Initiating Opioid Use Disorder Medication via Telemedicine During COVID-19: Implications for Proposed Reforms to the Ryan Haight Act.

BACKGROUND: The Ryan Haight Act generally requires a clinician to conduct an in-person visit before prescribing an opioid use disorder (OUD) medication. This requirement has impeded use of telemedicine to expand OUD treatment, and many policymakers have called for its removal. During the COVID-19 pandemic, beginning March 16, 2020, the requirement was temporarily waived. It is unclear whether clinicians who treat OUD patients perceive telemedicine to be a safe and effective means of OUD medication initiation. OBJECTIVE: To understand clinician use of and comfort level with using telemedicine to initiate patients on medication for opioid use disorder. DESIGN: National survey administered electronically via WebMD/Medscape's online clinician panel in fall 2020. PARTICIPANTS: A total of 602 clinicians (primary care providers, psychiatrists, nurse practitioners or certified nurse specialists, and physician assistants) participated in the survey. MAIN MEASURES: Frequency of video, audio-only, and in-person visits for medication initiation, comfort level with using video for new patient visits with OUD. KEY RESULTS: Clinicians varied substantially in their use of telemedicine for medication initiation. Approximately 25% used telemedicine for most initiations while 40% used only in-person visits. The majority (55.8%) expressed at least some discomfort with using telemedicine for treating new OUD patients, although clinicians with more OUD patients were less likely to express such discomfort. CONCLUSION: Findings suggest that a permanent relaxation of the Ryan Haight requirement may not result in widespread adoption of telemedicine for OUD medication initiation without additional supports or incentives.

Bridging the Acute-to-Outpatient Care Gap in Mental Health: Developing and Implementing a Mental Health Transition Process.

BACKGROUND: A national Department of Veterans Affairs (VA) mental health (MH) quality metric tracks engagement in outpatient MH care after discharge from residential and inpatient settings, with recommendations for 2 or more visits 30 days postdischarge. LOCAL PROBLEM: A gap in transitioning patients from residential to outpatient MH care was identified at this site. METHODS: A transition management process was developed and piloted, including a new MH Discharge Consult and an RN Transition Care Managers team. INTERVENTIONS: Transition Care Managers triaged Discharge Consults, communicated with schedulers and patients pre- and postdischarge, and tracked MH engagement for 30 days postdischarge. Process, outcome, and balancing measures were developed and iteratively adjusted using Plan-Do-Study-Act (PDSA) cycles. RESULTS: Over 55 weeks, 443 Discharge Consults were placed. There was an average 89% success rate in connecting patients with 2 or more MH visits versus 53% preintervention. CONCLUSIONS: This pilot showed promising results in improving postdischarge MH engagement with the use of PDSA cycles to collect data and refine processes.

Prospective and retrospective study of videoconference telemedicine follow-up after elective neurosurgery: results of a pilot program.

Existing literature suggests that use of telemedicine during postoperative appointments can increase access to care and is valued by patients and providers alike. While research examining the clinical equivalency of telemedicine visits for postoperative care has been growing, few studies have reported on telemedicine follow-up after neurosurgery. This study examined if a videoconferencing visit could substitute for an in-person clinic visit for elective neurosurgical cases in the USA. This was a single-center prospective study of patients who underwent elective neurosurgical procedures (aneurysm clipping, resection of cavernous angiomas, resection of arterial venous malformation, microvascular decompression for trigeminal neuralgia and hemifacial spasm, and certain benign brain tumors) and were offered telemedicine follow-up care by an allied health professional during the first 90 days after neurosurgery. Prospective data was compared to a historical group of patients who underwent the same procedures and received in-person postoperative follow-up. Patients in the prospective group were contacted by telephone 2-6 weeks after surgery by a nurse practitioner and assessed using a standard template that included incidence of reported postoperative seizures, fever, and performance of activities of daily living. Primary outcome measures included percentage of patients accepting telemedicine, clinical and functional status, complications, patient satisfaction, patient travel time and distance, and rates of emergency room care or hospitalization within 90 days of discharge. Ninety-nine patients were included in the study, with 57 in the prospective group and 42 in the historical group. Of the 57 prospective patients, 47 accepted telemedicine in lieu of an in-person clinic visit. Emergency room visits and readmission rates at 30 and 90 days postoperatively did not differ significantly between the study groups, nor was there any significant difference in clinical variables that were recorded in the electronic medical record more than 80% of the time. This study demonstrates the safety and value of telemedicine as an alternative method of postoperative clinical care for patients undergoing elective neurosurgery. Telemedicine avoids unnecessary travel time and was welcomed by the majority of patients without compromising clinical or functional outcomes.

