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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.

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,

Issue Brief 7

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

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

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

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).*

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

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

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

What Research Tells Us

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

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

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

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

What Research Tells Us

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

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Clinicians as gatekeepers. Mayo Clinic Proceedings,
94(12), 2510-2523.

https://pubmed.ncbi.nlm.nih.gov/31806104/

Young, L. B. (2012). Telemedicine interventions for
substance-use disorder: A literature review. Journal
of Telemedicine and Telecare, 18(1), 47-53. https://

doi.org/10.1016/j.jsat.2019.03.007

Chan, S., Li, L., Torous, J., Gratzer, D., &
Yellowlees, P. M. (2018). Review of use of
asynchronous technologies incorporated in mental
health care. Current Psychiatry Reports, 20(10), 85.
https://doi.org/10.1007/s11920-018-0954-3

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

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

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

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

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

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

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

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

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

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

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

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Prevention that Promotes Opioid Recovery and
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Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
Guidance for Implementing Evidence-Based Practices

57 Hoffman, J. A., Cunningham, J. R., Suleh, A. J.,
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org/10.1016/j.amepre.2010.02.018

%8 Center for Connected Health Policy. (2021). Cross

state licensing. https://www.cchpca.org/telehealth-
policy/cross-state-licensing

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

CHAPTER

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

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

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

Examples of Telehealth Implementation in Treatment Programs

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

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

Examples of Telehealth Implementation in Treatment Programs

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

CAROLINE COUNTY
HEALTH DEPARTMENT
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Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
Examples of Telehealth Implementation in Treatment Programs

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.

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

Examples of Telehealth Implementation in Treatment Programs

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

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

Examples of Telehealth Implementation in Treatment Programs

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.

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

Examples of Telehealth Implementation in Treatment Programs

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.

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

Examples of Telehealth Implementation in Treatment Programs

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.

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

Examples of Telehealth Implementation in Treatment Programs

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
Examples of Telehealth Implementation in Treatment Programs 58

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

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

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

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

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

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

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

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

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

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