Special Project
Introduction
With access to mental health services lagging in our area, the Deaconess health system rolled out a Telemental Health service for their patients to access from the comfort of their own homes. However, the rollout was sudden, did not involve a lot of preplanning or coordination with supervisors or staff, and there were many problems that arose that prevented patients from receiving the services they thought they would receive through this program. Frustration from clinicians seeking to provide care was also an unintended consequence of this program rollout. As a result of this program evaluation, interventions were proposed and if implemented have the potential to make the program hugely successful. My special project is entitled Telemental Health Evaluation and took place in Evansville, IN at Deaconess Cross Pointe from early March 2024 through July 5, 2024 and focused primarily on the human right to receive access to mental healthcare (or behavioral health) from one’s own home. The Telemental Health evaluation involved collecting and analyzing data available relating to the implementation via review of after-visit notes in our EPIC charting system. I transferred the data to a Google Sheets spreadsheet that I created for the evaluation process and reviewed data from appointments from 2/15/24 -7/5/24. At Deaconess Cross Pointe, it is the CARE TEAM that conducts the Plan of Care assessments that patients received at their Telemental Health appointments and whose notes I was able to review. The participants were the CARE TEAM staff and hospital supervisors and administrators to whose attention I would share my evaluation.
Social Issue
In order to promote service, social justice for all, the dignity and worth of persons, integrity, and competence it was important to evaluate whether the Telemental Health program offered by Deaconess Cross Pointe was achieving the goal of providing accessible mental health treatment options for our community. Assessing Plan of Care mental health assessments was the route used for a thorough evaluation of assessments provided. According to Dr. Monica Benson (2024), following the pandemic the need for mental health services increased and there was an insufficient answer to meet that need until telemental health services began to be employed. For many these rights are thwarted due to the lack of transportation for in-person assessments. In order to further the right to mental health assessments this service was available in on online format, removing the need for transportation to receive an assessment. As Gotra, et al. (2024) shares, telemental health services were crucial during the pandemic to meet the rising needs but is now here to stay as it provides greater options for patients and providers. Our program enabled assessments from any location convenient to patients, increasing the provision of services to patients. In theory, this program increased accessibility to Plan of Care mental health assessments. However, in practice, the program was ineffective and in need of changes in order to increase its effectiveness in achieving its goals for service. Specifically, the program had no policy in place regarding how the program was to operate, which lead to a host of other challenges. For instance, there was no training offered as to how the program would operate prior to the rollout, and the online training eventually provided was not specific to CARE TEAM Plan of Care mental health assessments and included poor audio. The poor audio resulted in an ineffective training experience. The program also did not consider conflicts in the scheduling of these appointments with our in-office appointments, walk-ins, and ER TeleMed appointments that we are simultaneously responsible to fulfill. The program also didn’t appear to address time limits for appointments and how those could be fulfilled. Furthermore, the continuous scheduling did not allow for lunch breaks for employees. Perhaps worse yet, the online advertisement and scheduling of the program did not indicate in all the avenues that one can schedule an appointment online that it only serves patients in the state of Indiana (though the hospital chain is present in Indiana, Illinois, and Kentucky) and referrals are best offered to those within a 1 hour radius of our location in Evansville, Indiana. Patients were also often not familiar with the service offerings we could provide and expect services we don’t provide, such as medication management, counseling, a full mental health assessment and diagnosis, and ability to speak with a psychiatrist. Finally, laws from adjacent states that practitioners could get licensed to practice in vary and could impact whether we could see them via Telemental Health from the state of Indiana. The impact of these issues resulted in staff working to solve conflicts that were not considered prior to the rollout, with the staff involved in creating resolutions to problems being experienced organically in real-time. Despite the downsides that were experienced by our local Telemental Health program, Lawson, et al. (2022) share that the overall impression by both patients and providers had been positive for telemental health services, as it provides both the accessibility and clinical efficacy that are so needed in the field of mental health. This project was significant in terms of determining how to improve the service provision to a community not fully aware of the program and how it works. This project was recommended by my field instructor as a project that would yield results that she would benefit from receiving, as well.
