Keeping Up with Technology: Use of Telehealth to Increase Mental Health Services to Veterans

Julia Rubinshteyn, PhD

Julia Rubinshteyn, PhD

Julia Rubinshteyn, PhD

Although mental health disorders affect a lot of Americans, many of those individuals do not seek treatment (Wang et al., 2007). The Veterans Affairs Healthcare System provides a treatment option for patients who experience barriers to attending in-person appointments in the form of videoconferencing technology called telehealth.

Telepsychology, which is a form of telehealth, is defined by the American Psychological Association as “the provision of psychological services using telecommunication technologies.” An increasing number of psychologists are providing services to patients using video teleconferencing. The VA Healthcare System has been a leader in providing telehealth to patients in rural areas (Backhaus et al., 2012). At the VA, patients can go to a remote VA Community Based Outpatient Clinic (CBOC) that is close to their home to access telehealth and communicate with a provider at the main VA campus. If this is not convenient for a patient, they also have access to telehealth services in their own homes.

In my clinic, I am currently using Jabber software, which can be used to conduct telehealth sessions with patients and can also be used to conduct meetings with other providers within the VA. The software was remotely downloaded onto my computer by a technical support specialist. The only equipment required is a computer with a working camera and microphone.

Providers require training in telehealth to learn to use the equipment properly and to learn about special considerations when working with patients who are not physically at the hospital. Training is conducted online through several modules, including how to use the equipment, make telehealth calls, and how to manage emergency situations when using telehealth. At the conclusion of online training, a brief test session is conducted with a technical support specialist to ensure that the provider has an understanding of how to use the software and all the equipment is working properly.

In my clinic, when I have a patient that I believe is a candidate for telehealth, I submit a formal consult through the electronic medical record. The consult is reviewed by a psychologist who is the Telemental Health and Technology Team Program manager. It is also reviewed by a technology support specialist. When submitting the consult, I am required to enter the following information regarding the patient’s eligibility to participate in telehealth:

  • whether the patient has a working computer, a working webcam, and a secure internet connection. If the patient does not have these, the VA can provide them with a tablet.
  • whether the patient has a working phone number, either a landline or cell phone. This is to ensure I can reach the patient in case the equipment is not working properly at the scheduled time of the visit.
  • whether the patient has a location to conduct sessions that maintains confidentiality and privacy.

Additionally, the following information must be indicated in the consult and considered when determining whether a patient is a good candidate for receiving mental health services through telehealth:

  • Does the patient have suicidal or homicidal ideation?
  • Does the patient have uncontrolled substance abuse?
  • Does the patient have psychosis?

If the answer to any of the above is yes, clinicians must provide justifications for why the patient is appropriate for telehealth despite having one of these conditions.

Once the consult is placed, patients are able to get access to the Jabber software that is downloaded onto their personal computer. The technical support specialist ensures that the patient has the correct equipment, and provides them with any additional equipment they need. After that, a test session is conducted with the patient to ensure everything is working properly. The therapist schedules the session, which sends an automatic email to the patient. The patient may click on the email to call the therapist at the scheduled appointment time for the therapy session. Sessions are conducted in the same way as a regular session. It is even possible to show a patient the therapist’s computer screen ..to display handouts and worksheets.

 

Benefits

Telehealth is a powerful tool in providing access to empirically supported treatments to patients who would otherwise not have access to services. This includes patients who do not have access to transportation and those with physical limitations. It also removes a barrier for patients who have financial barriers preventing them from traveling to hospitals or clinics. Telehealth has also been associated with lower overall total costs for treatment, suggesting that it may help cut long-term healthcare costs to institutions (Morland et al., 2013).

Studies have provided evidence that symptom outcomes for telehealth treatment and patient satisfaction are similar to those who receive face-to-face treatment using prolonged exposure for PTSD in combat veterans (Yuen et al., 2015; Gros et al., 2016). A review by Backhaus et al. (2012) suggests that telehealth can be used to treat diverse populations and typically yields high user satisfaction.

