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EVIDENCE-BASED RESOURCE GUIDE SERIES 


Telehealth for the 
Treatment of Serious 
Mental IlIness and 
Substance Use 
Disorders 


mats 


Substance Abuse and Mental Health 
Services Administration 





Telehealth for the Treatment of Serious 
Mental Illness and Substance Use Disorders 


Acknowledgments 

This report was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) 
under contract number HHSS283201700001/ 75S20319F42002 with SAMHSA, U.S. Department of Health 
and Human Services (HHS). Donelle Johnson served as contracting officer representative. 


Disclaimer 

The views, opinions, and content of this publication are those of the authors and do not necessarily reflect 
the views, opinions, or policies of SAMHSA. Nothing in this document constitutes a direct or indirect 
endorsement by SAMHSA of any non-federal entity’s products, services, or policies, and any reference to 
non-federal entity’s products, services, or policies should not be construed as such. 


Public Domain Notice 

All material appearing in this publication is in the public domain and may be reproduced or copied 
without permission from SAMHSA. Citation of the source is appreciated. However, this publication 
may not be reproduced or distributed for a fee without the specific, written authorization of the Office of 
Communications, SAMHSA. 

Electronic Access 

This publication may be downloaded from http://store.samhsa.gov 





Recommended Citation 

Substance Abuse and Mental Health Services Administration (SAMHSA). Telehealth for the Treatment 

of Serious Mental Illness and Substance Use Disorders. SAMHSA Publication No. PEP21-06-02-001 
Rockville, MD: National Mental Health and Substance Use Policy Laboratory. Substance Abuse and Mental 
Health Services Administration, 2021. 

Originating Office 

National Mental Health and Substance Use Policy Laboratory, Substance Abuse and Mental Health Services 
Administration, 5600 Fishers Lane, Rockville, MD 20857, Publication No. PEP21-06-02-001. 
Nondiscrimination Notice 


SAMHSA complies with applicable federal civil rights laws and does not discriminate on the basis of race, 
color, national origin, age, disability, or sex. 


SAMHSA cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de 
raza, color, nacionalidad, edad, discapacidad o sexo. 


Publication No. PEP21-06-02-001 


Released 2021 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
Acknowledgments I 


FOREWORD 





The Substance Abuse and Mental Health Services 
Administration (SAMHSA), and specifically, its 
National Mental Health and Substance Use Policy 
Laboratory (Policy Lab), is pleased to fulfill the charge 
of the 21st Century Cures Act to disseminate information 
on evidence-based practices and service delivery models 
to prevent substance misuse and help people with 
substance use disorders (SUDs), serious mental illness 
(SMJ), and serious emotional disturbances (SEDs) get 
the treatment and support they need. 


Treatment and recovery for SUD, SMI, and SED can 
vary based on several factors, including geography, 
socioeconomics, culture, gender, race, ethnicity, and 
age. This can complicate evaluating the effectiveness 
of services, treatments, and supports. Despite these 
variations, however, there is substantial evidence to 
inform the types of resources that can help reduce 
substance use, lessen symptoms of mental illness, and 
improve quality of life. 


The Evidence-Based Resource Guide Series is a 
comprehensive set of modules with resources to improve 
health outcomes for people at risk for, experiencing, 

or recovering from SMI and/or SUD. It is designed for 
practitioners, administrators, community leaders, and 
others considering an intervention for their organization 
or community. 


Evidence-Based Resource Guide 
Series Overview 


A priority topic for SAMHSA is increasing access to 
treatment for SMI and SUD using telehealth modalities. 
This guide reviews literature and research findings 
related to this issue, examines emerging and best 
practices, discusses gaps in knowledge, and identifies 
challenges and strategies for implementation. While this 
guide is focused on the needs of people experiencing 
SMI and SUD, readers can broadly apply its resources 
and lessons from the field for the treatment of any 
mental illness. 


Expert panels of federal, state, and non-governmental 
participants provided input for each guide in this series. 
The panels included accomplished scientists, researchers, 
service providers, community administrators, federal and 
state policy makers, and people with lived experience. 
Members provided input based on their knowledge of 
healthcare systems, implementation strategies, evidence- 
based practices, provision of services, and policies that 
foster change. 


Research shows that implementing evidence-based 
practices requires a comprehensive, multi-pronged 
approach. This guide is one piece of an overall 
approach to implement and sustain change. Readers are 
encouraged to visit the SAMHSA website for additional 
tools and technical assistance opportunities. 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Evidence-Based Resource Guide Series Overview 


Content of the Guide 


This guide contains a foreword and five chapters. The chapters stand alone 
and do not need to be read in order. Each chapter is designed to be brief 

and accessible to healthcare providers, healthcare system administrators, 
community members, policy makers, and others working to meet the needs of 
people at risk for, experiencing, or recovering from SMI and/or SUD. 


The goal of this guide is to review the literature on the effectiveness of 
telehealth modalities for the treatment of SMI and SUD, distill the research into 
recommendations for practice, and provide examples of how practitioners use 
these practices in their programs. 


FW 


Evidence-Based Resource Guide Series Overview 
Introduction to the series. 


Issue Brief 


Overview of the current landscape of telehealth, including its 
need, benefits, and challenges for the treatment of SMI and 
SUD among adults. 


What Research Tells Us 


Current evidence on effectiveness of integrating telehealth 
modalities for the treatment of SMI and SUD among adults across 
a continuum of services, including screening and assessment, 
treatment, medication management, case management, recovery 
support, and crisis services. 


Guidance for Implementing Evidence-based 
Practices 


Practical information to consider at the individual client and 
provider, provider-client, organizational, and regulatory levels 
when selecting and implementing telehealth modalities. 
Examples of Telehealth Implementation in 
Treatment Programs 


Examples of programs that have implemented telehealth 
modalities for the treatment of SMI and SUD among adults. 


Resources for Evaluation and Quality Improvement 


Guidance and resources for evaluating telehealth-delivered 
practices, monitoring outcomes, and improving quality. 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
Evidence-Based Resource Guide Series Overview 


FOCUS OF THE GUIDE 


SMI and SUD impact millions of 
Americans. Barriers to accessing 
care include access to appropriate 
services and providers, stigma 
associated with SMI or SUD, 

and competing priorities (e.g., 
employment and caregiving 
responsibilities). 


Telehealth is the use of two-way, 
interactive technology to provide 
health care and facilitate client- 
provider interactions. Telehealth 
modalities for SMI or SUD may 
be synchronous (live or real 
time) or asynchronous (delayed 
communication between clients 
and providers). 


Telehealth has the potential 

to address the treatment gap, 
making treatment services more 
accessible and convenient, 
improving health outcomes, and 
reducing health disparities. 





The framework below provides an overview of this guide. The guide addresses the use of telehealth to provide SMI and 
SUD treatment. The review of these treatments in Chapter 2 of the guide includes specific outcomes, practitioner types, 
and modes of delivery. 


GUIDE FRAMEWORK 






























CHALLENGES ADDRESSED IN THIS GUIDE: 
Using telehealth modalities to provide treatment 
services for individuals with SMI and SUD 





POPULATION OF FOCUS: 
Adults experiencing SMI or SUD 





STAGES OF THE CARE CONTINUUM: 
Screening and assessment, treatment (including 
pharmacotherapy, medication-assisted treatment, 

medication management, and behavioral therapies), case 

management, SUD recovery supports, and crisis services 


TREATMENTS 


Behavioral Activation Therapy 
Cognitive Behavioral Therapy 
Cognitive Processing Therapy 
Prolonged Exposure Therapy 
Medication-Assisted Treatment 


EVIDENCE REVIEW 


OUTCOMES ACHIEVED: 

* Improvements specific to SMI or SUD (e.g., improved health, 
reduction in symptoms, reduction in substance use) 

* Outcomes specific to care provided through telehealth modalities 

(e.g., treatment satisfaction, retention in care, therapeutic alliance) 









PRACTITIONERS: 
* Mental health and substance + MAT-waivered providers 
use Clinicians + Case managers 


* Pharmacists and pharmacy staff * Peers 





MODES OF DELIVERY: 
+ Videoconferencing and * Telephone 
web-based applications + Web-based applications 
through computers, tablets, 
and smartphones 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
Evidence-Based Resource Guide Series Overview IV 


CHAPTER 





Issue Brief 


Telehealth is the use of telecommunication 
technologies and electronic information to provide 
care and facilitate client-provider interactions. It is 
comprised of two forms: 


1. Two-way, synchronous, interactive client- 
provider communication through audio 
and video equipment (also referred to as 
telemedicine) 

2. Asynchronous client-provider interactions 
using various forms of technology (further 
described in the chart below)": 





Serious mental illness (SMI) is defined as a 
mental, behavioral, or emotional disorder among 
adults aged 18 and older resulting in serious 
functional impairment, which substantially interferes 


with or limits one or more major life activities. Ww 

Substance use disorder (SUD) is a diagnosis that Telehealth is a mode of service delivery that has been 
applies when the recurrent use of alcohol or drugs used in clinical settings for over 60 years and empirically 
causes Clinically significant impairment, including studied for just over 20 years.*’ Telehealth is not an 
health problems, disability, and failure to meet intervention itself, but rather a mode of delivering 

major responsibilities at work, school, or home.* services. This mode of service delivery increases access 


Co-occurring disorder (COD) refers to the to screening, assessment, treatment, recovery supports, 


a eae oe 
coexistence of both a substance use and mental crisis support, and medication management” ” across 
disorder. diverse behavioral health and primary care settings. 


Practitioners can offer telehealth through synchronous 
and asynchronous methods. 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
Issue Brief 1 


Timing Application a K-Ye1 alate) (oye hVM@) olirelal-y 


Real-time interactive client | Clinical assessments, ongoing care and treatment, and Telephone, video calls, 
and provider interactions. | triage of emergency service needs (e.g., for clients with and web-conferencing 
suicidal ideation).'° 


platforms." 


Synchronous 


Web-based portals 

(i.e., client portals), 

email messages, text 
messages, mobile 
applications, symptom 
management tracking, 
sensors, peripherals, 
client education modules, 
or electronic medical 
record data.'*'° 


Sharing of health Clinical assessments, symptom management, client 
information that is education, and treatment reminders that complement 
collected at one point in synchronous client-provider interactions and inform 
time and responded to or | updates to treatment plans through methods such as: 
interpreted at a later time 
to direct the next steps of 
a client’s treatment or care 
plan and complement 
synchronous treatment.’ 


e Store and forward (i.e., client uploads and transfers 
medical information, such as health histories, to 
identify or refine a treatment plan) 


Remote client monitoring (i.e., collecting medical 
and health data in one location and transmitting to 
Methods can be another) 

interactive (i.e., the 

client actively sending 
information to the 
provider) or passive (i.e., 
client data transmitted to 
providers through portals, 
sensors, or peripherals). 


Asynchronous 


mHealth (i.e., capture of health information by 

the client and transmission of the information to a 
provider through mobile applications, mobile devices, 
smartphones, tablets, or computers) 


Client education (e.g., online psychoeducation 
sessions and workbooks) 


While telehealth is used in health care for a broad range 
of ages and presenting problems, this guide focuses on 
synchronous, direct to consumer (sometimes referred to 
as “D to C’”) applications of telehealth for the treatment 
of SMI and SUD among adults.” 


Furthermore, this guide focuses on the needs of people 
experiencing SMI and SUD, but readers can broadly 
apply its resources and lessons for the treatment of any 
mental illness. 


Telehealth is an approach that 
connects clients and providers in 
multiple locations. 


ee? ee 


clinic >» home clinic > clinic 








Background 


Telehealth can connect clients and providers in multiple 
locations such as at a home, private space in a clinical 
setting, or another location in the community. The 
graphic below depicts examples of ways to connect 
using telehealth, but there are many ways to deliver and 
receive care that address connectivity barriers and client 
preferences. 


LOC? om i 


home > home clinic » community 
(e.g., private location, 


homeless shelter) 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Issue Brief 


A variety of providers (e.g., psychiatrists, primary care 
providers, mental health counselors, social workers, 
psychologists, addiction counselors, case managers, 
opioid treatment providers, peer workers) can implement 
telehealth methods. In addition, practitioners can 

use telehealth with a hybrid approach for increased 
flexibility. For instance, a client can receive both in- 
person and telehealth visits throughout their treatment 
process depending on their needs and preferences. 


Telehealth methods can be implemented during public 
health emergencies (e.g., pandemics, infectious disease 
outbreaks, wildfires, flooding, tornadoes, hurricanes)*'* 
to extend networks of providers (e.g., tapping into out- 
of-state providers to increase capacity). They can also 
expand capacity to provide direct client care when in- 
person, face-to-face interactions are not possible due to 
geographic barriers or a lack of providers or treatments 
in a given area. However, implementation of telehealth 
methods should not be reserved for emergencies or 

to serve as a bridge between providers and rural or 
underserved areas. Telehealth can be integrated into an 
organization’s standard practices, providing low-barrier 
pathways for clients and providers to connect to and 
assess treatment needs, create treatment plans, initiate 
treatment, and provide long-term continuity of care. 


SMI and SUD impact millions of Americans. However, 
for a variety of reasons and despite a perceived need, 
many do not seek treatment. 


e Among adults aged 18 or older in 2019, 5.2 
percent (13.1 million people) had an SMI. Of 
those, 47.7 percent (6.2 million people) reported 
an unmet need for mental health services in the 
past year. 


e Among people aged 12 or older in 2019, 
7.4 percent (20.4 million people) reported 
experiencing a SUD. Among people aged 12 or 
older in 2019, 7.8 percent (21.6 million people) 
needed substance use treatment in the past year. 
Of these 21.6 million people, 12.2 percent (2.6 
million) received substance use treatment at a 
specialty facility.*° 


Telehealth has the potential to address this treatment 
gap, making treatment services more accessible and 
convenient, improving health outcomes, and reducing 


health disparities. Clients experiencing SMI and SUD 
have traditionally been excluded from both treatments 
delivered through telehealth and research evaluating the 
efficacy of telehealth among people experiencing SMI 
and SUD. However, telehealth is a tool that providers 
can use for all clients. 


Appropriate and additional upfront work, provider- 
client agreements, and safeguards can ensure that clients 
experiencing SMI and SUD benefit from services 
delivered via telehealth. Providers can use assessments 
(further discussed in Chapter 3) to identify their 

clients’ specific barriers to participating in telehealth 
appointments (e.g., access and comfort with technology, 
ability to have private or confidential conversations, 
safety of the home environment) and inform 
conversations with their clients on strategies to address 
these barriers. 


Implementation and use of telehealth as a 

mode of service delivery has been increasing in 
recent years. Between 2016 and 2019, use of 
telehealth doubled from 14 to 28 percent.? This 
trend continued between 2019 and 2020, due in 
large part to the COVID-19 pandemic. Telehealth 
visits for mental health increased by 556 percent 
between March 11 and April 22, 2020.7’ 


The use of telehealth was steadily increasing prior 
to the COVID-19 pandemic. Between 2016 and 
2019, SUD treatment offered through telehealth 
increased from 13.5 to 17.4 percent. Greater 
adoption of telehealth was associated with rural 
locations, as well as those that provided multiple 
treatment settings, offered pharmacotherapy, and 
served both adult and pediatric populations.”® 


Telehealth visits increased among rural Medicare 
beneficiaries, including a 425 percent increase 
for mental health appointments between 2010 
and 2017. Among these beneficiaries, people 
living with schizophrenia or bipolar disorder in 
rural areas were more likely to use telehealth 

for mental health care than those with any other 
mental illness or those living in urban areas.”° 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Issue Brief 


Benefits of Telehealth 


Telehealth supports team-based care and its interrelated 
care objectives. The Quadruple Aim is a conceptual 
framework to understand, measure, and optimize health 
system performance. The Quadruple Aim organizes 
benefits of telehealth into four categories:°° 


e Improved provider experience 
e Improved client experience 

e Improved population health 

e Decreased costs 


1. Provider experience. Providers may improve the 
quality of care they provide and experience the 
following benefits from implementing telehealth 
methods: 


e Provision of timely client care. Providers 
may have increased flexibility in appointment 
scheduling by using telehealth. They can extend 
care beyond a clinic’s normal operating hours 
and its four walls and leverage “virtual walk-in 
visits.” Increased flexibility can help clinics to 
more effectively manage client “no-shows” and 
cancellations.**+3’ 


e Effective and efficient coordination of care. An 
estimated 40 to 60 percent of civilian clients (not 
inclusive of military populations) with mental 
and substance use disorders are currently treated 
in primary care offices rather than specialty 
care settings.*! Providers can use telehealth 
methods for tele-consultation, tele-supervision, 
and tele-education to coordinate, integrate, and 
improve care (e.g., through the “hub and spoke” 
model)? 

e Reduction in workforce shortages. This is 
especially true for underserved and rural areas.”*:*! 

e Ability to assess client’s home environment. 
Rather than rely on a client’s report of their 
home and living conditions, telehealth makes it 
possible for providers to see, with appropriate 
permission, inside a client’s home, meet family 
support systems, and determine if an in-person 
visit at a person’s home is needed.” 


