Table 2.

Domain 2: Flexibility and personalization.

CMOa title	References	Overarching CMO	Key contexts	Example strategies and solutions
CMO 2.1: Taking service users’ individual preferences into account—offering alternatives	[24, 36, 48, 50, 65, 67, 75, 77, 90, 91, 93-104, Eagle et al (email, August 31, 2022)]	When services using remote mental health care allow service users to choose the modality of telemental health and a choice of remote versus face-to-face care and regularly check their preferences (context), this allows service users to have greater autonomy and choice (mechanism), leading to them feeling more satisfied and able to engage with the type of care received (outcome 1), leading to improved uptake (outcome 2) and improved therapeutic relationships with their clinician (outcome 3).	Allowing service user choice and delivering services flexibly is a key principle across settings and populations, with the overall aim that care of equivalent quality should be available in a timely way whatever modality is chosen. Hybrid care, with a flexible mixture of face-to-face and telemental health care based on the purpose or function of appointment (eg, prescription review versus the first visit to see a clinician), preference, and circumstances, is especially relevant to service users receiving relatively complex care with multiple types of appointments, for example, from multidisciplinary community teams. Children and young people may particularly benefit from being offered a choice as it increases their feelings of autonomy and improves engagement in care.	Initial conversations about telemental health with all service users, in which their preferences regarding the mode of appointments and their access to and expertise and interest in using technology are explored (a shared decision-making tool could be used to structure this) Ensuring that clinicians making collaborative plans with service users for telemental health use are aware of risk factors for difficulties engaging with telemental health and digital exclusion, including individual difficulties and wider contextual factors, such as poverty and poor or shared housing Ensuring equal access to timely care of good quality regardless of choice of modality Regularly revisiting preferences and collaboratively planning how care will be delivered Ensuring that service users engaging in group therapies and activities have understood and consented to the ways of working of the group and that face-to-face alternatives are of equivalent quality
CMO 2.2: Removing barriers—greater convenience for service users and family/friends	[19, 24, 36, 38, 40, 42, 45, 54, 55, 67, 70, 75, 76, 79, 81, 82, 84, 90-92, 95, 97, 105-112]	Among some service users, family, and other supporters experiencing specific practical barriers to attending face-to-face services (childcare or other caring responsibilities; location, work, and mobility limitations; travel difficulties/costs, and work commitments) and those who have good access to telemental health (context), telemental health may provide increased flexibility that addresses individual practical barriers (mechanism), which can lead to telemental health being viewed by some service users and carers as more convenient and accessible than face-to-face care (outcome 1), easing attendance (outcome 2), increasing uptake (outcome 3), and reducing missed appointments (outcome 4).	This may be relevant for parents with young children, people with caring responsibilities, and people who struggle to travel because of work commitments/disability/costs; children and young people in school or higher education (so they can access mental health care without having to leave their place of education); people who live in remote areas or a long distance away from a specialist service; and people for whom travel is challenging because of impaired mobility or sensory impairments or mental health difficulties such as agoraphobia. There may be more advantages to treatments that involve the support of family and friends.	Offering explicit choice wherever possible between telemental health and face-to-face care, including home visits where services are able to provide this, also considering that different modalities may be used for different purposes Identification of people for whom attendance at office appointments is challenging so that telemental health (or home visits) can be considered Continuing to offer choice and checking preferences throughout the duration of care (ie, not just asking once) Avoiding missed appointments by offering a switch to telemental health as an option when a service user is unable at short notice to attend a face-to-face appointment
CMO 2.3: Involvement and support for family and friends	[79, 91, 113-115]	When family and other supporters are invited (with service user agreement) to join telemental health sessions (context), this may result in more holistic treatment planning and greater engagement of family and others in supporting service users (outcome 1); may help improve therapeutic relationships and treatment success (outcome 2), increase engagement (outcome 3), and reduce some uncertainty and anxiety around treatment (outcome 4); and may increase the satisfaction of and support for family and friends (outcome 5), as family and other supporters may be able to participate in care planning meetings and assessments that they would have found difficult to attend face-to-face, increasing their engagement in supporting service users and their understanding of their difficulties and care plans (mechanism).	This is especially helpful for those living in locations different from their family and friends or where family and friends have caring or work commitments preventing them from attending meetings face-to-face, children and young people (as this may allow their parents to be more involved in their care), and service users in inpatient settings where family and friends cannot visit (eg, because of epidemic-related restrictions) or as the hospital is in a remote location.	Working with service users to identify any family and friends whose attendance at care planning and other clinical meetings (including on inpatient wards) would be helpful, including those for whom telemental health would facilitate access, such as people in distant locations or whose commitments would make it difficult to attend face-to-face meetings Using strategies for service users to provide guidance on using telemental health to family and friends and prepare them for appointments Offering children and their families the opportunity to have telemental health appointments (or, if feasible, home visits) if they find it easier to participate as a family without having to travel to an appointment and to be seen in a clinical setting In inpatient wards, providing charged iPads, short cables, or charging lockers to allow service users to charge their own devices so that they can use technology to connect with family or other supporters
