Psychology of consulting and coaching

Barriers and Facilitators to Implementing a U.S. Department of Veterans Affairs Telemental Health (TMH) Program for Rural Veterans

Erica Shreck, Nicole Nehrig, Jennifer A. Schneider, Amy Palfrey, Julia Buckley, Brittney Jordan, Sagiv Ashkenazi, Lauren Wash, Alyssa L. Baer, and Cory K. Chen

VA NY Harbor Health Care System, New York, New York

Telemental health refers to the use of information and technology to provide mental health services when providers and patients are separated geographically. The U.S. Department of Veterans Affairs’ (VA) Telemental Health Hub (TMH) initiative started in 2002 to address the mental health needs of rural Veterans and has been increasingly used since that time. Services are typically provided from a VA medical center (VAMC) to a VA community-based outpatient clinic, as well as to Veterans’ homes. The VA NY Harbor Health Care System TMH Hub (VA NYH TMH Hub) was established in 2016 through funding from VA’s Office of Rural Health. Since March 2017, the VA NYH TMH Hub has provided individual, couples, and group therapy, as well as neuropsychological and psychodiagnostic testing to Veterans in rural New York and Iowa. As the TMH initiative continues to grow, it is increasingly important to understand program development, particu- larly barriers and facilitators to support ongoing growth. The present article examines factors that enhance and challenge the provision of psychotherapy via TMH, as experienced by TMH psychologists. Reflections are based on discussions among nine TMH psychologists regarding their experiences providing TMH treat- ment, generated and categorized during weekly staff and peer supervision meetings. Administrative, technical, and clinical barriers and facilitators are discussed. Unique considerations are also discussed, related to the structure of the VA NYH TMH Hub and the ways in which the therapeutic relationship may be impacted by TMH. Current considerations highlight strategies to improve telehealth processes and provide practical guidance to support TMH growth.

Keywords: telemental health, Veterans, remote mental health, mental health services

Telemental health (TMH) refers to the use of information and technology to provide

mental health services when providers and patients are separated geographically (Sood et al., 2007). TMH services span diagnostic as- sessment; individual, group, couples, and family therapy; neuropsychological testing; medication management; patient and provider education and collaboration. Services can be delivered through both asynchronous means (e.g., e-mail, chat rooms, remote monitoring device) or synchronous clinical video tele- health. Given its comprehensive nature, one of the major goals of TMH is to reduce dis- parities in access to high-quality, evidence- based, mental health care, making TMH par- ticularly well-suited to address the dearth of specialized mental health resources in rural areas (Grady et al., 2011; Monnier, Knapp, & Frueh, 2003; Norman, 2006).

X Erica Shreck, Nicole Nehrig, Jennifer A. Schneider, Amy Palfrey, Julia Buckley, Brittney Jordan, Sagiv Ashke- nazi, Lauren Wash, Alyssa L. Baer, and Cory K. Chen, Mental Health Service, VA NY Harbor Health Care System, New York, New York.

This research was supported by funding provided by U.S. Department of Veterans Affairs (VA) Office of Rural Health (ORH). Visit www.ruralhealth.va.gov to learn more. Acknowledgement to Adam Wolkin and Seena Mathew, for their involvement in the VA NY Harbor Health Care Sys- tem Telemental Health Hub implementation and ongoing support.

Correspondence concerning this article should be addressed to Erica Shreck, Mental Health Service, VA NY Harbor Health Care System, 423 East 23rd Street, Room 12086S, New York, NY 10010. E-mail: erica.shreck@va.gov

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

Journal of Rural Mental Health © 2020 American Psychological Association 2020, Vol. 44, No. 1, 1–15 ISSN: 1935-942X http://dx.doi.org/10.1037/rmh0000129

1

TMH in Veteran’s Health Administration

There is an increasing demand to address Veterans’ mental health needs, and the current body of literature highlights the mismatch be- tween the proportion of Veterans residing in rural areas and qualified mental health providers who are available to provide services (United States Department of Health and Human Ser- vices, National Center for Health Workforce, 2014; United States Department of Veteran Af- fairs (VA), Office of Rural Health, 2015). Con- sequently, the provision of TMH services has become a key focus of the Veteran’s Health Administration’s (VHA) efforts. Increasing ev- idence suggests that Veterans can be treated for a wide range of diagnoses via TMH, with effi- cacy and satisfaction comparable to that of in- person treatment, for individual and group ther- apy, as well as neuropsychological testing (Bouchard et al., 2004; Cullum, Hynan, Grosch, Parikh, & Weiner, 2014; Cullum, Weiner, Gehrmann, & Hynan, 2006; Gehrman, Shah, Miles, Kuna, & Godleski, 2016; Gros, Yoder, Tuerk, Lozano, & Acierno, 2011; Hilty et al., 2013; Morland et al., 2014; Morland, Hynes, Mackintosh, Resick, & Chard, 2011).

The VHA TMH Hub initiative was devel- oped in 2002, with the aim of using technology- facilitated care, to provide patient-centered, ex- pedient mental health services from a facility “hub” to “spoke” site facilities (e.g., VHA med- ical centers, VHA community-based outpatient clinics (CBOCs), residential treatment centers, student health centers and Veterans’ homes; Godleski, 2014). TMH interventions are deliv- ered in VHA through secure, real-time, interac- tive clinical videoconferencing systems, which provide high definition, two-way communica- tion between providers and Veterans. In 2017, VA’s TMH Hubs contributed to more than 151,600 Veterans receiving TMH services de- livered at CBOCs and 8,700 Veterans receiving mental health services in their homes or other non-VA locations, highlighting the accessibility and flexibility of the treatment modality (United States Department of VA, Office of Connected Care, 2018).

VA NYH TMH Hub Psychology Service

The VA NY Harbor Health Care System (VA NYH) was selected to serve as a Hub in 2016 as

part of an expansion of the original Hub initia- tive. Since its inception, the VA NYH TMH Hub has successfully delivered a wide range of mental health services to VA medical centers, CBOCs, domiciliary and residential posttrau- matic stress disorder (PTSD) programs, and to numerous Veterans’ homes. This hub-and- spoke model was designed to expand offerings for specialized mental health resources to rural areas and provide support to rural clinicians, rather than permanently replace local resources. The services offered through psychiatry include medication management and emergency room coverage. Psychology services include individ- ual, couples, and group psychotherapies; neuro- psychological and psychodiagnostic assess- ment; and other specialized psychological evaluations (e.g., PTSD assessments). Individ- ual and couples’ therapy are provided to VA medical centers, CBOCs and Veterans’ homes; group therapy is provided to VA domiciliary and PTSD residential programs and neuropsy- chological and psychodiagnostic assessments are provided to VA medical centers and CBOCs. The VA NYH TMH Hub uses a “net- work model,” whereby all TMH psychologists are available to deliver services to any spoke site or to Veterans’ homes in the spoke site catchment areas. Additional details about the specific services provided and the structure of the VA NYH TMH Hub program’s psychology service are outlined in Chen and colleagues’ (2019) paper.

