Provider and leadership attitudes towards telemental health at sites with high levels of video, phone, and in-person care: a qualitative analysis

Abstract

Objective:

This study examined mental health (MH) provider and leadership attitudes towards the use of video, phone, and in-person MH care within the US Department of Veterans Affairs (VA).

Methods:

Twenty-four semi-structured qualitative interviews were conducted at six VA medical centers between January-June 2024 (two high video use sites, two high phone sites, and two high in-person sites). Four interviews were conducted per site (three MH providers and one member of MH leadership). Interviews underwent rapid qualitative analysis informed by the Integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework.

Results:

Attitudes towards video care were largely positive across respondents and sites, and most respondents felt the quality of video care was comparable to in-person. Beliefs about phone care varied substantially, with some citing the loss of important non-verbal information as a major deterrent to use, while others noted phone’s benefits in increasing access to care for vulnerable Veterans. High video sites tended towards more negative views of phone care as opposed to the high phone and in-person sites. Site-level guidance varied regarding the permissibility of phone care.

Conclusions:

Findings describe a unique post-pandemic period in care modality decision-making in which there is an unprecedented amount of choice and variability in how MH services are delivered. It will be important to equip providers, patients, and leadership with comprehensive information regarding the relative benefits and drawbacks of each modality, as well as resources that can improve access to care, to help inform decision-making and ensure provision of high-quality MH services.

Introduction

The COVID-19 pandemic led to a rapid rise in the use of telemental health to ensure continued access to care while protecting patients and providers from infection during in-person visits (Appleton et al., 2021). The Department of Veterans Affairs (VA), the nation’s largest healthcare system, experienced a dramatic increase in both synchronous video visits and audio-only phone calls at the start of the pandemic (Connolly et al., 2021). Video visits, while allowing patients and providers to both see and hear each other, may be more complex to complete than phone calls, given that they require users to navigate a videoconferencing platform, have access to a video-enabled device, and have adequate broadband connectivity. For this reason, in the early months of COVID-19, a considerable amount of telemental health care within VA occurred via phone, as it had fewer barriers to access while VA was building up their video telehealth infrastructure (Rosen et al., 2021). As time has passed since the start of the pandemic, the relative use of video, phone, and in-person mental health (MH) care has shifted within VA (Ferguson et al., 2024b). Rates of in-person care grew as COVID-related restrictions were removed, and the amount of video use relative to phone increased as sites became better equipped to offer video care. Indeed, by the summer of 2020, VA had begun encouraging providers to shift away from phone care and designated video visits as the preferred remote care modality (Rosen et al., 2021).

In the current post-pandemic climate, MH patients, providers, and leadership have an unprecedented amount of choice regarding the modality through which care is delivered. Telemental health care has become commonplace in many healthcare systems and both patients and providers have become more comfortable navigating remote MH visits (Jones et al., 2024; Zhu et al., 2024). In addition, there is strong evidence that video care is equivalent to in-person services based on a collection of rigorous controlled trials (Acierno et al., 2016; Egede et al., 2015; Morland et al., 2020). At the same time, many are embracing a return to the benefits of in-person MH visits following the end of the COVID-19 public health emergency in May 2023 (U.S. Department of Health and Human Services, 2023). Site-level guidance regarding video versus phone care may also have continued to shift as video infrastructures have improved and concerns about the quality of, and preference for, phone care have emerged.

While a growing body of research conducted during the pandemic has demonstrated satisfaction with video and phone telehealth across both patients and providers (Connolly, Ferris et al., 2024), other evidence suggests that phone care may be lower quality or less preferred than video. Specifically, a meta-analysis found that both phone and video were effective in the treatment of depression and trauma in Veterans, but effect sizes were stronger within the video condition (McClellan et al., 2022). Similarly, a study conducted during COVID-19 found higher rates of psychiatric emergency room visits among Veterans primarily treated by phone versus video (Meshberg-Cohen et al., 2023). There has also been a collection of smoking cessation studies reporting higher medication compliance, treatment completion, and sustained abstinence among those treated by video versus phone (Kim et al., 2018; Liebmann et al., 2019; Richter et al., 2015). In addition, a qualitative review found that both providers and patients had concerns around the safety of phone visits and the ability to develop a strong therapeutic alliance when unable to see each other (Connolly, Adusumelli, et al., 2025). However, other research has demonstrated an important role for phone care in the treatment of vulnerable and hard-to-reach patients. This could include those who live in rural and remote locations, have transportation difficulties, or who may lack access to video visits due to technology-based barriers (e.g., not having a device, sufficient internet connectivity, or the degree of digital literacy required to navigate a telehealth platform) (Connolly et al., 2021; Connolly, Adusumelli et al., 2025,Connolly, Amspoker et al., 2025; Lam et al., 2020; Rodriguez et al., 2021).

