Chasing the curve: Program description of the Geisinger primary care behavioral health virtual first response to COVID-19.

Abstract

In response to the COVID-19 pandemic, an initiative to rapidly transition to a telebehavioral health (TBH) service delivery model was developed to maintain access to primary care behavioral health (PCBH) services at Geisinger, a predominantly rural health system based in Central Pennsylvania. In line with the "Virtual First" approach employed by Geisinger's Department of Psychiatry and Behavioral Health, we describe how we transitioned to TBH services while facilitating communication and collaboration among PCBH providers, staff, and trainees, and supported our Geisinger colleagues during the initial months of the pandemic. We report outcomes of our Virtual First approach from March 2020 through June 2020, as well as provider surveys of acceptability and usability of the InTouch platform used for TBH. We found that we were able to attain or surpass comparable patient access and utilization by implementing TBH services compared with in-person services over the last 2 years while maintaining a training program. InTouch was found to be acceptable and usable overall based on provider ratings, although it does not include capabilities that would further enhance access such as group treatments or shared office visits with the BHP and primary care clinician. Our Virtual First approach enabled us to maintain access and utilization of PCBH services during a time of widespread uncertainty and behavioral health vulnerability in rural regions. We conclude with a discussion of the limitations of our approach and the next steps in navigating the "new normal" of behavioral healthcare in the age of COVID-19. Public Health Significance StatementThis program description serves as a salient case example of successfully navigating the rapid transition to TBH services necessitated by the first wave of the COVID-19 pandemic in 2020. Planning and co-ordination of communication and task work among team members and an existing TBH platform capable of rapid scaling enabled rural access and utilization of PCBH services at Geisinger at comparable levels to the previous 2 years.

What works for whom with telemental health? A rapid realist review

“…1) Agree a back-up method of connecting, e.g., reverting to telephone calls in the event of disruption; 2) where connection issues cannot be readily resolved, and back up methods are not sufficient, strategies to address connection problems (as above) are required or moves to face-to-face care should be facilitated. CMO 1.5: Preparing service users for telemental health [93][94][95] When When service users are offered telemental health appointments because face-to-face appointments are restricted (e.g. due to COVID-19 or another emergency) (C), these appointments are likely to be accepted by some service users on the basis that they are the main way by which mental health care can continue (O1) and there is a reduced risk of infection from COVID-19 (O2), as face-to-face options are lacking or very restricted and telemental health is seen as preferable to receiving no support at all and as an alternative to cancelling appointments entirely (M).…”

“…health as an alternative means there is an option to receive care with more anonymity (M), which helps ensure their privacy and safety (O1), thereby increasing the accessibility of services (O2). CMO 3.3: Managing risk [24,53,95,101,130,131,138,144,[151][152][153][154][155] When services incorporate tailored risk management procedures in delivery of remote care (C), this encourages consideration of the risks associated with remote care specific to each individual, including risk of selfharm or suicide as well as risk from others in situations of domestic abuse, and ensures staff are aware of the procedures to try to assess and respond to risk or safeguarding concerns despite challenges associated with remote care (M), which has the potential to improve the safety and wellbeing of service users and others (O1). However, a disadvantage of telemental health is that real-time risk assessment limits an immediate response to be organised when someone is at imminent risk of harm and some distance away (O2).…”

“…using text functions on videoconferencing platforms or arranging face-to-face appointments). CMO 2.8: Communication between staff [19,95,140] When remote technology platforms are used to facilitate real-time communication between staff members, including managers or clinicians working in different teams (C), this can lead to improved efficiency, more convenient working and staff management (O1), improved communication and collaborative planning (O2), and process improvement opportunities (O3), as staff have the ability to rapidly share information, keep track of evolving telemental health Contexts where this is relevant include: 1) multidisciplinary teams who are not working on the same site; 2) complex provider organisations with management teams and clinicians working on multiple sites; 3) situations in which people may be receiving care from multiple teams, for example, from an inpatient or crisis service as well as a continuing care service. 1) Making use of telemental health platforms to strengthen liaison and collaboration between teams and professionals on different sites, for example, through increased enhanced liaison between managers across an organisation, or provide better access to a range of educational events; 2) using telemental health platforms to facilitate multidisciplinary team meetings between staff on different sites (especially if some are working from home).…”

“…1) Establishing a call-back number before commencement of the session in the case of disconnection when discussing distressing or sensitive topics; 2) increased coordination with service users/families to facilitate safe transport to emergency departments if needed; 3) setting clear protocols regarding when staff can be contacted via digital means, including who to contact instead in the case of emergency; 4) identification of where the service user is located at the start of the session to enable a faster response of inperson support if needed; 5) development of a "telehealth manual" containing information on what to do in the event of sudden ending of the call and who to contact; 6) codevelopment of a crisis plan with the service user; 7) offering 24/7 helplines and continued availability of face-to-face crisis response, including capacity for home visits; 8) ensuring adequate device battery or connecting to charger at the start of the session to reduce the risk of disconnection. CMO 3.4: Technological support and information security [95] When services provide technology support, software with appropriate security and devices (including mobile phones and headphones) to staff specifically for work use (C), this helps ensure privacy and confidentiality for both service users and staff (O), 1) In services where staff share office space and devices, or where shortage of devices may lead to use of personal devices, for example for home working; 2) when balancing service user preference with risk from using less secure software, or software with which staff are less 1) Providing data safeguarding and other technology-based training to all staff (as knowledge cannot be assumed); 2) providing information on which software is encrypted/secure; 3) providing funding to staff for the purchase of equipment; 4) setting recommended boundaries for both service because staff can store information securely on devices that are not shared with others (M1) and are able to ensure that service users are aware of when they will have access to their work devices (M2).…”