TMH Implementation Challenges

As with any new treatment modality, the im- plementation of telehealth services has high- lighted important challenges, namely systemic, technological, administrative, provider, and pa- tient issues. In terms of infrastructure, systemic issues that have been noted include licensing and credentialing regulations regarding the pro- vision of care across state lines, and questions related to reimbursement (Benavides-Vaello, Strode, & Sheeran, 2013; Castro, Miller, & Nager, 2014). Literature also suggests that tech- nological issues, such as bandwidth limitations, audio and visual quality and administrative challenges, such as clinic space, staffing and support from leadership, may increase hesitancy to adopt the TMH modality, both in VA and

2 SHRECK ET AL.

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

non-VA settings (Brooks, Turvey, & Auguster- fer, 2013).

A meta-analytic review of factors influencing adoption of TMH identified barriers to TMH implementation, include: providers’ concerns about increased administrative and documenta- tion load, adequately addressing risk and safety issues from afar and provider reluctance to work with a new modality (Bee et al., 2008). In addition, obstacles to disseminating information and educating patients about TMH have been raised as potential challenges to implementation in large, private health care systems (Ellimoot- til, An, Moyer, Sossong, & Hollander, 2018).

Nevertheless, evidence of factors facilitating TMH implementation include, increasing com- munication about treatment offerings to refer- ring providers and identifying staff that support telehealth at each level of the organization. One study that evaluated telehealth implementation within four large U.S. health care systems noted the positive impact of encouraging clinicians to consider the ways that telehealth may improve delivery of care in a unique, rather than one- size-fits-all manner; this was achieved through appointing a telehealth coordinator to simplify logistical procedures and patient outreach and maintaining consistency in scheduling and doc- umentation procedures (Ellimoottil et al., 2018). Another study evaluating use of TMH with fe- male Veterans identified driving forces in the expansion of TMH to be (a) efforts to reduce stigma in receiving mental health services, par- ticularly in small communities where maintain- ing anonymity is challenging; (b) opportunities to work with clinicians with specialized train- ing; and (c) ease of receiving services in one’s home (Moreau et al., 2018).

As TMH services and technology advances, it is increasingly important to understand the unique barriers and facilitators in the implemen- tation of TMH within VA. The present article examines factors that enhance and challenge the provision of psychotherapy via TMH, as expe- rienced by TMH psychologists. Strategies are offered to improve telehealth processes, en- hance effectiveness of mental health care for Veterans and support evolution, to flexibly meet the needs of Veterans and continually improve services, which benefits TMH clinical provid- ers, technical staff, hospital leadership and ad- ministration.

Method

The information presented here was gener- ated through discussion among nine psycholo- gists working in the TMH Hub, during weekly staff and peer supervision meetings, over the first two years of implementing TMH services. VA NYH TMH psychologists’ demographics include: 78% female, 89% Caucasian, and an average of 6 years of postdoctoral experience (SD � 3.61). Notes were taken during meetings regarding challenges encountered delivering in- dividual, group, couples’ therapy and neuropsy- chological assessment via TMH and ways to enhance the development of the TMH program to meet these challenges. One psychologist (Er- ica Shreck) organized these notes into catego- ries and specific barriers and facilitators were then discussed among the other eight psychol- ogists to ensure that all relevant issues were addressed.

Results

Perceived barriers and facilitators to the im- plementation and development of a TMH hub, specifically the telepsychology service, are dis- cussed across clinical, technical and administra- tive categories. Given the overlap between fac- tors that support and challenge program implementation, barriers, and facilitators are discussed together within each category. Table 1 provides a summary of the categories, with a brief description listed.

Clinical Issues

In terms of clinical issues, VA NYH TMH Hub psychologists identified three areas of dis- cussion: the “network model” of organization, provision of clinical services and the impact of telehealth on the therapeutic relationship.

“Network model” considerations. VA NYH TMH Hub psychologists identified that delivering psychotherapy over telehealth may facilitate the clinical process in several ways. VA NYH TMH Hub’s use of the “network model” allows for Hub psychologists to offer numerous specialized mental health treatments to each spoke site, thus engaging Veterans in specialty treatment they may not otherwise have access to, as Hub psychologists offer over 20 different evidence-based treatments (Chen et

3BARRIERS AND FACILITATORS OF TMH

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

al., 2019). However, given the short-term model of evidence-based treatments, connecting Vet- erans in need of additional services following telehealth treatment poses difficulties, due to the complexity of Veterans’ presenting issues and the lack of specialized clinical resources in spoke site areas. For example, because of ex- pertise in dialectical behavior therapy (DBT), Hub psychologists have increasingly received referrals to treat Veterans at high risk for suicide and/or homicide, often in conjunction with medical and mental health comorbidities. Such Veterans frequently require additional treatment following stabilization of risk-related issues. As such, Hub psychologists grapple with how to

ensure these Veterans continue to receive the ongoing supportive care they need to maintain therapeutic gains. In addition, working with multiple spoke sites connected to different hos- pital systems makes integration with multidis- ciplinary teams challenging. It can be difficult to coordinate care with other providers across sites, which impacts access to important infor- mation about Veterans that may be more readily available with on-site multidisciplinary commu- nication.

