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RRP 12-539 – HSR&D Study

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RRP 12-539
The Uptake of Home-Based Telemental Health by Mental Health Providers
Alejandro Interian PhD
Lyons Campus of the VA New Jersey Health Care System, Lyons, NJ
Lyons, NJ
Funding Period: June 2014 - November 2015

BACKGROUND/RATIONALE:
The VA has begun rolling out the use of Video-to-home technology (V2H) for providing mental health services. The technology allows veterans to videoconference from their homes with their providers. This new technology will radically transform the way in which mental health services are provided and will completely eliminate geographical barriers for accessing mental health treatments. At the same time, V2H will mark a significant departure from the traditional model of office-based, face-to-face services. VA clinicians, supervisors, and administrators will be required to adapt to a new infrastructure, and modified models of clinical practice and decision-making. This Highly-Partnered project seeks to provide VISN3 mental health leadership and the VISN3 Office of Virtual Health and Rehabilitation with information on the factors that need to be addressed to improve the implementation of V2H.

OBJECTIVE(S):
The project capitalized on the rollout of V2H in the VA by conducting a formative evaluation of the factors associated with its implementation. The project sought to answer two key questions: 1) What are the barriers and facilitators expressed by VA personnel stakeholders regarding the adoption of V2H technology to provide mental health services? 2) Which of these factors differentiate sites with high versus low levels of V2H encounter productivity and growth?

METHODS:
Participants of the research were VISN3 personnel (N=33) with different organizational levels and roles, but were involved or familiar with the implementation of V2H mental health services. The Consolidated Framework for Implementation Research (CFIR) was utilized for understanding barriers and facilitators across several organizational levels in VISN3.

Thirty-three semi-structured interviews with VA personnel stakeholders were conducted in three VISN3 facilities. Twenty-eight were mental health providers (social workers=12, psychologists=9; nurses=4; psychiatrists=3) and 5 were nonproviders of mental health (telehealth leads=4, program analyst=1) Most interviews were conducted by telephone (n=28), though some were conducted in-person (n=5). The sites selected varied by overall level of V2H productivity during FY15, as well as productivity growth during FY14 through FY15. Productivity was measured in terms of the total number of V2H mental health encounters.

Interviews were transcribed and imported into a qualitative analysis program (Atlas.ti). Each transcript was deductively coded using CFIR constructs. Next, each coded CFIR construct was assigned a numerical rating to capture its impact on implementation of V2H (-2, -1, 0, 1, or 2). These numerical ratings were then assigned to each of 3 groups according to participants' level of experience with V2H (no experience, some experience, high experience). In addition, these ratings were also assigned to each individual site (Site 1, Site 2, and Site 3).
All ratings were assigned by and discussed with all three team members initially to allow a team-based understanding and consensus to develop for the issue being rated. Once developed, ratings were conducted by at least two raters. Throughout the analytic process, consensus was used to arrive at final ratings.

Qualitative analyses first examined barriers and facilitators by participants' level of V2H experience (no direct experience, some experience, high experience) to identify the factors associated with each stage of experience. Next, analyses sought to identify the factors that differentiated the sites according to overall level of productivity (FY15), as well as productivity growth (FY14-15).

FINDINGS/RESULTS:
V2H Experience Level Analysis
Review of transcripts produced the following classifications according to participant level of V2H experience. Thirteen participants had no direct experience providing V2H, but were familiar with the program in some way (e.g., referred patients, had been invited to consider adopting the modality). Seven participants had some experience providing V2H (i.e., attempted to conduct a session or conducted a small number of sessions). Thirteen participants had a high level of experience (i.e., evidenced consistent use of V2H delivered to several Veterans or had high involvement in supporting others' use of V2H, such as telehealth support staff).

Participants with no direct V2H experience - These participants were most likely to express concerns about the issues that V2H would bring to mental health practice (compatibility). Sample concerns include those pertaining to impact on perceiving nonverbal cues and impact on therapeutic alliance. Despite these concerns, these participants acknowledged the promise of the technology for addressing access to care barriers (patient needs and resources). Review of qualitative data suggest that moving from this stage to becoming interested in adopting V2H is most facilitated by efforts to engage providers (champion, engaging providers).