Rural Workforce Shortages 


Approximately 80 percent of rural areas in 

the United States are classified as medically 
underserved and in health professional shortage 
areas (HPSAs). These regions are lacking the 
physicians, dentists, registered nurses, and other 
health professionals needed to care for a client 
throughout the lifespan. HPSAs also often have 
shortages in behavioral health providers (including 
psychiatrists, psychologists, and therapists).°" 


Shortages in the rural healthcare landscape 
disproportionately impact rural Americans who 
tend to be older, have lower socioeconomic 
status, are more reliant on public insurance, and 
have worse health outcomes.** °3 


e Ability to share information for 
psychoeducation and assessment. 
Psychoeducation, or the didactic communication 
of information to the client about therapeutic 
intervention or diagnosis, can be done through 
screensharing, thus allowing the clinician to 
seamlessly display videos, slideshows, and 
other visuals to the client. Mental health and 
substance use assessments can also be done this 
way, allowing the clinician to track the client’s 
responses in real-time.** 


e Efficient connections to crisis services. In 
emergencies, telehealth providers can instruct 
clients to call emergency response systems (e.g., 
911, 988) while the providers remain connected 
via telephone or video. Enhanced 911 (E911) 
automatically provides emergency dispatchers 
with the location of the client, rather than the client 
needing to provide their address to the dispatcher. 


e Reductions in provider burnout. Provider 
burnout is a pervasive issue in the healthcare field 
and exacerbated by numerous factors, including 
time pressures, fast-paced environments, 
family responsibilities, and time-consuming 
documentation.“ Telehealth may lead to 
reductions in provider stress and burnout through 
promoting more manageable schedules, greater 
flexibility, and reductions in commute time.***° 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Issue Brief 


2. Client experience. Clients may experience many 


benefits receiving mental health and substance use 
treatment by telehealth: 


e Increased access to experienced providers 
and high-quality care. Through telehealth, 
clients can access experienced providers that 
may be geographically distant from their homes. 
Through telehealth modalities, clients can access 
providers with expertise in their particular 
conditions and treatment plans that can provide 
care appropriate for their culture, race, gender, 
sexual orientation, and lived experience.” *” * 


e Improved access to and continuity of care. 
Telehealth provides a mechanism to increase 
access to quality care and reduce travel costs for 
clients, increasing the likelihood that clients will 
see their provider regularly and attend scheduled 
appointments.** ” 


e Increased convenience that removes 
traditional barriers to care, including: 

— Geographic barriers (e.g., transportation 
and distance to providers). Telehealth 
increases the opportunity for individuals 
in remote locations to access the care they 
need.* 9, 50-55 

— Psychological barriers. Clients who 
experience anxiety about leaving their 
homes to access treatment (e.g., clients 
experiencing panic disorder or agoraphobia) 
are able to receive care in a safe 
environment.** °7 


Accessibility. Individuals with physical, 
visual, or hearing impairments and clients who 
are isolated (e.g., older adults) or incarcerated 
are able to access needed health care through 
use of telehealth.* ** 

Employment. The use of telehealth allows 
clients to receive care while not requiring them 
to take significant leave from employment or 
other essential activities.*7 *8 

Childcare and caregiver responsibilities. 
Receiving home-based telehealth can help to 
reduce the burden of finding childcare. For 
family caregivers, telehealth technologies, 
such as remote monitoring, can relieve 

some caregiver responsibilities, thereby 
decreasing stress and improving quality of 
lite.” 

Team-based services and group-based 
interventions. Team-based and coordinated 
care is critical to high-quality client 
treatment. However, geographic distances 
between providers and clients can limit 
communication. Telehealth enhances team- 
based care across geographic barriers by 
remotely connecting multiple providers with 
a client, promoting provider collaboration 
and the exchange of health information.°' 
Similarly, telehealth improves access 

to group-based interventions, which 
demonstrate similar treatment outcomes as 
in-person groups.” 


Health Equity and Telehealth 


While telehealth has many benefits, concerns around access to telehealth and telemedicine services, especially 
for those with low technology literacy or disabilities, remain.’”” 


e Americans aged 65 and older (18 percent of the population) are most likely to have a chronic disease, 
but almost half (40 to 45 percent) do not own a smartphone or have broadband Internet access.” 


e People experiencing poverty report lower rates of smartphone ownership (71 percent), broadband 
Internet access (59 percent), and digital literacy (53 percent) compared to the general population.” ”° 


e People who are Black or Hispanic report having lower computer ownership (Black: 58 percent; Hispanic: 
57 percent) or home broadband Internet access (Black: 66 percent; Hispanic: 61 percent) than White 
respondents (82 and 79 percent, respectively), although smartphone access is nearly equal (Black: 80 
percent; Hispanic: 79 percent; White: 82 percent).’° 


Due to these limitations, some clients may not benefit from telehealth.”: 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
Issue Brief 5 


— Reduction in stigma associated with 
experiencing SMI and SUD and accessing 
treatment. Through telehealth, clients 
can disclose their SUD and/or SMI from 
the privacy of their own home.® In rural 
communities with fewer behavioral health 
providers, telehealth can connect clients 
with providers in other geographic locations, 
which can increase their privacy and protect 
their anonymity when accessing care.** °° 

— Satisfaction with care consistent with 
in-person treatment. Despite some initial 
client hesitancy towards using telehealth, 
clients often report comparable satisfaction 
between telehealth and in-person care.°”-”” 


3. Population health. Treatments delivered through 
telehealth have been shown to improve health 
outcomes, including improved quality of life and 
access to health care. For people experiencing SMI, 
telehealth has the potential to improve quality of 
life and general mental health, reduce depressive 
symptoms, build more confidence in managing 
depression, and increase satisfaction with mental 
health and coping skills (when compared to treatment 
offered in-person only).* 8 For people experiencing 
SUD, treatments delivered through telehealth have 
resulted in reductions in alcohol consumption, 
increased tobacco cessation, and increased engagement 
and retention in opioid use disorder treatment.** 


4. Costs. In rural communities in particular, 
implementing telehealth services reduces 
organizational costs by replacing the budget for a 
full-time, onsite behavioral health provider with as 
needed hourly fees.*° 


Internet 
Access 





U.S. Adults Use the U.S. Adults have U.S. Adults Own a U.S. Adults Own a U.S. Adults Own a 
Internet Home Broadband Desktop or Laptop Tablet Computer Cell Phone 
Computer 


Source: Pew Research Center (2021). Internet/Broadband Fact Sheet. https:/Awww.pewresearch.org/internet/fact-sheet/internet-broadband/. 


Implementation of Telehealth 


While the use of telehealth as a mode of service delivery 
is increasing, providers, clients, and healthcare settings 
continue to experience challenges related to adoption 
and implementation. For example, uptake of telehealth 
can be hindered by disparities in access to appropriate 
and needed technology. 


Recent advances in technology and access to personal 
computing devices and mobile phones have led to a 

rapid increase in the application of telehealth across the 
continuum of care (i.e., assessment, treatment, medication 
management/monitoring, recovery supports). Both 
providers and clients need access to appropriate technology 
to benefit from synchronous or asynchronous telehealth. 
Practitioners can provide synchronous SMI and SUD 
treatment through relatively low-tech options, including 
telephones, smartphones, tablets, and laptops.'° '4 


The age, usability, and functionality of clients’ 

devices may inhibit their use (e.g., ability to utilize 
various mHealth applications, appropriate data plans). 
Additionally, clients may be sharing devices with family 
members or others in a household, limiting the types 
of data a client would want to store or share through 

a device. For providers, some clinics struggle to have 
enough laptops to support staff working from home or 
outside of typical shared office space,” *°** and may 
not have updated devices or software systems to utilize 
available telehealth applications. 


Barriers associated with access to technology are 
compounded by challenges experienced on multiple, 
interrelated levels (further discussed in Chapter 3). 


Cell Phone 
Access 


Computer/Tablet 
Access 





Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Issue Brief 


e Increasing access to and comfort using telehealth 
e Preparing clients to use telehealth 
Organizational Assessing organizational needs 


e Increasing organizational readiness and workforce capacity to 
participate in telehealth 


e Ensuring security and confidentiality 


Regulatory and reimbursement environments e Complying with federal, state, and local regulations 


and cost benefits are emerging, the practices and 
programs included in Chapter 2 have demonstrated 
efficacy in improving client mental health and SUD 





The use of telehealth has increased substantially in 
recent years and has accelerated rapidly with the ; : ; 
COVID-19 pandemic. While the landscape of telehealth outcomes in multiple settings and contexts. 
is continually evolving, and provider, client, population, 


y 





Issue Brief 7 


Reference List 


Substance Abuse and Mental Health Services 
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care-coordination/telehealth-telemedicine 








Health Resources and Services Administration. 
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gov/patients/understanding-telehealth/#what-does- 
telehealth-mean 


3 National Institute of Mental Health. (2020). Mental 
illness. https://www.nimh.nih.gov/health/statistics/ 
mental-illness.shtml#:~:text=Two%20broad%20 
categories%20can%20be,the%20NIMH%20 
Health%20Topics%20Pages 


4 Substance Abuse and Mental Health Services 
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disorders 


> Bashshur, R. L., Shannon, G. W., Bashshur, N., & 
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dx.doi.org/10.1089%2Ftmj.2015.0206 


6 Lustig, T. (2012). The role of telehealth in an 
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7 Mace, S., Boccanelli, A., & Dormond, M. (2018). 
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https://store.samhsa. gov/product/TIP-60-Using- 
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° — American Medical Association. (2019). Telehealth 
implementation playbook. Digital Health 
Implementation Playbook Series. https://www. 
ama-assn.org/system/files/2020-04/ama-telehealth- 
implementation-playbook.pdf 












































20 


21 


Center for Connected Health Policy. (2020). Live 
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www.cchpca.org/about/about-telehealth/live-video- 
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Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
Issue Brief 


12 


What Research 
Tells Us 


Telehealth is the use of two-way, interactive, video and/ 
or audio technology to provide health care to individuals 
experiencing serious mental illness (SMI) or substance 
use disorder (SUD). The goal of this chapter is to present 
the evidence for specific telehealth-delivered treatments 
for individuals with SMI, SUD, and co-occurring 
disorders (CODs). While telehealth modalities for SMI 
or SUD may be synchronous (real-time) or asynchronous 
(non-urgent communication between clients and 
providers), the evidence review in this chapter focuses 
on synchronous interventions to treat SMI or SUD. In 
addition to treatments via telehealth modalities, this 
chapter also provides information on ways programs 

can provide telehealth-delivered services along the 
continuum of care for SMI and SUD, which includes 
screening and assessment, medication management, case 
management, recovery support, and crisis services. 


Telehealth is effective across 

the continuum of care for SMI 
and SUD, including screening 
and assessment, treatments, 
including pharmacotherapy, 
medication management, and 
behavioral therapies, case 
management, recovery supports, 
and crisis services. 


What Research Tells Us 





13 


Evidence Review and Rating Process 
This evidence review (detailed in Appendix 2) began with an environmental scan to identify treatments for 
mental disorders and SUD that have been found effective when implemented through telehealth modalities. 


STEP 1: Identify treatments that meet the inclusion criteria: 


e Have a standardized, replicable implementation protocol 
e Use synchronous telehealth modalities for treatment of SMI or SUD 
e Are currently being implemented in the field 


Following an environmental scan, review of the literature, and consultation with experts, Cognitive Behavioral 
Therapy (CBT), Cognitive Processing Therapy (CPT), Prolonged Exposure Therapy (PE), Behavioral Activation 
Therapy (BA), and Medication-Assisted Treatment (MAT) met the inclusion criteria. 


STEP 2: Identify studies that meet the following inclusion criteria: 


e Published in or after the year 2010 


e Employ a randomized or quasi-experimental design (RCT or QED) or are a single sample pre-post design or 
an epidemiological study that analyzes what would have happened in the absence of the intervention 


e Descriptive and implementation studies, meta-analyses, and systematic reviews were not included in the 
review. 


STEP 3: Review each study meeting inclusion criteria for strength of study design and statistically 
significant positive outcomes related to SMI and SUD. For each reviewed study, assign a study rating. 


Many of the telehealth studies examine a slightly different question than most evaluation studies. Typically, an 
evaluation of the effectiveness of a specific therapeutic practice will assess whether the practice yields better 
outcomes than a control consisting of no treatment or a treatment-as-usual approach. However, for many 
telehealth studies, the question posed is whether outcomes for telehealth recipients are comparable for those 
receiving the therapy in-person. Given that telehealth is typically less expensive and easier to access, the 
question addressed by these studies is one of “non-inferiority,” i.e., does telehealth-delivered evidence-based 
therapy produce similar (and no worse) outcomes than evidence-based therapy delivered in-person? 


STEP 4: Assign evidence rating for each treatment based on the number of studies demonstrating a 
high or moderate causal impact on mental health and substance use outcomes. 


See the evidence review methods and Appendix 2 for more information on the process for treatment selection 
and rating. 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
What Research Tells Us 14 




















CAUSAL EVIDENCE LEVELS 


Strong Evidence 


Causal impact demonstrated by at least 
two randomized controlled trials, 
quasi-experimental designs, or 
epidemiological studies with a high or 
moderate rating. 


Moderate Evidence 


Causal impact demonstrated by at least 
one randomized controlled trial, 
quasi-experimental design, or 
epidemiological study with a high or 
moderate rating. 


Emerging Evidence 


No study received a high or a moderate 
rating. The practice may have been 
evaluated with less rigorous studies (e.g., 
pre-post designs) that demonstrate an 
association between the practice and 
positive outcomes, but additional studies 
are needed to establish causal impact. 


ill 


The evidence for use of telehealth across the continuum 
of care for SMI and SUD is included below, with the 
detailed evidence review results (1.e., causal evidence 
level ratings) included for MAT and behavioral therapies. 


Using the approach identified in the evidence review 
methods (discussed above), interventions that have 
undergone a formal evidence review are included as 
illustrative examples of the application of telehealth- 
delivered services to treat people with SMI and SUD. 
One should not conclude that these are the only 
treatments that can be implemented using telehealth 
modalities for individuals experiencing SMI and SUD. 
When implemented using the same core steps and 
components as the original model (i.e., with fidelity to 
the model), synchronous telehealth treatments can be 
comparably effective to in-person services. 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


What Research Tells Us 


15 


Treatment (Pharmacotherapy, 
& Medication-Assisted Treatment, 
_/ Medication Monitoring, Behavioral Ji” 
Therapies) 


ir © Case Management 
\ SUD Recovery a, 
© 


Supports 


Screening and 
Assessment 


Screening and Assessment 


Screening and assessment for SMI and SUD are the 
first steps to effective treatment and can be effectively 
conducted using synchronous and asynchronous 
telehealth modalities. 


e SMI: Synchronous screenings and 
assessments for mental disorders conducted 
via videoconferencing modalities have similar 
reliability and accuracy to in-person screening 
and assessment. Asynchronous tools that are 
completed by a client and later reviewed by and 
discussed with a provider can increase access to 
screening and assessment when no clinician is 
available.! 


e SUD: Providers can administer screening tools 
to assess risk of SUD using telehealth.* Early 
evidence suggests computer-based assessment 
tools for SUD may increase engagement in the 
screening process, as well as response accuracy. 
However, confirmation and diagnosis of SUD 
through telehealth has limited evidence. This 
is largely due to the 2008 Ryan Haight Online 
Pharmacy Consumer Protection Act, which, 
prior to the COVID-19 pandemic, required in- 
person evaluations before providing medication- 
assisted treatment (MAT).* 


3 


© 
®@ Crisis Services & 





Telehealth modalities can be used to connect clients, 
care teams, and support systems during the creation and 
implementation of an individualized care plan by: 


1. Increasing the diversity of specialists (in terms 
of clinical specialty and geographic location) 
that can be consulted for diagnosis, assessment, 
and treatment 


2. Engaging administrative staff (via patient 
portals), clinicians, and providers (via 
electronic health records and videoconferencing 
consultations) and support networks such as 
friends and family (via videoconferencing 
and social media) in various components of 
treatment*° 


Once a diagnosis is made, clients and providers can 
determine together the appropriateness of various 
telehealth modalities and identify when telehealth, in- 
person, or a hybrid approach will best meet the client’s 
treatment goals. Appropriateness of telehealth may 
depend on several factors, including the: 


e Nature and complexity of the intervention and 
the client’s condition 

e Client’s comfort with technology and telehealth 
appointments 

e Ease and preferences of accessing in-person 
services or using technology 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


What Research Tells Us 


16 





Designing and updating the care plan is a collaborative As a result of changing regulations, evidence for the 


and iterative process between client and provider, and provision of MAT solely through telehealth modalities 
involves a conversation on client comfort, preferences, is limited. Studies included in the review (below) 
and goals (further discussed in Chapter 3). examined multiple components of MAT, some of which 


are provided via telehealth modalities and others through 
SMI and SUD Treatment a hybrid approach (combination of in-person and 
Pharmacotherapy, Medication-Assisted telehealth approach). 
Treatment, and Medication Management 


Pharmacotherapy can be implemented using “| 
synchronous telehealth for SMI. Prescribing and 
monitoring medication using telehealth can lead to 
reduced length of hospitalization and symptomology, 
and improved medication adherence.’ * There are also 
limitations to prescribing and monitoring medication that 
should be noted, such as evaluating movement disorders 
and the ability to test muscle tone (e.g., in order to gauge 
rigidity as a side effect of a medication). 


Medication-Assisted Treatment (MAT) uses 
pharmacological medications in combination with 
counseling and behavioral therapies to treat diagnosed 
SUD.’ MAT involves multiple components tailored to 
meet individual clients’ needs,'’ including initiating 
medication, monitoring adherence, and providing access 
to counseling and psychosocial supports.'' MAT includes 
FDA-approved treatments for opioid use disorder 

(using methadone, buprenorphine, and naltrexone),'*"'4 
and alcohol use disorder (using naltrexone, disulfiram, 
and acamprosate).'*'° Currently, there are no FDA- 
approved medications to treat stimulant or marijuana 
use-disorders.'” 


MAT is regulated by the Drug Enforcement 
Administration (DEA). Prior to the COVID-19 
pandemic, practitioners could not provide certain 
components via telehealth.'*: !° Due to temporary changes 
for COVID-19 that may or may not become permanent, 
there are several models for using a hybrid in-person 
and telehealth approach to delivering MAT.” For 
example, a physician may perform an initial assessment 
and prescribe medication via videoconference, while 
local clinicians provide counseling and follow up in- 
person; or, a physician could prescribe medications and 
monitoring during in-person visits and the client then 
receives counseling via telehealth.7! 





Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
What Research Tells Us 17 


Medication-Assisted Treatment using a hybrid telehealth and in-person approach 


(s) Strong Evidence 





Health outcomes 


Telehealth-specific 
outcomes 


When compared to in-person treatments: 


Reduction in rates of positive urine drug screens over course of study”? and no significant 
difference in positive urine screens between in-person and telehealth groups”: 7° 


No significant difference in retention?? and counseling attendance rates” 
No significant difference in and high level of client satisfaction” 
No significant difference in client and provider ratings of therapeutic alliance” 





Populations that 
benefit from the 
treatment 


People living with opioid use disorder? 7° 
Pregnant women living with opioid use disorder”? 





