A Pilot Project to Improve Access to Telepsychotherapy at Rural Clinics

Introduction

The U.S. Department of Veterans Affairs (VA) has pioneered telemental health (TMH), including individual, family, and group therapies, medication management, patient education, and psychological testing. ¹ TMH within the VA has become widespread, with over 500,000 documented encounters over the past decade. ²

TMH helps reach the over 40% of Veterans in rural communities, including returnees from Operations Enduring Freedom, Iraqi Freedom, and New Dawn. ³ Rural mental healthcare is ideally provided through community-based outpatient clinics, established to bring medical care close to where Veterans reside. However, many rural Veterans encounter difficulty securing mental healthcare, particularly psychotherapy.

One solution is telepsychotherapy provided by clinicians with specialized mental health expertise. Research has found that telepsychotherapy can be successfully used in several therapeutic formats, has similar outcomes to face-to-face treatment, and is considered satisfactory by most patients and therapists. ⁴ However, barriers to implementation include therapist reluctance, perceived patient discomfort, unfamiliarity with the modality, lack of time, safety concerns, and technological difficulties. ^{5 –9}

The South Central Mental Illness Research, Education and Clinical Center, a virtual center within the South Central Veterans Integrated Service Network 16 dedicated to improving healthcare services to Veterans with mental illness, especially rural Veterans, initiated a pilot project to increase telepsychotherapy in the South Central area. Three medical centers participated to provide services to six clinics. The project used a FOCUS-PDSA model, a quality-improvement framework used by many healthcare organizations, to plan and evaluate interventions. ¹⁰ Its goals were to improve access to telepsychotherapy at community clinics and identify facilitators and barriers to its implementation.

Participants and Procedure

Therapists completed required Web-based VA TMH training and also a 1-h live video presentation given by an experienced telepsychotherapist. Participating medical centers received two videoconferencing units. Project staff communicated with therapists at least monthly and clinical leaders every other month about progress. In addition, therapists completed two questionnaires. The first examined attitudes and knowledge regarding telepsychotherapy. The second assessed changes in attitudes and knowledge during the project and explored barriers and facilitators to implementation.

Results

Barriers and Facilitators

Two clinicians were offering telepsychotherapy after 10 months. Barriers were encountered at all sites, slowing implementation (Table 1). Unanticipated organizational constraints included limited space, misplaced equipment, lost work orders to install equipment, and difficulties setting up and supporting new clinics. Administrative barriers included inadequate staffing, delays in staff credentialing, poor communication from clinical leaders about priorities and workload, patient recruitment problems, and staff changes. Establishing organizational practices and therapist motivation helped facilitate implementation (Fig. 1) Participants had an opportunity to provide suggestions regarding the project. Nonadopters commented on implementation barriers, noting, “difficulties….are largely related to the clinical demands, staff shortages (mental health and clerical), scheduling problems, equipment failures…” and “clear goals, direction and support for individual providers would help [make] this more feasible.” An adopter suggested, “The novelty [of TMH] may enhance patients' interest, acting as a facilitator.” Finally, a nonadopter recommended other TMH alternatives: “…a greater need is for use of home units or use of encrypted Skype or other technology allowing for improved…access to care for rurally living Veterans who may not have the means to travel to and from the clinics.”

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Fig. 1.

Barriers and facilitators of the telepsychotherapy pilot project. IT, information technology.

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Table 1.

Descriptive Statistics for Barriers to Implementation of Telemental Health

QUESTION	ADOPTERS (N=2)	NONADOPTERS (N=8)
Access to TMH equipment has been/is difficult	2.00±0.00	2.88±1.36
Has been/continues to be difficult to locate office space to provide TMH	3.50±0.71	2.75±1.28
Lack of referrals and/or client disinterest inhibited implementation of TMH	2.50±2.12	3.13±1.46
There are/were problems setting up therapists' clinic	2.00±1.41	3.50±1.20
Staffing concerns limited therapists' ability to offer TMH	2.50±2.12	2.88±1.13
Credentialing process interfered with therapists' ability to offer TMH	1.00±0.00	2.25±1.58

Data are mean±standard deviation values. Scores range from 1=strongly disagree to 5=strongly agree.

TMH, telemental health.

Discussion and Conclusions

The goals of this project were to improve access to telepsychotherapy to community clinics and identify facilitators and barriers to implementation. Only two clinicians provided telepsychotherapy. The very act of simply providing telepsychotherapy coincided with a rise in reported knowledge, confidence, and motivation.

Therapists and clinical leaders identified barriers to implementation. Unanticipated barriers were identified. In many cases, clinical leaders had not acknowledged telepsychotherapy as a priority. It appeared some had not considered therapist characteristics that might best fit with telepsychotherapy, despite investigators stressing this. Some therapists reported little interest in conducting telepsychotherapy, and many were unprepared for the effort necessary. Other unanticipated barriers resulted from slow credentialing processes whereby licensed therapists were unable to provide direct care independently until their training had been verified and delays in equipment installation. At one site, work orders were lost and had to be resubmitted several times before installation could occur. At another, telehealth equipment was mislabeled and lost for months. At some clinics, placement of equipment limited its usability or accessibility: one had the system in a room that was not soundproof. In future, we recommend formalized decision-making with clinical leaders regarding project goals, better matching of therapists with this modality, and assessing medical center and clinic readiness. We also suggest identifying more therapists per site to account for attrition and increasing frequency of communication with clinical leaders. Identifying and using TMH champions, as recommended by Gagnon et al., ⁹ could also facilitate adoption.

We are now expanding TMH in partnership with the network. This new project, funded by the VA Central Office, establishes evidence-based TMH for posttraumatic stress disorder at seven medical centers. Although barriers to implementation remain, this project has moved faster and more successfully than the pilot study, perhaps partly because of changes in TMH processes. Establishing facility telehealth committees to manage equipment and connectivity demands, and support resources to deliver care remotely, and adding telehealth coordinators to help troubleshoot issues at the clinics have been significant. Lessons learned from the pilot helped project staff target processes earlier identified as barriers.

Implementing telepsychotherapy has been met with growing success. As we continue to improve and expand TMH, we expect it to help provide mental health services for rural residents, eventually bringing services into patients' homes.