Given this complex interplay of factors, it is critical to better understand the decision-making process around MH care modality use and how it may differ at the site level. It is unclear to what extent providers and MH leadership are aware of potential differences in quality and effectiveness of video and phone telehealth, and whether this information may inform their decision-making. It is also possible that some may be more open to phone care as a way to increase access for hard-to-reach Veterans. These differences may have impacts at both the provider and site levels, as MH leadership may provide guidance to their staff regarding site procedures and best practices. This study sought to explore these questions by conducting qualitative interviews with MH providers and leadership at six VA medical centers with high levels of video, phone, and in-person MH care. Interviews were informed by: 1) the Integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework (Harvey & Kitson, 2015), which examines the role that a given innovation, its recipients, and the context play in influencing uptake of an innovation; and 2) the National Academy of Medicine (NAM) definition of care quality, which considers the extent to which care is safe, timely, effective, efficient, equitable, and patient-centered (Committee on Quality of Health Care in America, 2001). Findings aim to shed light on the ways in which provider and leadership preference, beliefs about care quality, and site-level guidance may impact the MH care modality decision-making process. Results could help to identify ways to improve this decision-making process to ensure that providers and leadership are well-informed when choosing between video, phone, and in-person MH care.

Methods

Facility selection

Six sites were selected from 122 eligible VA medical centers across the United States; seven medical centers were excluded including one non-US site, five that are transitioning electronic medical record vendors, and one joint VA/Department of Defense facility. Sites were chosen based on the percentage of Veterans who had received most of their outpatient MH care via video, phone, or in-person visits between July 2021-October 2022, as determined by administrative data obtained from the VA Corporate Data Warehouse. Sites were ranked based on the percentage of patients that fell into each of these three categories. Two sites were chosen from among the ten sites with the highest percentages of patients receiving majority video care (high video sites; Site 1: 74% of patients received majority video care; Site 2: 60%). The same method was used to choose two high in-person sites (Site 3: 78% of patients received majority in-person care; Site 4: 65%) and two high phone sites (Site 5: 49% of patients received majority phone care; Site 6: 48%). The six sites represented a variety of geographic regions as well as hospital complexity levels. Hospital complexity scores account for factors including the size of the patient population, range of clinical services offered (e.g., whether there is an intensive care unit), research and educational programs (e.g., the number of trainees and research dollars), and operational costs (see National Academies of Sciences, Engineering, and Medicine, 2019). VA hospitals are assigned a complexity rating of 1a, 1b, 1c, 2, or 3, with Level 1a being the most complex and Level 3 being the least complex. Four sites were higher complexity facilities (one Level 1a, one 1b, and two 1c) and two sites were lower complexity (Level 3). One site was in the Northeast United States, one was in the Southeast, one was in the Midwest, one was in the Southwest, and two were in the West.

Study participants

Twenty-four employees participated in qualitative interviews between January-June 2024; 111 employees were invited to participate via a series of emails (22% participation rate). Recruitment emails emphasized that participation was voluntary and confidential. Providers were identified via the VA Support Service Center database, which lists providers’ names, discipline, and number and type of completed MH visits. Preference was given to providers who had recently completed visits via the modality group that their site was assigned to. For example, for the high video sites, providers who had recently completed video visits were prioritized for recruitment. Both medical MH providers (e.g., psychiatrists, nurse practitioners) and non-medical MH providers (e.g., psychologists, social workers), were interviewed at each site to represent the full breadth of MH services provided, including both medication management and psychotherapy, as the relative utilization and perceived benefits of video, phone, and in-person care may vary across visit types (Connolly, Charness, et al., 2024). Members of MH leadership were identified via medical center websites and information provided by interviewed MH providers.

