Home-Based Telemental Health: A Proposed Privacy and Safety Protocol and Tool.

Objectives: To describe the development of a protocol and practical tool for the safe delivery of telemental health (TMH) services to the home. The COVID-19 pandemic forced providers to rapidly transition their outpatient practices to home-based TMH (HB-TMH) without existing protocols or tools to guide them. This experience underscored the need for a standardized privacy and safety tool as HB-TMH is expected to continue as a resource during future crises as well as to become a component of the routine mental health care landscape. Methods: The authors represent a subset of the Child and Adolescent Psychiatry Telemental Health Consortium. They met weekly through videoconferencing to review published safety standards of care, existing TMH guidelines for clinic-based and home-based services, and their own institutional protocols. They agreed on three domains foundational to the delivery of HB-TMH: environmental safety, clinical safety, and disposition planning. Through multiple iterations, they agreed upon a final Privacy and Safety Protocol for HB-TMH. The protocol was then operationalized into the Privacy and Safety Assessment Tool (PSA Tool) based on two keystone medical safety constructs: the World Health Organization (WHO) Surgical Safety Checklist/Time-Out and the Checklist Manifesto.Results: The PSA Tool comprised four modules: (1) Screening for Safety for HB-TMH; (2) Assessment for Safety During the HB-TMH Initial Visit; (3) End of the Initial Visit and Disposition Planning; and (4) the TMH Time-Out and Reassessment during subsequent visits. A sample workflow guides implementation. Conclusions: The Privacy and Safety Protocol and PSA Tool aim to prepare providers for the private and safe delivery of HB-TMH. Its modular format can be adapted to each site's resources. Going forward, the PSA Tool should help to facilitate the integration of HB-TMH into the routine mental health care landscape.

A National Pediatric Telepsychiatry Curriculum for Graduate Medical Education and Continuing Medical Education.

Objectives: Our goal was to develop an open access nationally disseminated online curriculum for use in graduate and continuing medical education on the topic of pediatric telepsychiatry to enhance the uptake of telepsychiatry among child psychiatry training programs and improve access to mental health care for youth and families. Methods: Following Kern's 6-stage model of curriculum development, we identified a core problem, conducted a needs assessment, developed broad goals and measurable objectives in a competency-based model, and developed educational content and methods. The curriculum was reviewed by experts and feedback incorporated. Given the urgent need for such a curriculum due to the COVID-19 pandemic, the curriculum was immediately posted on the American Academy of Child and Adolescent Psychiatry and American Association of Directors of Psychiatric Residency Training websites. Further evaluation will be conducted over the next year. Results: The curriculum covers the six areas of core competence adapted for pediatric telepsychiatry and includes teaching content and resources, evaluation tools, and information about other resources. Conclusion: This online curriculum is available online and provides an important resource and set of standards for pediatric telepsychiatry training. Its online format allows for ongoing revision as the telepsychiatry landscape changes.

The Case for Telemental Health for Improving the Accessibility and Quality of Children's Mental Health Services.

OBJECTIVE: Children's mental health problems collectively impose a staggering public health burden. However, the quality of regionally accessible children's mental healthcare varies greatly, with youth in rural and other remote communities particularly underserved. Promoting knowledge and skill in telemental health (TMH) is critical to meaningfully overcoming traditional geographic barriers to children's mental healthcare. METHODS: To introduce this special section, we review the increasing need for child and adolescent mental health services, the decreasing child mental health workforce, and the role that TMH can play in new models of care. RESULTS: Authors in this special edition are experienced TMH innovators and providers, and offer expert perspectives on the current and evolving status of TMH practice in child and adolescent mental health. The articles in this collection draw on leading TMH examples, using a range of interventions implemented across diverse TMH settings, to systematically address the critical technical, ethical, regulatory, clinical, and service delivery aspects of TMH care. These articles strategically outline the key considerations requisite for effectively incorporating TMH into children's mental healthcare Conclusions: TMH is a rapidly developing service delivery model that is already beginning to innovate systems of care to meet the expanding mental healthcare needs of the nation's children.

Future Directions in the Use of Telemental Health to Improve the Accessibility and Quality of Children's Mental Health Services.

