Shifting to Remotely Delivered Mental Health Care: Quality Improvement in the COVID-19 Pandemic - MDPI

 
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Perspective
Shifting to Remotely Delivered Mental Health Care:
Quality Improvement in the COVID-19 Pandemic
Patrick Daigle and Abraham Rudnick *
 Department of Psychiatry and School of Occupational Therapy, Nova Scotia Operational Stress Injury Clinic,
 Dalhousie University, Halifax, NS B3H 4R2, Canada; patrick.daigle@nshealth.ca
 * Correspondence: harudnick@hotmail.com
                                                                                                    
 Received: 31 August 2020; Accepted: 22 September 2020; Published: 22 September 2020                

 Abstract: This paper presents an organizational (ambulatory) case study of shifting mental health care
 from in-person to remote service delivery due to the current (COVID-19) pandemic as a rapid quality
 improvement initiative. Remotely delivered mental health care, particularly using synchronous video
 and phone, has been shown to be cost-effective, especially for rural service users. Our provincial
 specialized mental health clinic rapidly shifted to such remote delivery during the current pandemic.
 We report on processes and outputs of this rapid quality improvement initiative, which serves a
 purpose beyond pandemic circumstances, such as improving access to such specialized mental health
 for rural and other service users at any time. In conclusion, shifting specialized mental health care
 from in-person to remotely delivered services as much as possible could be beneficial beyond the
 current pandemic. More research is needed to optimize the implementation of such a shift.

 Keywords: pandemic; quality improvement; remote delivery; rural; specialized mental health care

1. Introduction
      Approximately a fifth of the general population in developed countries such as Canada experience
at least one disruptive mental disorder in their lifetime [1], and even more experience mental health
challenges in many developing countries [2]. Many people live in urban environments, and hence may
benefit from mental health services, such as in-person mental health care, recognizing that due to social
disparities and other factors in most countries such care is often suboptimal [3]. Many other people
live in rural and remote environments and hence have less access to mental health care and related
services; digital services show promise to improve such access [4]. During the current (COVID-19)
pandemic, even urban populations cannot easily or at all access in-person mental health services. Hence,
digital (video and other, such as phone) remotely delivered mental health services may be particularly
helpful both during pandemic times as well as more generally such as for people who live rurally or
remotely [5]. Although remotely delivered mental health care and related services such as self-help
have been shown to be effective as well as cost-effective, such as internet-delivered psychotherapy [6]
and tele-psychiatry [7], respectively, they have not been widely implemented within and across many
jurisdictions [8], partly as startup resourcing is needed for such change (recognizing that there may
be no known disadvantage compared to in-person care for service users who have access to relevant
technology and feel comfortable with it). Arguably, it is unethical to not provide remotely delivered
mental health services as needed, such as to rural and remote populations in general [9] and to
anyone in need during pandemic [10]. Indeed, the current pandemic is an opportunity to shift to such
remotely delivered services as much as needed. The rest of this brief paper reports what processes and
outputs occurred when our specialized mental health care clinic shifted during the current pandemic
from in-person to remotely delivered mental health services. We conclude with suggestions that may

Psychiatry Int. 2020, 1, 31–35; doi:10.3390/psychiatryint1010005           www.mdpi.com/journal/psychiatryint
Psychiatry Int. 2020, 1                                                                                32

assist other mental health services and policy makers and that would require rigorous evaluation
and research.