Providers who can 
offer intervention 
services 


Technology used 


A range of providers can implement MAT activities depending on both the specific activity they 
conduct, the location of the prescriber and treatment program, and the type of medication offered. 


The care team can include: 


Waivered prescribers at buprenorphine’®“ and opioid treatment programs?° 

Social workers, peer recovery counselors, addiction counselors, outreach workers, and 
nurses 

Pharmacists” 


Videoconferencing and web-based applications? 2” 





Intensity, duration, 
and frequency 


MAT is designed to meet clients’ clinical needs, so there is no protocolized model for the 
intensity and duration of the program 

Clients may vary in the types of supports they need and those needs may change over the 
course of treatment and recovery" 

MAT begins with treatment initiation, followed by weekly urine drug screens, medication 
monitoring, and counseling sessions that taper to monthly depending on response to 
treatment? 2 

Medications are often administered gradually, and providers work with clients to appropriately 
adjust the dosage between initiation and stabilization” 





Lessons learned 
from transitioning 
from in-person 
care to telehealth 





Telehealth can be used to integrate care and extend the reach of specialty providers to make 
MAT available to underserved populations”? 

Although some clients experienced technical problems, most enjoyed the convenience of 
telehealth services? 

Providing MAT via telehealth is limited by regulatory constraints and practitioners should 
consult state and federal prescribing laws prior to initiating telehealth MAT programs?° 











Four studies met criteria for review (one RCT, two QEDs, and one single sample pre-post), resulting in a rating of Strong 
Support for Causal Evidence. 





Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


What Research Tells Us 


Medication management via telehealth ranges from 
automated, non-specific text messages to adherence 
counseling conducted over the telephone.” *° Examples 
of telehealth modalities for conducting medication 
management are described below: 


e Text message interventions, designed to remind 
clients to take their medication, have been found 
to be effective for people experiencing SMI 
even if the messages were not customized or 
specific to the dosage, timing, or medication 
prescribed.3! ? 


e Smart pill containers remind clients to take 
their medication, provide alerts about taking the 
wrong medication, and are linked to programs 
for the client to report side effects to providers. 
Used together with telephone support, smart pill 
containers have shown statistically significant 
improvement in medication adherence.*? 


e mHealth apps have been used in combination 
with smart pill containers, in-home dispensing 
devices, or other systems to dose medications. 
These apps remind clients to take medications 
and communicate medication use information 
to their healthcare provider through a client 
portal.** 


e Treatment support over the phone from case 
managers, nurses, or other health professionals 
offers clients prescribed medications for SMI 
and SUD information and adherence support. 
These approaches have shown statistically 
significant improvements on medication 
adherence rates. 


35-37 





Medication monitoring, including both support for 
medication adherence of the prescribed treatment and 
prevention of non-prescribed or illicit substance use 

that may cause dangerous interactions, is an essential 
component of MAT. Clinics or other agencies without a 
local, trained MAT provider have used telehealth to link 
clients to a remote MAT provider. The local clinic and 
agency can provide in-house medication monitoring and 
urine toxicology screening while providing space for the 
client to meet with the MAT provider using telehealth 
technology.”* In some treatment models, monitoring 
visits are conducted using telehealth, but the client is 
required to report in-person for regular urine toxicology 
screening.”> 7338 


Behavioral Therapies 


Practitioners can implement psychotherapy*’ and 
behavioral therapies through synchronous telehealth 
modalities while adhering to clinical specifications and 
producing clinical improvements similar to treatment 
outcomes from in-person care.” 


This evidence review identified four interventions that 
met evidence review criteria (described above and in 
Appendix 2) and improved health outcomes for people 
experiencing SMI, including Behavioral Activation 
(BA) Therapy, Cognitive Behavioral Therapy (CBT), 
Cognitive Processing Therapy (CPT), and Prolonged 
Exposure (PE) Therapy. Each behavioral therapy is 
described below, including associated health outcomes, 
populations that may benefit, and other important 
information for implementing these therapies using 
telehealth. 


—~S wae 





2 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


What Research Tells Us 


19 


Behavioral Activation (BA) Therapy via telehealth 


(Ss) Strong Evidence 





BA is a treatment component based on changing behavior to change one’s mood. It involves identifying, scheduling, and 
completing positive reinforcement activities.*' +? Behavioral Activation- Therapeutic Exposure (BA-TE) is an integrated, 
evidence-based treatment for Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD). BA-TE 
combines BA with exposure-based therapy. It involves weekly BA activities along with situational exposure to clients’ 
avoided stimuli and imaginal exposure to past traumatic events.‘ 4° 





Health outcomes 


Reduction in depression** and major depression* “3 symptoms 
Reductions in PTSD symptoms** *8 
Reduction in anxiety*? 





Telehealth-specific 
outcomes 


When compared to in-person treatments: 


Reduction in Veteran’s Affairs health utilization costs one-year post-telehealth intervention™ 
Similar rates reduction in PTSD symptoms (e.g., disturbing memories/thoughts about military 
experience, avoidance of external stimuli, nightmares, and re-experiencing)** *° 





Populations that 
benefit from the 
treatment 


People experiencing MDD, including: 


People experiencing PTSD, including: 


Older veterans (58+)"' 

Rural veterans*' 

Black/African American veterans“ 
Male veterans“ 


Male and female veterans of Operation Enduring/Iraqi Freedom* and the Vietnam War, the 
Persian Gulf War, and Operation New Dawn** 





Providers who can 
offer intervention 
services 


Master’s-level clinicians with over five years of experience who participate in a two-day 
training and who receive weekly supervision throughout the trial*’ 

Master’s-level counselors who completed an eight-hour workshop and shadowed a senior- 
level clinician administering the treatment*® 

Mental health therapists who completed a week-long training, shadowed a senior-level 
clinician, and received weekly supervision’? 





Technology used 


In-home videoconferencing technology, set up via an analogue telephone*' 

Computer, tablet, or smartphone with encrypted videoconferencing software similar to Skype 
or FaceTime**: *8 

A landline-based videoconferencing program which functions like a typical touch-phone but 
includes an adjacent video screen‘? 4° 





Intensity, duration, 
and frequency 


Eight 60- to 90-minute weekly sessions‘? 4° 





Lessons learned 
transitioning from 
in-person care to 
telehealth 


Telehealth treatment was effective even though the in-home videoconferencing technology 
used in the studies has become somewhat obsolete; researchers believe new technology 
can only improve communication between clients and providers, thus easing future 
implementation“ 

Home-based telehealth has potential advantages over hub-and-spoke models (e.g., where 
a Client is treated in an office setting by providers at another office setting) for addressing 
treatment barriers, including cost, stigma, and travel logistics*® 








Four studies met criteria for review (three RCTs and one single sample pre-post), resulting in a rating of Strong Support 
for Causal Evidence. 








Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


What Research Tells Us 


20 


Cognitive Behavioral Therapy (CBT) via telehealth 


(Ss) Strong Evidence 


trauma*’ 


CBT is a goal-oriented psychotherapy that seeks to modify an individual’s thought patterns, beliefs, and behaviors. CBT 
programs use a variety of cognitive and behavioral techniques in group and individual settings while remaining structured 
and time-limited.*® Through cognitive restructuring, CBT may be used to help clients re-evaluate their negative thought 
patterns that include overgeneralizing or catastrophizing negative outcomes.*” *® CBT techniques can be used to help 
clients address traumatic experiences and develop more effective thought patterns and realistic perspectives on the 





Health outcomes 


e Reduction in severity of depression symptoms’? °° 
e Reduction in symptoms of PTSD*' 
e Reductions in self-reported depressive and general anxiety symptoms*' 





Telehealth- 
specific outcomes 


When compared to enhanced usual care (defined as conversations with primary care physicians): 
e Higher level of client satisfaction *' 

e No significant difference in therapeutic working alliance between provider and client®’ 

When compared to in-person treatment: 

e Higher level of treatment completion*® 





Populations that 
benefit from the 


People experiencing major depressive disorder, including: 
e Primary care clients*® 











Lessons learned 
transitioning from 
in-person care to 
telehealth 





treatment Rural, Latino/Latina clients®° 

e People experiencing PTSD, including: 

— College women who are survivors of rape*' 

Providers e Doctoral-level therapists*® 
who can offer e Students working towards master’s in social work degree °° 
intervention e Master’s-level social workers 
services e Licensed social workers®° 
Technology used |e Telephone‘? °° 

e Computer-based online program facilitated by a therapist®' 
Intensity, e Participants were offered 8 to 18 sessions of CBT; sessions (offered in both English and 
duration, and Spanish) were designed to be 45 to 50 minutes*® °° 
frequency e Through an online, therapist-facilitated CBT program, clients completed nine modules over the 


course of 14 weeks*! 


Lack of telephones was not a significant barrier to participation®° 

Providing culturally tailored CBT via telephone has the potential to enhance access to care for 

Latinas/Latinos living in rural areas°° 

e Providers and clients developed a strong therapeutic working alliance despite the largely 
asynchronous nature of communication*' 

e Future research is needed to assess the effectiveness of delivering similar therapist-facilitated 

online programs to diverse populations and in multiple practice settings®' 








Four studies met criteria for review (four RCTs), resulting in a rating of Strong Support for Causal Evidence. 





Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


What Research Tells Us 


21 





Cognitive Processing Therapy (CPT) via telehealth* 


(Ss) Strong Evidence 


CPT is a trauma-focused cognitive therapy aimed at reducing symptoms of PTSD.** CPT has been found to be effective 
in reducing symptoms of PTSD developed as a result of experiencing traumatic events, such as child maltreatment, 
sexual assault, and military-related stressors.°**° CPT consists of four main components: 1) Education; 2) Processing; 
3) Challenging thoughts about the trauma to restructure thought patterns; and 4) Focus on trauma-related themes of 
safety, trust, power and control, esteem, and intimacy***” 


Health outcomes |e Greater or equivalent reduction in severity of PTSD symptoms °°: 5*6 
e Reduction in symptoms of depression®® °° 











Telehealth- When compared to in-person treatments: 


specific outcomes Increased access to care for underserved rural populations 


No significant difference in client treatment adherence (homework completion) and retention® °° 
No significant difference in client satisfaction® °° 
No significant difference in therapeutic alliance between provider and client® °°: © 





Populations that | People experiencing PTSD, including: 


benefit from the e Veterans 5. 60 





treatment Civilian women® 
e Male combat veterans living in rural areas®® 
Providers Licensed psychologists” 


who can offer 
intervention 
services 


Doctoral-level psychologists®: © 

Licensed social workers? 

Master’s-level and doctoral-level social workers®: °° 
Family therapists? 


Although formal CPT training is not required for practitioners, resources are available, including a 
program delivery manual and certification trainings 





Technology used |e Videoconference® °*° 





Intensity, e Participants received CPT over 12 sessions, conducted once or twice a week for 
duration, and approximately 50 to 90 minutes each °°: *°°° 
frequency 





Lessons learned |e Videoconference is a familiar format for many users? 

transitioning from |e Participants encountered few disruptions using videoconferencing (e.g., no sessions were 
in-person care to canceled due to technological difficulties)°° 

telehealth e Smaller technology screens may reduce rapport and communication’? 


Four studies met criteria for review (four RCTs), resulting in a rating of Strong Support for Causal Evidence. 

















“Originally, the primary version of CPT was administered with a written account of trauma and cognitive-only CPT was administered 
without a written account of trauma. Research comparing the efficacy of the two versions found that both versions are as effective, and, 
notably, the cognitive-only version led to a decrease in dropout rate. As a result, the terminology changed and CPT without a written 
account of trauma became the primary version implemented. For the purpose of this evidence review, this guide uses the terminology as 
CPT delivered with or without a written account of trauma. 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
What Research Tells Us 22 


Prolonged Exposure (PE) Therapy via telehealth 


(Ss) Strong Evidence 





PE is a type of CBT that focuses on helping individuals confront their fears from traumatic experiences. First developed 
as an intervention to treat sexual assault survivors suffering from PTSD, PE has been shown as effective for treating 
survivors of varied traumas, including combat, accidents, and disasters.** Through weekly sessions of PE, individuals learn 
how to gradually approach their trauma-related memories and feelings.*': ®* Exposure therapy through imaginal exposure 
(describing the traumatic event) and in vivo exposure (confronting feared stimuli) also helps reduce symptoms of PTSD.*°* 





Health outcomes 


Telehealth- 
specific outcomes 


When compared to in-person treatments: 


Reduction in the severity of PTSD symptoms? (compared with both no treatment and in- 
person PE therapy) 

Reductions in symptoms of anxiety®: °° ° 

Reductions in symptoms of depression*®® 


Increased access to care for rural veterans® 

No statistical differences in client satisfaction, although participants in the in-person group 
reported a higher level of comfort when communicating with their therapist than participants in 
the telehealth group™ 

High acceptability of telehealth modalities® 

Reductions in the extent to which PTSD interferes with activities of daily living (including 
health, diet, and work)® 





Populations that 
benefit from the 
treatment 


People experiencing PTSD, including: 


Veterans, predominantly male °° 
Rural veterans® 





Providers 
who can offer 
intervention 
services 


Clinical psychologists®: °*.°° 

Psychiatrists® 

Master’s-level therapists and counselors®: ©: °7 

Master’s-level social workers®: °° 

Psychology interns/fellows® 

Although formal PE training is not required, practitioners of PE often received training and 

supervision in the form of: 

— Weekly supervision from a licensed clinical psychologist who was a certified PE trainer® 

— 32-hour workshop training program in PE® 

— Observation of a senior-level clinician through a complete course of prolonged exposure, 
both in-person and via telehealth® 

— Recordings of therapy sessions for treatment fidelity®” 

— Extensive training and supervision in exposure therapy for PTSD®° 





Technology used 


Videoconferencing via computer™*® or smartphone® 





Intensity, 
duration, and 
frequency 


Participants received PE once a week ranging from approximately 60 to 90 minutes;®*°° they 
were typically offered between 6 to 12 sessions depending on treatment response,™: ®: §7-6° 
and up to 21 sessions in one case® 





Lessons learned 
transitioning from 
in-person care to 
telehealth 





Clients express general interest and acceptability in using PE delivered via videoconferencing® 
Telehealth-delivered PE can help overcome geographic barriers to care and help providers 
reach underserved populations® °° 

Providers can make small adaptations to telehealth-delivered care to increase adherence to 
PE; some small, yet useful changes in care include using smartphone calendar reminders, 
scheduling an initial in-person client meeting to build rapport, and using the PE Coach app to 
augment and supplement treatment® © 

During telehealth visits, the quality and positioning of video cameras and monitors can reduce 
providers’ ability to notice and respond to clients’ nonverbal communications® 











Seven studies met criteria for review (four RCTs, two QEDs, and one single sample pre-post), resulting in a rating of 
Strong Support for Causal Evidence. 





Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


What Research Tells Us 


23 


While this review focuses on synchronous interventions, 
providers can use asynchronous tools to complement, 
support, and reinforce synchronous client-provider 
interactions. Examples of asynchronous tools can be 
found through online repositories such as the M-Health 


Index and Navigation Database or the VA App Store. 


Case Management 


Ongoing case management may include routine 
check-ins and follow-ups, updates and modifications 

to care and treatment plans, identification of and 
connections with needed resources, and support in 
achieving the goals of an individualized care plan. 
These ongoing conversations are readily adapted to 
synchronous telehealth modalities and Health Insurance 
Portability and Accountability Act (HIPAA) compliant 
asynchronous messaging platforms, including texting 
and messaging through a clinic electronic health record 
(EHR) system. Specific studies have demonstrated 
ongoing case management interventions using 
telehealth are effective for people with depression”: 7! 
and schizophrenia.” 


SUD Recovery Supports 


Practitioners can provide ongoing recovery support 

for people in SUD treatment through synchronous 
telehealth methods. Peer recovery support services use 
peers (people who have similar lived experiences as 
the client, such as someone who is in SUD recovery 
themselves) to provide support for clients while in 
treatment and recovery.” Some peer recovery support 
services use technology-assisted peer support to engage 
clients, conducting regular check-ins over telephone or 
videoconference.” 


Crisis Services 


Telehealth modalities can increase the availability 

of needed crisis services, ensuring these services are 
available to anyone, anywhere, at any time, and that 
there is a “no-wrong-door” approach for entry into 
services.’° Crisis services are an effective strategy for 
suicide prevention and resolving acute mental health 
and substance use crises, as well as for reducing 
psychiatric hospital bed overuse, inappropriate use 
of emergency departments, inappropriate use of law 
enforcement resources, and the fragmentation of mental 
health care.” 


Cited by the National Guidelines for Behavioral Health 
Crisis Care as an essential element of an integrated 
crisis system, regional crisis call centers provide 
synchronous telephonic crisis services, text, and online 
chat technology to triage needs, assess for additional 
needs and preferences, and coordinate connections for 
additional post-crisis support. In addition to telephone 
calls and live online chats or texts, regional crisis call 
centers can also make use of the following technologies 
to support an individual’s well-being: 





e 24/7 outpatient scheduling 

e Crisis bed registry 

e GPS-enabled mobile crisis dispatch 

e Real-time performance outcome dashboards 


Asynchronous tools such as My Mental Health Crisis 





Plan” (designed by SAMHSA) can be used to create a 
personal advance directive, a legal document outlining 
an individual’s preferences during a mental health 
crisis should the individual not be able to determine or 
communicate their own decisions. 





Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


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24 


Suicide Screening and Assessment 


Telehealth modalities provide an effective alternative to in-person suicide screening and assessment.” The following 
suicide screening and assessment tools can be implemented through telehealth modalities: 


e The Ask Suicide-Screening Question Toolkit (ASQ) from the National Institute of Mental Health (NIMH) is 
an evidence-based, 20-second, four-question suicide screening tool.’® 


e The Collaborative Assessment and Management of Suicidality (CAMS) is an evidence-based 


intervention to assess, treat, and manage clients with suicidal ideation in a range of clinical settings.’**” 


e Columbia-Suicide Severity Rating Scale (C-SSRS), also known as the Columbia Protocol, can be used 
to determine whether someone is at risk for suicide, assess the severity and immediacy of that risk, and 
gauge the level of support the person needs.*® 


lf a client is at risk of imminent harm: 


1. Assess immediate danger. If the client is in immediate danger and the provider is unable to detain or 
physically intervene, the provider must contact emergency services. 


