Rapid Creation of Child Telemental Health Services During COVID-19 to Promote Continued Care for Underserved Children and Families

Abstract

The COVID-19 pandemic prompted the rapid transformation of child mental health services from mostly in-person to fully remote delivery at an urban safety-net hospital. No-show rates substantially declined when implementing video visits, and the volume of service delivery was unchanged compared to prepandemic in-person visits. In addition, no-show rates for telehealth sessions did not increase over time. Recommendations for telehealth quality assurance and improvement to best respond to children and families with existing mental health needs and limited resources during disasters and in their aftermath are suggested.

The 2020 COVID-19 outbreak is an unprecedented global pandemic and public health disaster in its need for both a prevention (i.e., physical/social distancing to prevent spread) and disaster response (i.e., when individuals and/or their family are sick/infected, concern for surging medical needs in hospitals) tailored for children and families. Each day, new and evolving recommendations require rapid decision-making with potential profound mental health impacts and implications for service delivery. National state and local government orders regarding the closure of nonessential business and sheltering at home created difficult choices in defining essential versus nonessential mental health services. These mandates forced public child mental health administrators to determine which services should be delivered in-person (with social distancing measures of 6 ft between persons and masking) versus remotely; all with the awareness that inadequate connection and supports for youth and families could have grave consequences. Telemental health provides a unique way to continue providing essential services outside hospitals and schools, if the infrastructure can be developed rapidly, and resources deployed and consistently supported. Yet “shelter-in-place” orders required the establishment of telemental health models that had to rapidly consider revised implementation practices. For example, providers were now faced with delivering telehealth sessions directly from their own home (vs. their office) and had to independently assure WiFi access, privacy within their home, and knowledge of Zoom videoconferencing functions without colleagues or supervisors nearby to support implementation and/or imminently troubleshoot when challenges arose. In 2008, the American Academy of Child and Adolescent Psychiatry (AACAP) published practice parameters for telepsychiatry with children and adolescents (Myers & Cain, 2008). Principle 3 (“The patient population, the model of health service delivery, and services to be offered should be determined”) addresses disaster planning, proposing telehealth to support victims and first responders, but Myers and Cain (2008) conclude more work in this area is needed. Emergency psychiatry services during public health emergencies (e.g., 9/11, Hurricane Katrina) are increasingly being incorporated into disaster planning models, however, there is a dearth of literature to guide service delivery (Reinhardt et al., 2019; Yellowlees et al., 2008). The COVID-19 pandemic and resultant “social distancing” state orders required urgent development and rapid deployment of telemental health services, particularly for our most underserved populations (e.g., publicly and uninsured children and families). This was critical because the additional stressors resulting from the crisis (financial and emotional) can increase youth risk for mental health problems in communities already experiencing chronic stressors (e.g., poverty and crime; Lai et al., 2013).

Yellowlees et al. (2020) recently described the successful rapid conversion of an outpatient adult psychiatric clinic to a 100% telepsychiatry clinic at UC Davis Health, discussing the process, challenges, and lessons learned. Although 98% of service delivery in the clinic was in-person prior to COVID-19, clinicians received training and supervision in telepsychiatry as part of their orientation to working in the clinic and some infrastructure was in place for remote service delivery. For many sites prior to COVID-19, however, little to no telehealth infrastructure was in place, clinicians had no training, supervision, or experience in telehealth service delivery, and little to no guidance existed for serving children and families across age ranges and developmental stages through telehealth. We present early monitoring and analysis of clinic telemental health utilization and satisfaction data followed by lessons learned from our urgent transformation of in-person safety-net pediatric mental health services to remote telehealth services in a large metropolitan county. To date, literature available on the experience of telemental health services implementation with minoritized, underserved youth and families is lacking (Ralston et al., 2019) and is an area of more needed focus during the COVID-19 pandemic (Fegert et al., 2020). The population of minoritized, publicly insured youth and families for whom our setting provides mental health services have been disproportionately impacted by the COVID-19 pandemic with respect to lesser healthcare access, significantly higher rates of COVID-related mortality, lesser access to basic needs, quality education, and financial supports and collective community trauma as a result. Understanding how to rapidly provide and sustain telemental health services and engagement for these youth and families is key to addressing the disproportionate mental health and traumatic impact of the pandemic for minoritized youth and families (Fortuna et al., 2020).