2. Shifting to Remotely Delivered Mental Health Care
      Our clinic is the Nova Scotia Operational Stress Injury Clinic (NSOSIC). It is a Canadian federally
funded provincial service that provides specialized mental health care for eligible members and
Veterans of the Canadian Armed Forces (CAF) and some North Atlantic Treaty Organization (NATO)
Veterans as well as for eligible members and Veterans of the Royal Canadian Mounted Police (RCMP).
It is part of a national network of such Operational Stress Injury Clinics across Canadian provinces.
The NSOSIC is also part of the Nova Scotia Health Authority (NSHA), is affiliated with Dalhousie
University’s Faculties of Health and Medicine, and is led by this paper’s two authors. It has a main
site (in Dartmouth, which is in Nova Scotia’s central zone that is urban and suburban) and a pilot
satellite site (in Cape Breton, which is in Nova Scotia’s Eastern zone that is semi-urban and rural).
The NSOSIC’s services involve outpatient mental health assessments and biopsychosocial interventions,
such as evidence-based/informed individual and group trauma-focused and other psychotherapies;
medications; occupational therapy such as for cognitive remediation; and primary care, delivered by
an inter-professional team composed of nurses, occupational therapists, primary care providers,
psychiatrists, psychologists, and social workers. It was established in 2015 and provided since then
some remotely delivered mental health care (primarily tele-psychiatry to rurally residing service users)
but mostly in-person (in-office more than outreach) services; those remotely delivered services were
primarily provided by the NSOSIC’s physicians (who are located in the main site) for service providers
residing in Cape Breton who could not or would not fly or drive long distance to the main site; until the
current pandemic, some resistance to remotely delivered health care was expressed by some of the
NSOSIC’s psychotherapists (as noted below), as well as by some of the other providers at the NSOSIC
and by some service users and their families as well as by some other third parties such as by some
referral sources.
      For the first few months of the current pandemic, the NSOSIC could not provide in-person services
and had to consider shifting all of its services to remote delivery (since then, the NSOSIC has been
providing some in-person services although much less so than remotely delivered services; Figure 1).
After a couple of weeks of service shut down, similar to other elective specialized outpatient services
of the NSHA, the NSOSIC reopened, initially with only remotely delivered services. As tele-psychiatry
had been provided (to a much lesser extent) before the current pandemic, including by secure video
software (Medeo), shifting all of its psychiatry services to remote delivery was rapid and fairly easy
and simple, including adding an alternative secure video software (Zoom Healthcare, approved by the
NSHA) in case the Medeo video software did not work well for some service users (and vice versa).
Other individual services were initially more challenging to shift to remote delivery, for historical
and other reasons, e.g., some psychotherapists were previously not comfortable with providing such
confidential care from home to home, although within a few weeks that challenge was resolved by
means of the clinic’s leadership clarification of safeguards and the psychotherapists’ recognition of the
need to provide care to service users; clinicians also had to set up secure internet access at their homes
with the clinic’s hardware and software to ensure they had access to all necessary resources such as the
NSOSIC’s electronic health record, and they were provided formal orientation (by NSHA) to remotely
delivered services. Group interventions were delayed for longer due to more complex confidentiality
challenges, which were resolved within a few months by the NSHA for all of its mental health services.
Occupational therapy proceeded rapidly (within a few weeks) with the shift to remote delivery, as did
primary care (with exceptions when a physical examination was required). Sessions length varied
according to care plan and type of intervention, e.g., ~half an hour for psychiatry follow up and ~an
hour for psychotherapy (no different than in person care). As the NSOSIC uses an electronic health
record and digital forms, documentation proceeded seamlessly, with e-signatures and their digital
equivalents approved by the NSHA leadership.
Psychiatry Int. 2020, 1, FOR PEER REVIEW                                                                                                           3
Psychiatry Int. 2020, 1                                                                                                                          33
       To illustrate the rapid shift to remotely delivered clinical services by internet-based
 (synchronous) video and phone at the NSOSIC soon after the current pandemic started, we highlight
 hereTo   illustrate
       a couple          the rapid
                     of process        shift to remotely
                                    indicators     in supportdelivered
                                                                  of that clinical
                                                                             (recognizingservices    byin
                                                                                                 that,   internet-based        (synchronous)
                                                                                                            health care, process            quality
video   and    phone     at the  NSOSIC       soon   after  the   current     pandemic        started,
 is distinct from content quality, which has to be addressed with standardized clinical measures         we   highlight      here   a couplethat  of
process
 cannot be indicators
               reportedinhere support
                                    due to ofproprietary
                                              that (recognizing
                                                              and other that,considerations).
                                                                                in health care, processWe use quality
                                                                                                                  the termisrapiddistinct     from
                                                                                                                                          to mean
content   quality,     which    has   to be  addressed      with    standardized         clinical  measures
 weeks to very few (a couple of) months, as typically change in health care is much slower, i.e., in the          that  cannot     be    reported
here
 orderdueof to    proprietary
              years.    First, the and   other
                                       ratio  of considerations).
                                                  in-person to remotely   We use delivered
                                                                                      the term rapidservicesto mean
                                                                                                                 changed weeks     to very few
                                                                                                                               extremely,         as,
(a  couple of)tomonths,
 compared           2019, when as typically
                                     more than  change
                                                     95%in ofhealth
                                                               mentalcare      is much
                                                                           health     care slower,     i.e., in the
                                                                                             was delivered            order of in
                                                                                                                   in-person,      years.     First,
                                                                                                                                        May-July
the  ratio
 2020,  moreof in-person
                  than 90%toofremotely
                                    mental delivered
                                              health care  services     changed extremely,
                                                               was delivered           remotely as,      compared
                                                                                                     (Figure    1); the tofirst
                                                                                                                            2019,four
                                                                                                                                    when      more
                                                                                                                                           months
than   95%are
 of 2020       of confounded
                   mental health    bycare   was
                                         a mix   ofdelivered
                                                     pre-pandemic in-person,
                                                                           data andin May-July        2020, moreconstraints
                                                                                          start-of-pandemic            than 90% of      (ofmental
                                                                                                                                             initial
health   care   was    delivered     remotely     (Figure   1);  the   first four    months      of
 closure of non-urgent services such as the NSOSIC), hence their data are not addressed here (also  2020    are  confounded         by    a mix   of