Provision of clinical services. Telehealth treatment provides unique opportunities in clin- ical assessment and delivery of psychotherapy, as well as the ability to reduce wait times for

Table 1 Perceived Barriers and Facilitators Across Categories

Category Facilitators Barriers

Clinical Provision of

services Enhance access to services where resources are

limited in rural areas Treatment planning challenges due to

complexity of issues and dearth of spoke site resourcesIncrease likelihood of reaching diagnostically

complex patients “Network model” Maximizes access to range of specialty services Integration challenges with spoke site

multidisciplinary teams Therapeutic

relationship impact

Physical distance fosters opportunities for safety and comfort in disclosure and engagement

Challenges navigating cultural differences with spoke sites

Treatment can be tailored to telehealth modality Limitations associated with distance in created shared space

Introduction of third party into therapeutic relationship

Technical Evolution of

technology Expands range of clinical services available Audio/visual glitches occur regularly Use of tablets and handheld devices enhance

flexibility for treatment adaptations Challenges increase in at-home

sessions due to connectivity issues Use of materials Allows for screen sharing to review handouts

and measures in session, in real time Electronic transmission often delays

reviewing measures in session Transmission limitations if patient

does not use secure messaging Administrative

Integration of Hub missions

Supports Hub growth through feedback on clinician productivity, patient progress, and satisfaction

Challenges in balancing three missions and greater departmental roles and responsibilities

Facilitates training next generation of telehealth providers

Contributes to growing body of literature on telehealth expansion

“Network model”

Point of contact (POC) develops familiarity with spoke site to establish rapport, continuity, and enhance organization

Hub clinicians juggle variations in procedures and organization across spoke sites

Procedural set-up of services

Allows flexibility in modifying protocols, materials, and frequency of communication to match spoke site’s needs and expectations

Without national standards, variations in Hub and spoke site scheduling, documentation, and procedural coordination exist

4 SHRECK ET AL.

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

initial appointments and improve overall access to quality mental health care. Video-to-home (V2H) provides the opportunity for Hub psy- chologists to engage with Veterans outside of the confines of VA facilities, which can be used to modify treatments to increase their effective- ness. For example, a cognitive behavioral ther- apy for insomnia therapist can recommend changes to a Veteran’s sleep environment after observing their bedroom, and a cognitive be- havioral therapy for depression therapist can use the order of a Veteran’s home to assess changes over time in a Veteran’s energy and motivation. Hub psychologists can design and implement interventions to be delivered within the most appropriate environment, such as having Veter- ans with obsessive-compulsive disorder engage in exposure exercises within or outside their own home. V2H may increase the possibility that the treatment intervention can be general- ized beyond the therapy room if it takes place at the site where change is needed. Hub psychol- ogists also recognized potential barriers in V2H, in terms of potentially reinforcing patterns of avoidance or maintaining isolation for Veterans who prefer not to leave their homes. Concerns regarding maintaining privacy with V2H visits are discussed at the outset of treatment through the verbal informed consent process, to mitigate issues that may arise due to having less control over the therapeutic space in one’s home (e.g., sessions should be conducted in a safe, confi- dential space and should be treated similarly to an in-person session).

Impact on therapeutic relationship. Hub psychologists noted that the therapeutic rela- tionship is affected by various external factors, including limitations imposed by physical dis- tance on the ability to create safety and comfort within the Veteran’s session space. For in- stance, the Hub psychologist has little control over the temperature of the room, noise level, or privacy. Hub psychologists noted examples of seeing Veterans in medical treatment rooms, in spaces where no tissues were available. This effect is magnified in TMH V2H, in which it is the veteran who has control over the therapeutic environment. More specifically, the Veteran may be seen in a location that is experienced as provocative or overstimulating (e.g., the bed- room) or one which is filled with distractions, which can negatively impact the Veteran’s ca- pacity to focus or feel comfortable being fully

vulnerable and open (e.g., in a car parked out- side of their work). As such, the Hub psychol- ogist may be a passive bystander to certain happenings without the ability to intervene, even to provide a Veteran with tissues or re- spond if a Veteran leaves the treatment room during the session.

Nevertheless, for Veterans seen V2H, the Veteran’s ability to exert control over the space in which therapy is conducted may increase comfort and facilitate openness. The VA facility itself may be triggering for Veterans, in terms of experiences of harassment for marginalized groups and previous memories of negative health care experiences. Thus, TMH offers an avenue to avoid unnecessary barriers to obtain- ing the treatment that Veterans need. There may be a sense that the power dynamic is diffused by seeing the Hub psychologist in an environment they have shaped, rather than a therapist’s office and may put Veterans who are reticent about engaging in therapy at ease by having it occur on their “turf.” The Hub psychologist may also be introduced to other important people and/or pets in the Veteran’s life which creates a richer sense of connection. For example, Hub psychol- ogists have found that Veterans often have dogs or cats with them during V2H sessions, which helps with emotion regulation during discussion of difficult material. In addition, TMH treat- ment, especially when delivered via V2H, pro- vides flexibility in terms of timing and location of sessions, facilitating treatment to Veterans who typically would have difficulty attending regular in-person sessions (e.g., those who work full-time and/or travel for work, have childcare needs, lack transportation, have medical condi- tions that make travel difficult, or who live far from a VA facility).

When Veterans are seen at local CBOCs, the therapeutic relationship is impacted by the ad- dition of a third person, the telehealth clinical technician (TCT). The TCT, not the Hub psy- chologist, greets the Veteran in the waiting room, escorts them to the treatment room, as- sesses for the Veteran’s comfort, and assists with dial-up and transmission of homework as- signments and handouts. The set-up impacts the amount of information available to the Hub psychologist (e.g., observations regarding where the Veteran is sitting in the waiting area, who they interact with and how, and mental status observations such as smelling alcohol or

5BARRIERS AND FACILITATORS OF TMH

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

observing how someone is walking), as well as the Veteran’s observation and experience of the psychologist. It can also affect the Veteran’s transition into the therapeutic experience in ways that are beyond the clinician’s control. For instance, a Hub psychologist may be available at the session time but the TCT schedule calls for participation in additional responsibilities at that time. The role of the TCT in transmitting questionnaires and homework means that they are privy to personal information that is typi- cally privileged between clinician and Veteran, which may increase feelings of distance and impact the Veteran’s openness in treatment. Nevertheless, clinical advantages in having TCT involvement include, knowledge of the culture of the community and the clinic/local VA, as well as ability to share clinical data via secure message prior to, during or after an ap- pointment (e.g., TCT encouraging a Veteran to return to a couples’ session after leaving the room escalated).

Hub psychologists identified that the experi- ence of physical distance is exacerbated by cul- tural differences that exist inherently, because the clinician and Veteran are in different lo- cales, which may create challenges to the ther- apeutic relationship. The VA NYH TMH Hub is in New York City, with care provided to rural areas in upstate New York and Iowa. Cultural differences span a range of factors including socioeconomic status, racial/ethnic diversity, age, education/profession, family structure and political views. Awareness of certain cultural norms based on geography can represent a bar- rier to both clinician understanding and Veter- ans’ willingness to engage with the therapeutic process. For example, Hub psychologists noted the challenges of fully grasping agrarian life and the centrality of the needs of the farm, making it difficult to collaborate with Veterans around enhancing self-care. Challenges were also ob- served in brainstorming pleasurable activities in a behavioral activation protocol, due to reduced awareness of what is typical in the Veterans’ geographic region. Hub psychologists have ob- served that constant noise in the New York City area (e.g., frequent sirens that are often heard through the technology) may be a trigger during sessions for Veterans with anxiety and PTSD.