We offer practical and clinical considerations as well as recommendations for telehealth quality assurance and improvement to best respond to children and families with existing mental health needs, and significantly more limited resources during pandemics, like COVID-19, disasters, and in their aftermath.

Method

Transformation of In-Person Outpatient Child Psychiatry Services to Fully Remote

A large safety-net hospital underwent a rapid transformation to telehealth services, incorporating practical and clinical considerations described above, in response to the shelter-in-place order issued on March 17, 2020 in San Francisco, CA due to the COVID-19 pandemic. The psychiatry division which serves children, youth, and families provides evidence-based, culturally tailored, and trauma-informed mental health services for publicly insured, predominantly Latinx, Black and Asian youth (from birth to age 24 years) and their families as part of a comprehensive, coordinated approach to care across the developmental age spectrum. Programs and services encompass clinic and community-based inpatient and outpatient direct care (ranging from individual, family, and/or group therapy and/or medication management) and consultation services, training, and research. The clinic’s standard practice is to see clients once per week for therapy sessions. The division is comprised of 83 trainees, clinical providers, faculty attendings, research assistants, and administrators who collectively serve approximately 3,000 patients a year. All clinicians, regardless of discipline, were required to complete the American Psychological Association Telepsychology Best Practices 101 Series (8 hr total) within the first 2 weeks of the shelter-in-place order.

As part of a COVID-19 telehealth rapid quality improvement (QI) effort, our division was interested in understanding the rates of telemental health provision, client service utilization, and provider perceived satisfaction and experiences (successes and challenges) with the rapid conversion from in-person to telehealth. Given the exploratory nature of this QI effort, there were no a priori hypotheses related to provision, utilization, and provider experience outcomes. QI data were approved for dissemination by the site’s Institutional Review Board.

Results

All hired clinicians (licensed credentialed psychologist and MA-level providers and trainees, n = 55) were asked to complete a daily REDCap survey for 2 weeks (3/30/20–4/10/20) to track their initial provision of and experience with telehealth services; the survey yielded a 45% survey response rate (246 out of 550 possible responses). During the 10 days of service provision (Monday to Friday each week), providers conducted 185 phone sessions and 114 video sessions; of these sessions, 77% of phone and 97% of the video sessions were scheduled ahead of time. No-show rates for scheduled sessions were 23% for phone sessions and 14% for video sessions; this rate is noticeably lower than the usual 30%–60% in-person no-show rate typically experienced within the division. Providers were asked to report how their sessions went in general (four-item scale from I never really felt like we settled in to After we settled in, the sessions seemed to go very well); 85% reported their sessions went pretty well or very well. Additionally, the analysis of units of service (UOS; defined as a minute of service provided to clients used to charge and invoice for services) shows that a similar amount of service charges (50%) was generated during the first half of the month prior to transitioning to telehealth as the second half of the month when all in-person services were converted to telehealth visits.

A follow-up QI survey was sent approximately 3 months later (6/15/20–6/19/20) to 49 providers. Between the time that the first and second QI surveys were administered, seven providers indicated that their responsibilities did not include direct clinical care provision and so did not receive the second survey. In addition, one provider (who was providing clinical care) inadvertently did not receive the first survey and only completed the second. The second survey asked about 1 week of service provision and yielded a 40% survey response rate (98 out of 245 possible responses). During the 5 days of service provision (Monday to Friday), providers conducted a combined total of 60 phone sessions, 61 video sessions, and 3 combined phone/video sessions (i.e., the session began using one modality and transitioned to another modality within the same session); of these sessions, 68% of phone, 98% of the video, and 100% of combined sessions were scheduled ahead of time. No-show rates for scheduled sessions were 21% for phone sessions and 17% for video sessions; this rate is comparable to the original QI data. Providers were asked about their satisfaction with the technical (e.g., access to equipment or software and internet connection) and clinical (e.g., rapport and client engagement) aspects of their sessions (5-point scale from extremely satisfied to extremely dissatisfied); see Table 1. Providers were predominantly satisfied with the clinical aspects of the sessions (76% reporting they were somewhat or extremely satisfied) and generally satisfied with the technical aspects of the sessions (69% of reporting they were somewhat or extremely satisfied). The analysis of UOS demonstrated stability in service charges generated over the 3-month period (April through June 2020) consistent with observed the frequency of telehealth sessions and no-show rates over time.

