Factors influencing uptake of telemental health via videoconferencing at high and low adoption sites within the Department of Veterans Affairs during COVID-19: a qualitative study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic dramatically increased the use of telemental health via videoconferencing (TMH-V). While TMH-V has been found to be effective and satisfactory to both patients and providers, little is known regarding factors that influence site-level uptake. We examined facilitators and barriers to TMH-V uptake at higher and lower adoption sites within the US Department of Veterans Affairs (VA).

METHODS

We conducted twenty-four semi-structured qualitative interviews at four northeastern VA medical centers (two with higher TMH-V adoption and two with lower adoption). Six interviews were conducted per site (one member of mental health leadership, one facility telehealth coordinator/technician, and four mental health providers per site). We performed directed content analysis, guided by the Consolidated Framework for Implementation Research (CFIR), followed by a matrix rating process to rank the degree of influence of each of the 19 included CFIR constructs at the four sites. Positive overall influences, negative overall influences, and differentiators were then identified based on patterns in ratings across sites.

RESULTS

Five CFIR constructs had positive overall influences across sites: Relative advantage, Patient needs and resources, Relative priority, Knowledge and beliefs, and Self-efficacy. Complexity had a negative overall influence across sites. Four constructs significantly differentiated between higher and lower adoption sites with regards to TMH-V use: Quality, Compatibility, Leadership engagement, and Champions.

CONCLUSIONS

Several positive overall influences on TMH-V uptake were identified across sites; respondents acknowledged multiple advantages of TMH-V (e.g., convenience), and providers' attitudes towards TMH-V improved as they gained experience. In contrast, complexity was a negative overall influence; TMH-V platforms and processes must be simple and user friendly to promote use. The emergence of Quality, Leadership engagement, and Champions as differentiators speaks to the importance of educating frontline staff and leadership at lower adoption sites about the evidence base demonstrating that TMH-V is high-quality care. Compatibility also emerged as a differentiator; if TMH-V is not easily integrated into provider workflows, uptake will falter. Future work should draw from these findings to develop implementation strategies aiming to increase TMH-V uptake at lower adoption sites, thereby increasing access to high-quality mental health care.

Patient and provider predictors of telemental health use prior to and during the COVID-19 pandemic within the Department of Veterans Affairs

The current study examined patient and provider differences in use of phone, video, and in-person mental health (MH) services. Participants included patients who completed ≥ 1 MH appointment within the Department of Veterans Affairs (VA) from 10/1/17-7/10/20 and providers who completed ≥ 100 VA MH appointments from 10/1/17-7/10/20. Adjusted odds ratios (aORs) are reported of patients and providers: (a) completing ≥1 video MH appointment in the pre-COVID (10/1/17-3/10/20) and COVID (3/11/20-7/10/20) periods; and (b) completing the majority of MH visits via phone, video, or in-person during COVID. The sample included 2,480,119 patients/31,971 providers in the pre-COVID period, and 1,054,670 patients/23,712 providers in the COVID period. During the pre-COVID and COVID periods, older patients had lower odds of completing ≥ 1 video visit (aORs < .65). During the COVID period, older age and low socioeconomic status predicted lower odds of having ≥ 50% of visits via video versus in-person or phone (aORs < .68); schizophrenia and MH hospitalization history predicted lower odds of having ≥ 50% of visits via video or phone versus in-person (aORs < . 64). During the pre-COVID and COVID periods, nonpsychologists (e.g., psychiatrists) had lower odds of completing video visits (aORs < . 44). Older providers had lower odds of completing ≥ 50% of visits via video during COVID (aORs <. 69). Findings demonstrate a digital divide, such that older and lower income patients, and older providers, engaged in less video care. Nonpsychologists also had lower video use. Barriers to use must be identified and strategies must be implemented to ensure equitable access to video MH services. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Rapid Increase in Telemental Health Within the Department of Veterans Affairs During the COVID-19 Pandemic

