Patient Satisfaction With a Coach-Guided, Technology-Based Mental Health Treatment: Qualitative Interview Study and Theme Analysis.

BACKGROUND: Technology-based mental health interventions address barriers rural veterans face in accessing care, including provider scarcity and distance from the hospital or clinic. webSTAIR is a 10-module, web-based treatment based on Skills Training in Affective and Interpersonal Regulation, designed to treat posttraumatic stress disorder and depression in individuals exposed to trauma. Previous work has demonstrated that webSTAIR is acceptable to participants and effective at reducing symptoms of posttraumatic stress disorder and depression when delivered synchronously or asynchronously (over 5 or 10 sessions). OBJECTIVE: This study explored factors that lead to greater patient satisfaction with webSTAIR, a web-based, coach-guided intervention. METHODS: We analyzed qualitative interview data to identify themes related to patient satisfaction with webSTAIR delivered with synchronous video-based coaching. RESULTS: Four themes emerged from the data: (1) coaching provides accountability and support, (2) self-pacing offers value that meets individual needs, (3) participants like the comfort and convenience of the web-based format, and (4) technical issues were common but not insurmountable. CONCLUSIONS: We conclude that participants valued the accountability, flexibility, and convenience of tech-based interventions with video-delivered coaching.

Improving Veteran Engagement with Virtual Care Technologies: a Veterans Health Administration State of the Art Conference Research Agenda.

Although the availability of virtual care technologies in the Veterans Health Administration (VHA) continues to expand, ensuring engagement with these technologies among Veterans remains a challenge. VHA Health Services Research & Development convened a Virtual Care State of The Art (SOTA) conference in May 2022 to create a research agenda for improving virtual care access, engagement, and outcomes. This article reports findings from the Virtual Care SOTA engagement workgroup, which comprised fourteen VHA subject matter experts representing VHA clinical care, research, administration, and operations. Workgroup members reviewed current evidence on factors and strategies that may affect Veteran engagement with virtual care technologies and generated key questions to address evidence gaps. The workgroup agreed that although extensive literature exists on factors that affect Veteran engagement, more work is needed to identify effective strategies to increase and sustain engagement. Workgroup members identified key priorities for research on Veteran engagement with virtual care technologies through a series of breakout discussion groups and ranking exercises. The top three priorities were to (1) understand the Veteran journey from active service to VHA enrollment and beyond, and when and how virtual care technologies can best be introduced along that journey to maximize engagement and promote seamless care; (2) utilize the meaningful relationships in a Veteran's life, including family, friends, peers, and other informal or formal caregivers, to support Veteran adoption and sustained use of virtual care technologies; and (3) test promising strategies in meaningful combinations to promote Veteran adoption and/or sustained use of virtual care technologies. Research in these priority areas has the potential to help VHA refine strategies to improve virtual care user engagement, and by extension, outcomes.

A protocol for a randomized controlled trial of exposure and response prevention for veterans with obsessive compulsive disorder.

BACKGROUND: Obsessive compulsive disorder (OCD) is effectively treated with exposure and response prevention (ERP), yet very few veterans receive ERP for OCD within the Veterans Health Administration (VHA). Veterans are a clinically complex population, and no prior research has evaluated the effectiveness of ERP in veterans with OCD or comorbid OCD and posttraumatic stress disorder (PTSD). Given the limited accessibility of ERP-trained providers within VHA, assessment of video telehealth (VTH) delivery of ERP is warranted. METHODS: A sample of 160 veterans with OCD (80 diagnosed with comorbid PTSD) will be randomly assigned to receive up to 16 sessions of ERP or a stress management training control delivered via VTH. Assessments will occur at baseline, posttreatment, and 6-month follow-up. The primary outcome will evaluate the impact of ERP on participants' functioning, and secondary outcomes will include quality of life and OCD symptoms. At posttreatment, qualitative interviews with veterans, clinicians, and administrators will explore barriers and facilitators to treatment delivery, and the implementation potential of ERP. CONCLUSIONS: Results will provide direction for the treatment of OCD and comorbid PTSD in veterans, as well as guidance for future implementation efforts for ERP within VHA. CLINICALTRIALS: gov Identifier:NCT05240924.