Interventions
My mission was to assess the efficacy of the current telemental health program to determine the utility for individuals within our community. My goal was to make administrators aware of any problems that I encountered to increase service provision and reduce negative reactions. In order to address the deficiencies in the current Telemental Health program I chose a 4-prong approach. To begin with, my first subgoal included a complete review of the current program in which I discovered the deficiencies being experienced by both patients and clinicians. It included creating a spreadsheet that tracked the frequency of successful visits and the reasons for unsuccessful visits, following review of after-visit notes. This tracking element was essential. As Koch, et al. (2024) report, when Telemental Health programs are reviewed in order to reduce variables that make them less effective, especially for those over 55, mental health services are expanded, there is a reduction in blackout zones for mental health care, and there are less transfers of patients that occur in order to effect the appropriate treatment. In short, we provide the right service sooner when we create a program that that is accessible and clear in its presentation. Unfortunately, the program evaluation highlighted that the program delivery did not match the intent of the program implementation.
My second subgoal was to ensure that the program was operating according to the policy in place. When I asked for the policies related to this program I was provided with two policies. The first was a broader Telehealth policy that the hospital has in place primarily for medical telehealth purposes. This policy, however, did not address how the Telemental Health program should function. Secondly, I perused a policy that is in place for assessments that are done online for admitted patients in local ERs that the CARE TEAM sees via Zoom. Since neither of those policies were specific to the current program in reivew, they were used as a template in framing a new policy that would relate directly to the Telemental Health assessments that the new program allowed for from the comfort of one’s own home. This new policy that I created gave specific directives to ensure that CARE TEAM staff understand how the program worked and dovetailed with the workload already being experienced by the CARE TEAM. And the creation of telemental health policies are the work that social workers should be involved in at all levels (Lee & Cook, 2023). In order to support social justice, social workers should be at the forefront of this modality, ensuring its accessibility, creating policies regarding practice, and establishing best practices that are evidenced based and include training (ibid.). This goal also showed that a policy was not in place when the program was implemented, which marks a major flaw in the program.
The third subgoal I included was an element of education. I sought to educate my superiors as to the challenges being faced by this new program. To accomplish this, I created a PowerPoint presentation that highlighted the major areas of concern that needed to be addressed by upper management, including their Marketing and Advertising teams. Additionally, I learned from coworkers that the training of the new Telemental Health program was inadequate and also an area that needed improvement. I understood this education piece to be my role as a social work intern, as social workers are often at the forefront of education regarding ineffective social problems. Robertson and Lowell (2021) concur with this view. After speaking with counseling educators, counseling supervisors, and counseling practitioners, Robertson and Lowell (2021) found that dissatisfaction with telemental health program training is due to the content being ineffective or insufficient, a need for a consistent protocol, and the need for telemental health service delivery to be addressed in collegiate social work programs. Truly, education at all levels of telemental health service provision is sorely needed and social workers can help to get it right. Educating supervisors on challenges I discovered personally or from communication with coworkers highlighted the need to understand the lack of program delivery due to the ineffective program implementation at various levels initially.
And the final subgoal in addressing the deficiencies in the Telemental Health program included recommendations to improve the website’s information regarding the program and all other advertising/marketing avenues as well as a recommendation regarding the convergence of the 2 appointment creation systems so that double appointments were not being experienced. Without proper educational or marketing materials regarding telemental health programs for the public we will not reach our targeted audience. As Xue et al. (2023) found, “education” or marketing of our program offerings must consider various demographics and provide for ease of use, trust, and the advantage it offers potential patients. Without meeting these essential components, we are creating a program that will not serve those we wish to serve. This goal centered on improving eventual program delivery as a result of better program implementation by fixing key areas that were preventing the program from realizing its potential.
The theoretical frameworks that the interventions were based upon within each goal included systems theory, task-centered theory, and problem-solving theory. These interventions clearly pointed to the need for various systems to interact with one another in order to effect essential changes to the current service provision being provided by the Telemental Health program. Additionally, task-centered and problem-solving theories were needed as the social work team must advocate for the needs that the hospital system did not anticipate in their rollout of this program by seeking solutions to the problems being faced and accomplishing those objectives using a task-centered model. These frameworks enabled the social work team, in conjunction with other hospital partners using a systems framework, to follow a problem-solving approach until completion of the enactment of new protocols essential to the success of the program.