OBJECTIVES: This concluding commentary offers a brief overview of progress to date in providing telemental health services to children, and then offers a critical vision for future research needed to provide the rigorous empirical foundation for telemental health to be considered a well-established format for the delivery of children's mental health services. METHODS: We review how recent years have witnessed advances in the science and practice of children's telemental health, and the articles in this special series collectively offered a critical step forward in the establishment of a guiding literature to provide informed direction for child providers incorporating remote technologies to extend their practices. RESULTS: Researchers must be cautious not to develop a "horse race" mentality and a misguided search for a decisive "winner" regarding the ultimate effectiveness of child telemental health versus traditional clinic-based treatments. Instead, research efforts are needed to examine key mediators and moderators of telemental health treatment response. The question should not be simply whether telemental health strategies are supported, but rather when, under what circumstances, and for whom telemental health formats may be most indicated. Barriers to the continued evolution of children's telemental health are discussed, and we consider issues of telemental health reimbursement and matters of cross-state professional jurisdiction. CONCLUSIONS: Continued efforts are needed in order to fully actualize the potential of children's telemental health to optimize the quality and transform the accessibility of mental health services for all children, regardless of income or geography.

Telemental health: responding to mandates for reform in primary healthcare.

Telemental health (TMH) has established a niche as a feasible, acceptable, and effective service model to improve the mental healthcare and outcomes for individuals who cannot access traditional mental health services. The Accountability Care Act has mandated reforms in the structure, functioning, and financing of primary care that provide an opportunity for TMH to move into the mainstream healthcare system. By partnering with the Integrated Behavioral Healthcare Model, TMH offers a spectrum of tools to unite primary care physicians and mental health specialist in a mind-body view of patients' healthcare needs and to activate patients in their own care. TMH tools include video-teleconferencing to telecommute mental health specialists to the primary care setting to collaborate with a team in caring for patients' mental healthcare needs and to provide direct services to patients who are not progressing optimally with this collaborative model. Asynchronous tools include online therapies that offer an efficient first step to treatment for selected disorders such as depression and anxiety. Patients activate themselves in their care through portals that provide access to their healthcare information and Web sites that offer on-demand information and communication with a healthcare team. These synchronous and asynchronous TMH tools may move the site of mental healthcare from the clinic to the home. The evolving role of social media in facilitating communication among patients or with their healthcare team deserves further consideration as a tool to activate patients and provide more personalized care.

Implementing a low-cost web-based clinical trial management system for community studies: a case study.

BACKGROUND: Clinical trials with multiple intervention locations and a single research coordinating center can be logistically difficult to implement. Increasingly, web-based systems are used to provide clinical trial support with many commercial, open source, and proprietary systems in use. New web-based tools are available which can be customized without programming expertise to deliver web-based clinical trial management and data collection functions. PURPOSE: To demonstrate the feasibility of utilizing low-cost configurable applications to create a customized web-based data collection and study management system for a five intervention site randomized clinical trial establishing the efficacy of providing evidence-based treatment via teleconferencing to children with attention-deficit hyperactivity disorder. The sites are small communities that would not usually be included in traditional randomized trials. A major goal was to develop database that participants could access from computers in their home communities for direct data entry. METHODS: Discussed is the selection process leading to the identification and utilization of a cost-effective and user-friendly set of tools capable of customization for data collection and study management tasks. RESULTS: An online assessment collection application, template-based web portal creation application, and web-accessible Access 2007 database were selected and customized to provide the following features: schedule appointments, administer and monitor online secure assessments, issue subject incentives, and securely transmit electronic documents between sites. Each tool was configured by users with limited programming expertise. As of June 2011, the system has successfully been used with 125 participants in 5 communities, who have completed 536 sets of assessment questionnaires, 8 community therapists, and 11 research staff at the research coordinating center. LIMITATIONS: Total automation of processes is not possible with the current set of tools as each is loosely affiliated, creating some inefficiency. This system is best suited to investigations with a single data source e.g., psychosocial questionnaires. CONCLUSIONS: New web-based applications can be used by investigators with limited programming experience to implement user-friendly, efficient, and cost-effective tools for multi-site clinical trials with small distant communities. Such systems allow the inclusion in research of populations that are not usually involved in clinical trials.

Primary health care quality in a national sample of children and youth with mental health impairment.