Identify the client’s location in case emergency services are necessary. 


Work with other care providers (e.g., suicide prevention coordinators) when contacting 
emergency services. Remain connected with the client as the client connects with emergency services 
or while arranging hospitalization.®° 


4. Support clients as they navigate the triage process at an emergency department. Treatment 
programs should have safety protocols to mitigate risks and create a workflow to support the client; 
providers should determine the suicide risk level with criteria that identify the appropriate clinical 
response.°° % 


Future Directions 


This evidence review supported conclusions related to 
treatment outcomes: 


e Telehealth is effective across the continuum 
of care for SMI and SUD, including screening 
and assessment, treatments, including 
pharmacotherapy, medication management, and 
behavioral therapies, case management, recovery 
supports, and crisis services. 

e Evidence-based treatments for SMI and SUD, 
traditionally provided face-to-face, are also 
effective when delivered using telehealth and 
have outcomes comparable to in-person service 
delivery. 


e Therapeutic services provided using telehealth 
modalities generate positive outcomes for the 
client, including engagement in treatment, 
retention in care, and client satisfaction, which 
in turn lead to improved long-term health 
outcomes. 





Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
What Research Tells Us 25 


e Positive outcomes are dependent on the provider 
and client having the necessary resources to 
conduct telehealth well, including training and 
technology (more information on supporting 
telehealth implementation can be found in 
Chapter 3). 


Additionally, several conclusions related to healthcare 
access and utilization can be made from this evidence- 
review: 


e Use of telehealth modalities increases 
individuals’ and communities’ access to trained 
providers and evidence-based practices that may 
otherwise be unavailable to them. 


e When geographic and other access barriers (e.g., 
transportation, mobility, and obligations like 
employment and caretaking responsibilities) 
prevent individuals from accessing services, 
telehealth fills a treatment gap and improves 
health outcomes. 


e Some clients may prefer to receive services 
wholly or partially by telehealth, and any of the 
treatment practices presented in this chapter may 
be part of an overall treatment plan that includes 
a hybrid of telehealth and in-person services. 


However, research on the telehealth application of 
evidence-based practices has been limited for the 
following reasons: 


e Evidence review limitations. While there may 
be innovative behavioral therapies currently 
delivered via telehealth for specific conditions, 
this evidence review relies on specific types 
of published research to determine the 
strength of evidence. Included studies must 
be either randomized controlled trials, use a 
quasi-experimental design, or use a pre-post 
design with a strong counterfactual; therefore, 
innovative treatments and interventions that 
have not been studied with such rigorous 
methods are excluded. 


e Limitations of the literature. While telehealth 
has been used for numerous other conditions, 
individuals experiencing SMI and SUD have 
traditionally been regarded as having complex 
conditions and therefore excluded from 
telehealth research. With limited implementation 
of telehealth for people with SMI and SUD, 
it offered fewer opportunities for researching 
treatment to treat those conditions. Some 
providers have been reluctant to offer telehealth 
in the past, in part due to negative views 
towards the modality and perception of clients’ 
experiences with telehealth,”” which has slowed 
access to telehealth for individuals experiencing 
SMI or SUD. 


e Need examination of asynchronous forms of 
treatment. This evidence review demonstrated 
strong evidence to support synchronous 
interventions to support telehealth-delivered, 
evidence-based treatments. However, more 
research is needed to determine the effectiveness 
of asynchronous treatments, which can be 
effective complementary tools to synchronous 
virtual or in-person treatment by increasing 
client engagement, promoting healthy behaviors, 
reducing feelings of stigma, and increasing 
access to treatment.** °* Text messages, online 
chat features, email, and social networking 
sites can also be used to facilitate ongoing 
communication outside of face-to-face sessions.° 


While there are limitations to the research, telehealth is a 
key strategy to increasing and ensuring access to care for 
people living with SMI, SUD, or COD. Future research 
could expand beyond telehealth efficacy and focus on 
implementation and evaluation considerations, including 
provider/patient buy-in, necessary technological 
infrastructure, and methods of quality improvement. 
Considerations related to implementation and evaluation 
will be discussed in Chapters 3 and 5, respectively. 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


What Research Tells Us 


26 


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Moller, P., Landro, N. I., & Jobes, D. (2016). 
Collaborative assessment and management of 
suicidality (CAMS) compared to treatment as usual 
(TAU) for suicidal patients: Study protocol for 

a randomized controlled trial. Zrials, 17(1), 481. 
https://doi.org/10.1186/s13063-016-1602-z 


Jobes, D. A., Comtois, K. A., Gutierrez, P. M., Brenner, 
L. A., Huh, D., Chalker, S. A., Ruhe, G., Kerbrat, A. 
H., Atkins, D. C., & Jennings, K. (2017). A randomized 
controlled trial of the collaborative assessment and 
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usual with suicidal soldiers. Psychiatry, 80(4), 339- 
356. https://doi.org/10.1080/00332747.2017.1354607 


Huh, D., Jobes, D. A., Comtois, K. A., Kerbrat, A. H., 
Chalker, S. A., Gutierrez, P. M., & Jennings, K. W. 
(2018). The collaborative assessment and management 
of suicidality (CAMS) versus enhanced care as 

usual (E-CAU) with suicidal soldiers: Moderator 
analyses from a randomized controlled trial. Military 


Psychology, 30(6), 495-506. https://doi.org/10.1080/08 
995605.2018.1503001 


Pistorello, J., Jobes, D. A., Compton, S. N., Locey, 
N.S., Walloch, J. C., Gallop, R., Au, J. S., Noose, 

S. K., Young, M., & Johnson, J. (2018). Developing 
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Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
What Research Tells Us 


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Dimeff, L. A., Jobes, D. A., Chalker, S. A., Piehl, 
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B., Brown, G., Fisher, P., Zelazny, J., Burke, A., 
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McCann, R. A., Rojas, S. M., & Felker, B. L. (2019). 


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Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
What Research Tells Us 


32 


CHAPTER 


Guidance for 
implementing 
Evidence-Based 
Practices 


Before using telehealth modalities for screening, 
assessing, treating, and supporting people with serious 
mental illness (SMI) and substance use disorder 
(SUD), clinicians should consider several important 
implementation factors. While this guide is focused on 
telehealth-delivered treatments for people experiencing 
SMI and SUD, the implementation considerations 

and strategies discussed in this chapter can be broadly 
applied for the treatment of any mental illness. 


Regulatory and 
Reimbursement 


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Provider 





This chapter presents implementation considerations 


and strategies to facilitate effective implementation on 
multiple, interrelated levels. 


This chapter starts with factors focused on the individual 
level, including the client and provider. It then identifies 
considerations and strategies across the interpersonal 
client-provider relationship, the organization, and the 
policy and regulatory landscape. 


* Comply with federal, state, and local regulations 


+ Assess organizational needs 

* Increase organizational readiness and workforce 
capacity to participate in telehealth 

+ Ensure security and confidentiality 


+ Prepare clients to use telehealth 
* Build a therapeutic relationship 


* Assess access to and comfort using telehealth 





Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Guidance for Implementing Evidence-Based Practices 


33 


Individual-Level Considerations 
Client-Level 


Clients have different levels of: 


e Comfort or willingness to engage with telehealth 
e Access to technology or high-speed Internet 


e Apprehension about using technology or 
concern about the privacy risks involved 


The recent proliferation of smartphones provides a 
convenient way for many to engage in telehealth. 
Access to smartphones allows for both synchronous 
videoconferencing for telehealth-based therapy, as well 
as asynchronous apps to support medication monitoring, 
symptom recording, and messaging between the client 
and provider. 


Health Equity and Telehealth 


Telehealth holds the promise of increasing access 
to equitable health. However, telehealth-delivered 
treatments require access to technology and the 
Internet. Approximately 10 percent of Americans 
did not have Internet access in 2019. People who 
don’t use the Internet tend to live in rural areas, 
be 65 and older, have less than a high school 
education, and be people of color.' Organizations 
and practitioners should be aware of and address 
equity issues and guard against increasing 
disparities in equitable healthcare access for 
underserved populations.” Translation services 
increase accessibility for clients not proficient in 
English.? 


Strategies to increase client access to and comfort 
using telehealth 


e Increase access to mobile phones and 
Internet — In addition to a fast and stable Internet 
connection, clients need tablets, computers, 
or smartphones that support face-to-face 
videoconferencing or eHealth app services. 
Technical difficulties, such as low image 
resolution, audio delays, or other glitches in 
communication can disrupt the regular flow of 
conversation between the provider and client.*° 
— Providers can supply devices and signal 

boosters to clients who need them.°® 
However, purchasing phones and 


maintaining Internet access involves 

significant start-up and maintenance costs.’ 
— Clients who do not have smartphones, 

tablets, or computers have reported 

high satisfaction using the telephone for 

psychotherapy.® ? 

e Increase awareness of telehealth — Post 
signage about telehealth in waiting or exam 
rooms, share promotional materials during the 
visit or as part of the after-visit summary, or 
provide telehealth demonstrations.* 


Discuss the individual-level benefits of telehealth — 
Clients may experience benefits that go beyond SMI or 
SUD outcomes. For example, for clients who experience 
physical limitations (e.g., chronic pain or mobility- 
related challenges), have panic disorders, or are more 
comfortable in environments they can predict and control, 
telehealth modalities can help them focus on their care in 
a safe and comfortable setting of their choosing. 


e Conduct a health technology trial-run — 
While many technologies are designed to be 
easy to use, people who have less comfort 
with technology may struggle with telehealth 
platforms, devices, and applications and worry 
about technical problems that could occur.'*'” 
Test the connection and interface before a first 
session to reduce technology anxiety and manage 
minor issues.’ Assign an IT or other staff 
member to set up a brief pre-appointment with 
the client to work through the functionalities of 
their telehealth appointment and help the client 
overcome any challenges. This staff member can 
demonstrate how to use the program or app and 
give tips about how to use the device to interface 
with the program (e.g., how to effectively “tap” 
to press start or stop), how to use the camera, 
how to record or view recordings, and how to 
upload and delete files.'4 

e “Let’s try it and see if you like it” — Prior to 
engaging in telehealth, clients may have fears 
or concerns about the experience and the care 
they will receive in a virtual format. Testing out 
the technology, encouraging clients to try out 
various synchronous forms of communication, 
and reminding clients that they can discontinue 
telehealth at any time can support client 
engagement in telehealth visits. 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Guidance for Implementing Evidence-Based Practices 


34 


Strategies for providers to prepare clients for 
telehealth 


Provider-level 


Provider reticence to adopt telehealth can occur for 
several reasons, including concerns related to poor 
therapeutic relationship, less commitment from the 
client to therapy, and technological difficulties affecting 
the therapeutic experience.'*'’ However, acceptability 
studies have found many benefits to therapy using 
telehealth,> 11820 


Strategies to increase provider comfort with 
telehealth 


e Review the literature on the efficacy and 
effectiveness of telehealth (see Chapters | and 2 
of this guide). 

e Provide trainings — Increase digital literacy 
through trainings to increase comfort and 
familiarity with various digital platforms. Use 
training time to get input from providers on what 
works and what can be improved.?!:” 


e Identify individual provider-level benefits — 
Individual providers may find that through 
telehealth, they are able to create flexible work 
schedules, expand the number and kinds of 
clients they work with, and reduce provider 
burnout. 


e Engage clinical and IT staff to support 
telehealth — Using telehealth coordinators 
or trained medical assistants to schedule and 
provide reminders for telehealth visits can 
improve no-show rates and provide needed 
technical assistance. Providing available staff to 
effectively manage technical difficulties can also 
improve provider acceptance of telehealth. 


Interpersonal Client-Provider Relationship 
Considerations 


Client-provider relationships are essential to successful 
SMI and SUD treatment. However, telehealth can 

be challenging to building an effective therapeutic 
relationship. Client-provider pre-work (i.e., discussions, 
planning, and training prior to beginning treatment) 

and special attention to building therapeutic alliances 
can help overcome barriers to developing strong client- 
provider relationships. 


Assess client for appropriateness to engage in 
telehealth — Relationships between clients and 
providers begin with screening and assessment 
prior to starting treatment or therapy. Telehealth 
modalities may not be appropriate for all clients 
at all points of their treatment plans. Some 
treatment and follow-up care requires in-person 
visits (e.g., urine drug screenings for clients on 
medication for SUD). Some clients may respond 
differently to in-person versus videoconference 
therapy and may benefit from a hybrid or in- 
person approach. Screening and assessing clients 
for their readiness to participate in and conduct 
appropriate activities using telehealth modalities 
can inform both care planning and delivery. 

In addition, it can mitigate client challenges 
through careful preparation and structured 
conversations. 


Conduct a thorough informed consent process — 
Use tools such as the easy-to-understand 
telehealth consent form template developed by 
the Agency for Healthcare Research and Quality 
(AHRQ). The informed consent process includes 
the following key pieces: 


— What is telehealth: Explain what telehealth 
is and why you are using it for the client’s 
care. 

— Potential privacy concerns: The presence of 
family members, caregivers, or roommates 
in the home during a telehealth visit could 
hinder a client’s ability to fully engage in the 
visit.” Remind the client to be in a private 
space, away from other people, and assure the 
client that their conversation is private on the 
provider’s side. Ensure the client knows how 
to mute the audio and disable video in case 
they want privacy during disruptions.” 

— Patient communications: Notify clients 
about how electronic client communications 
are stored and who may access these 
communications.” 

— Backup plan: Discuss protocols in the case 
that technology fails or clients need a higher 
level of care.” 





Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Guidance for Implementing Evidence-Based Practices 


35 


e Develop a telehealth checklist for the provider 


to use prior to each visit — A checklist can be 
a convenient way to ensure the provider has 
followed appropriate procedures and shared 
relevant information with the client.” 


e Discuss ways to ensure client privacy during 
sessions — To guarantee privacy, consider making 
it a practice to clarify the client’s location and 
who is in the virtual room in case someone is off- 
camera. This action can affirm your commitment 
to the client’s privacy. 


Special Considerations 


Some clients may have difficulty engaging in tele- 

health, including those with hearing loss, disabili- 

ties, or language barriers.”° 

e The National Association of the Deaf has 
resources for accessibility for clients who are 
deaf and hard of hearing. 


e The American Psychological Association has 
a tip sheet about using telehealth with persons 
with disabilities. 


e Providing translation services can help ensure 
equitable access to health care. Many existing 
translation services already occur over the 
phone. Consider ways to expand translation 
services for use in telehealth. 


Strategies for building therapeutic relationship 


Providing treatment through telehealth modalities will 
impact the way a provider builds therapeutic alliance (the 
relationship developed between the provider and client in 
working toward the goals of therapy)’ during the screening 
and consent process and during treatment. The strategies 
below help to ensure a client’s commitment to therapy, 
address technological difficulties impacting the therapeutic 
experience, and mitigate the potential for a client to feel as 
though conversations are “impersonal.””!*'7-*8 


e Acknowledge differences between in-person 
and virtual visits — Slight audio or video lags 
may disrupt natural communication, which may 
affect rapport-building. Use traditional tools and 
strategies to build the therapeutic relationship 
and implement additional strategies to overcome 
challenges to building rapport over video, such 
as using exaggerated non-verbal cues.” *° 


Guidance for Implementing Evidence-Based Practices 


Inform the Client of Telehealth 
Norms 


Provide the client with an overview of expected 
norms and behaviors for telehealth. 


The camera angle and quality, screen size, 
and other factors can limit the ability to read 
a client’s behavior. Ask the client to adjust the 
camera angle, if possible, to aid in reading 
non-verbal cues. 


While the session may be taking place in 

the client's home, ask that the client dress 
appropriately. 

Remind clients not to multi-task while 
engaging in the session, such as texting or 
using the Internet. Empower the client to 
share if they are having difficulties hearing or 
engaging with the provider. 

Remind the client that while the provider may 
be taking notes or documenting in the medical 
record, the provider’s attention is focused on 
the client. 


Start with small talk — Create a similar 
environment to that of an in-person visit by 
asking about a person’s day, the weather, or 
other light topics to warm up the conversation 
and build familiarity through a virtual visit. 


Meet in person when needed — This strategy 
may be less feasible during pandemics or 

natural disasters, but may be useful in certain 
circumstances, such as meeting first while in 

a hospital setting. In-person meetings are not 
essential to successful telehealth visits, but can be 
used at the discretion of the client and provider. 
Requiring in-person visits can create a barrier to 
seeking or accessing care, so the decision to have 
in-person visits should be made in collaboration 
with the client. 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


36 


Considerations for Working with Groups Using Telehealth 
Group therapy raises additional concerns when using telehealth, especially related to group dynamics and privacy. 
Evidence supports the efficacy of telehealth-delivered mental health groups for veterans with outcomes similar to 
those of in-person groups. However, groups are associated with lower therapeutic alliance and group cohesion ratings 
(although these differences did not impact group clinical outcomes). 
e The American Psychological Association has a list of considerations for group therapy using telehealth modalities. 
e The Mental Health Technology Transfer Center (MHTTC) Central East has a Tip Sheet for Group Teletherapy. 


Groups may happen in hybrid formats (e.g., some audio only, some video plus audio, some in 
person). Consider limiting to two delivery modalities to better facilitate groups and troubleshoot 
challenges. 


Considerations Who can benefit most from group therapy? Problem-solve barriers to participation (e.g., is a 
patient’s technological set-up appropriate to support a telehealth group?). 


Are there any potential negative impacts that the telehealth group could have on potential group 
members (e.g., paranoia symptoms, disruptive behavior)? 


What group size allows for effective engagement while also being able to address emergencies 
or troubleshoot technology issues, if needed? 


Should the groups be closed or open? 


Is there a mechanism for reminder calls before the group meeting to proactively address any 
issues, including technical ones? 