Table 1.

Frequency of Responses for Provider Ratings

Survey question	%
Initial Survey: For those clients you DID hold a session with by phone or by video, and understanding all clients are different, in general terms, how did you experience your sessions today?
After we settled in, the sessions seemed to go very well	43.2%
After we settled in, the sessions seemed to go pretty well	41.2%
After we settled in, it took quite a while to feel OK—but I think things will be better next time	9.5%
I never really felt like we settled in	5.4%
Follow-up Survey: Please rate your overall experience with the clinical aspects of these sessions (i.e., rapport, client engagement, therapeutic intervention, treatment planning)
Extremely satisfied	42%
Somewhat satisfied	34%
Neither satisfied nor dissatisfied	8%
Somewhat dissatisfied	17%
Extremely dissatisfied	0%
Follow-up Survey: Please rate your overall experience with the technical aspects of these sessions (i.e., access to equipment or software, internet connection, sound, and video quality)
Extremely satisfied	34%
Somewhat satisfied	35%
Neither satisfied nor dissatisfied	12%
Somewhat dissatisfied	17%
Extremely dissatisfied	2%

Note. Initial Survey n = 148 item responses; Follow-up survey n = 65 item responses.

Providers were asked to provide qualitative responses at the time of the first survey to questions of “What is going well?” (facilitators) and “What are the challenges?” (barriers) in providing telemental health services to publicly insured youth and families. Challenges included both logistical and clinical challenges. Providers’ responses were grouped (by the 1st and 2nd authors) according to four common themes each of facilitators of and barriers to telemental health care. Facilitators included: (a) clients’ expression of gratitude for continued care; (b) allowing youth to connect with one another in groups; (c) creative engagement practices that can occur through Zoom videoconferencing, and (d) some clients’ preference for telehealth. Thirty-four percent of respondents indicated they were spending time helping their clients set up the technology. Logistical barriers raised included: Limited data plans/internet access; trouble with audio; clients’ discomfort with clinician seeing the home environment; lack of privacy within home environment. The most common clinical barriers raised were: Engaging younger children; clients with competing demands for attention (e.g., other children); implementing dyadic interventions with parents and children, and discussing more sensitive subjects (e.g., trauma) when privacy is limited.

Discussion

Lessons Learned: Practical Considerations in Telehealth Transition

Based on our two surveys of providers and the authors’ experience providing and supervising telemental health services delivered to publicly insured children and families, we offer the following practical considerations for transitioning to and sustaining telemental health services.

Access

To engage in telemental health requires each youth, family, and clinician to have access to technology. At a minimum, they need a working phone, for voice/phone sessions and at best, a smartphone, tablet, or laptop with accessible WiFi or extensive data plan to allow for home-based video sessions. Certain services (e.g., family sessions) may require tablets or computers for multiple people to simultaneously participate and be visible. The most expeditious way to expand telemental health access might be to deploy devices with prepaid data plans. A meta-analysis of mobile health (mHealth) interventions on child health behavior change (e.g., with immunizations and diabetes medication adherence) suggests moderate effectiveness and promise, but few studies focused on or evaluated child mental health outcomes (Fedele et al., 2017); thus, the effectiveness of this approach for child telemental health, particularly for minoritized youth and families, is still being evaluated. Since many families will not have funds for continued purchase of data plans or sustained access to reliable WiFi or internet, mental health administrators need to use existing allowable budgetary lines and/or secure additional flexible funding sources (e.g., philanthropy) to purchase devices with data plans and acknowledge devices may not be recouped. Further, youth will likely use technology for other purposes (e.g., watch videos and interact with friends) during social distancing, so preserving data for telemental health may be difficult. Youth and families must also have sufficient technology literacy to set up and use video teleconferencing. They may need support orienting to how to maximize the use of data plans or how to access public WiFi where available. Instructions must attend to differences in language, technological and overall literacy and comfort. Interpreter services must also be seamlessly integrated into sessions whenever needed and ideally through secure video technology. Partnership with schools is also instrumental in furthering access to resources as many school districts in requiring distance learning are also required to provide families with all of the necessary technology and access.