In addition, a cultural disconnect may exist between providers at the Hub and spoke sites. This may, in turn, impact referrals and the abil-

ity to coordinate care where spoke site providers hold the belief that Hub psychologists will be unable to fully understand the Veteran’s expe- rience or perspective. When initiating TMH ser- vices, a spoke site referring provider expressed concern that Hub psychologists’ may not appre- ciate how overlapping/dual roles are common and unavoidable in small communities. Subse- quently, this may affect Veterans’ willingness to engage in treatment, due to concerns about anonymity and confidentiality, as Veterans’ family members and friends may be employed in the health care field.

Somewhat paradoxically, the physical dis- tance between the Veteran and clinician may also facilitate closeness within the therapeutic relationship. As Hub psychologists live far re- moved from the Veteran’s community, ano- nymity increases and may allow for greater openness on the part of the Veteran. Further- more, Hub psychologists have observed in- creased feelings of safety discussing homicidal ideation and violent thoughts, given the physi- cal distance.

Technical Issues

Technical barriers and facilitators are dis- cussed in the areas of technological advance- ments and the presentation and transmission of materials in treatment.

Technological advancements. Telehealth technology serves as the foundational infra- structure and a key facilitator in the provision of clinical care to spoke site areas, by bolstering the quality of care and expanding the breadth of clinical services provided. In addition to indi- vidual and couples’ therapy, technology facili- tates access to neuropsychological and psy- chodiagnostic assessment, as well as group therapy with Veterans and clinicians located at multiple sites. Camera capabilities, such as a document reader, make it feasible to administer complex neuropsychological measures by mir- roring measures to the Hub psychologist’s screen, as Hub psychologists use Cisco DX80 devices (23-in. liquid crystal display monitors with a 1,920 � 1,080 resolution) to administer TMH treatment and neuropsychological and psychodiagnostic assessments; additional de- tails regarding the specific technology used in the VA NYH TMH Hub are outlined in Chen and colleagues’ (2019) paper.

6 SHRECK ET AL.

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

Multiway video capabilities set the stage for facilitating groups in different locations, maxi- mizing access to care. Another identified tech- nological facilitator is the opportunity to use different types of equipment (e.g., laptop, desk- top, tablet, and smartphone), which improves ease of use for Veterans and continuity of care if the Veteran is traveling, as well increases clinicians’ flexibility to work remotely if they are unable to be at a VA facility. The technol- ogy also supports flexible application of expo- sure-based interventions (e.g., using one’s home environment for obsessive-compulsive disor- der-related exposures) or in planning the hier- archically based transition from one’s home to clinic in treating symptoms of agoraphobia.

Although the rapid evolution of telehealth technology has been instrumental in facilitating spoke site access to expert clinical care, the technology also presents limitations to care de- livery. Hub psychologists noted that disruption in the video and/or audio connection may lead to missing session content and/or reducing the capacity to glean information from nonverbal cues. Furthermore, technical disruptions may interrupt the flow of session and sense of safety created for a Veteran who is communicating particularly emotionally charged material (e.g., a Hub psychologist lost connection with a Vet- eran during recounting an imaginal exposure in a prolonged exposure session). In addition, be- cause of the positioning of the camera, the Hub psychologist is generally only able to see the upper body of the Veteran, which reduces the ability to assess for lower body movement and issues with gait or mobility. One Hub psychol- ogist was unaware that a Veteran ambulated with a walker, whereas another clinician did not realize that a Veteran had lost a significant amount of weight throughout the course of treatment, potentially impacting treatment rec- ommendations in a behaviorally focused treat- ment. In couples’ therapy, this limited view- point can interfere with identifying moments when one partner reaches out for another. Nev- ertheless, Hub psychologists have observed in- creased attunement to the Veteran’s face at times, as it occupies a large portion of the screen (e.g., Hub psychologist inquiring about Veteran’s feelings of anxiety after clearly no- ticing beads of sweat forming on the Veteran’s brow).

Though these disruptions can vary in intensity and frequency based on the Veteran’s location, they occur in both clinic-based and at-home ap- pointments, as well as across individual, couples and group therapy, with issues often most pro- nounced in a group setting. Group members can vary from nearly inaudible to extremely loud, which may be contingent on the level of ambient noise in the group room; side conversations dur- ing group are particularly disruptive. In terms of visual quality in the group setting, the varying distance of group members from the camera, combined with the relatively small size of the screen on the clinician’s side, often makes it difficult to identify the group mem- ber speaking or assess for nonverbal signs of communication.

Use of materials in treatment. When con- sidering technical barriers and facilitators, Hub psychologists noted how the use of ma- terials in treatment may be impacted by this modality. For instance, screen sharing facili- tates the presentation of worksheets and re- viewing data with the Veteran in real time. This enhances Hub psychologists’ ability to provide psychoeducation, improve engage- ment and flexibly adapt and meet the Veteran where he or she is in session (e.g., pacing the presentation of information to match the Vet- eran’s style). However, transferring measures and handouts outside of session can be diffi- cult, particularly for Veterans seen at home. Though the VA has a secure electronic plat- form available to facilitate this transfer (My- HealtheVet), Hub psychologists experience frequent issues when relying on this medium, such as messages not being delivered, Veter- ans having difficulty accessing the system, and only a fraction of Veterans being regis- tered to use this system. These barriers result in delays in receiving the data, transferring information, and increase the administrative burden on the Hub psychologist to rely on other methods (e.g., postal service or verbally administering measures). In addition, for tele- health clinic appointments, Hub psychologists rely on technical staff (TCTs) to transmit materials and the reliability and speed with which materials are received by Hub psychol- ogists is significantly impacted by the staff member’s availability.

7BARRIERS AND FACILITATORS OF TMH

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

Administrative Issues

Lastly, administrative issues are discussed in the areas of overall logistical processes and the development of the Hub structure, the “network model” and integrating VA NYH TMH Hub’s missions.