The role of depression and anxiety symptom severity in remotely delivered mental health care.

This study examined differences in mental health characteristics of Veterans who received VA Video Connect (VVC) or audio-only care during initial phases of the COVID-19 pandemic. A cohort of Veterans with primary diagnoses of depressive or anxiety disorders (diagnosed between March 2019 and February 2020) was identified, and data were obtained for Veterans who engaged in virtual care from April to December 2020. Two groups were created: Veterans receiving audio-only care (n = 161,071) and Veterans receiving two or more VVC visits (n = 84,505). Multiple logistic regression models examined symptom severity in the year before COVID as a predictor of treatment modality during COVID. Chi-square tests examined associations between modality and the number of assessments. Symptom severity as evaluated by the nine-item Patient Health Questionnaire and Generalized Anxiety Disorder-7 significantly predicted modality of encounters during the pandemic such that those who had moderate or severe symptoms prior to COVID-19 were more likely than those with low or no symptoms to have two or more VVC encounters during the pandemic. Of those who received VVC, 55.62% had no Patient Health Questionnaire-9 assessments compared to 68.96% of those who received audio-only. In the VVC group, 70.36% had no Generalized Anxiety Disorder-7 assessments compared to 81.02% in the audio-only group. Taken together, these findings suggest that VVC, when compared to audio-only, was used during the pandemic to reach Veterans with more severe mental health symptomatology and to engage in administration of measurement-based care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Telemental Health Use Is Associated With Lower Health Care Spending Among Medicare Beneficiaries With Major Depression.

BACKGROUND: Some policymakers are concerned that expanding telehealth coverage may increase Medicare expenditures. However, there is limited evidence on the association of telehealth use with utilization and spending among Medicare beneficiaries with major depression. OBJECTIVE: To examine the differences in spending and utilization among telemental health users and non-telemental health users with major depression. METHODS: We examined 2014-2019 traditional Medicare claims data for beneficiaries aged ≥50 years with major depression in Texas. Multivariable generalized linear models were used to assess the relationships between telemental health use and Medicare spending and utilization while adjusting for patient demographics and programmatic and clinical factors. RESULTS: In each of the years between 2014 and 2019, an average of 4.6% Medicare beneficiaries with major depression had at least 1 telemental health visit. Compared with beneficiaries without a telemental health visit, those who had a telemental health visit were significantly more likely to be enrolled in Medicaid, be Medicare eligible due to a disability, live in a lower income area or in a rural area, and have a higher comorbidity index. Beneficiaries utilizing telemental health services incurred higher unadjusted Medicare spending than those not receiving telemental health services. However, this difference appeared due to beneficiary and programmatic characteristics rather than telemental health use. Adjusting for model covariates, the telemental health group had lower overall per member per year predicted spending, inpatient admissions, and emergency department visits than non-telemental health users. CONCLUSION: Our findings suggest that telemental health care use may improve access to mental health care without increasing Medicare spending among telemental health users in Texas.

Black veteran use of video telehealth for mental health care.

