Palliative Care

Psychotherapy Telemental Health Center and Regional Pilot

A pilot program that delivers telemental health care for posttraumatic stress disorder provides best practices for facilities looking to expand in-home and remote care to veterans.

Fed Pract. 2015 July;32(7):48-55

Author(s):

Kathryn Williams, PhD

Shira Kern, MA

Steven R. Thorp, PhD

Martin Paulus, MD

Nilesh Shah, MD

Leslie Morland, PhD

Peter Hauser, MD

References

1. U.S. Department of Veterans Affairs. What is telehealth? U.S. Department of Veterans Affairs Website. http://www.telehealth.va.gov. Update May 13, 2014. Accessed April 30, 2015.

2. Morland LA, Greene CJ, Rosen C, Mauldin PD, Frueh CB. Issues in the design of a randomized noninferiority clinical trial of telemental health psychotherapy for rural combat veterans with PTSD. Contemp Clin Trials. 2009;30(6):513-522.

3. Strachan M, Gros DF, Ruggiero KJ, Lejuez CW, Acierno R. An integrated approach to delivering exposure-based treatment for symptoms of PTSD and depression in OIF/OEF veterans: preliminary findings. Behav Ther. 2012;43(3):560-569.

4. Yuen EK, Gros DF, Price M, et al. Randomized controlled trial of home-based telehealth versus in-person prolonged exposure for combat-related PTSD in veterans: preliminary results. J Clin Psychol. 2015;71(6):500-512.

5. Ruskin PE, Reed S, Kumar R, et al. Reliability and acceptability of psychiatric diagnosis via telecommunication and audiovisual technology. Psychiatr Serv. 1998;49(8):1086-1088.

6. Gros DF, Morland LA, Greene CJ, et al. Delivery of evidence-based psychotherapy via video telehealth. J Psychopathol Behav Assess. 2013;35(4):506-521.

7. Backhaus A, Agha Z, Maglione ML, et al. Videoconferencing psychotherapy: a systematic review. Psychol Serv. 2012;9(2):111-131.

8. Egede LE, Frueh CB, Richardson LK, et al. Rationale and design: telepsychology service delivery for depressed elderly veterans. Trials. 2009;10:22.

9. Frueh BC, Deitsch SE, Santos AB, et al. Procedural and methodological issues in telepsychiatry research and program development. Psychiatr Serv. 2000;51(12):1522-1527.

10. Grubaugh AL, Cain GD, Elhai JD, Patrick SL, Frueh BC. Attitudes toward medical and mental health care delivered via telehealth applications among rural and urban primary care patients. J Nerv Ment Dis. 2008;196(2):166-170.

11. Jameson JP, Farmer MS, Head KJ, Fortney J, Teal CR. VA community mental health service providers’ utilization of and attitudes towards telemental health care: the gatekeeper’s perspective. J Rural Health. 2011;27(4):425-432.

12. Thorp SR, Fidler J, Moreno L, Floto E, Agha Z. Lessons learned from studies of psychotherapy for posttraumatic stress disorder via video teleconferencing. Psychol Serv. 2012;9(2):197-199.

13. Gros DF, Yoder M, Tuerk PW, Lozano BE, Acierno R. Exposure therapy for PTSD delivered to veterans via telehealth: predictors of treatment completion and outcome and comparison to treatment delivered in person. Behav Ther. 2011;42(2):276-283.

14. Zarate CA Jr, Weinstock L, Cukor P, et al. Applicability of telemedicine for assessing patients with schizophrenia: acceptance and reliability. J Clin Psychiatry. 1997;58(1):22-25.

15. Jones AM, Shealy KM, Reid-Quiñones K, et al. Guidelines for establishing a telemental health program to provide evidence-based therapy for trauma-exposed children and families. Psychol Serv. 2014;11(4):398-409.

16. Frueh BC, Monnier J, Grubaugh AL, Elhai JD, Yim E, Knapp R. Therapist adherence and competence with manualized cognitive-behavioral therapy for PTSD delivered via videoconferencing technology. Behav Modif. 2007;31(6):856-866.

17. Morland LA, Hynes AK, Mackintosh MA, Resick PA, Chard KM. Group cognitive processing therapy delivered to veterans via telehealth: a pilot cohort. J Trauma Stress. 2011;24(4):465-469.