Procedures and logistics. Since imple- mentation of the VA NYH TMH Hub, a range of administrative barriers have been addressed to facilitate delivery of services offered through the Hub. When the Hub was created, unique challenges to offering telehealth services were present, such as a lack of regulatory clarity on psychologists’ ability to practice across state lines, the need to develop and implement a mission statement, as well as the need to tailor various policies and procedures to meet the requirements of the spoke sites in the absence of national TMH standards (e.g., referral pro- cesses, clinic availability, scheduling, risk/ safety protocols). Since that time, the develop- ment of national recommendations regarding protocols and procedures are underway. Hub leadership consulted with multiple VA commit- tees (including ethics and regional counsel), li- censing boards, and non-VA national associa- tions to ensure that the delivery of services were within the scope of practice of the Hub psychol- ogists. The American Psychological Associa- tion’s “Guidelines for the Practice of Telepsy- chology” and the 50-state review were reviewed (Joint Task Force for the Development of Tele- psychology Guidelines for Psychologists, 2013). Subsequently in 2018, VA implemented a national Anywhere to Anywhere program to further increase the accessibility of services to Veterans across the United States (Authority of Health Care Providers to Practice Telehealth, 2018). This key piece of legislation allows VA clinicians to provide care across state lines, de- spite varying state licensure requirements, di- rectly ameliorating challenges to deliver neces- sary services in areas where retaining providers may be difficult. The steps taken by VA NYH TMH Hub leadership, the presence of state and expansion of national guidelines, in conjunction with the growing body of research on the effi- cacy of telehealth services, have enhanced the ease of delivery of TMH services.

“Network model” considerations. The VA NYH TMH Hub is structured as a “network model,” with one Hub psychologist serving as a

primary point of contact (POC) for each spoke site, to provide full access to the range of clini- cians’ expertise to all spoke sites. The POC acts as the first line of communication between re- ferring providers, telehealth staff, administra- tive and leadership staff at the spoke site and shares information directly to the Hub psychol- ogists at weekly staff meetings. This model allows for efficient bidirectional communica- tion between the spoke site and Hub psycholo- gists, timely assignment of new referrals and facilitates expansion of services to new spoke sites. The administrative demands inherent in the POC role have shifted through the establish- ment of services, with more frequent telephone and e-mail contact between Hub psychologists and spoke site clinical and technical staff during initiation of services, and reduced contact, as collaboratively agreed upon by Hub and spoke site staff, throughout maintenance and growth of services. A challenge inherent in this model is the administrative load on Hub psychologists who are required to maintain up-to-date knowledge regarding variations in procedures across spoke sites (e.g., preferences for scheduling and manage- ment of emergency situations) and subsequently set shift multiple times throughout the day, de- pending on the Veteran’s spoke site location.

Integration of Hub missions. On a pro- grammatic level, an ongoing challenge of the Hub has been to meet the multiple demands of the mission alongside the general VA require- ments of mental health providers. The VA NYH TMH Hub’s mission is threefold: (a) provide high-quality, short-term, evidence-based clini- cal care to rural Veterans, (b) evaluate the ef- fectiveness of TMH and ability to successfully treat complex presenting issues through ongo- ing research and quality improvement; (d) train psychology graduate students at various levels of training (e.g., extern, predoctoral interns and postdoctoral fellows) in the provision of TMH services. Consistent with the mission, Hub psy- chologists provide direct patient care, as well as play an active role in quality improvement, re- search projects, and supervision of doctoral- level students. Hub psychologists attend three weekly meetings (staff, quality improvement/ research, and peer supervision) to discuss ad- ministrative/logistical issues, research projects and clinical issues, in addition to larger depart- mental and supervision meetings. Because of the evolving initiatives of VA to increase ac-

8 SHRECK ET AL.

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

cessibility of direct patient care, practical chal- lenges have been noted in balancing the Hub’s three missions, with the requirements and needs of the larger psychology department, in terms of delineation of time in clinical and administra- tive duties. Nevertheless, balancing the Hub’s three missions facilitates a key dynamic feed- back loop by expanding and improving clinical care through ongoing research and training.

Lastly, in alignment with VA’s mission to improve access to care and to ease the admin- istrative load on Hub psychologists, a large shift has been made to increase V2H visits. The transition to V2H sessions reduces common scheduling challenges of limited clinic and/or telehealth equipment availability at rural VA outpatient clinics. Hub psychologists consider the appropriateness of fit for V2H visits prior to initiation (e.g., risk level and/or a Veteran with severe depression and anhedonia may benefit from leaving his or her home for an appoint- ment) and discuss possible options with the Veteran, referring providers and spoke site staff as needed. In addition, to facilitate the scheduling processes of all VA appointments (e.g., clinic ap- pointments and V2H visits), Hub psychologists have transitioned to using a standard scheduling order, thus limiting scheduling correspondences via e-mail between various schedulers at each spoke site. The combination of the use of V2H visits and standardized scheduling procedures has improved the efficiency of the scheduling process and decreased the administrative burden on Hub providers, thus facilitating increased availability for high quality, direct patient care.

Discussion

As TMH services grow within VA and other community mental health settings, pragmatic support regarding program development will continue to inform effective implementation and expansion for clinicians, technical and lead- ership staff. Hub psychologists emphasized the value of considering clinical, technical and ad- ministrative barriers and facilitators, as well as how the facilitators can be utilized to mitigate challenges moving forward. The issues raised are largely consistent with previous research, yet the current work expands the literature base by highlighting additional considerations for implementing TMH services, specifically re- lated to the structure of the NYH TMH Hub and

the ways in which the therapeutic relationship may be impacted. See Figure 1 and Figure 2 for a summary of key considerations.

Hub Structure and “Network Model” of Organization

The VA NYH TMH Hub network model of organization was consistently recognized as an important factor supporting implementation of services. Although integration into multidisci- plinary teams and procedural variations across sites was noted to be challenging, the model of organization supports access to a range of spe- cialized, evidence-based therapies and assess- ments across various modalities, maximizing the breadth and depth of services provided to Veterans in rural areas. A designated POC at each spoke site streamlines logistical processes and serves as conduit of communication be- tween leadership, clinical providers and techni- cal staff. Furthermore, the network model al- lows for adaptation and flexibility, as the stage of program development evolves over time. The VA NYH TMH Hub established services with spoke sites in a gradual, stepwise manner, which allowed for collaboration among POCs to discuss key tips and troubleshoot issues, prior to initiating services with a new site.

Hub psychologists also identified the integra- tion of the Hub’s three missions: clinical, re- search, and training, as a critical factor support- ing the program growth and development. Hub psychologists recognized challenges delineating time to simultaneously support clinical, re- search and training goals, while also balancing the larger clinical priorities of the VA medical center. However, consideration of these three overlapping processes ultimately support growth and change. More specifically, research goals focused on evaluating and understanding clinical outcomes and satisfaction with tele- health, allow the program to readily adapt and improve, as well as consider how to engage hard-to-reach Veterans. In addition, the integra- tion of the three missions serves as a critical framework to train the next generation of TMH providers. Hub psychologists supervise doctoral students, as well as provide education and con- sultation to spoke site clinical providers, which ultimately supports dissemination of education and information regarding implementation of evidence-based therapies via TMH.