Perceptions of stimulant and buprenorphine diversion and strategies to address it.

There is ongoing policy debate on the prescribing of controlled substances such as buprenorphine and stimulants via telemedicine. The goal of federal and state policymakers is to ensure access to care while limiting diversion risk. However, there is little evidence on how clinicians view and address diversion and on telemedicine's role in diversion. From December 2023 to January 2024, we conducted semi-structured interviews with 21 psychiatrists and primary care physicians engaged in hybrid (telemedicine and in-person) care models in which we explored perceptions of diversion and strategies used to monitor for diversion. Most physicians reported monitoring for diversion, but there was little consistency on how monitoring was done and reported strategies did not differ between telemedicine vs in-person care. When physicians suspected diversion, there was also wide variation in responses: some clinicians did not immediately take any action while others imposed more requirements on patients (e.g., more frequent visits), no longer prescribed the controlled substance, or terminated the patient from their practice. Few physicians had ever reported a case of suspected diversion to law enforcement. Our findings suggest that the Drug Enforcement Administration could clarify reporting requirements and professional societies could provide additional guidance on how to respond to suspected diversion, given the current variation in practice across clinicians could be exploited by individuals who want to divert.

Trends in Use of Telemedicine for Stimulant Initiation Among Children and Adults.

OBJECTIVE: The authors sought to examine trends in stimulant initiation and follow-up care for attention-deficit hyperactivity disorder (ADHD) via telemedicine. METHODS: This retrospective longitudinal study used national, deidentified commercial health insurance outpatient claims among children (ages 2-17 years; N=535,629) and adults (ages 18-64 years; N=2,116,160) from January 2019 through April 2022. Regression analyses were used to examine risk for stimulant initiation, whether initiation occurred via telemedicine or in-person care, and receipt of a follow-up visit. RESULTS: The mean monthly adjusted number of stimulant initiations per 100,000 enrollees was similar for children before and during the COVID-19 pandemic (prepandemic, 57 initiations; during pandemic, 56 initiations) but increased for adults (prepandemic, 27 initiations; during pandemic, 33 initiations). Initiations via telemedicine peaked at 53%-57% in April 2020 and dropped to about 14% among children and 28% among adults in April 2022. Telemedicine initiations were significantly more common among psychiatrists than among other prescribers (OR=3.70, 95% CI=3.38-4.06 [children]; OR=3.02, 95% CI=2.87-3.17 [adults]) and less common for rural residents (OR=0.57, 95% CI=0.40-0.82 [children]; OR=0.75, 95% CI=0.61-0.92 [adults]). Follow-up care was significantly more common among individuals whose care was initiated via telemedicine than among those receiving in-person care (OR=1.09, 95% CI=1.00-1.19 [children]; OR=1.61, 95% CI=1.53-1.69 [adults]). CONCLUSIONS: Many stimulant treatments were initiated via telemedicine. Proposed rules to prohibit controlled substance prescribing without an in-person evaluation would require significant changes in current practice, potentially limiting access to stimulant medications for ADHD.

Effects of Virtual Care and Same-Day Access to Integrated Care on Specialty Mental Health Engagement in the Veterans Health Administration.