18. Tuerk PW, Yoder M, Ruggiero KJ, Gros DF, Acierno R. A pilot study of prolonged exposure therapy for posttraumatic stress disorder delivered via telehealth technology. J Trauma Stress. 2010;23(1):116-123.

19. Fortney JC, Pyne JM, Kimbrell TA, et al. Telemedicine- based collaborative care for posttraumatic stress disorder: a randomized clinical trial. JAMA Psychiatry. 2015;72(1):58-67.

20. Germain V, Marchand A, Bouchard S, Drouin MS, Guay S. Effectiveness of cognitive behavioural therapy administered by videoconference for posttraumatic stress disorder. Cogn Behav Ther. 2009;38(1):42-53.

21. Morland LA, Mackintosh M, Greene CJ, et al. Cognitive processing therapy for posttraumatic stress disorder delivered to rural veterans via telemental health: a randomized noninferiority clinical trial. J Clin Psychiatry. 2014;75(5):470-476.

22. Tuerk PW, Fortney J, Bosworth HB, et al. Toward the development of national telehealth services: the role of Veterans Health Administration and future directions for research. Telemed J E Health. 2010;16(1):115-117.

23. Godleski L, Darkins A, Peters J. Outcomes of 98,609 U.S. Department of Veterans Affairs patients enrolled in telemental health services, 2006-2010. Psychiatr Serv. 2012;63(4):383-385.

24. Strachan M, Gros DF, Yuen E, Ruggiero KJ, Foa EB, Acierno R. Home-based telehealth to deliver evidence-based psychotherapy in veterans with PTSD. Contemp Clin Trials. 2012;33(2):402-409.

Within VHA, telemental health (TMH) refers to behavioral health services that are provided remotely, using secure communication technologies, to veterans who are separated by distance from their mental health providers. ¹ Telemental health sometimes involves video teleconferencing (VTC) technology, where a veteran (or group of veterans) in one location and a provider in a different location are able to communicate in real time through a computer monitor or television screen. ² In the VHA, TMH visits are typically conducted from a central location (such as a medical center hospital) to a community-based outpatient clinic (CBOC), but pilot projects have also tested VTC in homes as well. ^1,3,4

In addition to providing timely access to behavioral health services in rural or underserved locations, TMH eliminates travel that may be disruptive or costly and allows mental health providers to consult with or provide supervision to one another. Telemental health can be used to make diagnoses, manage care, perform checkups, and provide long-term, follow-up care. Other uses for TMH include clinical assessment, individual and group psychotherapy, psycho-educational interventions, cognitive testing, and general psychiatric care. ^1,5,6More recently, TMH has been used to provide evidence-based psychotherapies (EBPs) to individuals with posttraumatic stress disorder (PTSD) and other mental health diagnoses. ^6,7 Such care may be particularly advantageous for veterans with PTSD, because traveling can be a burden for them or a trigger for PTSD symptoms.

Although interactive video technology is becoming widely available, its use is limited in health care systems due to lack of knowledge, education, logistical guidance, and technical training. The authors have conducted EBPs using VTC across VISN 22 in both office-to-office and office-to-home modalities and are providing EBPs using VTC to CBOCs in other VISNs across the western U.S. This article addresses these issues, outlining the necessary steps required to establish a TMH clinic and to share the successes of the EBP TMH Center and Regional Pilot used at VISN 22.

Telemental Health

Telemental health is an effective alternative to in-person treatment and is well regarded by both mental health providers and veterans. Overall, mental health providers believe it can help reduce the stigma associated with traditional mental health care and ease transportation-related issues for veterans. Telemental health allows access to care for veterans living in rural or remote areas in addition to those who are incarcerated or are otherwise unable to attend visits at primary VA facilities. ^2,8-10 In an assessment of TMH services in 40 CBOCs across VISN 16, most CBOC mental health providers found it to be an acceptable alternative to face-to-face care, recognize the value of TMH, and endorse a willingness to use and expand TMH programs within their clinics. ¹¹

Veterans who participated in TMH via VTC have expressed satisfaction with the decreased travel time and expenses, fewer interactions with crowds, and fewer parking problems. ¹² Several studies suggested that veterans preferred TMH to in-person contact due to more rapid access to care and specialists who would otherwise be unavailable at remote locations.5,10 Similarly, veterans who avoid in-person mental health care were more open to remote therapy for many of the reasons listed earlier. Studies suggest that veterans from both rural and urban locations are generally receptive to receiving mental health services via TMH. ^5,10