CMO 2.4: Widening the range of available mental health services and treatments for service users via telemental health	[49, 116-118]	For service users who may benefit from services that they cannot readily access locally and that provide specialized forms of treatment and support regionally or nationally (context), telemental health can widen the range of specialist assessment, treatment, and support available (mechanism), which potentially leads to improved access to services tailored to individual needs and culturally appropriate or specialist services (outcome 1) and improved satisfaction and treatment outcomes (outcome 2), although an impoverished range of local face-to-face provision may be a risk if referral to distant specialist care via telemental health becomes routine (outcome 3).	People to whom this is relevant may include people who have complex clinical needs or rarer conditions such that they would potentially benefit from assessment, treatment, and support from specialist services provided at regional and national rather than local levels; people who may be able to access distant therapists who speak their own language or interpreters of rare languages not available locally; people who would benefit from support from voluntary organizations that meet specific needs that are not catered for locally (eg, that support particular cultural groups; lesbian, gay, bisexual, transgender, and queer groups; or people with sensory impairments); and people who would benefit from a wider choice of therapies and support (including peer support) than is available locally.	Development (including of funding arrangements) and dissemination of information about specialist services accessible via telemental health Access for service users, their family and friends, and clinicians to information and signposting regarding community and voluntary sector organizations beyond their catchment area, which are accessible via telemental health Development of safeguards against the erosion of local and in-person national specialist services in favor of routine specialist telemental health, in line with public-sector equality duty to anticipate and provide for the needs of groups with protected characteristics under the Equality Act (eg, pregnant people who are at increased risk of domestic violence, people whose disabilities cause sensory hypersensitivity, and people who struggle with screen time)
CMO 2.5: Adaptations for service users with sensory or psychological barriers to telemental health	[40, 50, 77, 119]	Offering face-to-face (or telephone) appointments to people who struggle to cope with sensory (visual or auditory) aspects of telemental health or have symptoms that are exacerbated by it (context) may help to improve engagement with mental health care (outcome) as the adverse effects of the switch to telemental health for these symptoms and sensory or cognitive impairments may be avoided and service users are able to access their preferred modality of care (mechanism).	This may be relevant for people with symptoms that may interfere with or be exacerbated by engaging with telemental health, such as persecutory ideas or hearing voices; autism; sensory or cognitive impairments; and migraines.	Ensuring that face-to-face appointments (including home visits if there are impediments to office appointments) remain available Making clinicians aware of the types of clients who may find it particularly difficult to engage with telemental health Adapting telemental health where helpful, for example, through switching off cameras, using telephone rather than video calls, or communicating via SMS text message
CMO 2.6: Inclusion of multidisciplinary and interagency teams in service users’ care	[89,115]	When mental health consultations are conducted using telemental health (context), it enables the inclusion of staff in appointments who are based geographically far away or who have schedules that would not have allowed them to join a face-to-face session (outcome 1), meaning care and support has potential to be more holistic and integrated (outcome 2), as it is possible for staff from different services and sectors to provide perspectives and contribute to plans (mechanism).	Key contexts include hospital inpatients, where telemental health may enable staff who work with them in community settings to join reviews and ward rounds (especially in pandemic conditions where they cannot attend in person), and people with complex treatment and support, who are receiving support from >1 team or sector.	Working with service users to identify staff whom it would be helpful to involve in consultations such as review and care planning meetings, including in social care, housing, and the voluntary sector Facilitating the involvement of such staff in reviews via telemental health, especially where face-to-face attendance is not feasible
CMO 2.7: Continuing to offer face-to-face care to service users	[53, 81, 92, 116, 120]	When service providers offer care of equivalent quality and timeliness face-to-face (including home visits where needed) rather than via telemental health to service users who do not wish or do not feel able to receive their care remotely (context), it ensures that care can continue and that inequalities in provision are not created or exacerbated (outcome), as it provides a choice to service users and avoids the negative impacts of digital exclusion (mechanism).	People for whom face-to-face options may be preferable, and choice is especially important, include those who do not have access to private spaces, live with people they do not wish to be overheard by in their appointments (including perpetrators of domestic abuse), do not feel comfortable communicating via remote means, and do not want therapy to intrude on their private lives should be included. In addition, some service users who value the time spent traveling to and from face-to-face appointments to process emotions may find face-to-face options particularly useful.	Ensuring services are able to offer a choice between telemental health and equivalent care delivered face-to-face (especially when telemental health is part of routine care rather than a means of managing a national emergency) Ensuring (as in CMO 2.1) that clinicians are fully aware of service user preferences and circumstances (which may be elicited via a shared decision-making tool) and continue to monitor these over time That clinicians are alert for any changing circumstances during telemental health where a service user does not feel comfortable to speak and make alternative arrangements accordingly (eg, using text functions on videoconferencing platforms or arranging face-to-face appointments)
CMO 2.8: Communication between staff	[19, 85, 121]	When remote technology platforms are used to facilitate real-time communication between staff members, including managers or clinicians working in different teams (context), it can lead to improved efficiency, more convenient working and staff management (outcome 1), improved communication and collaborative planning (outcome 2), and process improvement opportunities (outcome 3), as staff have the ability to rapidly share information, keep track of evolving telemental health procedures (eg, during emergencies), and make collaborative decisions (mechanism).	Contexts in which this is relevant include multidisciplinary teams who are not working on the same site; complex provider organizations with management teams and clinicians working on multiple sites; situations in which people may be receiving care from multiple teams, for example, from an inpatient or crisis service, as well as a continuing care service.	Making use of telemental health platforms to strengthen liaison and collaboration between teams and professionals on different sites (eg, through increased enhanced liaison between managers across an organization) or provide better access to a range of educational events Using telemental health platforms to facilitate multidisciplinary team meetings between staff on different sites (especially if some are working from home) However, awareness is needed that perceived pressure for staff to provide an immediate response may also negatively affect their work-life balance

^aCMO: context-mechanism-outcome.