BACKGROUND: In the Veterans Health Administration (VA), Primary Care-Mental Health Integration (PC-MHI) clinics offer mental health services embedded in primary care, a strategy shown to reduce overall specialty mental health clinic burden while facilitating prompt referrals when indicated. Among newly initiated patients, same-day access to PC-MHI from primary care increases subsequent specialty mental health engagement. However, the impact of virtual care on the association between same-day access to PC-MHI and subsequent mental health engagement remains unclear. OBJECTIVE: To examine the effects of same-day access to PC-MHI and virtual care use on specialty mental health engagement. METHODS: We used administrative data from 3066 veterans who initiated mental health care at a large, California VA PC-MHI clinic during 3/1/2018 to 2/28/2022 and had no previous mental health visits for at least 2 years prior to the index appointment. We conducted Poisson regression analyses to examine the effects of same-day access to PC-MHI, virtual access to PC-MHI and their combined effect on subsequent specialty mental health engagement. RESULTS: Same-day access to PC-MHI from primary care was positively associated with specialty mental health engagement (IRR = 1.19; 95% CI 1.14-1.24). Virtual access to PC-MHI was negatively associated with specialty mental health engagement (IRR = 0.83; 95% CI 0.79-0.87). The positive effect of same-day access on specialty mental health engagement was smaller among patients who initiated PC-MHI in a virtual visit (IRR = 1.07) compared to in-person visits (IRR = 1.29; 95% CI 1.22-1.36). CONCLUSIONS: Although same-day access to PC-MHI increased overall specialty mental health engagement, the magnitude of this effect varied between in-person and virtual modalities. More research is needed to understand mechanisms of the association between virtual care use, same-day access to PC-MHI, and specialty mental health engagement.

Choosing Or Losing In Behavioral Health: A Study Of Patients' Experiences Selecting Telehealth Versus In-Person Care.

It is not known how the growth of telehealth has affected patients' choice of visit modalities (telehealth versus in person). In 2023 we conducted a mixed-methods study that paired a nationally representative survey of 2,071 adults (including 571 who used behavioral health services) and semistructured interviews with twenty-six people with depression or bipolar disorder. We explored patients' experiences with visit modality selection and their agency in the decision. Approximately one-third of patients receiving therapy or medication visits reported that their clinicians did not offer both modalities. Thirty-two percent reported that they did not typically receive their preferred modality, and 45 percent did not believe that their clinician considered their modality preferences. Qualitative findings revealed that some clinicians did not elicit patients' modality preferences. Perceived lack of choice affected satisfaction and rapport with clinicians and encouraged some people to seek care elsewhere. These findings highlight trade-offs in policies to preserve patient choice and approaches that clinicians can take to identify and accommodate patients' preferences.

Access challenges for patients with limited English proficiency: a secret-shopper study of in-person and telehealth behavioral health services in California safety-net clinics.

The recent growth of telehealth may be impacting access to care for patients, including those with limited English proficiency (LEP). Using a secret-shopper design, simulated patients contacted 386 safety-net clinics in California in both Spanish and English from February-March 2023. Callers stated that they were new patients seeking medication for depression, and they documented time to an appointment and available visit modalities (telehealth and in-person). Multinomial logistic regression models examined associations between clinic characteristics and available modalities. English-speaking callers were more likely to speak with a live scheduler and to obtain appointment information from a scheduler who could engage with them in their preferred language. Among Spanish-speaking callers who reached a live scheduler, 22% reached someone who did not engage (eg, were hung up on) and, as a result, could not obtain appointment information. The mean estimated time to a prescribing visit was 36 days and did not differ by language. Sixty-four percent of clinics offered both telehealth and in-person visits, 14% only offered in-person visits, and 22% only offered telehealth visits. More attention and resources are needed to support patients with LEP at the point of scheduling and to ensure choice of visit modality for all patient populations.

Use of Telemedicine and Quality of Care Among Medicare Enrollees With Serious Mental Illness.