OBJECTIVE: To examine the general pediatric health care quality experiences of children and youth with mental health impairment. METHODS: We conducted a cross-sectional analysis of 2006 Medical Expenditures Panel Survey data for children and youth aged 5 to 17 years (n = 7263). Mental health impairment was defined using the recommended cut-point (score ≥ 16) on the parent version of the Columbia Impairment Scale. Health care quality was measured with the Consumer Assessment of Healthcare Providers and Systems including parent ratings in 3 domains: provider communication, getting needed care, and getting care quickly. Logistic regression was used to test associations between mental health impairment and dichotomized Consumer Assessment of Healthcare Providers and Systems measures (poor vs good quality) adjusted for demographic characteristics, health insurance, and socioeconomic status. Analysis was conducted with Stata, Version 10.1 SE, and all estimates accounted for the Medical Expenditures Panel Survey complex sampling design. RESULTS: In multivariable analysis, health care experiences of children with mental health impairment (versus those without) were consistently rated less favorably by parents, with greater odds of inferior quality of care ratings in all domains: getting needed care (odds ratio [OR] = 2.35), getting care quickly (OR = 1.41), physician communication (OR = 1.72), and overall health care quality (OR = 1.63). CONCLUSIONS: Further research is needed to identify specific aspects of care that families find problematic in relation to the organization and delivery of care within each quality domain. Interventions are needed to improve service systems for children and youth with mental health impairment, especially to support access to needed care.

Practice parameter for telepsychiatry with children and adolescents.

This practice parameter discusses the use of telepsychiatry to provide services to children and adolescents. The parameter defines terms and reviews the status of telepsychiatry as a mode of health service delivery. Because many of the issues addressed are unique to telepsychiatry, the parameter presents principles for establishing a telepsychiatry service and optimizing clinical practice within that service. The principles presented are based on existing scientific evidence and clinical consensus. Telepsychiatry is still evolving, and this parameter represents a first approach to determining "best practices." The parameter emphasizes the integration of telepsychiatry within other practice parameters of the American Academy of Child and Adolescent Psychiatry.

Feasibility, acceptability, and sustainability of telepsychiatry for children and adolescents.

OBJECTIVE: This study examined the feasibility, acceptability, and sustainability of a telepsychiatry service for children and adolescents living in nonmetropolitan communities. METHODS: Using high-bandwidth interactive video teleconferencing, psychiatrists at a children's hospital provided care to patients of primary care physicians at four nonmetropolitan sites. Review of one-year utilization provided feasibility data. Surveys of referring physicians examined acceptability of telepsychiatry. Reimbursement records provided sustainability data. RESULTS: Overall, 387 sessions were provided to 172 youths (mean=2.25 sessions) whose clinical profiles were representative of national samples. Referring providers endorsed high satisfaction with telepsychiatric care, although pediatricians were consistently more satisfied than family physicians. Sustainability of telepsychiatry is challenged by infrastructure costs and low reimbursement by public payers. CONCLUSIONS: Telepsychiatry is a feasible and acceptable approach to providing psychiatric services to youths in underserved communities. Sustainability will depend on developing financial alternatives to fee-for-service, especially if caseloads emphasize publicly funded programs.

Telepsychiatry with children and adolescents: are patients comparable to those evaluated in usual outpatient care?

Several studies have described successful applications of telepsychiatry with children and adolescents. However, there has been little examination of the populations served by telepsychiatry and the ability to evaluate youth accurately through this medium. In this article, we examined whether telepsychiatry patients are representative of those in usual outpatient care. Participants included 369 patients 3-19 years old evaluated at two clinics. A new telepsychiatry clinic (TPC) developed to provide services to under-served communities, and a child and adolescent psychiatric outpatient clinic (CAPOC) that served youth from predominantly metropolitan areas were included in the study. The telepsychiatry sites were linked using ISDN lines at 384 KB/sec. We examined these two samples regarding demographics, payor status, and diagnostic profiles. Results indicated that youth evaluated through the TPC were broadly comparable to youth evaluated in the CAPOC. Therefore, telepsychiatry appears to serve youth that are representative of those seeking psychiatric care, and it is not restricted to youth with no medical insurance or with selected diagnoses. The similarity of diagnoses further suggests that telepsychiatry provides adequate technical resolution and doctor-patient rapport to detect psychopathology of youths. These findings suggest the need for further systematic investigation of telepsychiatry as a tool for providing psychiatric care to young people.