How can client privacy and confidentiality be protected in a group setting? 
Facilitation Before the meeting: 


e Plan ahead by establishing and reviewing curriculum, facilitation prompts, and ways to handle 
emergencies or disruptions 


e Send participant materials through the mail or secure messaging platforms 
e Use aco-facilitator to help with troubleshooting issues or emergencies 


At the start of the meeting: 


e Review group rules/expectations, including guidelines to protect group and individual privacy and 
confidentiality 


e Use the “share screen” function to share a document with group instructions 


During the meeting: 
Lock the sessions once participants have joined 
Utilize the chat box 
Utilize the raise hand feature 
Mute incoming audio 
Allow time for questions and troubleshooting 


Emergencies Document each patient’s physical location and emergency contacts 


Remind participants of emergency plan and rules during first group session 
Consider co-leading videoconferencing groups with another clinician to: 
— Ensure group sessions do not have to be cancelled if a clinician is unexpectedly out 


— Enable a provider to problem-solve technical issues or attend to emergencies while the other 
clinician proceeds with group material 





Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
Guidance for Implementing Evidence-Based Practices 37 


Organizational-Level Considerations 


Telehealth requires organization-level change to 

be sustained. Before a treatment program or clinic 
implements telehealth services, it is important to assess 
the appropriateness of the services for the setting, the 
clients being served, and the providers who will be using 
telehealth to deliver treatment services. An organization 
must ensure there is appropriate space, technology, 
training, financial and human resources, and support to 
implement telehealth. 


Strategies to assess organizational needs and 
readiness 


Prior to implementing telehealth practices, each program 
or organization should conduct a needs assessment to 
explore the following factors: 


e The organization’s readiness for telehealth — 
Review existing protocols and procedures 
(e.g., intake procedures, scheduling) that could 
facilitate or impede implementation using 
a readiness assessment tool. The American 
Psychological Association has an office and 
technology checklist for telepsychological 
services that is a tool for checking client and 
agency readiness. Similarly, the American 
Psychiatric Association has a comprehensive 
Telepsychiatry Toolkit to provide information 
and resources about using telehealth for 
psychiatric care.3!° 








Guidance for Implementing Evidence-Based Practices 





A program’s or organization’s strengths and 
areas for development — Review the budget, 
infrastructure, information management support, 
understanding and compliance with regulations, 
billing and reimbursement policies, and 
organizational ability to support telehealth. 


Available internal resources and local 
factors — Identify internal resources (e.g., 
staffing, technology, space) and local factors 
(e.g., geography, transportation, availability of 
telehealth, availability of high-speed Internet) 
that could affect service delivery via telehealth. 


Financial implications — Determine the costs 
of implementing and sustaining telehealth 
modalities. Verify that payers will reimburse for 
services provided over telehealth and whether 
reimbursement rates are sufficient. 


Characteristics of the client population — 
Identify the population of focus and their 

unique risk factors, cultures, challenges, assets, 
technology access (including broadband and 
equipment), and ways that telehealth can be used 
to overcome client challenges.** *5 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


38 


Based on results of the needs assessment, organizational 
leaders can work with their clinical teams, 
administrators, client representatives or patient advisory 
boards, community members, and partners to create an 
implementation plan that includes the following: 


e Organizational priorities, technology needs, 
necessary changes to existing policies and 
workflows, and training needs 


e Short- and long-term outcomes (to be measured 
using tools identified in Chapter 5) 


e A logic model (a graphic depiction of the 
relationship between a program’s activities and 
their expected outcomes) 


e Privacy, security, and confidentiality procedures 


Strategies for boosting internal readiness and 
workforce capacity to participate in telehealth 


e Identify a program champion — Program 
champions can serve a variety of roles in the 
clinic (e.g., providers, telehealth coordinators, 
leadership), but as champions they can advocate 
for telehealth to leadership, provide formal and 
informal training on telehealth, and identify 
challenges and propose solutions.* 

e Training and capacity-building — When 
possible, provide protected time to support 
implementation training.*° Training and 
capacity-building efforts should engage 
all involved staff and partners, and include 
information about the following: 

— Changing workflows (e.g., processes for 
intake, scheduling, and documenting visits) 
and the HIPAA (Health Insurance Portability 
and Accountability Act)-approved 
technology used. 

— Educating providers on the evidence- 
base for telehealth to increase provider 
and organizational buy-in for promoting 
telehealth for clients. 

— Messaging about the service and to set 
expectations that all staff should support 
telehealth.? 


e Create a pilot program — Motivated and 
engaged providers can test out implementation 
tools and then share their lessons back with 
fellow providers.*° Providers can also engage 
in peer learning consultations to share lessons 


learned and implementation strategies. 
According to the Diffusion of Innovation 
Theory,*’ these innovators can influence early 
adopters who can influence the majority of 
providers. 


Engage clinical staff to support telehealth — 
Staff at all levels will need to be engaged to 
effectively implement telehealth technologies. 
When a broad range of team members are 
trained, teams can maintain continuity when a 
team member is on leave or absent.** 


— Telehealth coordinators or trained medical 
assistants can schedule and provide 
reminders for telehealth visits, improving 
no-show rates, and provide needed technical 
assistance to clients.** 

— Engaging clinical staff in ongoing 
communication provides a mechanism for 
leadership to understand implementation 
challenges and successes.*° 


Obtain secure devices and videoconference 
platforms — Agencies that want to expand 
telehealth options must have reliable and 
sustainable technology and IT support.'?°? 


— Providers and agencies may need to 
purchase, upgrade, or maintain equipment 
to conduct telehealth sessions and securely 
send information both inside and outside 
of the clinic. Equipment that can be used 
outside the clinic is useful for when 
providers are not able to come into the clinic 
due to public health emergencies or natural 
disasters, and for the ability to flex their 
clinical schedules and work from home. 

— Clinics will need to provide a sufficient 
number of laptops to support staff working 
from home or outside of typical shared 
office space.*° 

— Typically, telehealth services must 
be delivered via a HIPAA-compliant 
platform;*' however, during public health 
emergencies, regulations may allow the use of 
videoconferencing applications, such as Skype 
or FaceTime. State medical privacy laws 
may still apply. The American Psychiatric 
Association has an overview of platform 


and software requirements for engaging in 
telepsychiatry. 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Guidance for Implementing Evidence-Based Practices 


39 


e Ensure high quality Internet connection — 
Invest in high quality broadband Internet to 
overcome challenges related to image resolution, 


Telehealth providers must use secure and private platforms 
to engage in telehealth with clients. Common strategies for 
addressing client concerns about privacy include: 


audio delays, or service disruption. 

— While disruptions can originate with either 
the client or the provider, it is critical the 
provider has stable Internet to reduce 
interruptions. 

— Agencies should consider providing signal 
boosters for clinicians who are working 
from home and providing telehealth services 
without stable high speed, broadband 
Internet.*° 

— Ensure provider devices are capable of 
videoconferencing and accessing the 
electronic health record simultaneously. 


e Provide ongoing technical support — Provide 
technology resources to maintain equipment, 
support changes in technology, and provide 
training and assistance as issues arise.'? 
Ensuring staff are available to troubleshoot 
emergent technology issues can make telehealth 
implementation easier. 


Strategies for ensuring security and confidentiality 


Clients and providers must trust that their personal 
information will remain secure when using telehealth 
and online systems.** Similarly, privacy and 
confidentiality concerns could deter clients from 
talking about sensitive health issues through telehealth 
modalities.° When clients experience a loss of 
confidentiality or privacy, it can negatively impact the 
client-provider relationship, treatment adherence, and 
compliance, and, therefore, treatment effectiveness.“* 


SAMHSA issued quidance on 42 CFR Part 2, 
emphasizing that providers are permitted to 
disclose patient information to medical personnel 
without the client’s written consent to treat a 

bona fide medical emergency. In the context of 
telehealth, this guidance is intended to ensure 
Clinically appropriate communications and access 
to SUD care in instances where a client may not 
be able to access normal care due to a public 
health emergency.*2 


Identify secure spaces to engage in telehealth — 
Providers may face concerns with lack of space 

and privacy, but having the appropriate space to 

engage in telehealth is essential.** “° 


— Identify private offices and meeting 
rooms (with doors that close to minimize 
interruptions and no windows to hallways 
where others can look in on sessions) 
that can be outfitted with the appropriate 
technology for telehealth visits. 

— The impact of breaches in client 
confidentiality is exacerbated in clinically 
unsupervised settings, like personal 
residences, because conversations may be 
overheard. Work with clients to identify 
secure spaces to engage in telehealth during 
the client pre-work. 


Secure data on devices — Use encryption and 
two-factor authentication on communication 
devices.”* Ensure that any time personal or 
health information is shared, such as signed 
assessment forms or treatment documentation, it 
is encrypted and securely sent. 


Provide education and technical assistance 
for providers on privacy, security, and 
confidentiality — Telehealth carries risks for 
breaches of protected health information (PHI), 
and yet most providers are not adequately 
trained in protecting client privacy while using 
telehealth. Providing training and support for 
providers can decrease discomfort around 
privacy and technological issues.'* 

— Training topics include: defining telehealth 
and telehealth etiquette, regulations and 
reimbursement, HIPAA and privacy 
concerns, ethical practice, and efficacy of 
telehealth.*° 

— Bolstering education and training programs 
and providing technical assistance support 
is key to mitigating the risk for breaches of 
PHI when using telehealth.”? 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Guidance for Implementing Evidence-Based Practices 


40 


Regulatory and Reimbursement Environment 


Before initiating a telehealth program, practitioners 
should consider regulatory issues, including licensing, 
prescribing laws, and reimbursement policies. Health 
systems implementing telehealth find reimbursement 
to be one of the biggest challenges.** Many of these 
regulations vary by state; treatment programs should 
consult state guidelines. 


Regulatory and reimbursement environments 
are constantly changing, especially throughout 
the COVID-19 pandemic. Regulations and 
reimbursement guidance may also vary state- 
to-state. Consult the links shared in this section 
for the most up-to-date guidance. 


Workforce-related licensure regulations 


Each mental health and SUD treatment provider type 
must abide by state-level requirements. Psychologists, 
clinical social workers, licensed professional counselors, 
licensed chemical dependency counselors, licensed 
marriage and family therapists, and prescribing providers 
(e.g., medical doctors, doctors of osteopathy, nurse 
practitioners, and physician assistants) should consult 
their licensing boards for updated guidance related to 
providing care using telehealth. 


For example, most state medical boards require that 
physicians engaging in telehealth be licensed in the state 
in which the client is located, which creates a significant 
barrier to widespread implementation of telehealth. 
Some states issue a special purpose license, telehealth 
license, or license to practice medicine across state lines 
to allow for the practice of telehealth;*° however, these 
requirements for special licensure have been shown to 
be a barrier to telehealth adoption.*” Some boards require 
additional requirements for telehealth visits, such as 
confirming the patient is who they say they are, prior to 
treatment. In addition, a provider’s malpractice insurance 
carrier may not be willing or able to provide coverage 
across state lines.** An American Medical Association 
(AMA) study found that malpractice coverage was a 
necessity for physicians considering the adoption of 
digital tools.” 


Medication-Assisted Treatment 
Prescribing Regulations 


Strict virtual prescribing regulations at the 
federal and state levels impact delivery of 
telehealth services, especially for medication- 
assisted treatment (MAT). Prior to the COVID-19 
pandemic, the Ryan Haight Online Pharmacy 
Consumer Protection Act of 2008 required 
providers to always conduct an in-person 
examination prior to prescribing controlled 
substances, such as buprenorphine, with certain 
flexibilities.~° 


Substance Abuse and Mental Health Services 
Administration (SAMHSA) 


e Federal statutes, regulations, and 
guidelines that apply to MAT for 
practitioners and opioid treatment 
programs (OTPs): https://www.samhsa. 
gov/medication-assisted-treatment/ 
statutes-regulations-guidelines 


The Drug Enforcement Administration (DEA) 


e The DEA has responded to public health 
emergencies by revising policies to 
allow for prescribing some controlled 
substances via telehealth without an 
in-person visit.*! In the absence of a public 
health emergency, the Ryan Haight Act 
allows for prescribing via telehealth if 
the client is located in a DEA-registered 
hospital and the prescribing physician is 
communicating with the client via video.” 


This chart reflects current prescribing guidelines 
for controlled substances as of March 2020: 
https://www.deadiversion.usdoj.gov/GDP/ 


(DEA-DC-023)(DEA075)Decision_Tree 
Final) 33120 2007.pdf 


Reimbursement 


Federal Medicaid law and regulations do not specifically 
address telehealth delivery methods or the criteria for 
implementation, leaving states flexibility to design 
programs.*? All 50 states and Washington, DC, have 
some form of Medicaid reimbursement for telehealth, 


but these programs vary. Treatment programs and 


organizations should consult their state Medicaid 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Guidance for Implementing Evidence-Based Practices 


41 


regulations before launching a telehealth program. 
Live video is reimbursed in all states; however, some 
asynchronous telehealth modalities (e.g., store-and- 
forward services) are only defined and reimbursed by 
some state Medicaid programs. Geographic restrictions 
also exist in some states. 


State policies requiring private payers to reimburse for 
telehealth services to the same extent as face-to-face 
services have been associated with greater adoption of 
telehealth.*” 


Resources for tracking current regulations and 
policies at the federal and state levels 


The 2018 SUPPORT Act loosened some reimbursement 
restrictions for treating individuals with SUD or COD. 
Under the 2018 SUPPORT Acct, the Centers for Medicare 
and Medicaid Services (CMS) issued guidance on state 
options for Medicaid reimbursement of telehealth- 
delivered services and treatment for SUD.*° 


Medicare only reimburses for limited telehealth services 
where certain parameters are met. There are limits 

on the type of professional who can provide services, 
and services must be delivered via live video. Eligible 
Medicare-reimbursed telehealth services related to 
treatment of SMI and SUD include:™ 


e Individual and family psychotherapy 


e Alcohol and/or substance (other than tobacco) 
use structured assessment and intervention 
services 


e Face-to-face behavioral counseling for alcohol 
misuse 


e Annual alcohol misuse screening 
e Annual depression screening 


e Smoking cessation services 


Based on the client’s location, Medicare also has limits 
on telehealth provided by certain facilities and in certain 
geographic locations. Telehealth services have been 
restricted to clients located in a Health Professional 
Shortage Area (HPSA) or in a county that is outside 
any Metropolitan Statistical Area (MSA). As of 

2020, CMS removed the geographic requirements for 
telehealth services for treating individuals with SUD 
or COD, as well as specified the home as an eligible 
facility for purposes of treating these individuals.** The 
Health Resources and Services Administration (HRSA) 
maintains a tool for providers to determine if a location 
is eligible for Medicare telehealth reimbursement.™ 


Forty-three states and DC have laws that regulate 
private payer telehealth reimbursement policies.°° 


Center for Connected Health Policy: The 

National Telehealth Policy Resource Center 

maintains a map of telehealth-related laws, 

regulations, and reimbursement policies for all 

50 states and the District of Columbia. They 

have also developed a report of state telehealth 

laws and reimbursement policies.** °° 

— Current State Laws and Reimbursement 
Policies, an interactive policy map 

— Telehealth Legislation and Regulation, an_ 


interactive map 
— Changes in national policy related to 


telehealth and Medicare, a website 





The American Medical Association provides 
a quick guide with resources on licensure 

and payment policies to assist providers in 
implementing telehealth programs.°** *’ 


In 2018, the Department of Veterans Affairs 
(VA) published a final rule allowing VA 
providers to provide telehealth services to VA 
beneficiaries, regardless of the physical location 
of the healthcare provider or the beneficiary.* 


State-level licensure and prescribing 
requirements 

— The Federation of State Medical Boards 
— The American Counseling Association 
— Association of Social Work Boards 

— American Association of Marriage and 


Family Therapy 
— Substance use disorder counseling 

















Interstate Medical Licensure Compact is 

an agreement across participating states to 
simplify licensing across state lines; Psychology 
Interjurisdictional Compact (PSYPACT) allows 
psychologists in PSYPACT states to practices 
telepsychology in other PSYPACT states.** 


The Centers for Medicare and Medicaid 
Services (CMS) maintains a website that lists 
waivers and flexibilities due to COVID-19. 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Guidance for Implementing Evidence-Based Practices 


42 


Resources 


Several resources are available to help practitioners and 
organizations implement telehealth-delivered services. 


e Telehealth Implementation Playbook, American 
Medical Association: Guidebook for practices to 
implement new digital solutions. 





e AMAalso has a learning module on telehealth. 


e California Telehealth Resource Center has 
developed a Telehealth Program Developer Kit, 
a comprehensive overview of how to develop 
and implement a telehealth program. 





e ProviderBridge.org assists in mobilizing 
volunteer healthcare professionals to treat 
patients during public health emergencies. 
The site supports medical license portability 
to connect healthcare professionals with 
state agencies and healthcare entities to 
increase access to care for patients in rural 
and underserved communities. The site also 
provides state-by-state telehealth information 
and resources to assist providers with telehealth 
licensure questions. 


e Licensureproject.org provides up-to-date 
information on emergency regulation and 


licensing for psychologists, occupational 
therapists, physician assistants, and social 
workers. Resources include state-specific tools 
related to licensure and telehealth, as well as 
online and phone support. 


e In Brief: Rural Behavioral Health: Telehealth 
Challenges and Opportunities This SAMHSA 
guide explores barriers to accessing substance use 
disorder and mental health treatment services in 
rural communities, and the benefits of telehealth 
for these communities. It assists practitioners with 
implementing telehealth technologies as a means 
to increase access to services. 








Supporting Access to Telehealth for Addiction 
Services: Regulatory Overview and General 
Practice Considerations, American Society 

of Addiction Medicine provides guidance 

for clinicians and programs on regulatory 

and practice issues related to using telehealth 
to provide substance use treatment during 
COVID-19. 


TIP 60: Using Technology-Based Therapeutic 
Tools in Behavioral Health Services: This 
SAMHSA manual assists clinicians with 
implementing technology-assisted care. It 
highlights the importance of using technology- 
based assessments and interventions in behavioral 
health treatment services. The manual also 
discusses how technology reduces barriers to 
accessing care. 