Importance: During the COVID-19 pandemic, a large fraction of mental health care was provided via telemedicine. The implications of this shift in care for use of mental health service and quality of care have not been characterized. Objective: To compare changes in care patterns and quality during the first year of the pandemic among Medicare beneficiaries with serious mental illness (schizophrenia or bipolar I disorder) cared for at practices with higher vs lower telemedicine use. Design, Setting, and Participants: In this cohort study, Medicare fee-for-service beneficiaries with schizophrenia or bipolar I disorder were attributed to specialty mental health practices that delivered the majority of their mental health care in 2019. Practices were categorized into 3 groups based on the proportion of telemental health visits provided during the first year of the pandemic (March 2020-February 2021): lowest use (0%-49%), middle use (50%-89%), or highest use (90%-100%). Across the 3 groups of practices, differential changes in patient outcomes were calculated from the year before the pandemic started to the year after. These changes were also compared with differential changes from a 2-year prepandemic period. Analyses were conducted in November 2022. Exposure: Practice-level use of telemedicine during the first year of the COVID-19 pandemic. Main Outcomes and Measures: The primary outcome was the total number of mental health visits (telemedicine plus in-person) per person. Secondary outcomes included the number of acute hospital and emergency department encounters, all-cause mortality, and quality outcomes, including adherence to antipsychotic and mood-stabilizing medications (as measured by the number of months of medication fills) and 7- and 30-day outpatient follow-up rates after discharge for a mental health hospitalization. Results: The pandemic cohort included 120 050 Medicare beneficiaries (mean [SD] age, 56.5 [14.5] years; 66 638 females [55.5%]) with serious mental illness. Compared with prepandemic changes and relative to patients receiving care at practices with the lowest telemedicine use: patients receiving care at practices in the middle and highest telemedicine use groups had 1.11 (95% CI, 0.45-1.76) and 1.94 (95% CI, 1.28-2.59) more mental health visits per patient per year (or 7.5% [95% CI, 3.0%-11.9%] and 13.0% [95% CI, 8.6%-17.4%] more mental health visits per year, respectively). Among patients of practices with middle and highest telemedicine use, changes in adherence to antipsychotic and mood-stabilizing medications were -0.4% (95% CI, -1.3% to 0.5%) and -0.1% (95% CI, -1.0% to 0.8%), and hospital and emergency department use for any reason changed by 2.4% (95% CI, -1.5% to 6.2%) and 2.8% (95% CI, -1.2% to 6.8%), respectively. There were no significant differential changes in postdischarge follow-up or mortality rates according to the level of telemedicine use. Conclusions and Relevance: In this cohort study of Medicare beneficiaries with serious mental illness, patients receiving care from practices that had a higher level of telemedicine use during the COVID-19 pandemic had more mental health visits per year compared with prepandemic levels, with no differential changes in other observed quality metrics over the same period.

Association Between Virtual Care Use and Same-Day Primary Care Access in VA Primary Care-Mental Health Integration.

INTRODUCTION: Same-day referrals from primary care to mental health increase subsequent mental health treatment engagement. VA Primary Care-Mental Health Integration (PC-MHI) clinics offer integrated mental health services embedded in primary care clinics, providing a key entry point to mental health care. Although telehealth use expanded rapidly after the onset of COVID-19, the impact of telehealth on same-day primary care access among new PC-MHI mental health patients is unknown. To address this knowledge gap, we examined associations between telehealth use and same-day primary care access in VA PC-MHI. METHODS: We examined electronic health record data to identify same-day primary care appointments among PC-MHI patients who initiated care during 3/1/2018 to 10/29/2021. We used logistic regression analyses to evaluate the effect of telehealth on same-day primary care access. Time, demographic characteristics, mental health diagnoses (PTSD and depression), and substance use disorder diagnosis were evaluated as covariates. RESULTS: New PC-MHI patients who were seen via telehealth were less likely to receive same-day primary care access than patients seen in person (OR: 0.54; 95% CI: 0.41-0.71; P < .001). CONCLUSIONS: Despite the potential advantages of using telehealth to increase access, VA patients with an initial PC-MHI visit via telehealth were less likely than patients seen in person to be referred from primary care. Telehealth may adversely affect primary care referrals to mental health services, an outcome that could ultimately reduce specialty mental health care continuity. There is an urgent need to identify strategies to facilitate PC-MHI care coordination in the telehealth context.

Disruptions in Care for Medicare Beneficiaries With Severe Mental Illness During the COVID-19 Pandemic.