Results
As a result of my special project, I formed a special collaborative meeting that included the CareTeam supervisor and the CareTeam associate supervisor, who also served as my field instructor. Within the course of that scheduled meeting, I had the opportunity to present my policy proposal for the new Telemental Health program that had been implemented without clear directives or written policies.
At the meeting I presented for their review a copy of the current hospital policies that discuss Telehealth policy within the hospital system and CareTeam remote functions when patients are at remote hospital campuses. I had accessed and evaluated these policies prior to our meeting and created copies of each in order to provide a basis for the policy that I created. As I gave them each a copy of those policies, I highlighted that neither one of those policies provides directives for the new Telemental Health program instituted. I illustrated how my policy proposal mimics the layout of the current Telehealth policy, however it is specifically catered to mental health services that the hospital is now offering on the same platform. It provided different directives than the medical telehealth service provides and an understanding regarding what the clinician that answers video appointments can and cannot offer. Additionally, I presented a PowerPoint presentation that highlighted the major areas of ineffectiveness that were manifesting in the current practice of the program we were implementing. I then provided some recommendations regarding website edits that were needed in order to best market and advertise the services that we could provide and to which constituencies (since that was a major area of confusion regarding states and locales served). I also recommended that a joint appointment system be created so that appointments created online by patients dovetailed with our current appointment system for in-person visits. In terms of implementation, this project takes the form of an evaluation tool with proposals for change which would occur at higher levels of leadership within the hospital system. For this reason, the timeline for accomplishing and fixing the errors cannot be determined and is in the hands of management to accomplish and push forward.
Additionally, I noted that, of those served, the average age of patients who registered for appointments was 36, females were 3 times more likely to make appointments as opposed to males, and a small percentage of one percentage point identified as a gender other than male or female. 58% of Telemental Health appointments were unsuccessful due to a number of factors. 41% were unable to be served due to a misunderstanding regarding services that the Telemental Health program offered. These misunderstandings included the idea that one could create an appointment for an individual without the presence of the legal guardian, the idea that one could receive services while residing out-of-state at the time of the online call, the idea that medication refills or prescriptions could be offered through that medium, the idea that they would be speaking with a psychiatrist, the idea that they would be able to have a full therapy session with an online therapist, among other misunderstandings. 35% of patients with appointments were out-of-state and thus unable to be served, 31% were no-shows, and just 42% were successful appointments. Successful appointments were denoted as appointments that met criteria, which included non-emergent mental health appointments in which outpatient service resources were the desired outcome.
Conclusions
One conclusion arrived at from the Telemental Health program evaluation included that there was a low number of Plan of Care mental health assessments online due to misleading advertisement online that suggested that full mental health assessments would be provided, a psychiatrist would be conducting the assessments directly, and they could receive medication management. Additionally, the hospital website did not advertise that services preclude residents from Kentucky and Illinois. Another conclusion was that merged scheduling between the online program and the onsite scheduling for the CARE TEAM would be ideal but is difficult to effect in a large hospital conglomerate where the wheels of change move slowly. This challenge is a limiting factor to any real changes being implemented. Additionally, the rollout of this program should have begun with a one-month notice which included a written policy, in-person staff trainings, a question-and-answer period, and an opportunity for the program kinks to be worked out via staff review. Additionally, random hospital visitors, in order to assess their ease in scheduling appointments and their understanding of what it offered, should have been invited to try to create appointments in order to determine the relative ease for average users and their understanding of the services that would be offered. I would recommend that after-visit questionnaires be submitted to patients online in order to best determine effectiveness and satisfaction according to the patient. All of that should have occurred prior to the rollout, but none of that was taken into consideration or part of the implementation process. The unexpected outcomes were misleading advertising, conflicting schedules for the CARE TEAM that would respond to the requests, and a program that was not fully created before being implemented. Finally, as this program improves it can reflect anti-racist efforts by noting the lack of access being experienced by people of color due in part to the inaccurate information provided. Subsequent false hopes that result from poor advertising can be countered by improved telemental health access that will be provided when these faults are corrected.
