Several studies have found that TMH services may have advantages over standard in-person care. These advantages include decreasing transportation costs, travel time, and time missed at work and increasing system coverage area. 13 Overall, both veterans and providers reported similar satisfaction between VTC and in-person sessions and, in some cases, prefer VTC interactions due to a sense of “easing into” intense therapies or having a “therapeutic distance” as treatment begins. 12
Utility
Previous studies have shown that TMH can be used successfully to provide psychopharmacologic treatment to veterans who have major depressive disorder or schizophrenia, among other psychiatric disorders. 5,8,14 Recent studies have focused on the feasibility of providing EBPs via TMH, particularly for the treatment of PTSD. 12,15 Studies have shown that TMH services via VTC can be used successfully to provide cognitive behavioral therapy (CBT), cognitive processing therapy (CPT), and prolonged exposure therapy (PE). 16-21 In these studies, both PE and CPT delivered via TMH were found to be as efficacious as in-person formats. Furthermore, TMH services were successfully used in individual and group sessions.
Research has emphasized the benefits of TMH for veterans who are uncomfortable in crowds, waiting rooms, or hospital lobbies. 7,12,18 For patients with PTSD who are initially limited by fears related to driving, TMH can facilitate access to care. Veterans with PTSD often avoid reminders of trauma (ie, uniforms, evidence of physical injury, artwork, photographs related to war), which can often be found at the larger VAMCs. These veterans may find mental health care services in their homes or at local CBOCs more appealing. 7,12,18
Implementation
Prior to the implementation of telehealth services, many CBOC providers would refer veterans in need of specialty care to the nearest VAMC, which were sometimes many hours away. 1 In response to travel and access concerns, the VA has implemented various telehealth modalities, including TMH.
In 2008, about 230,000 veterans received mental health services via real-time clinical VTC at 300 VA CBOCs, and about 40,000 veterans enrolled in the In-Home Telehealth program.22 By 2011, > 380,000 veterans used clinic-based telehealth services and about 100,000 veterans used the in-home program. 1 Between 2006 and 2008, the 98,000 veterans who used TMH modalities had fewer hospital admissions compared with those who did not; overall, the need for hospital services decreased by about 25% for those using TMH services. 23
Although research suggests that TMH is an effective treatment modality, it does have limitations. A recent study noted several visual and audio difficulties that can emerge, including pixilation, “tracer” images with movement, low resolution, “frozen” or “choppy” images, delays in sound, echoes, or “mechanical sounding” voices. 12 In some cases, physical details, such as crying, sniffling, or fidgeting, could not be clearly observed. 12 Overall, these unforeseen issues can impact the ability to give and receive care through TMH modalities. Proper procedures need to be developed and implemented for each site.
Getting Started
Using TMH to provide mental health care at other VHA facilities requires planning and preparation. Logistics, such as preparation of the room and equipment, should be considered. Similarly, veteran and provider convenience must be considered. 2,11 Before starting TMH at any VA facility, professionals working with the audiovisual technology and providing TMH care must complete necessary VA Talent Management System courses and obtain copies of certificates to assure they have met the appropriate training criteria. Providers must be credentialed to provide TMH services, including the telehealth curriculum offered by VA Employee Educational Services. 2,24 An appropriate memorandum of understanding (MOU) must be created, and credentialing and privileging must also be acquired.