9BARRIERS AND FACILITATORS OF TMH

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

Therapeutic Relationship Considerations

The impact of TMH on the clinical process is an important area to consider when developing

and modifying TMH programs. Geographical separation affects the ability to create a shared physical space to provide necessary comfort and can make it difficult to be attuned to nonverbal

Category Consideration

Hub Structure and “Network Model” of Organization

1. Point of contact (POC) designated for each spoke site allows for streamlining of

administrative processes and effective

communication between leadership, clinical

providers and technical staff.

2. Consideration of stage of development supports flexibility in advancing services.

a. Weekly telephone/video calls between Hub and spoke sites during

planning and initiation of services,

reduction in frequency and move to

more e-mail communication as

services and procedures develop.

3. Establishment of services in a gradual manner supports problem solving, troubleshooting and

consolidation of successful procedures and

strategies, prior to initiating services with a

new spoke site.

a. Spoke site leadership, clinical and technical staffs’ perception of

development and maintenance of

services is evaluated through self-

report questionnaires and qualitative

interviews, which supports revision

of procedures, incorporation of

feedback and deepening productive

relationships with spoke sites.

4. Weekly staff and peer supervision meetings support clinical consultation and ongoing

monitoring and adaptation of treatment for

patients who may not respond to treatment as

expected.

5. Emphasis on clinical, research and training objectives supports overall Hub growth and

evolution.

a. Evaluation of clinical outcomes and patient satisfaction allows Hub

services to improve and consider

how to engage hard-to-reach patients b. Training and consultation enhance

dissemination of education and

information regarding provision of

TMH services to referring clinicians

and supports next generation of TMH

providers.

Figure 1. Key considerations for developing and implementing a Telemental Health Hub (TMH) structure and “network model” of organization.

10 SHRECK ET AL.

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

communication. Technical difficulties can neg- atively affect Hub psychologists’ ability to see and hear Veterans, increasing challenges to emotional safety. Nevertheless, Hub psycholo-

gists emphasized the unique opportunities that TMH care presents, in terms of the ability to treat hard-to-reach patients, enhance clinical in- terventions by moving them outside the therapy

Category Consideration

Therapeutic Relationship and Clinical Considerations

1. Honest dialogue about the benefits and challenges of providing care via TMH

supports buy in and growth for patients,

clinical referring providers and leadership

staff and supports collaborative informed

consent in the decision-making process.

2. Regular discussion between TMH clinicians and patients regarding perception of TMH and

therapeutic process allows for issues to be

discussed and addressed effectively, as well as

for treatment to adapt flexibly.

3. Consistent communication with clinical referring providers (telephone, email and print

materials) to enhance education related to

TMH process, to determinate appropriate

referrals and introduce TMH modality

effectively to patients.

4. Collaboration among TMH programs supports strategies to address treatment of

diagnostically complex cases, management of

risk issues and brainstorm regarding

additional resources available following

completion of short-term treatment.

5. Development of specific referral process for diagnostically complex patients facilitates

appropriate assessment and diagnostic

clarification prior to initiation of treatment.

a. Psychodiagnostic and/or neuropsychological testing may be

important to guide treatment

planning.

b. Collaboration with spoke site referring providers to specifically

discuss targeted treatment areas for

TMH and ensure adequate support

from spoke site when needed (e.g.

concurrent check in from Suicide

Prevention Coordinator when patient

is deemed high-risk).

6. Expansion of SCAN-ECHO model to support structured teaching and consultation around

complex referrals, both for trainees and spoke

site providers to continue to support

dissemination of evidence-based therapies.

Figure 2. Key clinical considerations for Telemental Health (TMH) providers for develop- ing and implementing a TMH program.

11BARRIERS AND FACILITATORS OF TMH

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

office, and paradoxically foster closeness in some therapeutic relationships, through allow- ing vulnerability to develop in a unique manner. Hub psychologists regularly discuss perceptions of TMH and the therapeutic process with Vet- erans throughout treatment, to identify pertinent issues and adapt treatment accordingly. In ad- dition, Hub psychologists recognize the impor- tance of liaising with spoke site clinical refer- ring providers to effectively introduce TMH to Veterans, answer questions and consider the appropriateness of referrals. It is important to note that although this paper focuses on pro- vider experiences, Hub psychologists are also pursuing formalized assessment of Veterans’ experiences of TMH through qualitative tele- phone interviews at the conclusion of treatment, to better understand challenges and facilitators from the Veteran perspective. Recognition of the challenges and facilitators of TMH treat- ment can encourage buy in and growth of the TMH modality for patients, clinical referring providers, and leadership staff, as it opens an honest dialogue about expectations of psycho- therapy through TMH.

Implications and Future Directions

The VA NYH TMH Hub continues to evolve in response to the considerations outlined in this paper. To address clinical barriers, Hub psy- chologists have created patient and provider materials to disseminate education and informa- tion regarding the TMH process, expectations and clinicians’ areas of expertise, to support fruitful discussion related to the benefits and challenges of TMH and highlight referrals that best fit the TMH modality and structure. More- over, materials support collaborative informed consent prior to initiation of treatment, so Vet- erans can freely choose to decline or participate in TMH services, consistent with guidelines that support shared decision making (United States Department of Veteran Affairs, 2009). In addi- tion, Hub psychologists have initiated commu- nication with spoke site clinical and leadership staff to collaborate regarding treatment plan- ning and disposition of diagnostically complex cases during and following TMH treatment. It is also possible for Hub psychologists to collabo- rate with additional TMH programs in the NYC area, particularly to refer Veterans’ family members for treatment when applicable.

Weekly staff and peer supervision meetings provide opportunities for consultation regarding clinical challenges, as well as to monitor and adapt treatment for Veterans who may not re- spond to interventions as expected. Hub psy- chologists are working to develop a referral protocol for Veterans with complex presenting issues, to further support assessment and diag- nostic clarification prior to the initiation of treat- ment, as well as to target key treatment goals and anticipate challenges for disposition when short-term treatment ends. Collaboration among TMH programs will be useful to creatively and effectively address resource related issues, as programs develop to meet the needs of Veterans presenting with complicated presenting prob- lems.