Black veterans experience disparities in mental health (MH) care access and are disproportionately affected by COVID-19. Video telehealth to home (VTH) may reduce disparities by addressing barriers, particularly with pandemic-related shifts to remotely delivered care. Considering potential needs for tailored implementation across racial/ethnic groups, we examined differences in VTH use by non-Hispanic Black veterans versus all other races/ethnicities and among Black (Hispanic and non-Hispanic) veterans by age, rurality, and gender during the pandemic. We extracted a cohort of Veterans Health Administration-enrolled veterans receiving at least one MH encounter between October 2019 and September 2020 (n = 1,627,791) from electronic health records. Multilevel linear growth curve models examined the percentage of VTH use for non-Hispanic Black versus other races/ethnicities before and after pandemic onset. Black veteran-only subgroup analyses examined differences by ethnicity in percentage of VTH MH encounters since pandemic onset by age, rurality, and gender, using regression and analysis of covariance models. Despite significant increases in VTH during the pandemic, on average, VTH use was consistently lower for non-Hispanic Black veterans across both periods. During the pandemic, differences in VTH use between non-Hispanic Black and non-Black veterans accelerated over time. VTH use was greater during the pandemic for Black veterans who were Hispanic, younger, urban, and female. Adoption of VTH for MH was low for non-Hispanic Black veterans before COVID-19 and during COVID-19 compared to non-Black groups. Future VTH research and implementation efforts should question why adoption remains low, work to meet cultural needs, and promote equitable adoption for Black veterans. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Rural Veterans with HIV and Alcohol Use Disorder receive less video telehealth than urban Veterans.

PURPOSE: Alcohol use disorder (AUD) is highly prevalent among Veterans with HIV. Rural Veterans with HIV are at especially high risk for not receiving appropriate treatment. This retrospective cohort cross-sectional study aimed to investigate patterns of mental health treatment utilization across delivery modality among Veterans diagnosed with HIV and AUD. It was hypothesized that rural Veterans with HIV and AUD would receive a lower rate of mental health treatment delivered via video telehealth than urban Veterans with HIV and AUD. METHODS: A national Veterans Health Association administrative database was used to identify a cohort of Veterans diagnosed with HIV and AUD (N = 2,075). Geocoding was used to categorize rural Veterans (n = 246) and urban Veterans (n = 1,829). Negative binomial regression models tested associations between rurality and mental health treatment delivered via face-to-face, audio-only, and video telehealth modalities. FINDINGS: Results demonstrated that rural Veterans with HIV and AUD received fewer mental health treatment sessions delivered via telehealth than urban Veterans with HIV and AUD (incidence rate ratio = 0.62; 95% confidence intervals [0.44, 0.87]; P < .01). No differences were found in terms of treatment delivered face-to-face or by audio-only. CONCLUSIONS: Rural Veterans with HIV and AUD represent a vulnerable subpopulation of Veterans who may most benefit from video telehealth. Efforts to increase access and improve the uptake of evidence-based mental health treatment delivered via video telehealth are needed.

Rural-Urban Disparities in Video Telehealth Use During Rapid Mental Health Care Virtualization Among American Indian/Alaska Native Veterans.

