Provision of high quality telemental health care during COVID-19 and beyond

背景：远程医疗(TMH)通过视频会议或电话可以增加退伍军人获得 心理健康(MH)护理。TMH可以消除包括旅行距离和成本在内的障碍，以及物理障碍 限制、照顾责任和MH症状会使离开家变得困难。在COVID之前- 19、VA中TMH发生率较低(~9%)。新冠肺炎期间出现了向TMH的戏剧性转变，以防止 感染，约50%的护理通过电话提供，约25%通过视频提供，约25%通过面对面提供。利弊得失 在选择MH护理模式时，必须考虑电话、视频和面对面护理的组合。如果病人， 提供商和/或领导层认为电话服务的质量与视频和/或面对面服务相同，他们可能 更有可能选择这种方式，因为它通常具有最少的使用障碍；然而，基于有限的 证据表明，电话服务的质量可能低于视频和面对面服务。我们需要更多细微差别的分析 关于：1)电话、视频和面对面护理的相对质量(例如，对于更复杂的患者， 心理治疗疗程与较短的药物管理预约)，以及2)患者的偏好。AS 作为一名具有TMH经验的临床心理学家和HSR&D调查员，我很有能力进行这项工作 研究。这项提议将提供关键的方法论培训，并推动我朝着成为 一位领先的卫生服务研究人员和实施科学家，具有远程医疗方面的专业知识。 意义/影响：卫生保健、远程医疗、可获得性和护理质量都是主要的HSR&D研究重点。这个 新冠肺炎期间TMH使用量的增加导致了大量未开发的数据，我们可以通过这些数据来检查 TMH护理的相对质量以及不同模式的患者偏好，以改善护理 情态决策过程。结果，这将纳入数百万患者的数据和 数以千计的医疗服务提供者，有可能在全国范围内影响高质量卫生保健服务的提供。 创新：据我们所知，还没有发表过的研究：1)比较质量和耐心 首选电话、视频和面对面MH护理，以及2)使用此信息来开发和实施 以证据为基础的策略，在临床有效和患者喜欢的情况下增加视频使用。 具体目标：目标1：检查电话、视频和面对面MH护理的质量结果(例如， MH住院率)。假设：视频护理将等同于面对面护理，优于电话 护理更复杂的患者(例如，MH住院史，3+MH诊断)和心理治疗 预约。目标2：对MH患者、提供者和领导层进行定性访谈。研究问题： 根据利益相关者的态度、偏好和决策，视频使用的促进者/障碍是什么 流程，以及这些因素在电话、视频和面对面护理水平较高的站点之间有何不同？ 目标3：制定/试行实施战略，以增加视频在临床环境中的使用 有效，深受患者青睐。假设：实施策略将增加视频使用量。 方法：在目标1中，我将通过~2个样本测试不同医疗模式之间的质量结果差异 使用比较有效性研究在2020年3月至2021年3月期间接受MH护理的百万退伍军人 战略。在目标2中，我将与主要利益相关者进行访谈，以了解促进者和障碍 基于态度、偏好和当前决策过程的视频使用。在目标3中，我将合成 目标1和目标2：在一个VISN 1 MH站点制定和试行实施战略，以增加视频 在临床有效且患者偏好的情况下使用。战略将针对 根据目标1和2的调查结果确定患者、提供者和/或系统级别。 下一步/实施：试点战略将推广到更多的MH地点，并最终推广到其他地点 临床服务，通过在随后的IIR中进行混合实施-有效性试验。调查结果将是 与MH和互联护理运营合作伙伴进行沟通，以告知VA MH护理交付的未来。

Background: Telemental health (TMH) via videoconferencing or phone can increase Veterans’ access to mental health (MH) care. TMH can eliminate barriers including travel distance and cost, as well as physical limitations, caregiving responsibilities, and MH symptoms that can make leaving home difficult. Prior to COVID- 19, rates of TMH in VA were low (~9%). There was a dramatic shift towards TMH during COVID-19 to prevent infection, with ~50% of care delivered by phone, ~25% by video, and ~25% in-person. Benefits and drawbacks of phone, video, and in-person care must be considered when choosing a MH care modality. If patients, providers, and/or leadership believe that phone care is equivalent in quality to video and/or in-person, they may be more likely to choose this modality as it often has the fewest barriers to use; however, based on limited evidence, phone care may be lower quality than video and in-person. We need more nuanced analyses regarding: 1) the relative quality of phone, video, and in-person care (e.g., for more complex patients, for psychotherapy sessions versus shorter medication management appointments), and 2) patient preferences. As a clinical psychologist and HSR&D investigator with TMH experience, I am well-positioned to conduct this research. This proposal will provide key methodological training and advance me toward my goal of becoming a leading health services researcher and implementation scientist with expertise in telehealth. Significance/Impact: MH, telehealth, access, and quality of care are all major HSR&D research priorities. The increased use of TMH during COVID-19 has led to a wealth of untapped data through which we can examine the relative quality of TMH care as well as patient preferences across modalities, in order to improve care modality decision-making processes. Results, which will incorporate data from millions of patients and thousands of providers, have the potential to impact delivery of high-quality MH care on a national scale. Innovation: To our knowledge, there has been no published research that: 1) compares the quality and patient preference of phone, video, and in-person MH care, and 2) uses this information to develop and implement evidenced-based strategies to increase video use when clinically effective and preferred by patients. Specific Aims: Aim 1: Examine quality outcomes of phone, video, and in-person MH care (e.g., differences in MH hospitalization rates). Hypothesis: Video care will be equivalent to in-person care and superior to phone care for more complex patients (e.g., history of MH hospitalization, 3+ MH diagnoses) and for psychotherapy appointments. Aim 2: Qualitative interviews with MH patients, providers, and leadership. Research question: What are facilitators/barriers to video use based on stakeholder attitudes, preferences, and decision-making processes, and how do these factors vary between sites with high levels of phone, video, and in-person care? Aim 3: Develop/pilot implementation strategies to increase video use in circumstances where it is clinically effective and preferred by patients. Hypothesis: Implementation strategies will increase video use. Methodology: In Aim 1, I will test for differences in quality outcomes between modalities via a sample of ~2 million Veterans who received MH care between 3/2020-3/2021 using comparative effectiveness research strategies. In Aim 2, I will conduct interviews with key stakeholders to understand facilitators and barriers to video use based on attitudes, preferences and current decision-making processes. In Aim 3, I will synthesize Aim 1 and 2 findings to develop and pilot implementation strategies at one VISN 1 MH site to increase video use in circumstances where it is clinically effective and preferred by patients. Strategies will be targeted at the patient, provider, and/or system levels based on Aim 1 and 2 findings. Next Steps/Implementation: The piloted strategies will be spread to additional MH sites, and ultimately other clinical services, via hybrid implementation-effectiveness trials in subsequent IIRs. Findings will be communicated to MH and Connected Care operational partners to inform the future of VA MH care delivery.