The Providers Clinical Support System and 
Opioid Response Network developed a 
Telehealth Tipsheet for treating opioid use 
disorder over telehealth. 








Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Guidance for Implementing Evidence-Based Practices 


43 


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46 


57 Hoffman, J. A., Cunningham, J. R., Suleh, A. J., 
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policy/cross-state-licensing 





Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
Guidance for Implementing Evidence-Based Practices 47 


CHAPTER 


A 





Examples of 
Telehealth 
Implementation in 
Treatment Programs 


This chapter provides three examples of organizations 
that provide the telehealth-delivered practices discussed 
in Chapter 2 to treat serious mental illness (SMI) and 
substance use disorder (SUD): 


e Eastern Shore Mobile Care Collaborative 
(ESMCC) at the Caroline County Health 
Department in partnership with the University 
of Maryland School of Medicine, Division of 
Addiction Research and Treatment 


e Citywide Case Management Program at the 
University of California San Francisco (UCSF)/ 
Zuckerberg San Francisco General (ZSFG) 
Department of Psychiatry 


e Respectful, Equitable Access to Compassionate 
Healthcare (REACH) Project in Ithaca, NY 


The three programs highlighted in this chapter are diverse 
examples of programs and settings that are effectively 
treating individuals with SMI and SUD using telehealth 
modalities. The programs highlighted key themes: 


e Telephones are the least expensive and 
most accessible form of communication for 
populations experiencing SMI and SUD, 
especially Black, Indigenous, and people of 
color (BIPOC) and low-income populations. 
Telephone use should be encouraged, as it 
reduces prior structural and institutional barriers 
that have made contacting these groups difficult. 


e Clients need training and assistance with 
technology literacy, as do providers. 





e The use of technology is much more client- 
centered than many traditional approaches and 
can allow for creative ways to meet clients’ 
needs efficiently and effectively. 


e Telehealth approaches should be maintained 
long term and integrated into the available 
treatment choices. 


The examples detailed in this chapter: 


e Include one or more of the treatment 
interventions identified in Chapter 2 


e Have research to support their impact on SMI or 
SUD, or are identified as a promising practice 


e Are appropriate and effective for varied 
geographic areas, practice settings, and 
populations 


Treatment programs should implement telehealth- 
delivered practices with fidelity to evaluated models. 
Fidelity is the degree to which a program delivers a 
practice as intended and must be maintained for desired 
therapy outcomes. Regardless of whether a practice 

is delivered in person, using telehealth modalities, 

or through a combination of in-person and virtual 
modalities, clinicians must ensure treatment services 
maintain fidelity to the original practice. As practitioners 
modify practices to use telehealth modalities and address 
the needs and constraints of their population, budget, 
setting, and other local factors, they should strive to 
adhere to the practice’s foundational principles and 
document any adaptations so they can be evaluated. 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Examples of Telehealth Implementation in Treatment Programs 


48 


Eastern Shore Mobile Care Collaborative (ESMCC) 


Caroline County, MD 


The Eastern Shore Mobile Care Collaborative (ESMCC) 
at Caroline County Health Department is a Mobile 
Treatment Unit (a van referred to as the Unit) that aims 
to increase access to care in Caroline County on the 
Eastern Shore of Maryland by providing medication- 
based treatment for individuals with opioid use disorders 
(OUD) in underserved rural communities through hybrid 
in-person and telehealth services. 


The ESMCC is a partnership between the Caroline 
County Health Department and the University of 
Maryland School of Medicine (UMSOM) Division 

of Addiction Research and Treatment. This program 

is funded through the Health Resources and Services 
Administration’s Federal Office of Rural Health Policy, 
the University of Maryland School of Medicine, the 
Maryland Department of Health and Behavioral Health 
Administration, and the Caroline County Health 
Department. The ESMCC began in 2015 as a response 
to surging client need for OUD treatment and a lack 

of providers approved by the Drug Enforcement 
Administration (DEA) to prescribe OUD medications in 
rural Maryland (also referred to as “waivered providers”). 





A mobile van addresses the challenge posed 

by lack of access to technology and waivered 
medication-assisted treatment (MAT) prescribers 
in rural areas, bringing OUD services delivered 
through both in-person and telehealth 
appointments. 


Treatment Offered 
Medication-Assisted Treatment (MAT) 
Population of Focus 

People experiencing opioid use disorder 


Related Resources 
e Project website 
e §=Introduction to ESMCC video 


e University of Maryland Division of Addiction 
Research and Treatment website 


e Telemedicine’s Role in Addressing the Opioid 
Epidemic article 


e Expanding Access to Buprenorphine 
Treatment in Rural Areas with the Use of 


Telemedicine study 


The Unit travels to three townships in Caroline County 
four days a week, parking at community centers, 
churches, and health department parking lots. Whereas 
traditional telehealth programs rely on client access to 
and proficiency with technology, the Unit brings the 
technology and wraparound services directly to the 
clients. 


Client Population 


Approximately 125 clients receive treatment through 
the Unit. These clients have an average age of 37, and 
are primarily White (76.3 percent White, 17.5 percent 


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Black, 6.2 percent unknown, and 3.1 percent Hispanic). 

In addition to experiencing OUD, clients may experience 
anxiety, depression, mood disorders, attention-deficit/ 
hyperactivity disorder, and/or tobacco, alcohol, or 
stimulant use disorder. The majority of clients have 

low income and are Medicaid recipients. Some clients 
previously started medications for OUD treatment through 
in-patient or out-patient settings, have undergone medically 
managed withdrawal, or are currently using opioids. 


Form(s) of Telehealth 


At this time, the ESMCC only uses synchronous forms 
of telehealth, but is exploring ways to expand and 
integrate asynchronous platforms. 


Services Offered Through Telehealth Modalities 


The Mobile Treatment Unit is outfitted with encrypted, 
HIPAA (Health Insurance Portability and Accountability 
Act)-compliant videoconferencing technology and an in- 
person team of treatment staff that provide SUD care. 


Becoming a client of the Unit: 


There are multiple pathways for becoming a client of the 
Unit. Clients can be connected through providers, the 
health department, or word of mouth (from individuals in 
the community) and can self-refer. Contact information 
is clearly stated on the side of the Unit, so many call to 
make appointments or walk up to receive services. 


In-person services: 


Once a client arrives at the Unit, they are met by the 
nurse who tracks all client appointments and activities 
and conducts intake and nursing assessments (e.g., vital 
signs, urine drug screens, medical history). In addition to 
the nurse, the Unit is staffed by a peer recovery specialist 
and counselor who provide in-person support and 
counseling. Individual counseling is offered on the Unit 
and the team has partnered with local community-based 
organizations and churches to provide both a place to 
park the Unit and provide in-person group counseling. If 
a client needs additional or different treatment than what 
is available on the Unit, the mobile team refers them to 
the appropriate level and type of care. 


Telehealth-delivered services: 


The back of the Unit has a private room with a computer 
that has secure, interactive videoconferencing software. 
Clients are connected virtually to an addiction medicine 


specialist at the University of Maryland, School of 
Medicine in Baltimore who provides assessment and 
diagnosis at the initial visit and monitoring (including 
medication management and monitoring) during follow- 
up visits. The Unit does not carry medication, but has 
partnered with local pharmacies to ensure consistent 
access to medications for OUD (e.g., buprenorphine). 


By using a hybrid approach, the Unit has removed 

the need to provide client coaching on how to use the 
technology. A staff member is always available to answer 
questions and troubleshoot. 


Findings and Outcomes 


e Clients have the option to participate in a 
six-month evaluation, consisting of a baseline 
visit and four subsequent visits 30, 60, 90, and 
180 days following the start of treatment. The 
evaluation collects client information using the 
PHQ9, GAD-7, Promis, and DUDIT-C to assess 
changes in depression, anxiety, substance use, 
and overall health. Clients who participate in the 
monthly surveys reported decreased depression, 
anxiety, and overall drug use since starting 
treatment. 


e An analysis of client records for those served 
between August 2015 and April 2019 found that 
retention rates and toxicology results (e.g., urine 
drug screenings) were comparable to services 
delivered solely in-person.! 


e Clients have saved an average of 9.93 travel 
miles by receiving treatment on the mobile 
treatment unit instead of traveling to their 
nearest clinic. 


Lessons Learned 


e Partnerships with regulatory bodies can 
facilitate implementation of innovative ideas. 
Medications for OUD are heavily regulated 
by the Drug Enforcement Administration 
(DEA). The UMSOM team consulted with 
the DEA throughout program design and early 
implementation to launch the Unit successfully 
and safely. 

e Implementation will involve trial and error — 
be flexible to trying different approaches and 
look for creative solutions. For example, the 


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Unit had unreliable Internet connections in one 
township. The team found that certain wireless 
providers had better coverage in that area and 
changed carriers to secure consistent high-speed 
wireless Internet in the Unit. 


e IT staff are key for troubleshooting. The 
UMSOM team relied on the UMSOM IT 
department and resources to build the Unit, 
maintain and update the technology, and 
troubleshoot any technical challenges. UMSOM 
IT has been able to quickly respond to IT needs 
while the Unit is in the field, ensuring continuity 
of service delivery. 

e Listen to on-the-ground partners. The 
UMSOM team has developed strong relationships 
with local community organizations, health 





211 Maryland 


Get Connected. Get Help 


departments, and pharmacies to increase access 
and break down stigma related to SUD and 
medications to treat OUD. 


Engage newer providers to create a unique 
training opportunity. Medical students, 
residents, and addiction medicine fellows are 
able to train in both addiction medicine and 
telehealth through participation in this program. 


Telehealth may not be appropriate for all 
clients all the time. Providers have found that 
some individuals with SUD or SMI may need 
more intensive mental health treatment than the 
Unit is able to provide. These clients are referred 
to more intensive services to meet their needs. 


t 
Att 


oa 


CAROLINE COUNTY 
HEALTH DEPARTMENT 
te ing fee Corsting 
THE BASTSGM SHORE hac 
oT THE CASOMNE Cc 





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Citywide Case Management Program 


San Francisco, CA 


The Citywide Case Management Program (Citywide) is 
a division of the University of California San Francisco’s 
(UCSF) Department of Psychiatry and operates under 
direction of Zuckerberg San Francisco General Hospital 
(ZSFG). Citywide has been in operation since 1981 and 
became part of ZSFG in 1983. 


Citywide has 170 staff and is the largest provider of 
intensive case management (ICM) services in San 
Francisco. Citywide’s mission is to support the recovery 
of adults with SMI in San Francisco, reduce their use of 
institutional and acute care (e.g., psychiatric emergency 
services, hospital care, jails), and help maximize their 
ability to maintain stable, productive, and fulfilling lives 
in the community. 


Citywide is located outside the academic medical setting 
in the community it serves and engages individuals 

who receive regular care from the medical system. 
Citywide programs are funded through the San Francisco 
Department of Public Health and other governmental 
resources. 


Citywide ICM teams are interdisciplinary teams of social 
workers, nurses, psychiatrists, employment specialists, 
and peer counselors, providing services to around 100 to 
200 clients per team. 


To appropriately meet the clients’ needs, Citywide has four 
culturally and linguistically focused ICM teams: 


e Hong Ling Team (Chinese) 
e Cross Currents Team (LGBTQ and women) 


e Kujichagulia Team (African-American and 
European-American) 


e Senderos Team (Latino and Korean) 


In addition, Citywide has teams that specialize in 
working with justice-involved individuals. 


In addition to ICM, Citywide provides psychosocial 
treatment, medication-assisted treatment (MAT), 
substance use treatment groups, and socialization 
groups, and utilizes a combination of behavioral 


A division of the UCSF Department of Psychiatry 
that provides case management and behavioral 
health treatments to some of San Francisco’s 
most vulnerable populations, including those who 
are experiencing unstable housing. 


Treatment Offered 


Behavioral Therapies, Medication-Assisted 
Treatment (MAT), and Case Management 


Population of Focus 


Adults with serious mental illness (SMI) who are 
experiencing unstable housing or homelessnes 


Related Resources 
e Project website 


e Introduction to Citywide’s “Para-TeleHealth” 
Approach 


e Profile on Citywide’s Telehealth Services 
during COVID-19 


therapies, including cognitive behavioral therapy 
(CBT), CBT for psychosis, Behavioral Activation 
(BA) Therapy, Cognitive processing therapy (CPT), 
Dialectical Behavior Therapy (DBT), and Acceptance 
and Commitment Therapy (ACT). Due to the COVID-19 
pandemic, Citywide shifted some of its services 

to telehealth, including case management and care 
coordination by phone and “Para-Telehealth” video 
sessions (further described below), while maintaining 
outreach-based care to those unable to participate in 
telehealth. 


Client Population 


Citywide serves approximately 1,500 clients at any 
given time. Citywide clients primarily experience 
SMI (e.g., schizophrenia, schizoaffective disorder, and 
bipolar disorder), co-occurring SUD, and significant 
psychosocial challenges. 


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Most clients experience poverty, with approximately 90 
percent of clients subsisting on social security or county 
general assistance. Most clients also experience unstable 
housing and cycle in and out of homelessness, living in 
single-room occupancy hotels or shelters. Many clients 
have experienced extensive trauma from their housing 
instability and often persistent and lifelong encounters 
with child welfare and justice system institutions. 


Citywide clients are disproportionately racial minorities; 
for instance, while San Francisco’s Black or African 
American population is below 5 percent, Citywide’s 
client population is 30 percent Black or African 
American. 


Form(s) of Telehealth 


Citywide uses synchronous forms of telehealth, 
including phone and video calls between clients and 
providers. 


Services Offered Through Telehealth Modalities 


The COVID-19 pandemic was the catalyst for Citywide 
to offer telehealth-delivered services. Prior to the 
pandemic, Citywide staff occasionally had synchronous 
phone visits for care coordination and case management 
but did not have video appointments with clients. 


Case Management and Care Coordination: 


At the beginning of the pandemic, Citywide conducted 

a survey of clients about their technology use and found 
that only about one-third of their 1,500 clients owned a 
cellphone. With a donation to UCSF, Citywide purchased 
and distributed 250 flip-phones to clients (including data 
plans). When the pandemic forced Citywide’s clinic to 
close for indoor face-to-face contact, the phones allowed 
clinicians to reach out and mitigate isolation for clients 
sheltering in place and enabled staff to coordinate street 
outreach to clients experiencing homelessness who, 
without a phone, would have been very difficult to find 
in the community. Using these phones, Citywide also 
continued the evidence-based behavioral therapies 
provided before the pandemic, such as CBT and BA, 

to keep clients engaged in treatment (e.g., medication 
adherence, symptom management, etc.) and support 
clients in their recovery process. 


“Para-Telehealth” Program: 


Despite the usefulness of phone contacts, it became 
clear a few months into the pandemic that some clients 
found phone contact to be insufficient. While clinicians 
were also meeting with clients outdoors (e.g., on busy 
urban sidewalks) while wearing N-95 masks and face 
shields for short fifteen-minute appointments, clients 
were often unable to remain masked due to existing 
cognitive or behavioral issues and the encounters were 
not therapeutic or private. As such, Citywide developed 
anew appointment type called “Para-Telehealth.” 


Through “Para-Telehealth,” Citywide reopened its 
physical clinic site using video-based technology 

to connect providers and clients who sat in separate 
interview rooms. This hybrid model allowed lengthier 
sessions without the barriers of personal protective 
equipment, while ensuring a safer interaction from 
COVID-19 transmission. To train staff on how to 
conduct “Para-Telehealth” visits in a safe and effective 
manner, Citywide developed a “Para-Telehealth” video 
tutorial, protocol, and online walkthrough. The “Para- 
Telehealth” appointment modality has been extended to 
conduct CBT groups, allowing the inclusion of clients 
with technological limitations, whether it be due to 
equipment, connectivity, or literacy. 


Findings and Outcomes 


During the early part of the COVID-19 pandemic (April 
2020), Citywide conducted two clinician-facing surveys 
to characterize clients’ access to technology, their ability 
to retain these devices, and the impact of distributing 
flip-phones to them. Citywide observed the following 
results: 


e Citywide’s purchase and distribution of 250 flip- 
phones to clients increased cellular telephonic 
access to clients by nearly 40 percent. 


e More than 50 percent of clients used the donor 
phones to contact other healthcare providers, 
and approximately 66 percent of clients used the 
donated phones to contact their support systems. 

e Citywide was able to reach a client through 
one of the donated flip-phones the day after 
he experienced an overdose on fentanyl. Case 
managers were able to speak with the client, 
coach him on accessing Narcan, and enroll him 


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in a Substance Treatment Outpatient Program 
(STOP) group at Citywide. 

e Citywide was able to notify a client of his 
exposure to COVID-19 via the donated phone. 
Contact tracers were unable to locate the client 
since they did not have a number on record for 
him, so they contacted Citywide case managers 
who were able to notify the client using the 
donated phone. 


Lessons Learned 


e The pandemic has reinforced the importance 
of an individual approach to treatment 
for engaging some of the hardest to reach 
populations in care. Citywide uses a client- 
centered approach with treatment plans tailored 
to each client. This approach of meeting clients 
“where they are,” both physically and in 
therapeutic orientation, is critical to engaging 
those who carry significant societal trauma (e.g., 
from institutionalization, racism, poverty) and 
are thus hesitant to engage in care. 


e Sustainable telehealth requires an assessment 
of client’s technology context. Distributing 
phones to clients at the beginning of the 
pandemic was an effective way to initially 
maintain contact with clients. However, phone 
attrition was significant over time due to 
factors such as the utility of the phones (e.g., 
some clients did not know how to use the 
phones), challenges to maintain data or operate 
the phones (e.g., difficulty keeping phones 
charged while experiencing homelessness), 
lack of motivation to keep the phones, and 
theft. Additional challenges included client 
interest and ability to maintain equipment and 
connectivity, existing physical and behavioral 
challenges, and baseline literacy. Knowing these 
factors allowed staff to match clients to the right 
equipment and connectivity plan. 


e Clients need additional assistance to succeed 
in telehealth, telehealth needs to be adapted 
for clients, and telehealth may not work for 
all clients. Citywide clients require assistance 
in setting up technology and using it. Since 
clients have difficulty using and maintaining 
possession of phones and other technology 


(e.g., laptops, computers), Citywide staff 

used a contingency management approach to 
provide incentives to clients to not lose them. 
Also, clients need reliable Wi-Fi access, as the 
cell phone data plans alone were insufficient 
for video-based telehealth sessions. However, 
access to technology does not replace the need 
for in-person services. By providing “Para- 
Telehealth,” Citywide can reach clients who do 
not have technology tools while also providing 
technology literacy training. Additionally, 
Citywide found that some clients with psychosis 
felt more suspicious of video sessions with 
clinicians. 