Importance: American Indian/Alaska Native veterans experience a high risk for health inequities, including mental health (MH) care access. Rapid virtualization of MH care in response to the COVID-19 pandemic facilitated care continuity across the Veterans Health Administration (VHA), but the association between virtualization of care and health inequities among American Indian/Alaska Native veterans is unknown. Objective: To examine differences in video telehealth (VTH) use for MH care between American Indian/Alaska Native and non-American Indian/Alaska Native veterans by rurality and urbanicity. Design, Setting, and Participants: In this cohort study, VHA administrative data on VTH use among a veteran cohort that received MH care from October 1, 2019, to February 29, 2020 (prepandemic), and April 1 to December 31, 2020 (early pandemic), were examined. Exposures: At least 1 outpatient MH encounter during the study period. Main Outcomes and Measures: The main outcome was use of VTH among all study groups (ie, American Indian/Alaska Native, non-American Indian/Alaska Native, rural, or urban) before and during the early pandemic. American Indian/Alaska Native veteran status and rurality were examined as factors associated with VTH utilization through mixed models. Results: Of 1 754 311 veterans (mean [SD] age, 54.89 [16.23] years; 85.21% male), 0.48% were rural American Indian/Alaska Native; 29.04%, rural non-American Indian/Alaska Native; 0.77%, urban American Indian/Alaska Native; and 69.71%, urban non-American Indian/Alaska Native. Before the pandemic, a lower percentage of urban (b = -0.91; SE, 0.02; 95% CI, -0.95 to -0.87; P < .001) and non-American Indian/Alaska Native (b = -0.29; SE, 0.09; 95% CI, -0.47 to -0.11; P < .001) veterans used VTH. During the early pandemic period, a greater percentage of urban (b = 1.37; SE, 0.05; 95% CI, 1.27-1.47; P < .001) and non-American Indian/Alaska Native (b = 0.55; SE, 0.19; 95% CI, 0.18-0.92; P = .003) veterans used VTH. There was a significant interaction between rurality and American Indian/Alaska Native status during the early pandemic (b = -1.49; SE, 0.39; 95% CI, -2.25 to -0.73; P < .001). Urban veterans used VTH more than rural veterans, especially American Indian/Alaska Native veterans (non-American Indian/Alaska Native: rurality b = 1.35 [SE, 0.05; 95% CI, 1.25-1.45; P < .001]; American Indian/Alaska Native: rurality b = 2.91 [SE, 0.38; 95% CI, 2.17-3.65; P < .001]). The mean (SE) increase in VTH was 20.34 (0.38) and 15.35 (0.49) percentage points for American Indian/Alaska Native urban and rural veterans, respectively (difference in differences [DID], 4.99 percentage points; SE, 0.62; 95% CI, 3.77-6.21; t = -7.999; df, 11 000; P < .001), and 12.97 (0.24) and 11.31 (0.44) percentage points for non-American Indian/Alaska Native urban and rural veterans, respectively (DID, 1.66; SE, 0.50; 95% CI, 0.68-2.64; t = -3.32; df, 15 000; P < .001). Conclusions and Relevance: In this cohort study, although rapid virtualization of MH care was associated with greater VTH use in all veteran groups studied, a significant difference in VTH use was seen between rural and urban populations, especially among American Indian/Alaska Native veterans. The findings suggest that American Indian/Alaska Native veterans in rural areas may be at risk for VTH access disparities.

Coaching with Internet-Based Mental Health Program: Patient and Coach Experiences.

Introduction: The COVID-19 pandemic has laid bare the need for mental health treatment and the shortage of available providers. Internet-based, asynchronous mental health programs that incorporate coaching with a licensed provider address this widespread challenge. This study provides an in-depth exploration of both the patient and provider experience in webSTAIR, a coached, internet-based psychoeducational program, where coaching took place over video-telehealth. We focus on how patients and licensed mental health providers understood their coaching relationship in an internet-based mental health program. Materials and Methods: We interviewed a purposive sample of 60 patients who completed the coached, internet-based program and all 9 providers who provided coaching from 2017 to 2020. The project team and interviewers took notes during interviews. Patient interviews were studied using content and matrix analysis. Coach interviews were studied using thematic analysis. Results: Interviews across patients and coaches reveal the continued importance of relationship building and rapport and emphasized the central role of the coach in providing content clarification and application of skills. Discussion: For patients, coaches were critical for understanding and completing the internet-based program. As well, positive relationship with their coach further enhanced their experience in the program. Providers echoed the importance of relationship building and rapport for program success and saw their main role as helping patients to understand content and apply skills.

Technology Implementation for Mental Health End Users: A Model to Guide Digital Transformation for Inpatient Mental Health Professionals.