Privacy

Youth autonomy, confidentiality, and privacy can be challenging during shelter-in-place when all household members must stay at home. Many families live in small residences with extended families and have a limited number of closed-door rooms. When participating in group therapy via telemental health, lack of privacy can also lead to inadvertent breaches of confidentiality (e.g., a family member walks in and sees other group members).

Other privacy concerns include communicating with patients via non-HIPAA compliant platforms. Although Health Insurance Portability & Accountability Act (HIPAA) restrictions were lifted for nonpublic facing platforms during the COVID-19 pandemic in order to expand access (United States Department of Health & Human Services, 2020), using non-HIPAA compliant social media applications is not sustainable or advisable, even if youth have high rates of social media utilization and prefer it for communication (e.g., direct messaging through Instagram; Curtis et al., 2019). Most youth do not use phones for voice conversation, instead preferring texting and direct messaging (Rideout & Robb, 2018) but local clinical or regulatory bodies often restrict the use of texting with patients and/or require doing so using work-purchased encrypted phones with HIPAA compliant text messaging platforms, which are not always accessible to clinicians in underresourced public institutions.

Informed Consent

Using telehealth technology involves additional privacy risks (e.g., possible online data breaches). Patients must be informed of the added risks of participating in telemental health services before using them (e.g., obtain consent by phone before beginning video-based therapy).

Provider Training

Most providers have not delivered telemental health services or been trained to do so; as such, competency in this area should not be assumed. Standardized training in telemental health treatment delivery, including the use of free online resources (e.g., American Psychological Association Telepsychology Best Practice 101 Series or the AACAP Telepsychiatry Toolkit), may increase provider competency and confidence.

Lessons Learned: Clinical Considerations in Telehealth Transformation

Social isolation due to physical/social distancing is likely increasing youth anxiety and distress, and exacerbating preexisting mental health difficulties, such as depression (Brooks et al., 2020); this is further worsened by higher rates of family stress and increased domestic violence commonly seen during disasters (Becker-Blease et al., 2010; Schumacher et al., 2010). A child considered stable and not in imminent need of mental health intervention 1 week prior may be experiencing increased/acute need for intervention shortly later, making videoconferencing services essential. Clinicians must be able to regularly assess changes in clinical presentation, requiring the family has access to the necessary technology. Without access, children are left without adequate supports, vulnerable to experiencing increasing distress, and may even require mobilization of child crisis services, which is often with limited availability during disasters. Given that children are also not in school or attending pediatric visits as regularly, this compounds the difficulty in successfully monitoring for increased need.

Clinicians may also need to make adaptations depending upon the patient’s age, treatment approach, and practical limitations impacting service delivery. For example, engaging in coaching for Parent–Child Interaction Therapy, which requires making direct observations of caregiver–child interactions, would not be possible if a family could only participate in audio-only phone sessions. It might also be difficult to engage a school-age child over video for a standard 50-min session due to limited attention span. Clinicians working with younger children over telehealth should use interactive activities tailored to the child’s interests and take frequent breaks to maintain engagement (Dueweke et al., 2020).