Competency 1: Demonstrate Ethical and Professional Behavior
Within the course of this special project, I created a Google Sheets spreadsheet that was securely shared with both my field instructor and task supervisor. All of the information generated for the spreadsheet was represented in a confidential manner and did not include names or dates of birth. Information generated was simply to determine success of visit but also includes ages, genders, and times of appointments for further analysis in-house. Additionally, I retrieved notes from online encounters from the onboarding system EPIC that is used for charting, and my transfer of information into my spreadsheet was conducted in an ethical manner.
TeleHealth – Video-BH – Sheet1
Competency 2: Advance Human Rights and Social, Racial, Economic, and Environmental Justice
I advanced the human right of providing a quality mental health Plan of Care assessment when I created a PowerPoint presentation to supervisors within this department to highlight challenges being faced with the current Telemental Health system, including the scheduling conflicts. I also created a document for local referral counseling sources that listed their next available appointment times in order to accurately provide wait times to patients during the referral process.
Telemental-Health-Outpatient (2)
Therapy earliest available local
Competency 3: Engage Anti-racism, Diversity, Equity, and Inclusion (ADEI) in Practice
I recommended that we engage tracking of after-care visits with questionnaires to determine if certain ethnicities were excluded from receiving service from us. I also recommend language accessibility be incorporated into the program so that a diverse population can receive, read, and schedule appointments in their own language and relay their language of preference directly to our team. Service provision should be available to all patients, regardless of their language preference.
Competency 4: Engage in Practice-Informed Research and Research-Informed Practice
Due to the challenges being experienced with the Telemental Health program, I researched and evaluated the policies that were in place for telemental health at the hospital and discovered that none of the policies available were relevant to the current program. The first policy that appeared to relate in some way to the program was a general telehealth policy that did not address mental health at all. The second, a TeleMental Health policy, only addressed seeing patients from area hospital ERs. There was no policy in place for seeing patients via Telemental Health services from their own homes. From this research conducted, I set out to utilize this research information to devise a macro level solution to this dilemma and create a policy that could be used in practice.
Additionally, I researched the data and analytics available regarding local therapy resources for our patients. To gain data for research, I contacted local mental health counseling resource centers to determine availability and determined that there are major deficits in this region to acquire appointments in the near future for symptoms being experienced. The wait times are often months-out, denying the patients the right to efficient and effective care. This information was crutial to my practice and enabled me to inform my clients on realistic wait times for the therapy sources they may wish to pursue. With this information, they could choose the resource with the shortest wait time available if it was covered by their insurance.
TeleMental Health Policy w/ Hospitals Scannable Document on Sep 15, 2024 at 7_37_23 PM
Proposed TELEMENTAL HEALTH OUTPATIENT POLICY
Therapy earliest available local
Competency 5: Engage in Policy Practice
I created a policy for the Telemental Health program based upon the template provided for other similar programs that are offered but was specific to the needs of this program. I shared that prospective policy with supervisors for their review and potential implementation at higher levels in the organization. They recognized that the hospital system had not provided a specific policy for this program and one was needed to provide direction and to determine whether benchmarks were being met or not.
Proposed TELEMENTAL HEALTH OUTPATIENT POLICY
Competency 6: Engage with Individuals, Families, Groups, Organizations, and Communities
I engaged with the supervisor and his associate regarding the challenges being experienced by the sudden rollout of this new Telemental Health program and presented a PowerPoint presentation regarding the findings of areas of improvement that would benefit the program. The engagement we shared as we discussed elements that truly weren’t working as planned is intended to lead to further engagement at higher levels within the organization.