Importance: Little is known about changes in care for individuals with severe mental illness during the COVID-19 pandemic. Objective: To examine changes in mental health care during the pandemic and the use of telemedicine in outpatient care among Medicare beneficiaries with severe mental illness. Design, Setting, and Participants: This population-based cohort study included Medicare beneficiaries (age ≥18 years) diagnosed with schizophrenia and schizophrenia-related disorders or bipolar I disorder. Care patterns during January to September 2020 for a cohort defined in 2019 were compared with those during January to September 2019 for a cohort defined in 2018. Exposures: Start of COVID-19 pandemic in the United States, defined as week 12 of 2020. Main Outcomes and Measures: Use of mental health-related outpatient visits, emergency department visits, inpatient care, and oral prescription fills for antipsychotics and mood stabilizers during 4-week intervals. Multivariable logistic regression analyses examined whether the pandemic was associated with differential changes in outpatient care across patient characteristics. Results: The 2019 cohort of 686 214 individuals included 389 245 (53.8%) women, 114 073 (15.8%) Black and 526 301 (72.8%) White individuals, and 477 353 individuals (66.0%) younger than 65 years; the 2020 cohort of 723 045 individuals included 367 140 (53.5%) women, 106 699 (15.6%) Black and 497 885 (72.6%) White individuals, and 442 645 individuals (64.5%) younger than 65 years. Compared with 2019, there were large decreases during the pandemic's first month (calendar weeks 12-15) in individuals with outpatient visits (265 169 [36.7%] vs 200 590 [29.2%]; 20.3% decrease), with antipsychotic and mood stabilizer medication prescription fills (216 468 [29.9%] vs 163 796 [23.9%]; 20.3% decrease), with emergency department visits (12 383 [1.7%] vs 8503 [1.2%]; 27.7% decrease), and with hospital admissions (11 564 [1.6%] vs 7912 [1.2%]; 27.9% decrease). By weeks 32 to 35 of 2020, utilization rebounded but remained lower than in 2019, ranging from a relative decrease of 2.5% (outpatient visits) to 12.9% (admissions). During the full pandemic period (weeks 12-39) in 2020, 1 556 403 of 2 743 553 outpatient visits (56.7%) were provided via telemedicine. In multivariable analyses, outpatient visit use during weeks 12 to 25 of 2020 was lower among those with disability (odds ratio, 0.95; 95% CI, 0.93-0.96), and during weeks 26 to 39 of 2020, it was lower among Black vs non-Hispanic White individuals (OR, 0.97; 95% CI, 0.95-0.99) and those with dual Medicaid eligibility (OR, 0.96; 95% CI, 0.95-0.98). Conclusions and Relevance: In this cohort study, despite greater use of telemedicine, individuals with severe mental illness experienced large disruptions in care early in the pandemic. These narrowed but persisted through September 2020. Disruptions were greater for several disadvantaged populations.

Engaging Veterans With Serious Mental Illness in Primary Care.

Background: Veterans with serious mental illness (SMI) are at substantial risk for premature mortality. Engagement in primary care can mitigate these mortality risks. However, veterans with SMI often become disengaged from primary care. The US Department of Veterans Affairs (VA) measures and reports at VA facilities primary care engagement among enrolled veterans with SMI. This quarterly metric enables VA facilities to identify targets for quality improvement and track their progress. To inform quality improvement at our VA facility, we sought to identify promising practices for supporting engagement in primary care among veterans with SMI. Methods: We conducted semistructured telephone interviews from May 2019 through July 2019 with a purposeful sample of key informants at VA facilities with high levels of engagement in primary care among veterans with SMI. All interviews were recorded, summarized using a structured template, and summaries placed into a matrix. An interdisciplinary team reviewed and discussed matrices to identify and build consensus around findings. Results: We interviewed 18 key informants from 11 VA facilities. The strategies used to engage veterans with SMI fell into 2 general categories: targeted outreach and routine practices. Targeted outreach included proactive, deliberate, systematic approaches for identifying and contacting veterans with SMI who are at risk of disengaging from care. In targeted outreach, veterans were identified and prioritized for outreach independent of any visits with mental health or other VA services. Routine practices included activities embedded in regular clinical workflows at the time of veterans' mental health visits, assessing, and connecting/reconnecting veterans with SMI into primary care. In addition, we identified extensive formal and informal ties between mental health and primary care that facilitated engaging veterans with SMI in primary care. Conclusions: VA facilities with high levels of primary care engagement among veterans with SMI used extensive engagement strategies, including a diverse array of targeted outreach and routine practices. Intentionally designed organizational structures and processes and facilitating extensive formal and informal ties between mental health and primary care teams supported these efforts. Additional organizational cultural factors were especially relevant to routine practice strategies. The practices we identified should be evaluated empirically for their effects on establishing and maintaining engagement in primary care among veterans with SMI.

Association Between Telemedicine Use in Nonmetropolitan Counties and Quality of Care Received by Medicare Beneficiaries With Serious Mental Illness.