pre-pandemic         data  and   start-of-pandemic        constraints     (of  initial   closure
 note that the number of clinicians is addressed in Figure 1; this number includes an occupational  of non-urgent       services     such    as the
NSOSIC),
 therapist,hence       their dataand
               a psychiatrist        arethenot psychotherapists
                                                addressed here (also         noteNSOSIC
                                                                         at the      that the and
                                                                                                numbervaries of somewhat
                                                                                                                clinicians isfrom addressed
                                                                                                                                          week in  to
Figure   1;  this   number     includes     an  occupational       therapist,    a   psychiatrist
 week due to their leaves). Second, deviations from planned care such as psychotherapy protocols      and    the  psychotherapists           at the
NSOSIC
 reduced and soonvaries
                      aftersomewhat        from week of
                            full implementation           to week
                                                             remote    due   to theirof
                                                                          delivery       leaves).
                                                                                            servicesSecond,
                                                                                                        by thedeviations
                                                                                                                  NSOSIC, from            planned
                                                                                                                                 as monitored
care  such as psychotherapy
 (by clinician       self-report) during  protocols    reduced
                                                 3 months:          soon after
                                                                 May–July        2020full(Figure
                                                                                            implementation          of remote
                                                                                                      2); this suggests         thatdelivery
                                                                                                                                         both the of
services   by   the  NSOSIC,      as  monitored     (by  clinician    self-report)     during    3  months:
 clinicians and the service users gradually, yet fairly rapidly, felt more skilled and comfortable with         May–July       2020    (Figure    2);
this suggests
 remotely          that bothmental
               delivered       the clinicians
                                        health and     the service
                                                  services             users gradually,
                                                              (assessments         and care),  yet although
                                                                                                   fairly rapidly,
                                                                                                                 a few feltservice
                                                                                                                            more skilled
                                                                                                                                       users andhad
comfortable      with   remotely     delivered     mental   health    services    (assessments
 continued difficulty with not meeting their psychotherapist in person (hence within a few weeks they and   care),  although      a  few    service
users
 were had
        shiftedcontinued
                     back todifficulty
                                in person   with    notusing
                                                care,    meeting      their psychotherapist
                                                                 pandemic        safeguards such       in person      (hence
                                                                                                            as physical          within a few
                                                                                                                              distancing        and
weeks    they were
 protective      masks).shifted
                             The back
                                    numberto in of
                                                 person    care, to
                                                     referrals     using
                                                                       thepandemic
                                                                             NSOSIC safeguards
                                                                                             decreased at   suchtheasstart
                                                                                                                        physical
                                                                                                                               of the distancing
                                                                                                                                           current
and   protective
 pandemic,             masks). due
                 as expected       Thetonumber       of closure
                                           the initial   referralsoftoprovincial
                                                                          the NSOSIC           decreased
                                                                                         non-urgent           at thesuch
                                                                                                          services      startasofthetheNSOSIC,
                                                                                                                                           current
pandemic,       as expected
 that soon (within               due to
                           a couple     ofthe   initial increased—approximately
                                            months)     closure of provincial non-urgent          back services       such asnumber—and
                                                                                                          to the regular          the NSOSIC,
that
 waitsoon
       times  (within    a couple
                 for clinical     careof did
                                         months)     increased—approximately
                                              not lengthen        once the NSOSICback               to the regular
                                                                                               reopened       soon afternumber—and
                                                                                                                              the start ofwait   the
times   for   clinical   care   did   not  lengthen     once    the   NSOSIC        reopened
 current pandemic. Although the current pandemic did not considerably change the clinical needs ofsoon     after   the  start   of  the    current
pandemic.
 the serviceAlthough          the current
                   users (largely             pandemic did
                                        as addressing             notisolation
                                                             social     considerably         change
                                                                                       is often    parttheofclinical    needs of
                                                                                                               the clinical          the service
                                                                                                                                  focus      of the
users   (largely     as  addressing      social   isolation    is often    part   of   the
 NSOSIC), a mass shooting in Nova Scotia in April 2020 added stress and a few more referrals,clinical   focus   of   the  NSOSIC),         a  mass
shooting     in  Nova     Scotia   in  April   2020   added     stress   and   a  few     more
 particularly in relation to some RCMP officers who were directly or indirectly involved in that referrals,    particularly      in   relation    to
some   RCMP
 shooting.         officers
               There    were who
                               a fewwere    directly
                                        internet      or indirectlyininvolved
                                                    breakdowns            the remote    in that  shooting.
                                                                                            delivery           There were
                                                                                                        technology,       mainlya few     internet
                                                                                                                                       with   rural
breakdowns         in the  remote    delivery    technology,      mainly     with    rural    service
 service users, for which phone contact was used as a backup (allowing follow up more than other        users,  for   which     phone      contact
was   used as a backup
 interventions                 (allowing follow up more than other interventions in real time).
                     in real time).