Digital transformation is the adoption of digital technologies by an entity in an effort to increase operational efficiency. In mental health care, digital transformation entails technology implementation to improve the quality of care and mental health outcomes. Most psychiatric hospitals rely heavily on "high-touch" interventions or those that require in-person, face-to-face interaction with the patient. Those that are exploring digital mental health care interventions, particularly for outpatient care, often copiously commit to the "high-tech" model, losing the crucial human element. The process of digital transformation, especially within acute psychiatric treatment settings, is in its infancy. Existing implementation models outline the development of patient-facing treatment interventions within the primary care system; however, to our knowledge, there is no proposed or established model for implementing a new provider-facing ministration tool within an acute inpatient psychiatric setting. Solving the complex challenges within mental health care demands that new mental health technology is developed in concert with a use protocol by and for the inpatient mental health professional (IMHP; the end user), allowing the "high-touch" to inform the "high-tech" and vice versa. Therefore, in this viewpoint article, we propose the Technology Implementation for Mental-Health End-Users framework, which outlines the process for developing a prototype of an IMHP-facing digital intervention tool in parallel with a protocol for the IMHP end user to deliver the intervention. By balancing the design of the digital mental health care intervention tool with IMHP end user resource development, we can significantly improve mental health outcomes and pioneer digital transformation nationwide.

Culturally Centered Implementation of Video Telehealth for Rural Native Veterans.

Introduction: Native American Veterans are the most rural and experience heightened risk for mental health (MH) challenges while facing significant health care inequities and access barriers. Rural Native Veterans (RNVs) have experienced historical loss and racial discrimination, contributing to mistrust of Veterans Health Administration (VHA) and other Federal systems. Telemedicine, including video telehealth (VTH), can improve access to MH care for RNVs by addressing barriers. Understanding the cultural context and existing community resources can improve engagement and implementation efforts with RNVs. Objective: This article describes a model of culturally centered MH care and a flexible implementation approach, Personalized Implementation of Virtual Treatments for Rural Native Veterans (PIVOT-RNV), used to disseminate the model. Methods: Participants included four VHA sites serving large RNV populations where PIVOT-RNV was applied to expand the availability of virtual solutions, including VTH, for RNVs. A mixed methods formative evaluation tracked VTH utilization and used provider and RNV feedback to inform iterative process improvements. Results: Where PIVOT-RNV was used, number of providers using VTH with RNVs, number of unique RNVs receiving MH care through VTH, and number of VTH encounters with RNVs grew annually. Provider and RNV feedback highlighted the importance of addressing the unique barriers and cultural context of RNVs. Conclusions: PIVOT-RNV demonstrates promise for improving implementation of virtual treatments and access to MH care for RNVs. The integration of implementation science within a cultural safety framework helps address specific barriers to adoption of virtual treatments for RNVs. Next steps include expanding PIVOT-RNV efforts at additional sites.

Feasibility of Group-Based Implementation Facilitation for Video Telemental Health.

Video telehealth experienced rapid growth throughout the COVID-19 pandemic in many healthcare sectors, including mental health. The Veterans Health Administration's video telehealth platform, VA Video Connect, has been widely used to reach veterans who may have experienced difficulty accessing care, such as those living in rural areas or other barriers (e.g., transportation). Implementing VVC requires a multifaceted approach, including training providers on technical skills, increasing access to equipment for providers and veterans, and integrating VVC within the culture and processes of the clinic unit. Prior successful VVC implementation efforts in rural areas have focused on simultaneous one-on-one provider and leadership engagement using implementation facilitation (IF). However, given the rapid need for VVC expansion in light of limits and dangers associated with in-person care during the pandemic, our team developed group facilitation to increase the reach of VVC implementation through IF. Group facilitation combined training in technical and policy elements of VVC with IF with groups of providers from clinic units. This approach was designed to rapidly disseminate the necessary knowledge to conduct VVC combined with collaborative problem solving as a team to improve the ability of the clinical team to sustain VVC. Attendees were asked for feedback on the session through multiple choice and open-ended questions. Participants (N = 26) reported being highly satisfied with the training and reported a high degree of confidence in their ability to use VVC. Based on evaluation data and interview feedback, providers and clinic leaders were satisfied with group facilitation. Group facilitation may be a helpful tool in rapidly training clinical teams to implement and sustain video telemental health.

Patterns of Telehealth Use for Mental Health Treatment Among Hispanic Veterans.