Importance: Access to specialty mental health care remains challenging for people with serious mental illnesses, such as schizophrenia and bipolar disorder. Whether expansion of telemedicine is associated with improved access and quality of care for these patients is unclear. Objective: To assess whether greater telemedicine use in a nonmetropolitan county is associated with quality measures, including use of specialty mental health care and medication adherence. Design, Setting, and Participants: In this cohort study, the variable uptake of telemental health visits was examined across a national sample of fee-for-service claims from Medicare beneficiaries in 2916 nonmetropolitan counties between January 1, 2010, and December 31, 2018. Beneficiaries with schizophrenia and related psychotic disorders and/or bipolar I disorder during the study period were included. For each year of the study, each county was categorized based on per capita telemental health service use (none, low, moderate, and high). The association between telemental health service use in the county and quality measures was tested using a multivariate model controlling for both patient characteristics and county fixed effects. Analyses were conducted from January 1 to April 11, 2022. Before the COVID-19 pandemic, telemedicine reimbursement was limited to nonmetropolitan beneficiaries. Main Outcomes and Measures: Receipt of a minimum of 2 specialty mental health service visits (telemedicine or in-person) in the year, number of months per year with medication, hospitalization rate, and outpatient follow-up visits after a mental health hospitalization in a year. Results: In 2018, there were 2916 counties with 118 170 patients (77 068 [65.2%] men; mean [SD] age, 58.3 [15.6] years) in the sample. The fraction of counties that had high telemental health service use increased from 2% in 2010 to 17% in 2018. In 2018 there were 1.08 telemental health service visits per patient in the high telemental health counties. Compared with no telemental health care in the county, patients in high-use counties were 1.2 percentage points (95% CI, 0.81-1.60 percentage points) (8.0% relative increase) more likely to have a minimum number of specialty mental health service visits, 13.7 percentage points (95% CI, 5.1-22.3 percentage points) (6.5% relative increase) more likely to have outpatient follow-up within 7 days of a mental health hospitalization, and 0.47 percentage points (95% CI, 0.25-0.69 percentage points) (7.6% relative increase) more likely to be hospitalized in a year. Telemental health service use was not associated with changes in medication adherence. Conclusions and Relevance: The findings of this study suggest that greater use of telemental health visits in a county was associated with modest increases in contact with outpatient specialty mental health care professionals and greater likelihood of follow-up after hospitalization. No substantive changes in medication adherence were noted and an increase in mental health hospitalizations occurred.

Perspectives of Patients Receiving Telemedicine Services for Opioid Use Disorder Treatment: A Qualitative Analysis of User Experiences.

OBJECTIVE: Telemedicine for opioid use disorder (tele-OUD) has the potential to increase access to medications for OUD (MOUD). Fully virtual tele-OUD services, in which all care is provided via telemedicine, are increasingly common, yet few studies document the experiences of patients who use such services. Understanding patient perspectives is one of multiple considerations to inform the regulation and reimbursement of tele-OUD services. METHODS: We conducted semi-structured interviews with 20 adults receiving care from one fully virtual tele-OUD service who had received 3 to 5 weeks of treatment. Analyses were conducted using an inductive and deductive approach informed by the modified Unified Theory of Acceptance and Use of Technology model. RESULTS: Over three quarters of patients with past experience receiving in-person MOUD treatment described tele-OUD as more advantageous with its key strength being more patient centered. Over three quarters of patients said they felt tele-OUD helped to ameliorate social barriers to seeking treatment, and nearly all said they appreciated the speed at which they were able to initiate MOUD treatment via tele-OUD. Surprisingly, the pandemic was not among the factors that influenced patient interest in tele-OUD. CONCLUSIONS: Patients engaged in one fully virtual tele-OUD service described unique advantages of tele-OUD. More research is needed to determine the appropriateness of tele-OUD for people in various stages of recovery, and data on long-term treatment outcomes are needed to inform decisions regarding the regulation and reimbursement of fully virtual and hybrid care models for OUD.

Appropriateness of Telemedicine Versus In-Person Care: A Qualitative Exploration of Psychiatrists' Decision Making.