Participants with some direct V2H experience - These participants reported encountering several instrumental barriers. These included a complicated set up process (complexity), functionality problems with the technology, and finding Veterans who were able to access this technology (e.g., have a computer) and were interested in receiving these services (patient needs and resources). These findings suggest that once engaged to try V2H, providers will subsequently encounter these barriers and logistical/support resources at this juncture are critical.

Participants with high direct V2H experience -These participants reported the greatest frustration with functionality problems with the technology, as well as with available technical support. Conversely, they also received higher ratings for describing positive patient satisfaction with the modality (patient needs and resources). Concerns about issues involved with delivering mental health services via V2H remain in this group, though at lower levels (compatibility). Thus, even experienced users reported continued cautions with providing V2H. Examples would include considering issues such as suicidality, psychosis, or mental disorders where greater ability to leave the home is a treatment goal.

Site-level Analysis
Site 1 produced the largest number of encounters during FY15 (740), along with medium growth across FY14-15 (27%). This site was used to draw inferences pertaining to implementation leading to high productivity. Site 2 produced fewer encounters during FY15 (263), but showed high growth across FY14-15 (53%). Contrasts with this site generated inferences pertaining to implementation leading to V2H growth. Finally, Site 3 had the relatively lower number of FY15 encounters (171) and FY14-15 growth (3%). Contrasts with this site were used to generate inferences pertaining to relatively complicated V2H implementation.
High Encounter Productivity (Site 1) - This site was notable for having a team of providers who had protected time for providing telemental health (available resources). This site relied on these providers for making V2H available and thus was able to achieve a high level of productivity. On the other hand, this team of providers was operating at capacity and there was minimal adoption of the technology by providers outside this team, which limited growth. This site also reported mechanisms for engaging interested Veterans (engaging patients). One such mechanism including a process by which need for telemental health services was considered when receiving all new requests for standard mental health services. Participants also reported key involvements in community-based health expos that promoted the availability of V2H services. Finally, participants at this site described securing of external funds to provide webcams to Veterans who did not have one (patient needs and resources).

High Encounter Growth (Site 2) - This site was notable for the presence of an active champion, whose efforts were quite visible to several of the other participants at this site (champion). The champion, as well as other participants, at this site described several efforts to engage providers into adopting V2H (engaging providers). Once engaged, the process was followed by strong instrumental support for training, setup, and ongoing support (available resources). The availability of this support may have mitigated some of the barriers, such as setup complexity and technology problems, as these barriers were reported to have less negative impact at this site. The involvement of leaders at this site was rated higher than the other sites (leadership engagement).

Complicated V2H Implementation (Site 3) - There were several CFIR constructs that differentiated this site. First, while participants at this site acknowledged the need for V2H, they also described a relatively lower need given that this site served an urban, geographically concentrated community (patient needs and resources). This was combined with a concern among participants that the implementation impetus was external to the facility (intervention source-external) and was driven by performance measures (external policy and incentives). Thus, participants expressed a misalignment between local need for V2H and the impetus for implementation. Participants at this site also expressed the greatest concern about delivering mental health services via V2H (compatibility). Other factors included reports of fewer support resources for training and resolving functionality problems (available resources). This coincides with reporting the greatest negative impact related to the setup process (complexity), the occurrence of functionality problems with the technology, and resulting Veteran dissatisfaction.

IMPACT:
The current study highlights the factors that are associated with success and complications in the implementation of V2H for mental health. By understanding these factors, VHA policy makers, managers, and program staff can optimize ongoing implementation efforts. The current study's findings also inform the field of implementation science, as well as the study of the Consolidated Framework for Implementation Research.

PUBLICATIONS:
None at this time.


DRA: Mental, Cognitive and Behavioral Disorders
DRE: Technology Development and Assessment
Keywords: QUERI Implementation
MeSH Terms: none

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