Programs need additional resources to create 
a telehealth program. Though COVID-19 

has forced programs to implement telehealth- 
delivered services, a sustainable telehealth 
program is a new service type, not a temporary 
adaptation or addition to an existing program. 
As such, additional resources are needed to not 
only purchase the equipment and data plans, 
but also build the administrative capacity 

to operationalize every aspect of the new 
program (e.g., negotiating the appropriate 

data plan, creating dashboards for continuous 
improvement). Clinicians benefit from training 
on how to conduct telehealth sessions and 

how to best engage clients using technology. 
Programs can employ a technical peer navigator 
to assess clients’ technological needs, enhance 
technology literacy with in-home assessment of 
connectivity, and provide individual or group- 
based technology training. 


Technology equity is a social justice issue. As 
telehealth technology becomes more prominent 
in health care, disparities in technology access 
and literacy among clients with SMI will widen 
existing health disparities. Therefore, technology 
access and literacy are social determinants of 
health to be included in treatment plans. In 
addition, prioritizing this issue will not only 
improve health but also social supports and 
conditions. Comfort and ability to participate 

in technology is fundamental to maintaining 
connections, obtaining and maintaining a job, 
and accessing basic needs. These broaden its 
benefits for the client. 


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THE REACH PROJECT, INC. 


Ithaca, NY 


The REACH (Respectful, Equitable Access to 
Compassionate Healthcare) Project, Inc., is a harm 
reduction focused clinic in Ithaca, NY that provides 
low-threshold access to care, including SUD treatment. 
Started in 2018, the clinic uses a health equity framework 
to guide service access, delivery, and treatment. 
Medication-assisted treatment (MAT) is the core SUD 
treatment. In addition to MAT, REACH offers a holistic, 
integrated primary care model, including HIV screening 
and treatment, Pre-Exposure Prophylaxis (PrEP) and 
Post-Exposure Prophylaxis (PEP), viral hepatitis testing 
and treatment, and mental health treatment. 


The clinic uses a chronic disease management model of 
care, in which a medical provider prescribes MAT and 
conducts follow-up, while a community health worker and 
social workers provide additional case management and 
referral services. The clinic also offers case management 
services through partnerships with two community-based 
organizations who conduct outreach and engagement with 
individuals experiencing homelessness and other needs 
related to social determinants of health. 


REACH uses a team-based, non-hierarchal model, which 
involves collaborative teams of medical providers, social 
workers, and administrative staff to engage with and care 
for clients. 


In March 2020, in response to the COVID-19 pandemic, 
REACH shifted its programming entirely from in-person 
services to telehealth-delivered treatment. Regulatory 
changes, such as the ability to initiate buprenorphine 
without an in-person visit, allowed REACH to use 
telehealth to provide MAT to their clients. 


Providers now conduct visits virtually, via audio-video 
technology on tablets, computers, and smartphones. 
Some of REACH’s clients are rural and do not have 
access to broadband, so the clinic also conducts 
telehealth visits via landline phone. Besides computer 
and landline phone, REACH is also able to communicate 
with clients via text, using a HIPAA-compliant platform 
with a text messaging component. As COVID-19 
restrictions have lifted, some in-office care has resumed. 


Harm-reduction healthcare clinic in rural upstate 
New York that provides medication-assisted 
treatment (MAT) to people with substance use 
disorder (SUD). 


Treatment Offered 


Medication-Assisted Treatment (MAT), Primary 
Care, and Case Management 


Population of Focus 


People with SUD, co-occurring mental disorders, 
and other complex needs 


Related Resources 
e Project website 


e AHarm Reduction Approach to Treating 
Opioid Use Disorder in an Independent 
Primary Care Practice: A Qualitative Study 


e Telemedicine Increases Access to 


Buprenorphine Initiation During the COVID-19 
Pandemic 


Client Population 


REACH serves several rural and urban communities 
across 32 counties in upstate New York. Over 90 
percent of clients experience SUD. About 75 percent 
of REACH’s clients are White, though a major focus 
of REACH has been engaging BIPOC populations 

in care. The clinic estimates its BIPOC clients are 
overrepresented at the clinic relative to the local 
population as a whole. Most REACH clients have low 
income, with approximately 80 percent being Medicaid 
recipients. REACH also conducts outreach to homeless 
encampments and homeless shelters to provide healthcare 
services to individuals experiencing housing instability. 


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Form(s) of Telehealth 


REACH uses synchronous forms of telehealth, including 
phone (cellphone or landline) and video calls between 
clients and providers. REACH uses asynchronous secure 
text messaging and messaging through the electronic 
medical record system to complement synchronous 
connections. 


REACH uses a telehealth platform that does not require 
clients to have an email address; instead, providers were 
able to send clients invitations to the platform via text 
message. This ultimately reduces barriers for REACH’s 
clients, who might lack email addresses or consistent 
access to email. All staff are able to share their virtual 
“waiting rooms” with each other, so there is a seamless 
transition for the client if they are seeing multiple 
providers during one encounter. For example, a client 
meeting with a physician virtually for buprenorphine 
follow-up can remain on the line and be immediately 
connected to a social worker for further services. 


Services Offered Through Telehealth Modalities 


The COVID-19 pandemic was the catalyst for REACH 
to provide telehealth-delivered services, and telehealth is 
used across the offered services. 


Preparing to Participate in Telehealth: 


REACH has administrative staffers (mainly front desk 
staff), whom the clinic calls “guardians,” as key team 
members who often develop trusting relationships with 
the clients. In addition to acting as a primary engager, 
the guardian is also able to provide technical assistance 
to both clients and providers if there are problems with 
the telehealth software or equipment. 


MAT Treatment Initiation, Stabilization, and 
Wrap-Around Services: 


At the time of the appointment, the guardian will send 

the videoconferencing link to the client and provider to 
join. If the clinician cannot get in touch with the client, 
the guardian on the care team is notified. The guardian 
provides outreach to reduce the likelihood the client is 

reengaged in services. 


Treatment initiation and medication monitoring 
appointments for telehealth follow the same steps that are 
taken for in-person visits (for example, nurses conduct 
initial screening and information gathering). Urine drug 
screens are not routinely done; prior to COVID-19, urine 
screens were done upon initiation to buprenorphine and 
afterwards at the provider’s discretion. 





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Treatment stabilization (i.e., follow-up appointments 
with providers once a client has initiated MAT) is done 
by medical providers, and the timing of these visits 
varies by clients’ individual needs. Typically, newer 
clients check-in with a medical provider via a real-time, 
synchronous video connection every one to two weeks, 
while a client who is further stabilized on the medication 
will check in every 4 to 12 weeks. 


Additional services, including case management, 
recovery coaching, and support groups, are voluntary, 
and a client’s access to MAT is not linked to their 
willingness to receive additional services. If a client 
has needs related to mental health treatment or social 
determinants of health (e.g., income or housing 
supports), REACH tries to engage them and link them 
to the needed services. A visit with a social worker or 
community health worker can be made at the same time 
as a check-in with a medical provider, thus providing a 
handoff to non-medical services for further engagement. 


Findings and Outcomes 


Client engagement in care decreased at the start of the 
COVID-19 pandemic, signaling the need to expand 
methods for service delivery. When REACH expanded 
its offerings via telehealth modalities in March 2020, 
client engagement in telehealth appointments steadily 
increased. By shifting to telehealth, REACH initiated 
407 new clients on MAT and has continued to provide 
necessary healthcare services to people with SUD. The 
clinic reports high client satisfaction with telehealth, as 
it increases access to individuals who would otherwise 
be unable to attend the clinic in-person, whether due to 
work demands, transportation difficulties, or the stigma 
of seeking support for substance use. 


Lessons Learned 


e Telehealth responds to the changing landscape 
of care for mental illness and SUD. Prior to the 
pandemic, REACH adapted to clients’ varied and 
evolving needs; thus, flexibility is a large part of 
the clinic’s foundation. In the switch to telehealth, 


not implemented in planned stages. Some 
clinicians initially stopped providing services but 
transitioned to telehealth as they were brought 
back on board to see patients. Eventually all 
providers were able to switch to telehealth. 


Telehealth responds to changing client needs. 
REACH’s model emphasizes providing real-time 
services for clients at the moment they express 
need. Using telehealth to deliver care has allowed 
REACH to continue to provide low-threshold, 
accessible services to clients throughout New 
York State despite COVID-19 pandemic 
restrictions. 


Communication channels are key to 
providing effective care. A core component of 
REACH’s care model is being easily reachable 
and accessible to clients by providing multiple 
modes of communication. Telehealth has been 
central to expanding mechanisms for continuous 
communication between client and provider. 


Supporting providers is key to successfully 
implementing telehealth. REACH built off its 
existing commitment to professional development 
and team collaboration by providing specific 
trainings on adapting to changing technology. 

The trainings were led by REACH’s Director 

of Operations, who serves as the clinic’s IT 
point-person and technical support. The Director 
of Operations was available in real time to 
troubleshoot as front desk staff (guardians) and 
providers (both medical and non-medical) switched 
to telehealth. Through this process, the guardians 
learned to support providers and clients with 
technology needs during telehealth appointments. 


Diverse funding sources can support telehealth 
implementation. A large portion of telehealth 
equipment needs were covered by community 
partner Care Compass Network, and REACH 
provided additional funds. Diverse funding 
sources helped to facilitate implementation and 
will support long-term sustainability. 


“It is not about how do you [as a provider] reach 
your clients, but how do your clients reach you.” 


REACH relied on its strong commitment 

to avoiding any interruption of care to their 
clients, who depend on access to care. Sudden 
shutdowns of in-person care during COVID-19 
required the program to transition quickly to 
providing telehealth; therefore, services were 


Judy Griffin, MD 
Director of Research and Physician, REACH 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
Examples of Telehealth Implementation in Treatment Programs 57 


Reference List 


1 Weintraub, E., Greenblatt, A. D., Chang, J., Welsh, 
C. J., Berthiaume, A. P., Goodwin, S. R., Arnold, 
R., Himelhoch, S. S., Bennett, M. E., & Belcher, 
A. M. (2021). Outcomes for patients receiving 
telemedicine-delivered medication-based treatment 
for opioid use disorder: A retrospective chart 
review. Heroin Addiction and Related Clinical 
Problems, 23(2), 5. https://europepmc.org/article/ 
med/33551692 





Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
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CHAPTER 


Resources for 
Evaluation and Quality 
improvement 


Evaluating an intervention can answer critical questions 
about how well a practice has been implemented and 
determine what may or may not be working. Evaluation 
can also show how clients benefit from a practice. 

This information can be helpful in making practice 
adjustments, if necessary, and demonstrating the value 
of a practice or program to justify its continuation and 
secure additional funding. In addition, stakeholders 

can use information gathered through evaluation to 
encourage implementation of that practice in other 
settings or communities. 


This chapter provides an overview of approaches to 
evaluate implementation of and results from treatments 
for clients with serious mental illness (SMI) and 
substance use disorder (SUD) delivered using telehealth 
modalities. People with SMI and SUD have often 

been excluded from telehealth research studies, but, 

as demonstrated in Chapters | through 4 of this guide, 
telehealth is effective for people with SMI and SUD. 


To evaluate telehealth-delivered practices and programs, 
both the treatment (e.g., cognitive behavioral therapy) 
and the modality (e.g., synchronous telehealth 
videoconference) need to be evaluated. Ideally, patients 
would see a reduction in symptomology because of the 





practice, and a high level of retention, acceptability, 
or satisfaction with the modality. Additionally, both 
treatment providers and clients should be engaged in 
the generation of evaluation tools and plans to ensure 
data collection tools are appropriate for the evaluated 
communities and to secure buy-in. Reporting findings 
back to providers and clients should be prioritized to 
promote transparency and inform care choices. 


This chapter focuses on evaluation strategies for 
treatments offered via telehealth modalities discussed 
in Chapter 2. The chapter also includes information on 
implementing a continuous quality improvement (CQJ) 
process and an outcome-focused evaluation. Further, 

it provides specific evaluation resources, including 
potential outcomes to track. 


Types of Evaluations 


Researchers typically conduct evaluation before a 
treatment is implemented to determine its feasibility 
(formative evaluation), during implementation (process 
evaluation and CQJ), and after the treatment has been 
delivered to at least one client (outcome and impact 
evaluations). All four types of evaluation are necessary 
to assess a treatment’s effectiveness. 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Resources for Evaluation and Quality Improvement 


59 


EVALUATION PLAYS CRITICAL ROLES 
THROUGHOUT TREATMENT IMPLEMENTATION 


After the 
telehealth-delivered 
treatment is 
initiated with at 
least one client 


As soon as the 
telehealth-delivered 
treatment implementation 
lel-tellate-lalemelligiale, 
operation 


BIT glale me) el e-11(e) ame i 
the treatment, and at 
appropriate intervals 

at the end of 
telehealth-delivered 
treatment 


During the 
fe(=\V/=)[e)e)unt-sai me) mints 
telehealth-delivered 

bigs lttel-18] ome) gle) mice) 
si 0} | Sater: | (=) 
implementation 


Outcome/Effectiveness 
Evaluation 


+ Were the objectives of 
the telehealth-delivered 
treatment achieved? 

* Did client health, 
wellbeing, attitudes, 
beliefs, and behaviors 
change from the start of 
their participation in 
telehealth-delivered 
treatment? 


Formative Evaluation 


+ Is the telehealth-delivered 
treatment appropriate for 
the population of interest? 

+ What resources does the 
organization have and 
need to evaluate the 
telehealth-delivered 
treatment? 


Process/Implementation Evaluation 


+ Are telehealth-delivered treatment 
activities being implemented as 
intended? 

+ What are the barriers and facilitators 
to implementation of the treatment 
and telehealth modality? 

Continuous Quality Improvement 

+ What improvements could be made to 
the telehealth-delivered treatment? 

+ What parts of implementation were 
working and should be unchanged? 

* What organizational factors contributed 
to implementation successes and/or 
challenges? 


Impact Evaluation 


* To what extent can client 
outcomes be attributed to 
telehealth-delivered treatment 
activities? 


Engage clinic community members, key populations, and behavioral health care consumers 
throughout all phases of evaluation planning, data collection, analysis, and dissemination. 





Preparing to Collect Data 
Qualitative and quantitative data are 


complementary. Each provides critical insight into if 
and how the intervention is operating and achieving 


The following steps can help clinics and practitioners 
prepare to collect and analyze data: 


1. Determine if the purpose of the data 
collection is evaluation or research. 


Qualitative and quantitative evaluation and 
research enable managers and clinicians to learn 
from clients and obtain the perspective of those 
with lived experiences. Both evaluation and 
research can also involve collecting data from 
staff who deliver the treatment via telehealth 

to obtain their perspectives on facilitators and 
challenges to telehealth implementation. 


Where program evaluation supports program 
improvement, research systematically follows study 
protocols to develop generalizable knowledge. 
Research requires protocol and procedure approval 
by an Institutional Review Board (IRB) to adhere 
to human subject research protections. Most 
evaluations and quality improvement projects do 
not require IRB approval, but researchers should 
consult with their institutions during evaluation 
design to ensure they are following appropriate data 
collection procedures. 


the intended objectives. 


Qualitative data include any non-numeric, 
text-based information, such as verbal, visual, 

or written data. Qualitative data collection 
methods include interviews, focus groups, clinical 
observations, gathering data from documents and 
images, and open-ended survey questions and 
polling responses. 


Quantitative data are any numeric data that 
can be processed by mathematical or statistical 
analysis. Quantitative data collection includes 
close-ended survey questions and polling 
responses, services and utilization data, and 
claims and encounter data 


2. Determine outcomes of interest. 


A challenging step in the process of 
implementing new practices is to determine 
whether they have yielded desired outcomes. 
An outcome is the change a program plans to 
accomplish through the implementation of a 
practice. Evaluations exist across a continuum, 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
Resources for Evaluation and Quality Improvement 


60 


from tracking staff activities, numbers, client Programs need to identify team members who 
no-shows, and payments to conducting client can conduct evaluation activities and secure 
satisfaction surveys to comparing results funding for evaluation trainings, data collection, 
between clients receiving different treatment and data analysis. 


options. Engage stakeholders (within the clinic 
and the community) to identify both appropriate 
outcomes and the metrics used to assess Treatment of SMI and SUD using telehealth modalities 
outcomes. may be new to an organization, and the landscape 

of telehealth and treatment is continually evolving. 
Continuous Quality Improvement (CQI) can be used to 
systematically identify, document, and analyze barriers 
Regardless of the type of evaluation conducted, and facilitators to implementation for the purposes of 
collecting and analyzing data takes time. improving implementation. 


Conducting Continuous Quality Improvement 


3. Identify team members to conduct evaluation 
activities and capacity to conduct evaluations. 





Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
Resources for Evaluation and Quality Improvement 61 


CONTINUOUS QUALITY IMPROVEMENT (CQI) 
What is CQI? 


CQI involves a systematic process of assessing program or practice implementation and short-term outcomes and 
then involving program staff in identifying and implementing improvements in service delivery and organizational 
systems to achieve better treatment outcomes. CQI helps assess practice fidelity, the degree to which a program 
delivers a practice as intended. There are many potential CQI models and approaches (e.g., httos:/Awww.healthit. 
ov/faq/what-are-leading-continuous-quality-improvement-strategies-health-care-settings). 





