Telehealth Conversion of Serious Mental Illness Recovery Services During the COVID-19 Crisis
The COVID-19 crisis has challenged mental health care, especially for those with serious mental illness. This population has typically been provided in-person pharmacotherapy and/or recovery-oriented behavioral health services (RSs), but social distancing mandates have required rapid shifts in care management. Easing of telehealth regulations during the crisis has allowed for flexibility to approach RSs differently and to maintain care for this vulnerable population. If agencies can surmount the challenges to rapid and total transformation of the RS system, potential benefits include continuity of care and better mental and medical health outcomes.
Telehealth for treatment of serious mental illness has been used primarily for occasional individual sessions with known patients. RSs typically include intake, care coordination, psychotherapies, skills training, and vocational or educational supports delivered individually or in groups. During the COVID-19 crisis, most RSs have stopped all services except in-person pharmacotherapy and crisis intervention, leaving participants without the social and skills support they value. Here, we describe key factors addressed by the Lieber Recovery Clinic, an RS in New York City that serves adults with serious mental illness, to continue to provide all services via video-supported telehealth.
All stakeholders needed to know that the clinic would remain full service via telehealth. To minimize disruption, the clinic schedule of groups (i.e., cognitive-behavioral therapy, acceptance and commitment therapy, dialectal behavioral therapy, wellness recovery action planning, cognitive remediation, executive functioning group, recreational therapy groups, and social skills and cognition training) was maintained so that patients and clinicians retained their normally scheduled sessions. Staff required new workflows for enrolling patients in telehealth (e.g., consent, orientation to technology), booking and billing, assuring confidentiality, negotiating multiple telehealth platforms, and managing technology challenges. Clinicians were provided remote access to secure databases with information for managing patient crises (e.g., emergency contacts, safety plans). Operational issues required frequent, open virtual communication within the RS team, and between RS team leaders and the overarching administration that nimbly pivoted to adapt to the changing regulatory landscape.
Telehealth group treatment was unprecedented and thus the most challenging element to implement. Clinicians had to learn to manage group process and content virtually, and participants needed access to and education in use of telehealth platforms (e.g., WebEx, Zoom). Although all participants had access, a few required extensive individualized training via telephone to use the technology. Content of group sessions was revised to address COVID-related concerns and to promote engagement using telehealth. Some clients struggled with virtual etiquette (e.g., appropriate camera background, comportment); they were asked to help staff draft a guide to “Web-iquette,” which was periodically reviewed at the start of groups.
Procedures were developed for orienting new patients and their support system to a virtual clinic, engaging them, conducting virtual risk assessment and intake, and managing crises during group sessions. A daily “on-call” clinician was designated to provide virtual crisis management should a distressed group participant need to exit the telehealth session. Over 3 weeks, team meetings transitioned from a daily discussion of procedural challenges to the usual weekly clinical focus. However, the virtual environment provided no spontaneous opportunities for colleagues to discuss patient progress. To promote care coordination, team communication, and spirit in the virtual environment, clinicians e-mailed the RS team a daily log of who attended their sessions as well as patient updates.
All group modalities and individual coaching (i.e., supportive employment/education, social/life skills) offered at the RS transitioned to video-supported telehealth. Tracking the number of RS enrollees with active participation indicated that in the week before telehealth conversion, when shelter-in-place recommendations commenced, participation dropped from 94% to 52%; after telehealth conversion, participation rose from 67% in the first 4 days to 79% after 1 week and to 84% after 2 weeks. There were no psychiatric decompensations, and no client or clinician showed symptoms of COVID-19. Qualitative feedback from RS participants was consistently positive and included statements of gratitude for providing a way to stay connected. For example, one participant stated, “My groups are the highlight of my day.”
The advantages of telehealth for this RS included continuity of care while maximizing medical and mental health. Factors that supported this conversion were patient demographic homogeneity and higher socioeconomic status, which permitted access to high-speed internet, technology, and living spaces that provided privacy. Despite the challenges posed, which likely would be magnified in clinics serving individuals of lower socioeconomic status, the significant benefits of this conversion indicated an important role for RS telehealth during crises and perhaps thereafter.