Competency 7: Assess Individuals, Families, Groups, Organizations, and Communities
I initially created an assessment based upon auditory data gleaned from colleagues. I noticed that they were relating that there was confusion, a lack of clarity as to how to conduct and chart these assessments, a lack of policies to guide scheduling, etc., and no specific processes in place for how the Telemental Health program to patients’ homes was to work. My needs assessment was located on a Google Sheets Document that I created and information gathered about each visit was based upon the notes in our EPIC charting system regarding the online Telemental Health visits scheduled, whether they did or did not occur. I shared with my supervisor trends that I was noticing, such as a large population that were out-of-state and could therefore not be served, no-shows, and persons calling for services that we did not provide. Further, I illustrated that appointment times conflict with the scheduled in-person appointments we have in the office and the difficulty in serving both groups, in addition to serving walk-in patients at area hospitals that we are called upon to serve, as well. There were many populations to serve and it appeared possible that some appointments were missed if the demand became too great with insufficient staff to meet the need.
TeleHealth – Video-BH – Sheet1
Competency 8: Intervene with Individuals, Families, Groups, Organizations, and Communities
The 4 goals under which my interventions were located included an evaluation of the information and data collected on my Google Sheets spreadsheet regarding the online Telemental Health encounters, a policy proposal to create structure and awareness of the parameters of the program and expectations, an educational component that included a PowerPoint presentation to my supervisors, and finally recommendations for an improved website marketing program and an appointment system that merged both in-person and Telemental Health appointments so that there was one work flow to review. These interventions were meant to improve the experience for patients of all walks of life for their Telemental Health visits and the practitioners that see them.
TeleHealth – Video-BH – Sheet1
Proposed TELEMENTAL HEALTH OUTPATIENT POLICY
Telemental-Health-Outpatient (2)
Competency 9: Evaluate Practice with Individuals, Families, Groups, Organizations, and Communities
Based upon the document review and the subsequent meeting with supervisors, I evaluated whether changes were occurring on the website and whether the scheduling process was being merged into one system and determined that these goals are long range and will take significant time to accomplish within such a large organization. I also suggested that an after-visit questionnaire for patient satisfaction should be implemented in order to determine what aspects of service provision are not being performed as desired.
References
Benson, PHD, Monica. (2024, May 3). Online Therapy VS In-person Therapy: The Physician’s Perspective. Psychiatry Advisor. https://www.psychiatryadvisor.com/features/online-therapy-vs-in-person-therapy/
Gotra, M., Lindberg, K., Jasinski, N., Scarisbrick, D., Reilly, S., Perle, J., Miller, L., & Mahoney, III, J. (2024, April 29). Changes in the Clinical Practice of Mental Health Service Providers Throughout the COVID-19 Pandemic: Longitudinal Questionnaire Study. JMIR Publications, Volume 8. https://formative.jmir.org/2024/1/e50303
Koch, E. C., Ward, M. J., Jeffery, A. D., Reese, T. J., Dorn, C., Pugh, S., Rubenstein, M., Wilson, J. E., Campbell, C., & Han, J. H. (2024). Factors Associated with Acute Telemental Health Consultations in Older Veterans. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 25(3), 312–319. https://doi-org.ezproxy.southern.edu/10.5811/westjem.17996
Lawson, J.L., Doran, J.M., O’Shea, M., & Abel, E. (2022, June 11). The Good, The Bad, The Uncertain: Diverse Provider Experiences with Telemental Health During COVID-19. Psychiatry Quarterly, 93, 753–774 (2022). https://doi.org/10.1007/s11126-022-09990-7
Lee, Y., Bronstein, L., & Cook, K. (2023). Telemental Health for Rural University-Assisted Community Schools. Children & Schools, 45(1), 46–53. https://doi-org.ezproxy.southern.edu/10.1093/cs/cdac026
Robertson, H. C., & Lowell, R. (2021). Counselor Educator, Supervisor, and Practitioner Perspectives on Distance Counseling and Telemental Health Training and Practice. Journal of Counselor Preparation & Supervision, 14(3), 156–187.
Xue, Y., Saeed, S. A., Muppavarapu, K. S., Jones, K., & Xue, L. L. (2023). Exploring the Impact of Education Strategies on Individuals’ Attitude Towards Telemental Health Service: Findings from a Survey Experiment Study. Psychiatric Quarterly, 94(3), 483–499. https://doi-org.ezproxy.southern.edu/10.1007/s11126-023-10033-y