                         50
                         45
     # Of Appointments

                         40
                         35
                         30
                         25
                         20
                         15
                         10
                          5
                          0

                                                                          Week Of

                          # of In person Sessions   # of Telemedicine Sessions            # of Phone Sessions             # of Clinicians

             Figure 1.
            Figure   1. Remotely
                        Remotely delivered
                                 delivered vs.
                                           vs. in-person
                                               in-person mental health
                                                                health care
                                                                       care at
                                                                            at the
                                                                                the Nova
                                                                                    Nova Scotia
                                                                                         Scotia Operational
                                                                                                Operational Stress
                                                                                                            Stress
             Injury Clinic
            Injury  Clinic (NSOSIC)
                            (NSOSIC)(appointments/sessions
                                     (appointments/sessionsper
                                                            perweek).
                                                                week).
Psychiatry Int. 2020, 1                                                                                                                34
Psychiatry Int. 2020, 1, FOR PEER REVIEW                                                                                                 4

   100%                                                                                              3                            2
                                                               6                  2                            6        4
    90%                   10      6         6         7                  5                  6
               12
    80%
    70%
    60%
    50%                                                                                             53                           37
                                                              38                 17                           58       44
    40%                   41      27       32        35                 28                 28
               36
    30%
    20%
    10%
     0%

                                                                   Week Of

                                                # as planned            # with challenges

             Figure2.2. Deviations
             Figure     Deviations from
                                    from planned
                                         plannedcare
                                                 careat
                                                      atthe
                                                         theNSOSIC
                                                            NSOSIC(appointments/sessions
                                                                   (appointments/sessionsper
                                                                                          perweek).
                                                                                             week).

