telemedicine until recently. By 2019, telemedicine certainly had the promise to be easily and cheaply utilized; indeed, some health care sectors, most notably the Veterans Health Administration, have experienced rapid growth in use of telemedicine (Darkins, 2014). Yet, before the COVID-19 pandemic, use of telemedicine, particularly among Medicaid recipients, was extremely low (Douglas et al., 2017). A recent comparison of behavioral health telemedicine Medicaid claims in rural versus nonrural settings from 2012 to 2017 found low rates of use in both settings, although use increased over time; substance use disorder treatment in particular did not exceed 3% for either time point or geographic setting (Creedon et al., 2020). In response to the acute disruption resulting from COVID-19, regulators implemented dramatic but temporary changes in a variety of federal and state telemedicine regulations to facilitate continued access to care and payment for services (Goldman et al., 2020). Stay-at-home orders were implemented in many states, yet people with SMI needed ongoing services. The service delivery system required a dramatic overhaul to enable social distancing and infection control, while enabling providers to continue to provide services for this population. Thus,