 

Ethical/Legal considerations

Before initiating telehealth, it is important to ensure that the patient understands all treatment options available, including in-person psychotherapy. Psychologists should also ensure that the patient is located in a state where the therapist holds a valid license.

At the beginning of each session, several important pieces of information must be verified. First, it is essential to verify the patient’s location and to be equipped with emergency contact information for the location of the patient in case of an emergency. This includes an emergency contact person named by the patient and the phone number for local police/emergency responders. Next, the patient must verify that they are in a space that will maintain their confidentiality and privacy. The patient must also indicate any other people who are currently in the home during their session.

 

Additional Considerations

Providing services through this non-traditional forum introduces unique considerations, such as body language. For example, a clinician should be aware of communicating verbally to compensate for nonverbal communication that does not translate easily across a computer screen. It can also take additional effort in the beginning to be mindful about eye contact and ways to convey active listening to the patient while building rapport, such as using more verbal cues and fewer hand gestures to convey information.

Conducting telehealth instead of traditional face-to-face services may inadvertently reinforce some avoidance behaviors for patients who experience agoraphobia, PTSD, or other anxiety disorders by allowing them to receive treatment without having to leave their home. On the other hand, providing services in this non-traditional form provides a unique opportunity for interventions that can be powerful and effective by providing the clinician with additional insight into the patient’s symptoms and an opportunity to conduct in vivo exposures during sessions. This allows for unique intervention strategies that might not be possible in a traditional therapy setting.

 

Conclusions

Telehealth is a useful way to incorporate modern technology when providing psychological services to veterans in the VA Healthcare System. It could provide great benefit to patients and clients in the private sector as well. Although it has its limitations, telehealth also provides unique opportunities to provide interventions for patients that would otherwise have barriers to receiving services. As technology becomes more sophisticated and more ubiquitous, it can continue to evolve as a powerful tool in aiding delivery of empirically based interventions to our patients.

 

References:

Backhaus, A.., Agha, Z., Maglione, M. L., Repp, A., Ross, B., Zuest, D., Thorp, S. R. (2012). Videoconferencing psychotherapy: A systematic review. Psychological Services, 9(2), 111-131. doi: 10.1037/a0027924.

Gros, D. F., Luethcke Lancaster, C., Lopez, C. M., & Acierno, R. (2016). Treatment satisfaction of home-based telehealth versus in-person delivery of prolonged exposure for combat-related PTSD in veterans. Journal of Telemedicine and Telecare 0(0), 1-5. Doi: 10.1177/1357633X16671096.

Morland, L. A., Raab, M., Mackintosh, M.A., Rosen, C. S., Dismuke, C. E., & Greene, C. J. (2013). Telemedicine: A cost-reducing means of delivering psychotherapy to rural combat veterans with PTSD. Telemedicine and e-Health, 19(10), 754-759. doi: https://doi.org/10.1089/tmj.2012.0298.

Wang P.S., Aguilar-Gaxiola S., Alonso J., Angermeyer M..C, Borges G., Bromet E.J., Bruffaerts R., de Girolamo G., de Graaf R., Gureje O., Haro J.M., Karam E.G., Kessler R.C., Kovess V., Lane M.C., Lee S., Levinson D., Ono Y., Petukhova M., Posada-Villa J., Seedat S, Wells J.E. (2007). Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys, Lancet, 370,841-850. doi: 10.1016/S0140-6736(07)61414-7.

Yuen, E. K., Gros, D. F., Price, M., Zeigler, S., Tuerk, P. W., Foa, E. B., & Acierno, R. (2015). Randomized controlled trial of home-based telehealth versus in-person prolonged exposure for combat-related PTSD in veterans: Preliminary results. Journal of Clinical Psychology, 71(6), 500-512. doi: 71(6), 500–512.