Interview guide development

A semi-structured interview guide was developed in part based on the i-PARIHS framework; questions were mapped onto i-PARIHS constructs where applicable (i.e., Innovation, Recipients, Context) as well as corresponding subcodes from an established i-PARIHS qualitative data analysis codebook (see Ritchie et al., 2022 for full codebook). The i-PARIHS Innovation construct refers to characteristics of the innovation (e.g., video care) that may influence implementation, and includes subcodes such as Relative Advantage (e.g., perceived advantages of video care over phone). The Recipients construct examines characteristics of individuals that may help or hinder implementation and includes subcodes such as Skills and Knowledge (e.g., provider knowledge of differences in effectiveness of video and phone care). Finally, the i-PARIHS Context construct includes characteristics of the context in which an innovation is being implemented that could influence outcomes, and includes subcodes such as Leadership Support (e.g., the degree to which respondents feel leadership is supportive of video versus phone care). Questions comparing the quality of video, phone, and in-person care incorporated the NAM quality of care definition, such that respondents were asked to compare the extent to which each modality was safe, timely, effective, efficient, equitable, and patient-centered. The semi-structured nature of the guide allowed for additional discussion of any emerging factors that may have impacted modality use at the site. The first author (SLC) developed an initial draft of the interview guide and revised it based on feedback from authors JLS and CJM (see Supplementary Materials for full interview guide).

Procedure

Respondents participated in 30 to 60-minute semi-structured qualitative interviews conducted via telephone by SLC. Interviews were audio-recorded and professionally transcribed. The VA Boston Institutional Review Board (IRB) exempted this study from IRB review, and a waiver of documentation of informed consent was approved by the VA Boston Research and Development Committee, which maintained regulatory oversight for the study. Participants provided verbal informed consent prior to interview initiation and participation was voluntary.

Data coding and analysis

We used rapid qualitative analysis methods (Hamilton & Finley, 2019; Kowalski et al., 2024). SLC developed a summary template in Excel that was used to code each of the 24 interviews. Each interview question was listed in a separate row, and relevant segments of the interview transcript for a given respondent were directly pasted into the corresponding row. SLC read the transcript segments and wrote a summary of information based on the raw data. SDF then double-coded the transcript segments, adding any additional thoughts and noting disagreements with any of SLC’s impressions. Each row also indicated the a priori i-PARIHS construct and subcodes associated with each interview question. For example, the question comparing the relative quality of the modalities was labeled a priori with the Innovation construct and Relative Advantage subcode. SLC and SDF (hereafter referred to as the coders) added any additional i-PARIHS subcodes that they felt were applicable upon reviewing the raw transcript data, and also noted other themes that emerged outside of the i-PARIHS framework. The coders met weekly to discuss coding decisions, resolve conflicts, and come to final consensus.

Following this phase, the summaries for each interview question per participant were entered into site-level Excel matrices, with each row representing an interview question and each column representing one of the four respondents per site. The coders then developed high-level summaries of similarities and differences emerging at the site level for each interview question. They discussed their impressions, resolved any conflicts, and came to final consensus. These site-level impressions were then entered into a cross-site Excel matrix, with each row representing an interview question and each column representing a site. The coders summarized findings across sites, noting any similarities or differences that emerged between high video, phone, and in-person sites. They then met to review their summaries, resolve any conflicts that arose, and come to consensus. Finally, SLC looked across summaries and determined which interview questions stood alone as individual themes, and which could be combined together into a unifying theme. The corresponding i-PARIHS constructs and subcodes were then mapped onto this final set of themes.

To strengthen the rigor of our analyses, we followed the Standards for Reporting Qualitative Research (SRQR; O’Brien et al., 2014). We used an established qualitative analytic approach, clearly documented our sampling and analysis strategy, and involved multiple coders who met frequently to achieve final consensus. The creators of the interview guide (SLC, JLS, CJM) have substantial implementation science, MH, and qualitative research experience within VA; SLC and CJM are clinical psychologists, and JLS is an implementation scientist. SLC completed coding along with SDF, who has undergone rigorous qualitative training, has prior experience conducting qualitative analyses within VA, and has an educational background in health policy and mental health.

Results

Four interviews were completed at each of the six sites, including one to two nonmedical MH providers (total of five psychologists and six social workers), one to two medical MH providers (total of four psychiatrists, two nurse practitioners, and one clinical pharmacist), and one member of MH leadership (one psychology executive, one outpatient MH chief, one MH chief, one deputy MH chief, one MH program manager, and one MH outpatient division manager; all six members of MH leadership were psychologists by training). The sample included 17 women (71%) and 7 men (29%). Findings are reported below for each of the key themes, with notable cross-site differences highlighted throughout and relevant i-PARIHS constructs and subcodes included in parentheses. See Table 1 for a summary of findings.

Table 1.