Background: Video-to-home telehealth (VTH) is promising for increasing access to mental health (MH) services. VA Video Connect (VVC) facilitates video-based teleconferencing between patients and providers and can reduce barriers while maintaining clinical effectiveness. Little is known about the preferences of Hispanic veterans for VTH. Methods: A retrospective cohort investigation of VTH for MH care utilization among veterans having at least one MH visit from October 2019 to September 2020. The veterans consisted of 155,492 Hispanic/Latino and 1,544,958 non-Hispanic/Latino. VVC involved face-to-face synchronous video-based teleconferencing between patients and providers, enabling care at home or another private location. The main measures included the percentage of MH encounters delivered through VVC. Results: Compared with non-Hispanic veterans, Hispanic veterans had 3.28% greater percentage of VVC MH encounters. Furthermore, there was a 2.65% increase per month in percentage of VVC MH encounters. Conclusions: Contrary to preconceived notions, Hispanic veterans access VTH at higher rates than their non-Hispanic counterparts.

Prevalence of sexual desire and arousal difficulties among women veterans: A retrospective cohort design.

Low sexual desire and arousal are associated with several negative health outcomes, including reduced quality of life, depression, anxiety, and relationship discord. Although women veterans have high rates of risk factors for sexual dysfunctions (e.g., elevated rates of trauma, depression, anxiety), research on their sexual functioning is lacking. Using a retrospective cohort design, we examined the prevalence of documented sexual desire and arousal disorder diagnoses or symptoms, using International Classification of Diseases, 10th Revision codes, among 790,726 women veterans receiving care in the Veterans Health Administration (VHA). In fiscal year 2020, these symptoms and disorders were documented for only 0.19% (n = 1,494) of women veterans receiving care and symptoms of low sexual desire were documented more frequently than formal desire and arousal diagnoses. Most women veterans with desire and arousal problems were married (53.88%), and most (52.28%) were prescribed antidepressants. Mental health (MH) treatment for desire and arousal difficulties was commonly delivered in person (as compared to telephone or telehealth). Psychologists primarily treated desire and arousal concerns, providing an average of 2.81 MH encounters (SD = 7.53) compared to an average of 1.62 (SD = 5.25) MH encounters by social workers and 1.22 (SD = 2.53) by psychiatrists. Problems with low sexual desire and arousal are likely underassessed and undertreated within the VHA. Better assessment of women veterans' low desire and arousal is warranted to improve their well-being and quality of life. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Evidence of Phone vs Video-Conferencing for Mental Health Treatments: A Review of the Literature.

PURPOSE OF REVIEW: The goal of this paper is to provide a comparative review of using phone (audio-only) or video for mental health treatments. Our review includes evidence of phone and video's effectiveness in terms of reduced symptomology, retention, satisfaction, therapeutic alliance, and other outcomes of interest. This review also discusses how patients and providers' experiences and attitudes differ between these two modalities. Finally, we present information on different usage rates of phone and video across patient populations and mental health provider types, and different implementation strategies. RECENT FINDINGS: Treatments through phone and video are both able to reduce symptoms related to mental health conditions and have both been found to be non-inferior to in-person care. Both phone and video are more convenient to patients. Video offers important visual information that can be important to diagnosing mental health conditions. Phone, however, is more broadly accessible and may come with fewer technological issues. In the context of mental health care, where non-verbal cues are tied to symptomology and diagnosing, and a strong relationship between patient and provider can enhance treatment, we encourage the use of video, especially for psychotherapeutic services. However, as phone is more accessible, we ultimately recommend an accommodating approach, one that flexibly makes use of both phone and video. Future studies on telehealth should focus on direct, head-to-head comparisons between phone and video and conduct more rigorous testing on whether clinical differences exist.

Getting Connected: a Retrospective Cohort Investigation of Video-to-Home Telehealth for Mental Health Care Utilization Among Women Veterans.

