Table 3.

Adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) of facility- and state-level characteristics on Telemental health (TMH) adoption among mental health facilities in the United States, results from adjusted multi-level logistic regressions.

Variables	Model 2 AOR [95% CI]	Model 4 AOR [95% CI]	Model 5 AOR [95% CI]
Level-1: Facility characteristics
Type of facility
Care setting
Residential	1.27 [0.98, 1.63]	1.27 [0.99, 1.64]	1.27 [0.99, 1.64]
VAMC	18.30 [10.52, 31.82]***	18.38 [10.57, 31.97]***	18.53 [10.66, 32.21]***
CMHC	2.46 [2.03, 2.98]***	2.46 [2.03, 2.98]***	2.41 [1.99, 2.93]***
Outpatient	1.57 [1.30, 1.89]***	1.57 [1.31, 1.89]***	1.56 [1.30, 1.88]***
Multi-setting	1.94 [1.43, 2.62]***	1.94 [1.43, 2.63]***	1.94 [1.43, 2.63]***
Psychiatric inpatient	Reference
Ownership
Private-non-profit	1.10 [0.94, 1.29]	1.11 [0.95, 1.29]	1.10 [0.95, 1.29]
Public	1.67 [1.39, 2.01]***	1.67 [1.39, 2.01]***	1.66 [1.38, 2.00]***
Private-for-profit	Reference
Religious affiliation
Yes	0.72 [0.57, 0.91]**	0.72 [0.57, 0.91]**	0.72 [0.57, 0.91]**
No	Reference
Annual mental health admissions
100–250	1.10 [0.92, 1.32]	1.10 [0.92, 1.32]	1.10 [0.92, 1.32]
250–500	1.27 [1.05, 1.52]*	1.27 [1.05, 1.52]*	1.26 [1.05, 1.52]*
500–1000	1.33 [1.12, 1.59]**	1.33 [1.12, 1.58]**	1.33 [1.12, 1.59]**
>1000	1.39 [1.15, 1.67]**	1.39 [1.15, 1.67]**	1.39 [1.15, 1.68]**
0–100	Reference
Total patientsa
100–250	1.11 [0.97, 1.27]	1.11 [0.97, 1.27]	1.12 [0.98, 1.28]
250–500	1.10 [0.91, 1.32]	1.09 [0.91, 1.32]	1.11 [0.92, 1.33]
500–1000	0.86 [0.64, 1.15]	0.86 [0.64, 1.14]	0.87 [0.65, 1.16]
>1000	1.41 [1.08, 1.83]*	1.41 [1.08, 1.83]*	1.42 [1.09, 1.84]*
1–100	Reference
Comprehensiveness of mental health treatments
Treatment focus
Mental health & Substance Abuse	1.24 [1.10, 1.39]***	1.24 [1.10, 1.39]***	1.23 [1.10, 1.38]***
General services	1.38 [1.00, 1.90]*	1.38 [1.01, 1.90]*	1.38 [1.01, 1.90]*
Mental health only	Reference
# of mental health treatment approachesb
4–5	2.00 [1.69, 2.37]***	2.00 [1.69, 2.37]***	2.00 [1.69, 2.36]***
0–3	Reference
# of mental health servicesc
≥5	1.80 [1.61, 2.00]***	1.80 [1.61, 2.00]***	1.79 [1.61, 2.00]***
0–4	Reference
# of special mental care programmesd
4–5	1.15 [0.99, 1.34]	1.15 [0.99, 1.34]	1.15 [0.99, 1.34]
0–3	Reference
Non-English services
Yes	1.20 [1.07, 1.35]**	1.20 [1.08, 1.35]**	1.21 [1.08, 1.36]**
No	Reference
Quality improvement practice
# of Quality Improvement practicee
4	1.13 [0.99, 1.29]	1.13 [0.99, 1.29]	1.13 [0.99, 1.29]
5	1.35 [1.19, 1.53]***	1.35 [1.19, 1.53]***	1.35 [1.18, 1.53]***
0–3	Reference
IT capabilityf
Moderate	1.91 [1.65, 2.21]***	1.91 [1.65, 2.22]***	1.90 [1.64, 2.20]***
High	2.93 [2.13, 4.03]***	2.93 [2.13, 4.04]***	2.89 [2.10, 3.98]***
Low	Reference
Payer mix
Medicaid
Yes	1.13 [0.91, 1.41]	1.13 [0.91, 1.41]	1.12 [0.90, 1.40]
No	Reference
Medicare
Yes	1.25 [1.08, 1.45]**	1.25 [1.08, 1.45]**	1.26 [1.09, 1.47]**
No	Reference
Veteran Health Administration
Yes	1.37 [1.21, 1.56]***	1.37 [1.21, 1.56]***	1.36 [1.20, 1.55]***
No	Reference
Private
Yes	1.51 [1.27, 1.79]***	1.50 [1.27, 1.78]***	1.47 [1.24, 1.74]***
No	Reference
Case mix
% of female patientsa
11–50%	0.77 [0.57, 1.05]	0.77 [0.57, 1.05]	0.78 [0.57, 1.06]
>50%	0.83 [0.61, 1.13]	0.83 [0.61, 1.13]	0.83 [0.61, 1.14]
0–10%	Reference
Having elderly patientsa
Yes	1.17 [1.03, 1.32]*	1.16 [1.03, 1.32]*	1.16 [1.02, 1.31]*
No	Reference
% of African American patientsa
>20%	0.74 [0.65, 0.85]***	0.74 [0.65, 0.85]***	0.74 [0.65, 0.85]***
0–20%	Reference
Having Hispanic/Latino patientsa
Yes	1.09 [0.98, 1.22]	1.10 [0.98, 1.22]	1.10 [0.98, 1.23]
No	Reference
Any minority patientsa
Yes	1.25 [1.00, 1.57]	1.24 [0.99, 1.56]	1.24 [0.99, 1.56]
No	Reference
% of MHSA patientsa
20–40%	1.03 [0.89, 1.19]	1.03 [0.89, 1.19]	1.03 [0.89, 1.19]
40–60%	0.95 [0.80, 1.14]	0.95 [0.80, 1.14]	0.96 [0.81, 1.14]
>60%	0.83 [0.70, 0.98]*	0.83 [0.70, 0.98]*	0.83 [0.70, 0.98]*
Not reported	0.81 [0.67, 0.98]*	0.81 [0.67, 0.98]*	0.81 [0.67, 0.98]*
0–20%	Reference
Annual % of veteran patients
>50%	2.74 [1.65, 4.56]***	2.75 [1.65, 4.57]***	2.75 [1.65, 4.57]***
Not reported	1.24 [1.02, 1.50]*	1.24 [1.02, 1.50]*	1.24 [1.02, 1.50]*
0–50%	Reference
Level-2: Policy characteristicsg
ATA telehealth coverage & reimbursement gradingh
A	–	1.02 [0.47, 2.21]	0.57 [0.31, 1.05]
B	–	0.91 [0.49, 1.68]	0.74 [0.46, 1.19]
C	Reference
Patient consenti
Yes	–	0.82 [0.52, 1.29]	0.84 [0.61, 1.17]
No	Reference
Licensurei
Individual state	–	1.70 [0.82, 3.56]	1.54 [0.88, 2.72]
FSMB Compact	–	1.63 [0.93, 2.86]	1.05 [0.69, 1.59]
Special telehealth	–	2.28 [1.02, 5.06]*	2.24 [1.16, 4.32]*
With exemptions	–	1.37 [0.73, 2.58]	1.09 [0.67, 1.78]
Not required/defined	Reference
Level-2: Market characteristicsg
Provider shortagej
High	–	–	0.90 [0.53, 1.54]
Moderate	–	–	1.41 [0.83, 2.39]
Low	Reference
% rural countiesj
10–20%	–	–	2.09 [1.33, 3.29]**
≥20%	–	–	2.36 [1.34, 4.18]**
0–10%	Reference
Level-2: Environmental resourcesg
% counties with broadband accessk
10–20%	–	–	1.02 [0.65, 1.62]
≥20%	–	–	1.63 [0.92, 2.87]
0–10%	Reference