Study themes and corresponding i-PARIHS constructs and subcodes

Study theme	Summary of findings	i-PARIHS constructs and subcodes
Modality preference	Most preferred video or in-person care as opposed to phone In-person was preferred due to feelings of improved rapport, increased clinical effectiveness, and decreased distraction Video was preferred due to increased accessibility for patients and improved quality of life for providers working hybrid or remote schedules	Innovation: relative advantage; evidence (clinical experience, patient needs and preferences) Recipients: general attitude
Quality of care	Most agreed that the quality of video and in-person care was comparable with tradeoffs Video was seen as more convenient and accessible but could have technological glitches and requires tech literacy In-person care was noted by some as having clinical quality advantages Most felt the quality of phone care was inferior due to lack of non-verbal information Respondents from high phone and in-person sites were more likely to note benefits of phone including reaching vulnerable Veterans, serving as a back-up option, and working well for briefer visits and medication management	Innovation: relative advantage; complexity; evidence (clinical experience, patient needs and preferences)
Is phone care necessary	Some felt there was no need for phone as all patients could be accommodated in-person or via video, including by providing Veterans with a tablet if needed Others felt that certain Veterans would lose care without the option of phone (Veterans with mobility/transportation challenges, unreliable or no access to the internet, low tech literacy)	Innovation: complexity; evidence (patient needs and preferences) Context: infrastructure, resources, and support
Site level guidance and leadership involvement	Both high video sites and one high in-person site had guidance stating phone was “not allowed” Both high phone sites and one high in-person site discouraged phone but allowed it if necessary Multiple respondents cited lower workload credit as a contributor to the discouragement of phone, but there was no confirmation that this change in credit was ever enacted Leadership at high phone sites have made efforts to decrease phone use with varying success Leadership across sites support video use, in part because the ability to offer providers hybrid/remote work has increased recruitment and retention	Context: policies and priorities; leadership support; evaluation, monitoring, and feedback; culture and climate; incentives and rewards; infrastructure, resources, and support
Modality decision-making process	Respondents cite patient preference as a major contributor Clinical judgment was also a contributor, including deciding to shift modalities if needed to improve effectiveness Research demonstrating video’s effectiveness in part informs decision-making Less awareness of phone research but some have seen findings that phone is effective	Innovation: evidence (patient needs and preferences, clinical experience, research) Recipients: power; skills and knowledge Context: policies and priorities
Improving the decision-making process	Need for more access to data to inform decision-making, including relative effectiveness of the modalities and wait times Need for better ways to document decision-making process in the medical record Providers should balance honoring patient preference and using their clinical judgment as needed	Innovation: relative advantage; evidence (patient needs and preferences, clinical experience, research) Recipients: power; skills and knowledge Context: evaluation, monitoring, and feedback; structures and systems

Modality preference

Respondents were asked which MH care modality they most preferred: video, phone, or in-person. Preferences were largely split between in-person and video care (Recipients: general attitude). Respondents who preferred in-person care felt that it had advantages in terms of quality and effectiveness (Innovation: relative advantage; evidence [clinical experience]). Some expressed beliefs that patients took in-person visits more seriously than virtual appointments and were less likely to be distracted. Others noted being better able to build rapport with patients in-person as opposed to virtually, which was particularly relevant when treating new patients.

I prefer [in-person] especially for people that are new to treatment and are new to their sobriety, because it helps give them a point person, a face that they feel like they can rely on. There’s a little bit of a disconnect [on video calls] because there may be a little bit of delay speaking or [the video is blurry]. So sometimes it’s hard to create that rapport that you’ll want to have with a patient to really completely engage them…

(Participant 603, psychiatrist)

Some respondents who preferred video cited increased access to care and convenience for their patients, particularly those who lived further from the medical center or had busy schedules that made traveling to in-person appointments difficult, including those who worked full-time (Innovation: evidence [patient needs and preferences]). Others who preferred video described improved quality of life as a provider, as they were able to work from home some of the time (Innovation: relative advantage).

I think that helps me with provider burnout… I think it’s really nice to be home at least one day a week because [I don’t have to commute]. I don’t have a window in my office at work. It’s really nice to be able to step outside more easily and work near a window. Things like that, that make quality of life a little bit better…I think have an impact on how I show up for work on the other days.

(Participant 401, psychologist)

Regarding site-level differences, most respondents at one of the high video sites preferred video, and most respondents at one of the high in-person sites preferred in-person, but these patterns did not hold across all sites. One fully remote provider at a high phone site expressed a preference for phone sometimes as a break from feelings of screen fatigue on video calls. The remaining respondents at high phone sites preferred video or in-person.