CQI differs from process evaluation in that it involves quick assessments of program performance, timely 
identification of problems and potential solutions, and implementation of small improvements to enhance treatment 
quality. CQI is usually conducted by internal staff. Process evaluation involves longer-term assessments and is 
best conducted by an external evaluator. 


The Network for Improvement of Addiction Treatment (NIATx), a project originally funded by SAMHSA’s Center for 
Substance Abuse Treatment, offers tools to conduct CQI and improve services in substance use disorder treatment 


settings. NIATx is based on the principle of program improvement through a series of small changes, tested and 
implemented one at a time, that in the end have a cumulative effect. 


The Institute for Healthcare Improvement’s PDSA Model for Improvement identifies a scientific method for testing 
small-scale changes in an action-oriented, cyclical manner. The stages are: planning it (Plan), trying it (Do), 
observing the results (Study), and acting on what is learned (Act). 


Why use CQl? odel for Improvemen 
CQI takes a broader look at the systems in which programs or practices 


; F : FYerere)aale) it aita 
operate. Because of the pivotal role it plays in performance management, 
How will we know that a 





organizations implementing telehealth-delivered services with people 
experiencing SMI and/or SUD are encouraged to implement CQI 
procedures. that will result in improvement? 


What change can we make 


What are the steps involved in CQI? 


Although steps in the CQI process may vary based on objectives, typical 
CQI steps include: 





e Identify a program or practice issue needing improvement and a target 
improvement goal 

e Analyze the issue and its root causes 

e Develop an action plan to correct the root causes of the problem, 
including specific actions to be taken 

e Implement the actions in the action plan 

e Review the results to confirm that the issue and its root causes have been addressed and short-term and 
long-term treatment outcomes have improved 

e Repeat these steps to identify and address other issues as they arise 


Study Do 


Institute for Healthcare Improvement. (n.d.). Science of improvement: Testing changes. http:/Avww.ihi.org/resources/Pages/Howtolmprove/ScienceoflmprovementTestingChanges.aspx 
New Jersey Department of Children and Families. (n.d.). Five Stages of Continuous Quality Improvement. httos://www.nj.gov/dcflabout/divisions/opma/cai.html 
University of Wisconsin-Madison, NIATx National Program Office. (n.d.). What is NIATx? https://www.niatx.net/what-is-niatx/ 


U.S. Department of Health & Human Services Office of Adolescent Health. (n.d.). Continuous Quality Improvement, Part 1: Basics for Pregnancy Assistance Fund Programs. 
httos://www.hhs.gov/ash/oah/sites/default/files/cqi-intro.pdf 











Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
Resources for Evaluation and Quality Improvement 62 


Outcome Evaluations 


The table below provides a list of potential outcomes, 
illustrative outcome indicators, and qualitative and 
quantitative data sources that program managers, 
clinicians, and others may use to evaluate practices 


identified in Chapter 2. 


In Chapter 1, we introduced the Quadruple Aim 


Framework, which examines the impact of interventions 
with the goal of improving patient experience, improving 


provider experience, improving population health, and 


decreasing costs.' Using the Quadruple Aim Framework, 


we identified specific outcomes, illustrative indicators, 
and illustrative data sources. 


Outcome 


Client Experience 


Illustrative Indicators 


Patient health outcomes may be tracked at baseline and 
throughout the program duration through standardized 
screening, or through interviews with staff and clients. 
Telehealth-related patient outcomes, such as engagement 
and retention in telehealth, or therapeutic alliance may 
be obtained through administrative data, surveys, or 
interviews. Provider outcomes may be captured through 
surveys or interviews. Population health outcomes may 
be tracked through administrative data and interviews. 
Finally, cost-related outcomes can be captured through 
administrative data. 


Illustrative Data Sources 


Clinical Outcomes 


Reduction in 
Depression 
Symptoms 


Reduction in 
PTSD Symptoms 


Reduction 
in Anxiety 
Symptoms 


Substance Use 
Disorder 


Engagement 
and Retention in 
Telehealth Care 


Therapeutic 
Alliance (Client) 


Days of symptoms in the prior |e 


30 days 
Severity of symptoms 


Days of symptoms in the prior 
30 days 
Severity of symptoms 


Days of symptoms in the prior 
30 days 
Severity of symptoms 


Substance use 
Days of substance use in the 
prior 30 days 


Number of sessions attended 
Completed therapeutic 
treatment 


Access to care 
Acceptability of care 
Self-efficacy 


Client relationship with 
provider 
Emotional safety 





Structured scales and assessments (e.g., Beck 
Depression Inventory — 2" Edition, Geriatric Depression 
Scale, Structured Clinical Interview for DSM-IV (MDD 
module), Hamilton Depression Rating Scale, Center for 
Epidemiological Studies - Depression Scale, Patient Health 
Questionnaire-9 (PHQ-9)) 


Medical records 
Structured scales and assessments (e.g., PTSD Checklist 
- Specific (PCL-S), Clinician-Administered PTSD Scale 


(CAPS), PTSD Symptom Scale — Interview (PSS-1)) 


Medical records 
Structured scales and assessments (e.g., Beck Anxiety 
Inventory, Four Dimensional Anxiety Scale) 


Qualitative interviews (client) 

Urine drug screen 

Structured scales and assessments (e.g., SCID-I/P 
Substance Use Disorder) 


Qualitative interviews (staff and clients) 
Administrative data 
Intake/enrollment data 


Qualitative interviews (clients) 

Structured scales and assessments (e.g., Client 
Satisfaction Questionnaire, Satisfaction with Therapy 
and Therapist Scale, Telehealth Usability Questionnaire, 


Telemedicine Satisfaction and Acceptance Scale, Helping 
Alliance Questionnaire Il) 


Qualitative interviews (clients) 
Structured scales and assessments (e.g., Working Alliance 
Inventory short form) 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
Resources for Evaluation and Quality Improvement 


63 


Outcome Illustrative Indicators 
Provider Experience 


Provider Lack of burnout 
Satisfaction e Well-being at work 


Therapeutic e Client relationship with 
Alliance (Provider) provider 
e Emotional safety 


Clinician e Lack of burnout e 
Well-being e Well-being at work 


Population Health 


Number of people using e 
telehealth e 
e 


Percentage of clinical e 
encounters delivered via 
telehealth in communities with 
low and high income, with 
different races and ethnicities, 
and across zip codes 


Patient miles saved e 
Cost per visit ° 
Cost of technology/use/ 

upkeep 


Evaluation Resources 


Evaluating Program Implementation 


e A Framework for Program Evaluation, from the 
Program Performance and Evaluation Office at 


the Centers for Disease Control and Prevention, 
summarizes essential elements of program 
evaluation. 


e The Community Toolbox, from the Center for 
Community Health and Development at the 
University of Kansas, includes a step-by-step 
guide to developing an evaluation of a community 
program, specific tools, and examples. 





Evaluating Program Sustainability 


e Center for Public Health Systems Science 
at the Brown School at the Washington 
University in St. Louis has developed a Program 
Sustainability Assessment Tool (PSAT) and a 
Clinical Sustainability Assessment Tool (CSAT) 
to measure progress towards sustaining new 
implementation efforts. 





Illustrative Data Sources 


Qualitative interviews (providers) 
Structured scales and assessments (e.g., Telehealth 


Usability Questionnaire) 


Qualitative interviews (providers) 
Structured scales and assessments (e.g., Working Alliance 


Inventory short form) 
Structured scales and assessments (The Mayo Clinic’s 
Wellbeing Index, Mini-Z Survey) 


Administrative data 
Intake/enrollment data 
Qualitative interviews (clients) 


Administrative data 


Administrative data 
Qualitative interviews (clients and staff) 





Quality Improvement and Continuous 
Performance Monitoring 


e Institute for Healthcare Improvement’s Quality 
Improvement Essentials Toolkit includes 
the tools and templates to launch a quality 
improvement project and manage performance 
improvement. 





Evaluating Practices Using Telehealth for SMI, 
SUD, and COD 


e The American Medical Association developed 
a Telehealth Implementation Playbook that 
includes tools for planning, implementation, 
evaluation, and scaling. 

e Rural Health Information Hub (RHIhub) has 
created specific Evidence-Based Toolkits for Rural 
Community Health for evaluating Mental Health 
Substance Use, and Telehealth interventions (that 
can be broadly applied to both rural and non-rural 
settings). 














Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Resources for Evaluation and Quality Improvement 


64 


Reference List 


' Feeley, D. (2017, November 28). The triple aim or 
the quadruple aim? Four points to help set your 
strategy. http://www.ihi.org/communities/blogs/the- 
triple-aim-or-the-quadruple-aim-four-points-to-help- 
set-your-strategy. 








Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
Resources for Evaluation and Quality Improvement 65 


Appendix 1: Acknowledgments 


This publication was developed with significant contributions from Jan Lindsay, PhD and Alexis Marbach, MPH, PMP. 
The guide is based on the thoughtful input of SAMHSA staff and the Expert Panel on the use of telehealth modalities 
to treat serious mental illness and substance use disorder from October 2020 through April 2021. A series of guide 
development meetings was held virtually over a period of several months. Three expert panel meetings were convened 


during this time. 


SAMHSA Staff 
Robert Baillieu, MD, MPH, Center for Substance 
Abuse Treatment* 


Christine Cichetti, National Mental Health and 
Substance Use Policy Laboratory 


Thomas Clarke, PhD, National Mental Health and 
Substance Use Policy Laboratory 


Steven Dettwyler, PhD, Center for Mental Health 
Services* 


Amanda Doreson, MPA, National Mental Health and 
Substance Use Policy Laboratory* 


Tanya Geiger, PhD, MPH, National Mental Health and 
Substance Use Policy Laboratory* 


Donelle Johnson, PhD, MHSA, National Mental Health 
and Substance Use Policy Laboratory* 


John Palmieri, MD, MHA, Center for Mental Health 
Services* 
Expert Panel 


Bart Andrews, PhD, Behavioral Health Response, 
Chief Clinical Officer/ZeroSuicide Academy, Faculty 
Member 


Brian Hepburn, MD, National Association of State 
Mental Health Program Directors 


Mei Wa Kwong, JD, Center for Connected Health 
Policy, National Telehealth Policy Resource Center 


Jan Lindsay, PhD, Baylor College of Medicine* 


Thomas Milam, MD, MDiv, Iris Telehealth, Virginia 
Tech Carilion School of Medicine and Research Institute 


Joe Parks, MD, National Council for Behavioral Health 


Mark W. Parrino, MPA, American Association for the 
Treatment of Opioid Dependence 


Jay Shore, MD, MPH, Department of Psychiatry, 
University of Colorado Anschutz Medical Campus 


Sadie Silcott, MBA, MPH, Office for the Advancement 
of Telehealth, Health Resources and Services 
Administration 


Peter Yellowlees, MBBS, MD, University of California 
Davis Health 


Contract Staff 


Olivia Bacon, Abt Associates 

Korrin L. Bishop, Korrin Bishop Writing & Editing 
Ellen Childs, PhD, Abt Associates 

Yvonne Cristy, Abt Associates 

Margaret Gwaltney, MBA, Abt Associates* 
Alexis Marbach, MPH, PMP, Abt Associates* 
Nikitha Reddy, Abt Associates 

Daniel Jefferson Smith, Abt Associates 

Sarah Steverman, PhD, MSW, Abt Associates* 
Christopher Weiss, PhD, Abt Associates 

Elyse Yarmosky, LISCW, Abt Associates 


*Members of Guide Planning Team 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Appendix 1: Acknowledgments 


66 


Appendix 2: Evidence Review Methodology 


The authors followed a rigorous, systematic evidence 
review process in the development of this guide. 

This appendix provides an overview of the evidence 
review methodology used to identify the ratings for the 
treatments included in the guide: behavioral therapies 
(Behavioral Activation Therapy, Cognitive Behavioral 
Therapy, Cognitive Processing Therapy, Prolonged 
Exposure Therapy) and Medication-Assisted Treatment. 


Note: behavioral therapies and medication-assisted 
treatment are referred to as treatments throughout this 
appendix. 


Reviewers, in coordination with SAMHSA and experts, 
conducted a four-step process to select treatments, 
identify related studies, review and rate studies, and 
identify treatment ratings. 


Step 1: Treatment 
Selection 


The authors identified these treatments after a review 

of the literature and in consultation with experts. In an 
effort to include treatments offered through synchronous 
telehealth modalities that are most useful to addressing 
the needs of people living with SMI and/or SUD, 
eligible treatments were required to meet the following 
criteria for evidence review: 


e Be clearly defined and replicable 

e Address the target outcome of improving health 
outcomes for people living with SMI and SUD 
through telehealth modalities 

e Becurrently implemented in the field 

e Have studies of their effectiveness 

e Have accessible implementation and fidelity 
supports 


At the conclusion of this step, SAMHSA and the guide’s 
Expert Panel reviewed the proposed programs identified 
by the authors and agreed on four behavioral therapies 
and medication-assisted treatment for inclusion in the 
evidence review and rating process. 


Step 2: Study 
identification 


Once the treatments were identified, the reviewers 
conducted a comprehensive review of published research 
on these treatments to identify relevant studies. This 
review only included studies from eligible sources 

(1.e., peer reviewed journals and government reports) 
that avoid clear conflicts of interest. The reviewers 
documented all potential studies identified through the 
literature search. 


The studies identified in the literature search varied in 
type and rigor, so the reviewers assessed them further 
for inclusion in the evidence review. To be eligible for 
review and study rating, research studies had to: 


e Employ a randomized or quasi-experimental 
design, or 

e Beasingle sample pre-post design or 
an epidemiological study with a strong 
counterfactual (i.e., a study that analyzes what 
would have happened in the absence of the 
intervention) 


Literature reviews, descriptive articles, implementation 
studies, and meta-analyses were not included in the 
review, but were documented to provide context and 
identify implementation supports for the treatments. 


Additionally, to be eligible for further review and rating, 
studies had to: 


e Be published or prepared in or after 2010 


e Be available publicly as a peer-reviewed or 
research report 


e Be available in English 


e Include at least one eligible outcome related to 
improvements in health outcomes for people 
living with SMI and/or SUD 

e Have acomparison/control group that is 
treatment as usual or no/minimal intervention 
if using a randomized experimental or a quasi- 
experimental design 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Appendix 2: Evidence Review Methodology 


67 


In some studies of telehealth treatments, the comparison/ 
control group was not treatment as usual nor minimal/ 
no intervention; rather, the design compared the 
telehealth approach to the same treatment delivered in- 
person. In these cases, these non-inferiority studies tested 
whether administering the treatment using a telehealth 
modality leads to outcomes that are comparable, or no 
worse, than in-person treatment (which is known to be 
evidence-based). 


Step 3: Study Review and 
Rating 


Next, trained reviewers assessed each study to ensure 
the methodology was rigorous, and, therefore, could 
demonstrate causation between the treatment and 

the identified outcomes. Reviewers analyzed and 
documented each study to ensure: 


1. Experimental and comparison groups were 
statistically equivalent, with the only difference 
being that participants in the experimental 
group received the intervention and those in the 
comparison group received treatment as usual or 
no/minimal intervention. 


2. For randomized experiments with high attrition 
and for quasi-experimental designs, baseline 
equivalence was established between the 
treatment and comparison groups. 


3. For randomized experiments, randomization 
was not compromised. For example, ensuring 
reassignment of treatment status (usually made 
to balance the distribution of background 
variables between treatment and control groups) 
did not occur. 


4. Study did not have any confounding factors 
(i.e., those that affect the outcome but are not 
accounted for by the study). 


5. Missing data were addressed appropriately, 

including: 

—  Imputation based on surrounding cases was 
considered valid. 

— Complete case analysis was considered valid 
and accounted for as attrition. 

— Using model with dummy for missing as a 
covariate was considered valid. 


— Assuming all missing data points are either 
positive or negative was not considered 
valid. 

— Regression-based imputation was considered 
valid and mean imputation was not 
considered valid. 


6. Outcome measures were reliable, valid, and 
collected consistently from all participants. 

7. Valid statistical models were used to estimate 
impacts. 

8. Treatment demonstrated improved outcomes 
related to SMI and/or SUD. 


Based on the study design and these study 
characteristics, reviewers gave each study a rating for 
causal impact. Reviewers used the following scoring 
metric for each study based on the eight factors above: 


e High support of causal evidence 
e Moderate support of causal evidence 
e Low support of causal evidence 


Only randomized controlled trials, quasi-experimental 
designs, and epidemiological studies with a strong 
comparison were eligible to receive a high or moderate 
study rating. 


Step 4: Treatment Rating 


After all studies for a treatment were assessed for these 
criteria, the reviewers gave each treatment a rating 
based on the number of studies with strong, moderate, 
or emerging support of causal impact. Causal impact is 
evidence demonstrating that an intervention causes, or 
is responsible for, the outcome measured in the study’s 
sample population. 


The treatment was placed into one of the following 
categories based on the level of causal evidence of its 
studies: 


1. Strong Evidence: Causal impact demonstrated 
by at least two randomized controlled trials, 
quasi-experimental designs, or epidemiological 
studies with a high or moderate rating. 

2. Moderate Evidence: Causal impact 
demonstrated by at least one randomized 
controlled trial, quasi-experimental design, or 
epidemiological study with a high or moderate 
rating. 


Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 


Appendix 2: Evidence Review Methodology 


68 


3. Emerging Evidence: No study received a high 
or a moderate rating. The treatment may have 
been evaluated with less rigorous studies (e.g., 
pre-post designs) that demonstrate an association 
between the treatment and positive outcomes, 
but additional studies are needed to establish 
causal impact. 


The four-step process described above resulted in the 
identification and rating of four behavioral therapies and 
medication-assisted treatment, each provided to study 
samples using telehealth modalities. The rating given to 
each treatment is intended to inform decision making 
about adoption of new telehealth modalities that will 
improve outcomes for people with SMI and/or SUD. 





Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders 
Appendix 2: Evidence Review Methodology 69 










SAMIPISA 


Substance Abuse and Mental Health 
Services Administration 


SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities. 
1-877-SAMHSA -7 (1-877-726-4727) © 1-800-487-4889 (TDD) * www.samhsa.gov