Conversely, telemental health via video may provide new opportunities. For example, there is a unique option to more closely manage safety plans for suicide prevention with high-risk adolescents (e.g., those engaged in Dialectical Behavioral Therapy). In that situation, providers can use video to “move through” the home with the caregivers, directly identifying and intervening upon aspects of the safety plan which could be better implemented (e.g., medications locked up securely and removing items in the house that could be used for self-harm) versus sole reliance on self-report about adherence by the youth and caregiver. In general, telehealth via video can provide an opportunity for the clinician to see the natural environment that the child and family live in and improve clinician’s understanding of the child’s needs and safety. However, careful trust building between clinician, child, and family is needed, as families may have concerns about “home-based” telehealth intervention, particularly depending on their economic status (e.g., those living in poverty), system involvement (e.g., child and family are court-involved) and/or cultural background and values. Group telemental health may also reduce the psychological sequelae of social distancing and offerings like support groups for parents of children with special needs may be more easily coordinated. Video guidelines on special populations are available through AACAP’s telepsychiatry toolkit (https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/child-adolescent/introduction) and can further inform implementation.

Recommendations and Considerations for Implementation

Based on our experience and QI data, we offer nine summary recommendations for rapidly developing and deploying child telemental health services and considerations for disaster planning and ongoing pandemic need in a safety-net hospital in Table 2. Areas of priority for recommendation and considerations for implementation range from considering ways to garner funding to increase access to technology, training youth, families, and clinicians on technology utilization (and addressing language, knowledge, and other barriers, such as the use of interpreters), identifying licensing policies and engaging in advocacy to reduce barriers to care, and collecting services-related data to inform continued efforts to increase access to mental health care during and post disasters for publicly insured, minoritized youth and families who are disproportionately negatively impacted by disease pandemics and global disasters.

Table 2.

Telemental Health Recommendations and Considerations for Implementation

Recommendation	Considerations for implementation
1. Identify emergency funding source(s) to acquire and deploy technology with preinstalled data plans, minutes, WiFi (e.g., laptop, tablets, and smartphones) tailored to the clinical setting or service (e.g., home-based, emergency room, and pediatric clinics)	Partner with schools and/or other child-serving organizations who are mandated to have resources for educational learning access as a way to support youth and families accessing technology. Identify opportunities for philanthropy and foundation funding for technology needs
2. Identify technology deployment priorities	Provide equipment to staff without remote access capability or families without device access and to those with the most acute mental health needs
3. Identify ways to get technology to families safely and in accordance with public health mandates	Mail activated phones (loaded with relevant mHealth apps) to patients’ homes and require no-contact signature or setting up a pick-up point and covering equipment in plastic protective wrapping
4. Rapidly train clinicians to use telehealth technology and provide ongoing guidance and supervision	Understand more about clinician dissatisfaction and proactively develop plans to address given that telehealth delivery will be an ongoing need. Ensure clinicians know how to assess and assist with patient’s technological literacy including teaching patients how to determine WiFi/internet capacity in their homes, preserve data plans, and securely login to video-teleconferencing platforms. Use existing resources for training and supports that apply across disciplines (e.g., American Psychological Association https://www.apa.org/ed/ce/telehealth; American Psychiatric Association; https://www.psychiatry.org/psychiatrists/practice/telemental-health/toolkit/learning-telemental-health). Provide friendly instructional videos for families to visually demonstrate how to access and use the video platform (e.g., for Spanish speakers https://www.youtube.com/watch?v=2LIi5QBw9u8, and for groups https://www.youtube.com/watch?v=00HaKtHCpIM, addressing aforementioned barriers. Videos in various languages can provide ongoing training and support so clinicians are more ready for future disasters and waves of this pandemic are key for readiness to serve our population. Contact hospital interpreter services to see if they offer any provider trainings on working with interpreters via videoconferencing. Request that interpreter services participate in a brief “mock telemental health session” with the provider to practice logistics before the actual client session
5. Proactively train and support families to use telehealth technology to prepare for the longer term need during an ongoing pandemic	Provide families resources in multiple languages; for example, “Resources for Telehealth at Safety Net Settings,” by the UCSF Center for Vulnerable Populations is a very useful resource for patients: https://cvp.ucsf.edu/telehealth# Consider creative options for training and supports that could involve brief in-person (with appropriate personal protective equipment and physical distancing) telehealth utilization learning sessions for families and incorporating telehealth utilization supports (“booster sessions”) over time within the teletherapy framework to guide families in overcoming any new barriers that might arise over time (e.g., loss of WiFi and how to access public WiFi or request/purchase a WiFi hotspot). Such options may serve the dual purpose of finding and connecting with families who have not been able to engage through solely remote options (phone, video, and text) and for whom, a brief safe in-person encounter could serve to also reengage in care
6. Identify current state licensing policies related to child telehealth services during disaster planning and response	In some states, psychiatrists and nurse practitioners can currently practice telehealth across state lines without exception (see https://www.fsmb.org/advocacy/covid-19/), however, psychologists, social workers, and marriage and family therapists cannot without state-by-state licensing exception and such exception may be temporary during disaster response or extended as part of ongoing pandemic response need
7. Establish clinic email through university-based addresses with an auto-response in multiple languages	In low literacy level language, indicate what to do during social distancing, in crisis how to get resources and that this is not a crisis response email and not monitored outside business hours
8. Collect data on uptake, utilization, outcomes, and costs	In addition to service utilization and clinician feedback, collect data on client experience with telehealth services, including satisfaction and barriers to use
9. Consider brief check-ins throughout the week with patients who would benefit from more regular monitoring, have difficulty focusing or securing privacy, or have increased distress	Conduct check-ins (even automated) through HIPAA compliant platforms or use texting to reinforce coping skills to reduce distress and maintain therapeutic and social connection during social distancing. Increased monitoring allows clinicians to more rapidly detect changes in clinical presentation and risk of harm to self or others, and also convey provider accessibility to patients and enhance engagement