Quality of care

Respondents generally felt that the quality of video and in-person care was comparable, and that each modality had tradeoffs (Innovation: relative advantage). This pattern held across all sites. While video care was seen as more convenient and accessible for patients, respondents also cited the occurrence of technological glitches and the need for patients to have sufficient technological literacy (Innovation: evidence [patient needs and preferences], complexity). Conversely, in-person care was described as harder to access for some patients but was noted as having some advantages in terms of clinical effectiveness (Innovation: evidence [patient needs and preferences, clinical experience]).

There are pros and cons to both [video and in-person]. I think access to care, you got to give the nod to a video appointment. How convenient is it for someone with ambulation issues or financial issues, transportation issues to see [their provider] on video? I mean, it’s just… so much better. I do think there is a stronger connection that can be made [in-person]. You’re not using this other external medium of banking on someone’s internet connection or someone’s phone update. It’s just organic in the room.

(Participant 303, nurse practitioner)

When asked to compare the quality of phone care to video and in-person, there was general agreement across most respondents that the lack of nonverbal information on phone calls negatively impacted quality (Innovation: relative advantage; evidence [clinical experience]). This included being unable to interpret patients’ facial expressions, grooming, and their environment, including whether they were in a safe place.

I don’t like audio-only because I can’t see their expressions. I can’t see how they’re dressed. I can’t see how their self-care is. I’m going to react very differently to someone who’s just rolled out of bed and wearing their pajamas at one o’clock in the afternoon. And I think there’s a lot of things that they can just not disclose, and therapy really is about getting to where their pain is and helping them work through it and think differently. And you can’t get a good picture of what’s actually going on with them. And you don’t know, too, if [their symptoms are] severe.

(Participant 101, social worker)

However, a site-level distinction emerged, such that respondents at high video sites had more uniformly negative impressions of phone quality, while respondents at high in-person and phone sites also noted potential benefits of phone care. This included increasing access to care for Veterans who may have challenges connecting via video or in-person, such as highly rural Veterans who both live far from their nearest medical center but also may have poor broadband connectivity. Older Veterans who have mobility or transportation challenges and have trouble navigating video technology were also noted as benefiting from phone visits (Innovation: evidence [patient needs and preferences]; complexity). Some respondents also felt that phone can be an important option for Veterans in crisis who need to connect with a provider quickly: “There’s just a very low bar for [accessing] phone [care]. And so, I think that for especially those really vulnerable Veterans…having a low bar option is very valuable.” (Participant 304, MH chief)

Some respondents at high in-person and phone sites also shared beliefs that phone visits could be effective for treating lower severity, established patients whom they had already developed rapport with, as well as for quicker check-in appointments and medication management visits (Innovation: evidence [clinical experience]).

To be honest with you…other than me having a different idea of what they look like in my head…I mean, there’s a different level of connection, I guess, [when] you see what each other looks like. But as far as the quality of care… I still made beneficial [medication] changes [during phone visits] that I felt like the patients were improving in different areas with. I still felt like we were able to address their needs…so I don’t feel like [there] was any downfall [to phone visits].

(Participant 602, clinical pharmacist)

Is phone care necessary?

When asked whether offering phone care as an option was necessary, respondents had variable opinions, with no clear site-level differences emerging. Some felt that there was no need to offer phone care as all patients could be accommodated via in-person or video visits; some cited VA’s Connected Device program, which provides tablets with internet hotspots to Veterans without a device to complete video visits (Context: infrastructure, resources and support). This sentiment was shared by a member of leadership at one of the high video sites:

We’ve just had an issue with a Vet who apparently was very adamant that he’s refusing to come in or to do video. And we just said, no, [phone] is not good clinical care, in our opinion. We really need you to come in, and if you can’t come in, then we can’t continue to do this…[and] he actually agreed to try the [VA-issued] tablet.

(Participant 204, section chief of outpatient MH)

Multiple respondents worried, however, that certain Veterans would be unable to receive MH care if they were not allowed to complete phone visits (Innovation: evidence [patient needs and preferences]; complexity). This sentiment was shared by a provider at one of the high phone sites:

I think most folks would be negatively impacted by [not being able to receive care via phone]. Anyone from people with lack of resources, their internet’s down permanently, or they can’t afford [internet], or it’s just down today. Instead of canceling the appointment, I can still provide some good care [via phone]…and there are folks that aren’t going to drive three and a half hours to come to a one-hour [session], and they don’t have the resources to do that anyway. So, I think it’s huge barriers to care if… telephone [was] cut off.