Note: The study population included mental health facilities located in the 50 states and the District of Columbia that responded to the query about telemedicine use and patient characteristics in the 2016 N-MHSS. Facilities in American Samoa, Guam, Puerto Rico, and Virgin Islands were excluded due to insufficient information on telehealth policies.

^aN-MHSS measured total number of patients and patient mix of a facility on a specific day (April 29, 2016).

^bMental health treatment approaches evaluated in N-MHSS included individual psychotherapy, couples/family/group therapy, cognitive behavioural/dialectical behavioural therapy/behaviour modification, integrated dual disorders treatment, trauma therapy, activity therapy, electroconvulsive therapy, and psychotropic medication.

^cMental health services evaluated in N-MHSS included intensive case/case management/chronic disease/illness management, integrated primary care services, any counselling, family psychoeducation, education services, psychosocial rehabilitation services, psychiatric emergency walk-in services, suicide prevention services, peer support services, screening for tobacco use, smoking cessation services.

^dSpecial mental health programmes included mental health programmes that is dedicated or designed exclusively for serious mental illnesses, co-occurring mental and substance abuse disorders, post-traumatic stress disorder, senior/elderly patients or veterans.

^eQuality improvement practice evaluated in N-MHSS included continuing education, case review, outcome follow-up after discharge, utilization review, and satisfaction surveys.

^fThe IT capacity was defined as the level of technology involvement in 14 routine facility activities, including mental health intake, scheduling appointments, assessment/evaluation, treatment planning, client progress monitoring, discharge, referral, issue/receive lab results, prescribing/dispensing medications, checking medication interactions, health records, provider collaboration, billing, and satisfaction surveys. The level of technology involvement was measured by the mean score of all activities rated on a 3-point scale, where ‘1’ denotes no technology involvement (i.e. rely on paper), ‘2’ indicates partial involvement (i.e. both electronic and paper), and ‘3’ represents fully involvement (i.e. only electronic).

^genvironmental-, policy-, and market characteristics were measured for the state where the facility was located.

^hthe American Telemedicine Association (ATA) has given each state a grade (A, B, C, or F) for the coverage and reimbursement policies for TH, basing on health plan parity and Medicaid conditions of payment.

ⁱthe patient consent policy that requires informed consent before telehealth services and the licensure policy that requires licence for interstate telehealth practice were obtained from the Centers for Connected Health Policy’s (CCHP) annual State Telehealth Laws and Reimbursement Policies Report.

^jThe percentage counties with primary care physician (PCP) shortage, mental health professional (MHP) shortage, and the percentage of rural counties were obtained from the Area Health Resources File (AHRF).

^kBroadband access was defined as having access to 25Mbps/3 Mbps service; % counties with broadband access in the locating state were derived from the 2016 Broadband Progress Report.

^*p<0.05;

^**p<0.01;

^***p<0.001.