Background: The use of telemental health via videoconferencing (TMH-V) became critical during the Coronavirus disease 2019 (COVID-19) pandemic due to restriction of non-urgent in-person appointments. The current brief report demonstrates the rapid growth in TMH-V appointments in the weeks following the pandemic declaration within the Department of Veterans Affairs (VA), the largest healthcare system in the United States. Methods: COVID-19 changes in TMH-V appointments were captured during the six weeks following the World Health Organization's pandemic declaration (March 11, 2020-April 22, 2020). Pre-COVID-19 TMH-V encounters were assessed from October 1, 2017 to March 10, 2020. Results: Daily TMH-V encounters rose from 1,739 on March 11 to 11,406 on April 22 (556% growth, 222,349 total encounters). Between March 11-April 22, 114,714 patients were seen via TMH-V, and 77.5% were first-time TMH-V users. 12,342 MH providers completed a TMH-V appointment between March 11-April 22, and 34.7% were first-time TMH-V users. The percentage growth of TMH-V appointments was higher than the rise in telephone appointments (442% growth); in-person appointments dropped by 81% during this time period. Discussion and Conclusions: The speed of VA's growth in TMH-V appointments in the wake of the COVID-19 pandemic was facilitated by its pre-existing telehealth infrastructure, including earlier national efforts to increase the number of providers using TMH-V. Longstanding barriers to TMH-V implementation were lessened in the context of a pandemic, during which non-urgent in-person MH care was drastically reduced. Future work is necessary to understand the extent to which COVID-19 related changes in TMH-V use may permanently impact mental health care provision.

Innovating team-based outpatient mental health care in the Veterans Health Administration: Staff-perceived benefits and challenges to pilot implementation of the Behavioral Health Interdisciplinary Program (BHIP)

In the past decade, the demand for Veterans Health Administration (VHA) mental health care has increased rapidly. In response to the increased demand, the VHA developed the Behavioral Health Interdisciplinary Program (BHIP) team model as an innovative approach to transform VHA general outpatient mental health delivery. The present formative evaluation gathered information about pilot implementation of BHIP to understand the struggles and successes that staff experienced during facility transitions to the BHIP model. Using a purposive, nonrandom sampling approach, we conducted 1-on-1, semistructured interviews with 37 licensed and nonlicensed clinical providers and 13 clerical support staff assigned to BHIP teams in 21 facilities across the VHA. Interviews revealed that having actively involved facility mental health leaders, obtaining adequate staffing for teams to meet the requirements of the BHIP model, creating clear descriptions and expectations for team member roles within the BHIP framework, and allocating designated time for BHIP team meetings challenged many VHA sites but are crucial for successful BHIP implementation. Despite the challenges, staff reported that the transition to BHIP improved team work and improved patient care. Staff specifically highlighted the potential for the BHIP model to improve staff working relationships and enhance communication, collaboration, morale, and veteran treatment consistency. Future evaluations of the BHIP implementation process and BHIP team functioning focusing on patient outcomes, organizational outcomes, and staff functioning are recommended for fully understanding effects of transitioning to the BHIP model within VHA general mental health clinics and to identify best practices and areas for improvement. (PsycINFO Database Record

The impact of contracting and prompting substance abuse treatment entry: a pilot trial

Contracting and prompting clients to attend substance abuse treatment aftercare substantially improves treatment adherence and outcome. However, this approach has not been evaluated for improving entry into initial treatment. We recruited 102 individuals scheduled to begin a 28-day substance use disorder (SUD) residential treatment program and randomly assigned them to receive either our standard treatment (STX) or STX plus attendance contracting and prompting (CP). CP participants showed fewer subsequent hospitalization days, lower hospitalization costs, greater improvement in alcohol problem scores, and lower legal problem scores at a 3-month follow-up than the STX group. The two groups did not differ on treatment entry rate, time in treatment, or drug use problem scores. The clinical utility of CP procedures and areas for future research are discussed.

Family predictors of suicidal symptoms in young adolescents

A 1-year longitudinal study tested the model that the relation between maternal depression and adolescent suicidal symptoms is mediated by family functioning. Participants were 240 children (mean age = 11.86 years) and their mothers; 77% of the mothers had a history of a mood disorder and the remaining 23% were lifetime-free of psychopathology. An adolescent suicide index was created based on suicide items from the child and parent versions of the Children's Depression Inventory, Child Behavior Checklist and Children's Depression Rating Scale, administered at both Time 1 and 2. Family functioning was assessed with the Family Relationship Index completed by mothers and children at Time 1. Results indicated that the relation between maternal depression and adolescent suicide symptoms at Time 2 was mediated by perceived family functioning, controlling for suicide symptoms at Time 1.