(Participant 601, psychologist)

Site-level guidance and leadership involvement

Respondents at both high video sites described phone as being “not allowed,” while respondents at both high phone sites described more lenient guidance, such that phone was discouraged but could be used as needed (Context: policies and priorities). The high in-person sites varied, such that one did not allow phone while the other was open to using phone if necessary. Respondents across sites noted hearing that phone visits may receive less workload credit or reimbursement as compared to video or in-person visits, which they felt was impacting movement away from phone care, although no respondents confirmed that these changes had indeed been implemented (Context: incentives and rewards). Some felt that leadership’s decision to discourage phone visits was also tied to it being less clinically effective, although this was noted less frequently (Context: leadership support; Innovation: evidence [clinical experience]). Some respondents shared that MH leadership was explicitly tracking phone use and was following up with providers in an attempt to lower utilization (Context: evaluation, monitoring, and feedback). Both members of MH leadership at the high phone sites described efforts to decrease phone use, with varying success:

I pulled [visits] per provider and tracked that for a couple of years and really pushed the ones that were using more telephone to switch people over [to video]. [Providers] didn’t like it because, it kind of depends on their age, but some of them, it was easier to pick up the phone than it was to go in their calendar and pull up the right [video] link and then troubleshoot things with the Veteran…we had to push them. We also had to push the [schedulers] because they were offering telephone as equivalent. They were calling people saying, “Would you like to talk on the phone or do video or come in face-to-face?” …And we finally got them to stop even offering telephone, which was very helpful.

(Participant 604, outpatient MH division manager)

Leadership across sites was more uniformly in support of video use as compared to phone. A member of MH leadership at one of the high video sites described having “a culture here of therapists who liked doing [video] telehealth and really adapted to it” (Participant 104, psychology executive; Context: culture and climate). Leadership across facilities noted the value of allowing providers to have hybrid or fully remote work schedules which improved recruitment and retention efforts and helped to manage on-site space and parking issues which were noted across almost all sites (Context: infrastructure, resources, and support). Some members of MH leadership felt that higher level leadership at their facilities were not as supportive of remote work arrangements which was a source of frustration (Context: leadership support).

Modality decision-making process

When asked how it was determined whether a patient would receive their care via video, phone, or in-person, respondents across all sites emphasized the importance of considering patient preference (Innovation: evidence [patient needs and preferences]). Most noted that patients were explicitly asked which modality they would like to use, whether during their initial scheduling call or during follow up conversations with their provider. This typically involved a choice between video and in-person care, with phone being described as a last resort that was not presented to the patient as an initial option (Recipients: power). There was some variation in views towards phone care between sites, with one high video site describing phone as not an option in any circumstances, and one high phone site seeming more open to the possibility of offering phone visits. One high in-person site was unique in requiring all initial psychiatry appointments to occur in-person (Context: policies and priorities).

Multiple providers across sites noted that their clinical judgment also informed modality decision-making; if they felt a given modality was not working as effectively for their patient, they would recommend alternatives (Innovation: evidence [clinical experience]). Some also made shifting modalities an identified goal of treatment, such as for patients with anxiety and avoidance:

We start working on the coping skills, getting the basic foundation started [via video], and then we start increasing what the goals are… and then I’ll tell [the patient], “You know, one of the best things you could do… is [to meet with me in-person]”…and then I remind them, if it’s too much, sit out in your car and we’ll do a video, but make the drive. Let’s see what that’s like…it’s a matter of getting out of the house, depending on the circumstances we’ve worked up to that. We don’t just cold turkey it.

(Participant 203, social worker)

Some respondents noted that their decision-making was in part informed by existing telehealth research demonstrating the effectiveness of video care (Innovation: research; Recipients: skills and knowledge). Fewer respondents endorsed awareness of phone-related research, although some reported seeing evidence that phone was effective. There were some site-level differences in this regard. A member of MH leadership at one of the high video sites was open to seeing data demonstrating the effectiveness of phone care, but was skeptical that this would exist: “I mean, I guess if there was actual research that showed that there was efficacy for phone, we’d look at it and see whether or not it made sense. I just can’t imagine, though.” (Participant 204, section chief of outpatient MH). This perspective was contrasted with a member of MH leadership at one of the high phone sites, who cited examples of phone-based care being effective:

Way back when there was no video…there were a lot of studies published that were audio only. I can’t think of anything that I’ve seen recently that was audio only focused. I’m sure there’s stuff out there. I just haven’t seen it. But…the VA itself has several programs that were meant to be delivered over the phone…we’ve had audio only stuff in the VA for a long time… that has been shown to be useful… helpful and effective. This is why I have not outlawed phone visits. Because I think there’s still good work that’s done that way.