Limitations

This project was part of a QI effort to obtain feedback, during a time of worldwide crisis, on rapid clinic practice conversion from in-person to telemental health services and for a youth and family population for whom there is a paucity of literature on best practice to guide this type of mental health service delivery. Thus, it was not designed as a research study with specific aims or a priori hypotheses. Likewise, the survey was designed as a QI tool and rapidly developed by clinic leadership to obtain information to deliver back to the clinic in order to inform imminent implementation needs. Thus, our measure was not psychometrically tested. Given the immense stress on clinicians during this time, we opted for the briefest measure possible to obtain key data from clinicians while not overburdening them with an additional task. Thus, more specific data such as the total number of clients seen and what proportion may have been seen more than once were not collected. Survey response rates of 45% and 40% suggest that we might have a more selected sample, for example, providers who were more successfully and more imminently using telehealth; however, UOS collateral data suggest that rates of telehealth provision were high and unchanged from in-person—thus low response rates and decrease in response rate from first to second survey are likely due to enhanced burn-out, burden, and stress experienced by clinicians during this time. Our data demonstrate high rates of telephonic visits during this rapid conversion period and one-third of providers endorsed spending time helping clients access videoconferencing; unfortunately, we did not have data available on the rates of patients/families who did not have technology available for the video to further inform recommendations. Of note, we did not deploy technology to families, so rates of service utilization, especially video, may be even higher when sufficient access to necessary technology is ensured.

Conclusions

There is still much we can learn from the COVID-19 crisis that can prepare us for additional waves of this epidemic and future pandemics or disasters. Research on the implications of telemental health-facilitated disaster readiness, recovery, and ongoing care of publicly insured, racial, and ethnic minority youth is needed and essential to securing continued funds for sustaining telemental health services (e.g., if demonstrated increased access leads to better overall outcomes and reduced disparities) and advocating for a legislative change of restrictions lifted during the COVID-19 crisis. Telemental health and remote access to care have proven to be critical to maintaining the well-being of children and families during this challenging time. There is an opportunity for QI of these programs in the midst of this ongoing crisis, while also being proactive and optimizing our preparedness in terms of resources, training, and regulatory oversight so we can all better respond to the next disaster.

Impact Statement.

Rapid conversion to child telemental health service provision for publicly and uninsured, minoritized youth and families is feasible. Our clinic conversion did not result in substantial decreased service delivery volume, nor increased no-show rates and was sustained over time. Still, approximately 20% were not reachable; thus, as the COVID-19 pandemic continues, implementation of safe and creative quality improvement processes to increase telehealth reach, engagement, and retention are of paramount focus, as is a readiness to respond to unknown future disasters.