BACKGROUND: Increasingly, women are serving in the military and seeking care at the Veterans Health Administration (VHA). Women veterans face unique challenges and barriers in seeking mental health (MH) care within VHA. VA Video Connect (VVC), which facilitates video-based teleconferencing between patients and providers, can reduce barriers while maintaining clinical effectiveness. OBJECTIVE: Primary aims were to examine gender differences in VVC use, describe changes in VVC use over time (including pre-COVID and 6 months following the beginning of COVID), and determine whether changes over time differed by gender. DESIGN: A retrospective cohort investigation of video-to-home telehealth for MH care utilization among veterans having at least 1 MH visit from October 2019 to September 2020. PARTICIPANTS: Veterans (236,268 women; 1,318,024 men). INTERVENTIONS (IF APPLICABLE): VVC involves face-to-face, synchronous, video-based teleconferencing between patients and providers, enabling care at home or another private location. MAIN MEASURES: Percentage of MH encounters delivered via VA Video Connect. KEY RESULTS: Women veterans were more likely than men to have at least 1 VVC encounter and had a greater percentage of MH care delivered via VVC in FY20. There was an increase in the percentage of MH encounters that were VVC over FY20, and this increase was greater for women than men. Women veterans who were younger than 55 (compared to those 55 and older), lived in urban areas (compared to those in rural areas), or were Asian (compared to other races) had a greater percentage of MH encounters that were VVC since the start of the pandemic, controlling for the mean percentage of VVC MH encounters in the 6 months pre-pandemic. CONCLUSIONS: VVC use for MH care is greater in women veterans compared to male veterans and may reduce gender-specific access barriers. Future research and VVC implementation efforts should emphasize maximizing patient choice and satisfaction.

Differential Impact of COVID-19 on the Use of Tele-mental Health Among Veterans Living in Urban or Rural Areas.

OBJECTIVE: The authors examined the use of Veterans Affairs Video Connect (VVC) for mental health care by rural and urban veterans and the impact of the COVID-19 pandemic on patterns of VVC use. METHODS: Data from 557,668 rural and 1,384,093 urban veterans (collected July 2019-October 2020) from the Veterans Health Administration Corporate Data Warehouse were examined with interrupted time-series models to determine rural versus urban VVC use before and during the initial 7 months of the pandemic. RESULTS: Before COVID-19, rates of VVC use as percentages of all mental health care were higher among rural veterans. After implementation of pandemic restrictions, rural veteran VVC use continued to increase, but this increase was surpassed by that of urban veterans. CONCLUSIONS: These findings highlight the need to monitor emerging disparities in telehealth use and to encourage and support use of VVC and access to mental health care for all veterans, particularly those experiencing barriers to care.

Factors influencing uptake of telemental health via videoconferencing at high and low adoption sites within the Department of Veterans Affairs during COVID-19: a qualitative study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic dramatically increased the use of telemental health via videoconferencing (TMH-V). While TMH-V has been found to be effective and satisfactory to both patients and providers, little is known regarding factors that influence site-level uptake. We examined facilitators and barriers to TMH-V uptake at higher and lower adoption sites within the US Department of Veterans Affairs (VA). METHODS: We conducted twenty-four semi-structured qualitative interviews at four northeastern VA medical centers (two with higher TMH-V adoption and two with lower adoption). Six interviews were conducted per site (one member of mental health leadership, one facility telehealth coordinator/technician, and four mental health providers per site). We performed directed content analysis, guided by the Consolidated Framework for Implementation Research (CFIR), followed by a matrix rating process to rank the degree of influence of each of the 19 included CFIR constructs at the four sites. Positive overall influences, negative overall influences, and differentiators were then identified based on patterns in ratings across sites. RESULTS: Five CFIR constructs had positive overall influences across sites: Relative advantage, Patient needs and resources, Relative priority, Knowledge and beliefs, and Self-efficacy. Complexity had a negative overall influence across sites. Four constructs significantly differentiated between higher and lower adoption sites with regards to TMH-V use: Quality, Compatibility, Leadership engagement, and Champions. CONCLUSIONS: Several positive overall influences on TMH-V uptake were identified across sites; respondents acknowledged multiple advantages of TMH-V (e.g., convenience), and providers' attitudes towards TMH-V improved as they gained experience. In contrast, complexity was a negative overall influence; TMH-V platforms and processes must be simple and user friendly to promote use. The emergence of Quality, Leadership engagement, and Champions as differentiators speaks to the importance of educating frontline staff and leadership at lower adoption sites about the evidence base demonstrating that TMH-V is high-quality care. Compatibility also emerged as a differentiator; if TMH-V is not easily integrated into provider workflows, uptake will falter. Future work should draw from these findings to develop implementation strategies aiming to increase TMH-V uptake at lower adoption sites, thereby increasing access to high-quality mental health care.