(Participant 504, MH program manager)

Respondents were generally open to considering additional research regarding telehealth effectiveness to help inform decision-making.

Improving the decision-making process

Respondents across multiple sites discussed the importance of improving the ways in which patients are offered various modalities of care. This could include ensuring that patients are given options of virtual and in-person treatment and are able to weigh the pros and cons of each modality, such as via a shared decision-making process with their provider (Innovation: relative advantage; evidence [patient needs and preferences]; Recipients: power). Some noted that it would be helpful to have better ways to track and record this decision-making process in the medical record, as well as to have access to data that could help inform patients’ decisions, including estimated wait times and the relative effectiveness of each modality (Innovation: research; Recipients: skills and knowledge; Context: evaluation, monitoring, and feedback; structures and systems). Other respondents emphasized the importance of balancing patient preference with clinical judgment when deciding what modality is most appropriate (Innovation: evidence [patient needs and preferences, clinical experience]).

I think that the piece of having this clinically indicated conversation is really important. I think my clinic tends to lean towards, if a Veteran says he wants this kind of treatment with this kind of provider in this kind of modality, we tend to err towards giving it to them, which I think is important because I think patient-centered care is important. And I also think at times, there are really good clinical reasons for challenging some of those pieces.

(Participant 403, psychologist)

Discussion

The current study examined differences in attitudes towards video, phone, and in-person MH care among providers and leadership at sites with varying levels of modality use. Several common themes emerged across all sites. This included that most respondents preferred either video or in-person care, and most agreed that the quality of these two modalities was largely comparable but that each had unique benefits and drawbacks. Specifically, video care was seen as more convenient and accessible for many patients, while others noted that in-person care may confer clinical advantages in some circumstances. The use of video visits was supported by MH leadership across all sites, with many describing benefits of increasing patients’ access to care and allowing providers to have hybrid or remote work schedules. However, at the time of this writing—and after all data collection for this project had been completed— an Executive Order mandated the full-time return to in-person work for federal employees, including VA providers (The White House, 2025). While VA is taking steps to ensure that the quality of video visits is not impacted (Riddle, 2025), it is unclear to what extent such mandates will impact the perceived advantages and drawbacks of in-person versus video care moving forward.

Attitudes towards phone care demonstrated more significant variation across sites. Most respondents generally agreed that the quality of phone care was inferior to video and in-person, largely due to the loss of important non-verbal information. However, respondents at high in-person and phone sites more frequently noted potential advantages of phone visits, including providing access to care for Veterans with transportation or mobility challenges, lower technological literacy, and insufficient internet connectivity, including those in rural areas. It is worth noting that the high in-person and phone sites were located in more rural areas of the country as compared to the high video sites, which may have made these potential benefits of phone visits more salient, as has been demonstrated in prior work (Connolly, Adusumelli et al., 2025). Some providers also noted the benefits of phone visits in reaching patients in acute crisis, as well as for briefer check-in visits with established patients.

There was substantial disagreement between respondents regarding whether it was necessary to offer phone care as a choice. Some felt that all patients could be accommodated via video or in-person visits, while others feared that certain vulnerable Veterans would be left behind if they could not be treated by phone. Indeed, while both of the high video sites and one of the high in-person sites had clearer guidance stating that phone was “not allowed,” both of the high phone sites and the other high in-person site discouraged phone use but were more open to circumstances in which it may be permitted to meet Veterans’ needs. However, leadership at both high phone sites did note efforts to decrease overall phone use at their sites. Concerns regarding lower workload credit for phone visits were frequently noted as a reason why phone was discouraged, although no respondent confirmed that these changes in credit had been implemented.

Respondents across all sites highlighted the importance of incorporating patient preference into the decision-making process when choosing a care modality. The value of clinical judgment was also emphasized, and at times providers felt it was important to counsel patients to switch modalities to improve effectiveness. Many respondents noted an awareness of research demonstrating that video care was effective, which impacted care modality decision-making. However, respondents’ familiarity with phone-specific research was less common, although some referenced findings supporting the use of phone. Respondents felt the decision-making process could be improved by having more access to data to inform choice, such as the relative effectiveness of the modalities or estimated wait times.

