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/psychiatryintPsychiatry 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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