OBJECTIVE: With widespread adoption of telemedicine in response to the COVID-19 pandemic, psychiatrists must determine which visits are best conducted via telemedicine versus in person. Although some telepsychiatry guidelines and best practices have been developed, the literature has not described how psychiatrists make decisions about offering different care modalities. The authors explored how psychiatrists decide whether telemedicine is appropriate for a given patient. METHODS: From June 25 to August 4, 2021, the authors conducted semistructured interviews with 20 outpatient psychiatrists. The authors used a critical incident technique and clinical vignettes to identify conscious and unconscious factors that influence psychiatrists' decision to offer telemedicine. Using inductive thematic analysis, the authors analyzed interview data. RESULTS: Psychiatrists perceived that most patients are good candidates for telemedicine visits in the context of hybrid care models. Patient preference and situational factors, such as access to private spaces, rather than any particular diagnosis or patient demographic characteristic, drove telemedicine versus in-person care. Psychiatrists described numerous factors affecting their decision to offer telemedicine, and they were driven to try telemedicine and adjust as needed to "meet patients where they are" and to improve engagement in care. Psychiatrists reported using telemedicine as a bargaining chip in negotiations with patients, leveraging the offer of telemedicine to improve treatment attendance and adherence. CONCLUSIONS: This detailed assessment of how psychiatrists choose different care modalities can inform clinical practice guidelines and reimbursement policies that often mandate in-person visits. The results show that psychiatrists did not perceive intermittent in-person visits as essential for high-quality care.

Suicide Risk Among Military Veterans in the Southwestern United States Before and During the COVID-19 Pandemic.

INTRODUCTION: Military Veterans have an increased risk of suicide compared to the general population, but less is known about changes in risk with the onset of the COVID-19 pandemic, or whether any changes have been moderated by psychiatric or demographic factors. The primary objective was to test the hypothesis that the likelihood of suicide attempt or death by suicide was stable during the first year of the pandemic versus the preceding year for the full sample. A second objective was to test the hypothesis that, in contrast, risk increased for Veteran subgroups characterized by traditional risk factors (e.g., psychiatric diagnosis). MATERIALS AND METHODS: We extracted electronic health record data for 771,570 Veterans who received one or more health care visits between March 13, 2019, and March 12, 2021, at eight VA hospitals across the southwestern United States. Primary outcome measures were suicide attempts and deaths by suicide. Predictor variables included psychiatric diagnoses and demographic factors. RESULTS: Multivariable models indicated that the odds of death by suicide did not change during the first year of the COVID-19 pandemic, while the odds of making a suicide attempt declined. Veterans treated for major depression were at heightened risk for attempting suicide in both years, but the association was smaller during the pandemic than the year prior. In contrast, the relative risk of attempt for Veterans who were never married and Veterans treated for a non-alcohol, non-opioid substance-use disorder increased during the pandemic. CONCLUSIONS AND RELEVANCE: The findings suggest that the pandemic has not led to an increase in suicidal behavior, which is consistent with other studies, although the degree of decline varied across diagnostic and demographic groups. Further longitudinal research is needed to evaluate whether the prolonged nature of COVID-19 may lead to changes in risk over time.

Access to Care for Veterans With Serious Mental Illness During the COVID-19 Pandemic.

OBJECTIVE: The authors examined access to care among persons with serious mental illness during the pandemic and disparities in use of virtual care among this population versus among individuals with other psychiatric diagnoses. METHODS: Data from the Veterans Health Administration were used to examine whether the number of visits for serious mental illness differed for January-September 2019 versus the same period in 2020. Mixed-effects regression analyses tested whether the post-COVID-19 rate of growth in virtual care differed for people with serious mental illnesses versus those with other diagnoses. RESULTS: Fewer visits for serious mental illnesses occurred during the initial weeks of the pandemic but not subsequently. The rate of growth in video visits during 2020 was slower for serious mental illnesses than for other psychiatric diagnoses. CONCLUSIONS: Several months after the pandemic's start, the total number of visits for serious mental illnesses was similar to 2019; however, adoption of video care was slower than for other psychiatric diagnoses.

Use of telemedicine for opioid use disorder treatment - Perceptions and experiences of opioid use disorder clinicians.