Overall, findings reflect a unique post-pandemic period in care modality decision-making, in which MH providers and leadership are weighing the relative advantages and drawbacks of video, phone, and in-person MH care. The increased convenience and accessibility of video care was noted across respondents and sites and was consistent with attitudes reported in prior research (Appleton et al., 2021; Connolly et al., 2020). Some providers also acknowledged added benefits of in-person treatment that are not easily replicated over a video screen, such as increased feelings of connection; similar sentiments have been shared in other qualitative studies (Lipschitz et al., 2023). However, beliefs about phone care varied substantially across respondents, with some citing the loss of important non-verbal information as a major deterrent to use, while others touted phone’s benefits in increasing access for highly vulnerable Veterans. Similarly, site-level guidance and leadership attitudes towards phone care showed considerable variability, with some members of leadership being skeptical of phone’s effectiveness and deeming it “not allowed,” while others were aware of evidence demonstrating the value of phone and were more open to retaining audio-only care as a treatment option if needed. Indeed, this idea that phone care may be more accessible but potentially lower quality aligns with findings from a recent qualitative review of the topic (Connolly, Adusumelli, et al., 2024).

Moving forward, providers and leadership would benefit from increased access to research that directly compares the effectiveness of phone, video, and in-person care to help inform decision making. While phone care has been shown to be effective and satisfactory in the treatment of certain MH conditions, outcomes may be less favorable than video care when the two modalities are directly compared, suggesting that there may be benefits to choosing video if feasible (Connolly, Ferris et al., 2024; McClellan et al., 2022; Meshberg-Cohen et al., 2023). It will also be important to better understand why some Veterans receive phone care and whether they are experiencing barriers to video or in-person visits that could be addressed, such as by providing a VA-issued tablet (Ferguson et al., 2024a), offering increased technical support and telehealth training, or raising awareness of VA’s ability to reimburse travel to in-person appointments (U.S. Department of Veterans Affairs, 2024). However, despite these efforts, there will likely remain some Veterans who are unwilling or unable to receive care via video or in-person. In these cases, MH leadership and providers may need to reframe their decision-making as a choice between phone care and no care at all.

Similar concerns exist outside of the VA as well. A recent analysis of Federally Qualified Health Centers found steady continued use of both video and phone MH visits post-pandemic among low-income populations; between 2022 and 2024, approximately 25% of visits occurred by video and 25% occurred by phone (Uscher-Pines et al., 2025). As the Centers for Medicare and Medicaid Services and many private insurers continue to cover phone MH visits, audio-only care remains a viable option in the civilian population (Center for Connected Health Policy, 2023; Health Resources and Services Administration, 2023). Providers and patients will need to carefully weigh the pros and cons of each modality, particularly when treating vulnerable groups.

Limitations of this work include its restriction to six VA facilities, which may not be representative of other VA medical centers. However, we chose these six facilities based on their variety, both in terms of modality preferences and key facility-level variables such as geographic region and hospital complexity, to increase the applicability of these findings to other sites. Findings may also not generalize to non-VA locations which have different contextual considerations including insurance reimbursement as well as unique site-level guidance that may have impacted care modality use. Similar qualitative analyses conducted outside of VA that examine differences in attitudes between video, phone, and in-person care are needed to account for these differences. Patient perspectives are not included; it will be important to report their attitudes as well, particularly given that most respondents cited patient preference as a major contributor to care modality decision-making. Of note, the current study also included a patient interview component, and findings from this aim are forthcoming. Finally, while the authors took multiple steps to improve the rigor of qualitative analyses, there remains the potential for bias in the interpretation of study findings.

In sum, the current work reflects a new post-pandemic era of choice in how MH care is provided, whether by video, phone, or in-person. It will be important to equip providers, patients, and MH leadership with the most up to date research findings regarding the relative effectiveness of the modalities across various MH conditions, resources that can improve access to care, and additional contextual information such as wait times to help inform their decision-making process. These efforts will help to ensure that patients receive high quality MH care via a modality that is both clinically effective and aligned with their preferences.

Public Significance Statement:

This qualitative study of mental health providers and leadership found that attitudes towards video mental health care were positive, such that the quality of video care was seen as largely comparable to in-person. However, beliefs about phone care were more variable, with some viewing phone as an important way to increase access to care, while others were concerned that it may be lower quality. Attitudes towards phone varied by site.