Characterization of mitochondrial DNA using low-stringency single specific primer amplification analyzed by laser induced fluorescence--capillary electrophoresis

Polymerase chain reaction (PCR)-based DNA typing is routinely used in forensics for identity testing. Those assays that distinguish single nucleotide polymorphisms (SNPs) require other biochemical reactions in addition to PCR to identify the sequence polymorphisms. Low-stringency sequence-specific PCR (LSSP-PCR) is an example of a recent method that does not require additional biochemical treatments. The analysis of LSSP-PCR by capillary electrophoresis (CE) to discriminate the highly polymorphic mitochondrial DNA (mtDNA) D-loop region is described. The DNA from five individuals were amplified (first step) using sequence-specific primers to produce 1021 bp fragments containing the D-loop region. Each fragment was isolated by electroelution using CE and UV detection, and subjected to a second amplification (second step) using a single primer annealed under low stringency conditions. This generated a range or profile of PCR products for each sample, which were resolved and analyzed by CE with the intercalator TOTO-1 and laser-induced fluorescence (LIF) detection. The LSSP-PCR profiles were unique for each individual, indicating that this technique may be applicable for forensic identity testing.

Automated polymerase chain reaction product sample preparation for capillary electrophoresis analysis

The analysis of crude polymerase chain reaction (PCR) products by capillary electrophoresis (CE) is often compromised due to the presence of a high concentration of salt. Salt interferes with the electrokinetic injection and induces localized heating within the column; hence, PCR products must be desalted or cleaned-up prior to CE analysis. A variety of commercial clean-up systems are available that have been traditionally used to prepare PCR products for cloning, sequencing and digestion with restriction enzymes. These systems were tested for their effectiveness in preparing PCR products for CE analysis and were evaluated based on CE resolution, salt removal, DNA recovery, processing time and cost. One particularly effective clean-up system, membrane dialysis, was automated using a robotic workstation.

The evaluation of fast purification methods for preparing polymerase chain reaction (PCR) products for capillary electrophoresis analysis

The analysis of crude polymerase chain reaction (PCR) products by capillary electrophoresis (CE) is often compromised by the presence of a high concentration of salt. Salt interferes with the electrokinetic injection and induces localized heating within the column, hence, PCR products must be desalted or cleaned-up prior to CE analysis. A variety of commercial clean-up systems are available that have been traditionally used to prepare PCR products for cloning, sequencing, and digestion with restriction enzymes. These systems were tested for their effectiveness in preparing PCR products for CE analysis and were evaluated based on CE resolution, salt removal, DNA recovery, processing time, and cost.

Automated DNA purification and amplification from blood-stained cards using a robotic workstation

A new method for the purification of DNA on blood-stained cards was developed. This method was implemented into a high-throughput automated system using a Biomek 1000 robotic workstation. In addition, the processes of DNA purification and amplification were coupled into a completely automated and uninterrupted prototype system, and the resultant PCR products generated by this system were subjected to automated desalting for capillary electrophoresis analysis.

DNA amplification fingerprinting analysis of bermudagrass (Cynodon): genetic relationships between species and interspecific crosses

We have used DNA amplification fingerprinting (DAF) to study the genetic variation of bermudagrass (Cynodon) species and cultivars of interspecific crosses that exhibit leaf-blade textural characteristics ranging from coarse to fine. Arbitrary octamer primers produced complex and reproducible amplification profiles with high levels of polymorphic DNA. Phylogenetic analysis using parsimony (PAUP) and unweighted pair group cluster analysis using arithmetic means (UPGMA) grouped 13 bermudagrass cultivars into several clusters, including one containing the African-type bermudagrasses (C. transvaalensis) and another containing the common-type bermudagrasses (C. dactylon). The latter group included C. magennissii ('Sunturf') and a interspecific C. transvaalensisxC. dactylon cross ('Midiron'), 2 cultivars that exhibited leaf textural characteristics closer to the common-types. All other C. transvaalensisxC. dactylon crosses grouped between the African and common types. An extended screen of 81 octamer primers was needed to separate cultivar 'Tifway' from the irradiation-induced mutant 'Tifway II'. The use of either template endonuclease digestion prior to amplification or arbitrary mini-hairpin primers increased detection of polymorphic DNA and simplified the task of distinguishing these closely related cultivars. Alternatively, the use of capillary electrophoresis (CE) resolved fingerprints adequately and detected products with high sensitivity, thereby promising to increase throughput and the detection of polymorphic DNA. When used to fingerprint samples from commercial sources, DAF identified bermudagrass plant material on the basis of unique reference profiles generated with selected primers. DAF represents an excellent technique for bermudagrass cultivar verification, seed certification, varietal protection, and for the identification of mistakes in plantings, mislabeled plant materials, and contamination or substitutions of sod fields.