3.3. Conclusions
     Conclusions
       Remotely
       Remotelydelivered
                     delivered   mental
                                    mental health  carecare
                                              health     and and
                                                               related    services
                                                                      related         can becan
                                                                                  services     effective  and likely
                                                                                                    be effective      andcost-effective,
                                                                                                                             likely cost-
as
 effective, as shown in published research. Such services can also be implemented rapidly, in
    shown     in published       research.     Such   services     can   also    be implemented         rapidly,    as   illustrated     as
this quality    improvement         report   about   the  NSOSIC’s         recent   shift  to remotely
 illustrated in this quality improvement report about the NSOSIC’s recent shift to remotely delivered      delivered       (specialized
and   integrated)
 (specialized     and services    in the current
                           integrated)      servicespandemic.        As part of
                                                        in the current               that, evidence-based/informed
                                                                                  pandemic.       As part of that, evidence-      mental
health   assessments       and   interventions      can  be  provided,       with   little  deviation
 based/informed mental health assessments and interventions can be provided, with little deviation       from   planned        care  after
relatively
 from planneda short   period—a
                    care             few weeks
                           after relatively         to a couple
                                                a short  period—a   of months—of
                                                                         few weeks transition
                                                                                         to a couple  from   (mostly) in-person
                                                                                                         of months—of                   to
                                                                                                                               transition
(mostly)    remotely      delivered    services.    Beyond     the   pandemic
 from (mostly) in-person to (mostly) remotely delivered services. Beyond the pandemiccircumstances,       such   a  shift   can   benefit
people    with mental
 circumstances,       suchhealth
                              a shiftchallenges
                                        can benefitwho      live with
                                                        people     rurally     or remotely,
                                                                            mental               so that their
                                                                                       health challenges       whoaccesslive to   mental
                                                                                                                               rurally   or
health   services    is  not  compromised         because    of  their   distant    physical     location,
 remotely, so that their access to mental health services is not compromised because of their distant        and    indirect     costs  of
their  care location,
 physical    may be reduced         due to
                          and indirect       eliminating
                                          costs              the may
                                                 of their care     needbe  forreduced
                                                                                them todue drive   long distances
                                                                                               to eliminating      the(orneedfly)for
                                                                                                                                   tothem
                                                                                                                                      and
from   the long
 to drive   physical     location
                  distances     (or of  the
                                     fly) toservice
                                             and from  providers.
                                                          the physical Admittedly,
                                                                             location of universal    broadband
                                                                                            the service    providers.  (orAdmittedly,
                                                                                                                            equivalent,
such   as  satellite)   internet    access   is needed,    which      is in   progress     in Canada
 universal broadband (or equivalent, such as satellite) internet access is needed, which is in progress   and   elsewhere,        as well
as
 insufficiently
    Canada anduser         friendlyashardware
                     elsewhere,                     and software
                                        well as sufficiently       userfor   all to use
                                                                          friendly        at an affordable
                                                                                      hardware      and softwarecost.for Our allreport
                                                                                                                                 to use is
                                                                                                                                         at
limited   in that  it reports    a local  (process)   quality     improvement         initiative  rather
 an affordable cost. Our report is limited in that it reports a local (process) quality improvement        than   a  research     project.
Hence,   generalized
 initiative  rather than   conclusions
                              a researchhave      to be
                                            project.     qualified
                                                      Hence,           and wellconclusions
                                                                 generalized        controlled research
                                                                                                   have to be is needed
                                                                                                                 qualified    to and
                                                                                                                                 address
                                                                                                                                      well
processes,
 controlledoutcomes
                research and       their predictors
                             is needed     to addressinprocesses,
                                                           relation to outcomes
                                                                            shifting toand  remotely     delivered mental
                                                                                                 their predictors                  health
                                                                                                                         in relation     to
care.  Nevertheless,       our  findings    are  promising      for  such    a  shift  and   suggest
 shifting to remotely delivered mental health care. Nevertheless, our findings are promising for such  the  need     to  proceed     with
such   change
 a shift         in practice
          and suggest        theand
                                  need policy,  e.g., facilitating
                                          to proceed     with such    universal
                                                                         change access        to digital
                                                                                     in practice           technology
                                                                                                     and policy,      e.g., (hardware,
                                                                                                                              facilitating
software,
 universaland      broadband/satellite
               access     to digital technologyinternet).(hardware,
                                                           Hopefully,software,
                                                                             cross-sector  andcollaborations      will advance
                                                                                                  broadband/satellite                 and
                                                                                                                                internet).
uphold    such   access    and   person-centered      use  for   the  benefit    of the  large   number
 Hopefully, cross-sector collaborations will advance and uphold such access and person-centered use         of people      with   mental
health
 for thechallenges
          benefit of across
                        the largethenumber
                                       world. of people with mental health challenges across the world.

Author Contributions: Both authors contributed to the planning, data collection, data analysis/interpretation,
 Author Contributions: Both authors contributed to the planning, data collection, data analysis/interpretation,
and writing of this report. All authors have read and agreed to the published version of the manuscript.
 and writing of this report. All authors have read and agreed to the published version of the manuscript.
Funding: This report received no external funding.
 Funding: This report received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.
 Conflicts of Interest: The authors declare no conflicts of interest.
Psychiatry Int. 2020, 1                                                                                             35

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