The VA NYH TMH Hub works closely with technical staff to manage technology updates for services to Veterans’ homes to ameliorate the challenges of managing technological and equipment difficulties. Technical staff conduct test calls prior to initiation of TMH services to home to enhance Veteran knowledge of the platform, as well as explore whether video streaming is possible given the capabilities of the Veteran’s Internet service. The VA NYH TMH Hub is exploring options for online plat- forms that would allow for secure transmission of measures and handouts on a shared, en- crypted browser, to mitigate challenges associ- ated with transmitting sensitive materials be- tween veteran and clinician in the current system of communication.

To address administrative challenges, Hub psychologists regularly revise risk protocols, V2H protocols and scheduling procedures based on feedback from staff. Hub psycholo- gists also maintain up-to-date information re- garding spoke site scheduling, documentation and logistical procedures on a master spread- sheet. Additionally, plans to condense meetings on a rotating basis will be piloted (e.g., recur- ring weekly 60-min meetings with the focus of the meeting changing each week), to increase availability of Hub psychologists, while still providing sufficient support to meet the Hub’s mission and VA’s larger goals.

In consideration of expanding opportunities for training and expert consultation within TMH, it will be useful to look at applications of the Extension for Community Health Care Out- comes (ECHO) model. The model improves

12 SHRECK ET AL.

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

access to care for underserved populations man- aging complex medical conditions, by connect- ing rural areas with the resources of urban, medical centers via technology (Arora et al., 2007, 2011). The Specialty Care Access Net- work ECHO (SCAN-ECHO) is an outgrowth of the model, where VA specialty medical teams use telehealth to connect with Veterans’ local primary care providers to provide consultation, case discussion and didactics regarding issues such as pain management, diabetes, hepatitis C and liver disease. The model leverages technol- ogy to improve interdisciplinary collaboration and enhance chronic disease management out- comes, where resources are scarce (Arora et al., 2010; Ball, Wilson, Ober, & Mchaourab, 2018; Watts, Roush, Julius, & Sood, 2016). The SCAN-ECHO model creates a framework for consultation and teaching regarding psychiatric issues in a more structured manner, to continue to support training of psychology graduate stu- dents and spoke site staff involved in treating complex cases. Moreover, applications of the model are poised to effectively support TMH buy in and growth, by efficiently disseminating knowledge and best practices with technology aided means, reducing feelings of isolation among rural providers and enhancing rural pro- viders’ specialized skill sets in treating complex psychiatric issues.

The team has adapted to the “network” model, as clinical POCs maintain communica- tion with spoke site clinical and technical staff and relay information to team members at weekly meetings. In addition, Hub psycholo- gists collaborate with spoke site leadership, clinical and technical staff to assess their per- ceptions of barriers and facilitators to the pro- vision of TMH services. As a future quality improvement project, the experience of staff at the spoke sites is being gathered through a brief self-report questionnaire and qualitative tele- phone interview with TCTs, clinicians, and leadership, with the goal of continuing to revise procedures and protocols by incorporating spoke site feedback.

Identifying barriers and facilitators to pro- gram implementation provides a framework for the initiation and development of new Hubs, monitoring and improving structures and pro- cesses, and enhancing the effectiveness of men- tal health care in rural populations. Further- more, current considerations provide guidelines

for troubleshooting clinical, technical and ad- ministrative issues, as well as practical guidance for clinicians, technical and leadership staff to support TMH growth. As TMH continues to expand, a nuanced approach to the development and implementation of TMH programs has the potential to influence best practices.

References

Arora, S., Geppert, C. M. A., Kalishman, S., Dion, D., Pullara, F., Bjeletich, B., . . . Scaletti, J. V. (2007). Academic health center management of chronic dis- eases through knowledge networks: Project ECHO. Academi.c Medicine, 82, 154–160. http://dx.doi.org/ 10.1097/ACM.0b013e31802d8f68

Arora, S., Kalishman, S., Thornton, K., Dion, D., Murata, G., Deming, P., . . . Pak, W. (2010). Expanding access to hepatitis C virus treatment— Extension for Community Healthcare Outcomes (ECHO) project: Disruptive innovation in spe- cialty care. Hepatology, 52, 1124–1133. http://dx .doi.org/10.1002/hep.23802

Arora, S., Thornton, K., Murata, G., Deming, P., Kalishman, S., Dion, D., . . . Qualls, C. (2011). Outcomes of treatment for hepatitis C virus infec- tion by primary care providers. The New England Journal of Medicine, 364, 2199–2207. http://dx .doi.org/10.1056/NEJMoa1009370

Authority of Health Care Providers to Practice Tele- health. (2018). 83 FR 21897. Retrieved from https:// www.govinfo.gov/app/details/FR-2018-05-11/ 2018-10114

Ball, S., Wilson, B., Ober, S., & Mchaourab, A. (2018). SCAN-ECHO for pain management: Im- plementing a regional telementoring training for primary care providers. Pain Medicine, 19, 262– 268. http://dx.doi.org/10.1093/pm/pnx122

Bee, P. E., Bower, P., Lovell, K., Gilbody, S., Richards, D., Gask, L., & Roach, P. (2008). Psychotherapy mediated by remote communication technologies: A meta-analytic review. BMC Psychiatry, 8, 60. http:// dx.doi.org/10.1186/1471-244X-8-60

Benavides-Vaello, S., Strode, A., & Sheeran, B. C. (2013). Using technology in the delivery of mental health and substance abuse treatment in rural com- munities: A review. The Journal of Behavioral Health Services and Research, 40, 111–120. http:// dx.doi.org/10.1007/s11414-012-9299-6

Bouchard, S., Paquin, B., Payeur, R., Allard, M., Rivard, V., Fournier, T., . . . Lapierre, J. (2004). Delivering cognitive-behavior therapy for panic disorder with agoraphobia via videoconference. Telemedicine and e-Health, 10, 13–25. http://dx .doi.org/10.1089/153056204773644535

Brooks, E., Turvey, C., & Augusterfer, E. F. (2013). Provider barriers to telemental health: Obstacles

13BARRIERS AND FACILITATORS OF TMH

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

overcome, obstacles remaining. Telemedicine Jour- nal and e-Health, 19, 433–437. http://dx.doi.org/10 .1089/tmj.2013.0068

Castro, D., Miller, B., & Nager, A. (2014). Unlocking the potential of physician-to-patient telehealth ser- vices. Washington, DC: The Information Technol- ogy and Innovation Foundation. Retrieved from https://itif.org/publications/2014/05/12/unlocking- potential-physician-patient-telehealth-services