OBJECTIVE: To understand clinician use of and opinions about telemedicine for opioid use disorder (tele-OUD) during the COVID-19 pandemic. METHODS: An electronic national survey was administered in fall 2020 to 602 OUD clinicians recruited from WebMD/Medscape's online panel. The survey completion rate was 97.3 %. RESULTS: On average, clinicians reported that 56.9 % of their visits in the last month were via telemedicine (20.3 % via audio-only and 36.6 % via video). Most respondents (N = 376, 62.5 %) agreed that telemedicine has been as effective as in-person care. The majority (N = 535, 88.9 %) were comfortable using video for clinically stable patients, while half (N = 297, 49.3 %) were comfortable using video for patients who are not clinically stable. After the pandemic, most respondents (N = 422, 70.1 %) preferred to return to in-person care for the majority of visits; however, 95.3 % thought telemedicine should be offered in some form. Most (N = 481, 79.9 %) would continue to offer telemedicine if reimbursement were the same as in-person, while 242 (40.2 %) would continue if reimbursement were 25 % lower. Clinicians with more OUD patients used more telemedicine and reported higher comfort levels treating clinically unstable patients, and clinicians with more Medicaid/uninsured patients used more audio-only and preferred to continue using telemedicine post-pandemic. CONCLUSIONS: Telemedicine made up the majority of OUD visits provided by surveyed clinicians, and the vast majority of clinicians would like the option to offer telemedicine to at least some of their patients in the future if there is adequate reimbursement. These findings can help inform telemedicine's future role in the treatment of OUD.

Health center implementation of telemedicine for opioid use disorders: A qualitative assessment of adopters and nonadopters.

OBJECTIVE: Although use of telemedicine for the treatment of opioid use disorders (Tele-OUD) is growing, there is limited research on how it is actually being deployed in treatment. We explored how health centers across the U.S. are using tele-OUD in treatment as well as reasons for nonadoption. METHODS: We used the 2018 SAMHSA Behavioral Health Treatment Services Locator database and literature review to create a sample of community mental health centers and federally qualified health centers with telemental health services. From this list of health centers, we ued maximum diversity sampling to identify and recruit health center leaders to participate in semistructured interviews. We used inductive and deductive approaches to develop site summaries. RESULTS: Twenty-two health centers from 14 different states participated. Of these, 8 offered tele-OUD. Among centers with tele-OUD, medication management was the most common service provided via video. Typically, health centers offered telemedicine visits after an initial, in-person visit with a waivered (prescribing) provider. Some programs only offered counseling via telemedicine. Leading barriers to treatment that tele-OUD program representatives mentioned included regulations on the prescribing of controlled substances, including buprenorphine, and difficulties in sending lab results to distant (prescribing) providers. Nonadopters reported not offering tele-OUD due to regulations in controlled substance prescribing, complexities and regulatory barriers to offering group visits, and the belief that in-person OUD services were meeting patient need. CONCLUSIONS: Tele-OUD is being deployed in a variety of ways. Describing current delivery models can inform strategies to promote and implement tele-OUD to combat the opioid epidemic.

Treatment of opioid use disorder during COVID-19: Experiences of clinicians transitioning to telemedicine.

OBJECTIVE: The COVID-19 pandemic has transformed care delivery for patients with opioid use disorder (OUD); however, little is known about the experiences of front-line clinicians in the transition to telemedicine. This study described how, in the context of the early stages of the pandemic, clinicians used telemedicine for OUD in conjunction with in-person care, barriers encountered, and implications for quality of care. METHODS: In April 2020, we conducted semistructured interviews with clinicians waivered to prescribe buprenorphine. We used maximum variation sampling. We used standard qualitative analysis techniques, consisting of both inductive and deductive approaches, to identify and characterize themes. RESULTS: Eighteen clinicians representing 10 states participated. Nearly all interview participants were doing some telemedicine, and more than half were only doing telemedicine visits. Most participants reported changing their typical clinical care patterns to help patients remain at home and minimize exposure to COVID-19. Changes included waiving urine toxicology screening, sending patients home with a larger supply of OUD medications, and requiring fewer visits. Although several participants were serving new patients via telemedicine during the early weeks of the pandemic, others were not. Some clinicians identified positive impacts of telemedicine on the quality of their patient interactions, including increased access for patients. Others noted negative impacts including less structure and accountability, less information to inform clinical decision-making, challenges in establishing a connection, technological challenges, and shorter visits. CONCLUSIONS: In the context of the pandemic, buprenorphine prescribers quickly transitioned to providing telemedicine visits in high volume; nonetheless, there are still many unknowns, including the quality and safety of widespread use of telemedicine for OUD treatment.