Current Approaches in Telehealth and Telerehabilitation for Spinal Cord Injury (TeleSCI).

Purpose of Review: Telehealth and telerehabilitation in spinal cord injury (teleSCI) is a growing field that can improve access to care and improve health outcomes in the spinal cord injury population. This review provides an overview of the recent literature on the topic of teleSCI and provides insights on current evidence, future directions, and considerations when using teleSCI for clinical care. Recent Findings: TeleSCI is used most often for preventive health; management of chronic pain, anxiety, and depression; and rehabilitation-related interventions. As video telehealth becomes mainstream, growth in wearable monitors, bio and neurofeedback mechanisms, and app-based care is expected. Summary: TeleSCI is growing in prevalence, demonstrates positive impact on health outcomes, and requires ongoing study to identify, refine, and implement best practices.

Comparing the Ratio of Therapist Support to Internet Sessions in a Blended Therapy Delivered to Trauma-Exposed Veterans: Quasi-experimental Comparison Study.

BACKGROUND: Blended models of therapy, which incorporate elements of both internet and face-to-face methods, have been shown to be effective, but therapists and patients have expressed concerns that fewer face-to-face therapy sessions than self-guided internet sessions may be associated with lower therapeutic alliance, lower program completion rates, and poorer outcomes. OBJECTIVE: A multisite quasi-experimental comparison study with a noninferiority design implemented in routine clinical care was used to assess webSTAIR, a 10-module blended therapy derived from STAIR (skills training in affective and interpersonal regulation) for trauma-exposed individuals delivered with 10 weekly therapist sessions (termed Coach10) compared to 5 biweekly sessions (Coach5). It was hypothesized that Coach5 would be as good as Coach10 in a range of outcomes. METHODS: A total of 202 veterans were enrolled in the study with 101 assigned to Coach5 and 101 to Coach10. Posttraumatic stress disorder (PTSD) symptoms, depression, emotion regulation, interpersonal problems, and social functioning measures were collected pre-, mid-, and posttreatment, and at a 3-month follow-up. Noninferiority analyses were conducted on symptom outcome measures. Comparisons were made of continuous and categorical measures regarding participant and therapist activities. RESULTS: Participants reported moderate to severe levels of baseline PTSD, depression, or both. Significant reductions were obtained in all symptom measures posttreatment and at the 3-month follow up. Coach5 was not inferior to Coach10 in any outcome. Therapeutic alliance was at an equivalently high level across the 2 treatment conditions; completion rates and web usage were similar. Total session time was substantially less for the Coach5 therapists than the Coach10 therapists. Both programs were associated with a low, but equal number of therapist activities related to scheduling and crisis or motivational sessions. CONCLUSIONS: A blended model delivered with 5 sessions of therapist support was noninferior to 10 sessions in individuals with moderate to severe symptoms. Future studies identifying patient characteristics as moderators of outcomes with high versus low doses of therapist support will help create flexible, technology-based intervention programming.