Integrating Telemental Health Into Primary Care Aids Diagnosis and Treatement-The HSB Blog 3/7/22

Our Take:

Telebehavioral health (TBH) and Telepsychiatry (TP) are increasingly gaining traction as a means of integrating behavioral health into primary care. With the tumultuous past two years and present time residual effects of the Pandemic, this may be the best time for the rise of telebehavioral healthcare. TBH and TP may allow for more accessible and affordable care with equal or better outcomes than in-person care, especially for diagnosis and treatment. Integration of TBH and TP is an important step in the reduction of disparities and a means of vouching for equity in different communities while consolidating health information on an online database and platform. The range of TBH and TP services comes in a magnitude of different approaches which allows for many levels of support and managed care coordination either synchronous or asynchronous (interaction in “real-time” and interaction at one’s pace, respectively). Patients have the advantage of their information being shared between their primary care physicians (PCPs) and telebehavioral health practitioners in a timely manner and with coordination to provide the best form of treatment.

Key Takeaways:

Psychologists reported increases in treating anxiety disorders, depressive disorders as well as trauma-and stress-related disorders according to the American Psychological Association’s 2021 COVID Practitioner Survey,
TBH and TP may allow for more accessible and affordable care with equal or better outcomes than in-person care, especially for diagnosis and treatment
There will be a 20% drop in the supply of psychiatrists by 2030, and the number of child psychiatrists is believed to already be insufficient to fulfill present and future demand
Telepsychiatry is [now] a covered insurance benefit for 87 million people according to Array Behavioral care a telepsychiatry provider.

The Problem:

Since the Covid 19 pandemic, not only has the need for behavioral health services increased, but telebehavioral health care has shown to be in even more demand. For example, in the American Psychological Association’s 2021 COVID Practitioner Survey, psychologists reported “increases in treating anxiety disorders (84%, up from 74%), depressive disorders (72%, up from 60%), and trauma-and stress-related disorders (62%, up from 50%).” Moreover, telepsychiatry “is [now] a covered insurance benefit for 87 million people and counting” per Array Behavioral care which claims to be the largest provider of telepsychiatry services. In addition, due to the national shortage of telebehavioral clinicians available for in-person care, many providers have been attempting to bridge the gap by delivering care through online platforms that can help make care more accessible and provide the same quality of care. For example, according to the Health Resources & Services Administration (HRSA), there will be a 20% drop in the supply of psychiatrists by 2030, and the number of child psychiatrists is already believed to be insufficient to fulfill present and future demand. As a result, many have turned to telebehavioral health to fill the void.

Similarly, the urgent need to broaden the delivery of mental health care has been recognized by health insurance providers who have not only supported TBH and TP but have paved the way by collaborating with providers to integrate TB into primary care and creating/joining programs to accelerate telebehavioral services. In 2020 when Association for Health Insurance Plans (AHIP) joined Psych Hub, a platform that created a space to speak on and gain educational insight on mental health, substance use/abuse, and suicide prevention. Psych Hub's Scientific Advisory Board, which identifies ideas to enhance mental health care delivery, includes a number of AHIP member health insurance carriers. These solutions are a means of establishing quality metrics to improve quality of care and “integrating evidence-based practices throughout the continuum of care.” This is of high importance more specifically for teens and adolescents who may have gone through setbacks and are experiencing social isolation, anxiety, and depression due to school closings, graduation cancellations, and other burdens linked to the Pandemic.

The Backdrop:

Telemedicine continues to show exceptional outcomes for patient care with a plethora of different approaches and models. According to a study entitled “Use of Telemental Health Services During and After COVID-19”, “the survey findings support the continued use of telehealth services offered by mental health providers and organizations, as respondents indicated a desire to use these services more following the pandemic.” TP and TBH have shown benefits and have been sought after by many patients who are unable to receive care in person or unable to use in-person care due to lack of transportation, an inability to take time off from work, or other caretaker responsibilities. However, while the delivery of behavioral health services digitally increased during COVID, one area that continues to need additional progress is the integration of behavioral health services into primary care services.

There are a number of telebehavioral health models for care delivery including the Collaborative model, the Integrated model, and the Stepped Care model. All of these have provided a framework to make TBH services viable and feasible to integrate into primary care. The Collaborative Care model is a systematic approach that links care managers and psychiatrists with primary care physicians. This model allows for flexibility and engagement with patients to encourage management self-management and treatment adherence. Outreach encounters are maximized through the collaboration of many practitioners to ensure diagnosis and care are effectively coordinated and handled in a timely manner. The Stepped Care approach model uses more intensive care when less intensive treatments appear insufficient in primary care. It can be used in TP for the treatment of anxiety and depression and other mental health illnesses. In the Integrated based model, “a team of primary care and BH clinicians work together with patients and families using a systematic and cost-effective approach to provide patient-centered experiences to address health behaviors, medical illness, life stressors and crises, mental illness, substance, and ineffective patterns of health care utilization.” The integrated approach is not as extensive timewise and is driven to resolve behavioral healthcare issues while not heavily relying on technology (not evaluated for TBH or TP).

Implications:

The integration of TBH and TP into primary care has brought about many positive outcomes for both clinicians and patients. The flexibility of practitioners working from home and the access patients have for mental health care online removes any barriers that are present with in-person care such as transportation, convenience or exposure to disease such as COVID. The coordination and collaboration of primary care physicians with mental health providers enables more patient addition points of entry to the health system and a smooth transition to delivering a diagnosis and treatment in a timely manner. It is also a more cost-effective means of providing patient-centered care by cutting costs of additional fees or referrals and facilitating inclusive value-based care.

However, one issue is the current and projected shortage in the behavioral health workforce even with the advent of telebehavioral health solutions. While telebehavioral health can help extend strained resources, it will not completely close the gap. In addition, even with the current increase in the use of digital tools some practices are not fully equipped to integrate TBH or TP into their practice structure or make system-level changes due to limiting factors such as technological capabilities. Some PCPs do not have the skill set needed to use the appropriate based evidence-based therapies and intervention techniques to work alongside behavioral practitioners since the specialties have always been handled separately. It is imperative that policymakers provide PCPs with additional training and resources to allow for a smooth transfer of TBH and TP into their practice by implementing integrated care models to yield appropriate improvements in quality care, particularly at times of stress like during the Pandemic.