Chen, C. K., Palfrey, A., Shreck, E., Silvestri, B., Wash, L., Nehrig, N., . . . Chodosh, J. (2019). Implementation of Telemental Health (TMH) Psy- chological Services for Rural Veterans at the VA New York Harbor Healthcare System. Psycholog- ical Services. Advance online publication. http:// dx.doi.org/10.1037/ser0000323

Cullum, C., Hynan, L. S., Grosch, M., Parikh, M., & Weiner, M. F. (2014). Teleneuropsychology: Evi- dence for video teleconference-based neuropsycho- logical assessment. Journal of the International Neu- ropsychological Society, 20, 1028–1033. http://dx .doi.org/10.1017/S1355617714000873

Cullum, C. M., Weiner, M. F., Gehrmann, H. R., & Hynan, L. S. (2006). Feasibility of telecognitive assessment in dementia. Assessment, 13, 385–390. http://dx.doi.org/10.1177/1073191106289065

Ellimoottil, C., An, L., Moyer, M., Sossong, S., & Hollander, J. E. (2018). Challenges and opportu- nities faced by large health systems implementing telehealth. Health Affairs, 37, 1955–1959. http:// dx.doi.org/10.1377/hlthaff.2018.05099

Gehrman, P., Shah, M. T., Miles, A., Kuna, S., & Godleski, L. (2016). Feasibility of group cogni- tive-behavioral treatment of insomnia delivered by clinical video telehealth. Telemedicine and e- Health, 22, 1041–1046. http://dx.doi.org/10.1089/ tmj.2016.0032

Godleski, L. (2014). Telemental health in VA: Laying the groundwork for opportunities to access to cog- nitive behavioral therapy for pain: Part 1 [Pow- erpoint slides]. Retrieved from https://www.hsrd .research.va.gov/for_researchers/cyber_seminars/ archives/869-notes.pdf

Grady, B., Myers, K. M., Nelson, E. L., Belz, N., Bennett, L., Carnahan, L., . . . the American Tele- medicine Association Telemental Health Stan- dards and Guidelines Working Group. (2011). Ev- idence-based practice for telemental health. Telemedicine and e-Health, 17, 131–148. http://dx .doi.org/10.1089/tmj.2010.0158

Gros, D. F., Yoder, M., Tuerk, P. W., Lozano, B. E., & Acierno, R. (2011). Exposure therapy for PTSD delivered to veterans via telehealth: Predictors of treatment completion and outcome and compari- son to treatment delivered in person. Behavior Therapy, 42, 276–283. http://dx.doi.org/10.1016/j .beth.2010.07.005

Hilty, D. M., Ferrer, D. C., Parish, M. B., Johnston, B., Callahan, E. J., & Yellowlees, P. M. (2013). The effectiveness of telemental health: A 2013 review. Telemedicine and e-Health, 19, 444–454. http://dx.doi.org/10.1089/tmj.2013.0075

Joint Task Force for the Development of Telepsy- chology Guidelines for Psychologists. (2013). Guidelines for the practice of telepsychology. American Psychologist, 68, 791–800. http://dx.doi .org/10.1037/a0035001

Monnier, J., Knapp, R. G., & Frueh, B. C. (2003). Recent Advances in Telepsychiatry: An updated review. Psychiatric Services, 54, 1604–1609. http://dx.doi.org/10.1176/appi.ps.54.12.1604

Moreau, J. L., Cordasco, K. M., Young, A. S., Oishi, S. M., Rose, D. E., Canelo, I., . . . Hamilton, A. B. (2018). The use of telemental health to meet the mental health needs of women using Department of Veterans Affairs Services. Women’s Health Is- sues, 28, 181–187. http://dx.doi.org/10.1016/j.whi .2017.12.005

Morland, L. A., Hynes, A. K., Mackintosh, M. A., Resick, P. A., & Chard, K. M. (2011). Group cognitive processing therapy delivered to Veterans via telehealth; a pilot cohort. Journal of Traumatic Stress, 24, 265–469. http://dx.doi.org/10.1002/jts .20661

Morland, L. A., Mackintosh, M. A., Greene, C. J., Rosen, C. S., Chard, K. M., Resick, P., & Frueh, B. C. (2014). Cognitive processing therapy for posttraumatic stress disorder delivered to rural vet- erans via telemental health: A randomized nonin- feriority clinical trial. The Journal of Clinical Psy- chiatry, 75, 470–476. http://dx.doi.org/10.4088/ JCP.13m08842

Norman, S. (2006). The use of telemedicine in psy- chiatry. Journal of Psychiatric and Mental Health Nursing, 13, 771–777. http://dx.doi.org/10.1111/j .1365-2850.2006.01033.x

Sood, S., Mbarika, V., Jugoo, S., Dookhy, R., Doarn, C. R., Prakash, N., & Merrell, R. C. (2007). What is telemedicine? A collection of 104 peer-reviewed perspectives and theoretical underpinnings. Tele- medicine and e-Health, 13, 573–590. http://dx.doi .org/10.1089/tmj.2006.0073

United States Department of Health and Human Ser- vices, National Center for Health Workforce Anal- ysis. (2014). Distribution of U.S. health care pro- viders residing in rural and urban areas. Retrieved from https://bhw.hrsa.gov/sites/default/ files/bhw/nchwa/nchwafactsheet.pdf

United States Department of Veteran Affairs. (2009). Informed consent for clinical procedures and treatment. Retrieved from https://www.ethics.va .gov/policy.asp#Informed Consent for Clinical Treatments and Procedures.

United States Department of Veteran Affairs, Office of Connected Care. (2018). Telemental health in

14 SHRECK ET AL.

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

the Department of Veteran Affairs fact sheet. Washington, DC: Office of Public Affairs Media Relations.

United States Department of Veteran Affairs, Office of Rural Health. (2015). Office of rural health annual report. Retrieved from https://www.ruralhealth.va .gov/docs/ORH_Annual_Report_2015_FINAL.pdf

Watts, S. A., Roush, L., Julius, M., & Sood, A. (2016). Improved glycemic control in veterans with poorly controlled diabetes mellitus using a

Specialty Care Access Network-Extension for Community Healthcare Outcomes model at pri- mary care clinics. Journal of Telemedicine and Telecare, 22, 221–224. http://dx.doi.org/10.1177/ 1357633X15598052

Received September 6, 2019 Revision received November 21, 2019

Accepted December 10, 2019 �

15BARRIERS AND FACILITATORS OF TMH

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.