Psychology of consulting and coaching

Psychological Services Implementation of Telemental Health (TMH) Psychological Services for Rural Veterans at the VA New York Harbor Healthcare System Cory K. Chen, Amy Palfrey, Erica Shreck, Brittney Silvestri, Lauren Wash, Nicole Nehrig, Alyssa L. Baer, Jennifer A. Schneider, Sagiv Ashkenazi, Scott E. Sherman, and Joshua Chodosh Online First Publication, February 11, 2019. http://dx.doi.org/10.1037/ser0000323

CITATION Chen, C. K., Palfrey, A., Shreck, E., Silvestri, B., Wash, L., Nehrig, N., Baer, A. L., Schneider, J. A., Ashkenazi, S., Sherman, S. E., & Chodosh, J. (2019, February 11). Implementation of Telemental Health (TMH) Psychological Services for Rural Veterans at the VA New York Harbor Healthcare System. Psychological Services. Advance online publication. http://dx.doi.org/10.1037/ser0000323

Implementation of Telemental Health (TMH) Psychological Services for Rural Veterans at the VA New York Harbor Healthcare System

Cory K. Chen, Amy Palfrey, Erica Shreck, Brittney Silvestri, Lauren Wash, Nicole Nehrig, Alyssa L. Baer, Jennifer A. Schneider, Sagiv Ashkenazi, Scott E. Sherman, and Joshua Chodosh

Veterans Affairs New York Harbor Healthcare System, New York, New York

Meeting the mental health needs of our current veteran population is one of the primary challenges facing the Veteran’s Health Administration (VHA). Particularly for veterans residing in rural areas, the lack of providers, high provider turnover, and the burden of traveling long distances to VHA facilities may contribute to difficulties accessing mental health care. Telemental Health (TMH) services help bridge the geographic gap between mental health providers and veterans who need mental health services. The VHA TMH Hub initiative has attempted to leverage changes in technology-facilitated care by developing a model in which a facility “hub” could expand mental health resources to remote “spoke” clinics and veterans’ residences. This paper describes the implementation of the VA New York Harbor Health care System (VA NYH) TMH Hub, which was one of 6 programs funded by the VHA Office of Rural Health (ORH) in September 2016. We will describe the structure of the program, services provided, veterans served, and our efforts to integrate quality improvement, research, and clinical training into the operations of the program.

Keywords: telehealth, veterans, remote mental health, telemental health

Meeting the mental health needs of our current veteran popula- tion is one of the primary challenges facing the Veteran’s Health Administration (VHA). The wars in Iraq and Afghanistan in- creased the need for mental health providers trained to deliver evidence-based treatments to veterans diagnosed with a range of mental health issues including posttraumatic stress disorder (PTSD), mood disorders, anxiety disorders, and substance use disorders (Seal, Bertenthal, Miner, Sen, & Marmar, 2007). Addi- tionally, the VHA also serves a significantly older veteran popu- lation that requires care for both preexisting mental health issues as well as new conditions associated with chronic health stressors and/or cognitive decline. Between 2001 and 2014, the proportion of veterans with mental health conditions or substance use disor- ders who utilize VHA services increased from 27% to 41% (United States Department of Veterans Affairs, Office of Mental Health and Suicide Prevention [OMHSP], 2017).

A barrier to meeting the mental health needs of veterans lies in a geographic misalignment between the location of mental health providers and where many veterans reside. Less than 10% of psychologists live in rural areas (United States Department of Health and Human Services, National Center for Health Work- force [NCHW], 2014). In contrast, 23% of all veterans reside in rural areas (United States Department of Veterans Affairs, Office of Rural Health [ORH], 2015). This lack of providers (which impacts recruitment of qualified mental health providers in rural VHA facilities), in addition to high provider turnover, as well as the burden of traveling long distances to VHA facilities may contribute to rural veterans’ limited access to mental health care. Telemental health (TMH) services are increasingly recognized as a way to address regional disparities in mental health care avail- ability and to bridge the geographic gap between mental health providers and the veterans who need these mental health services (Deen, Godleski, & Fortney, 2012).

Defined as the provision of mental health care from a distance, TMH grew out of a need to provide high quality, affordable, mental health care to patients living where access to such services was limited (Grady et al., 2011). While TMH service providers can utilize a variety of mediums (e.g., telephone, clinical video tele- health (CVT), Internet), there has been a growing body of litera- ture that has explored the delivery of mental health services via synchronous CVT. Evidence suggests that a wide variety of treat- ments for a range of diagnoses (e.g., PTSD, insomnia, depression, anger, anxiety) can be effectively administered via TMH, with efficacy comparable to that of in-person treatment (Bouchard et al., 2004; Gros et al., 2013; Hilty et al., 2013). Similar findings regarding the effectiveness of treatment delivery via TMH have been found with veteran samples (Fortney et al., 2007; Gehrman,

Cory K. Chen, Amy Palfrey, Erica Shreck, Brittney Silvestri, Lauren Wash, Nicole Nehrig, Alyssa L. Baer, Jennifer A. Schneider, and Sagiv Ashkenazi, Mental Health Service, Veterans Affairs New York Harbor Healthcare System, New York, New York; Scott E. Sherman, and Joshua Chodosh, Department of Medicine, Veterans Affairs New York Harbor Healthcare System.

This research was supported by grants from the Veterans Health Ad- ministration Office of Rural Health. Acknowledgement to Seena Mathew for her involvement in the NYH TMH Hub implementation.

Correspondence concerning this article should be addressed to Cory K. Chen, Co-Director of the Telemental Health Hub, VA New York Harbor Healthcare System, 423 East 23rd Street, Room 15135N, New York, NY 10010. E-mail: [email protected]

Psychological Services In the public domain 2019, Vol. 1, No. 999, 000

http://dx.doi.org/10.1037/ser0000323

1

Shah, Miles, Kuna, & Godleski, 2016; Gros, Yoder, Tuerk, Lo- zano, & Acierno, 2011; Morland, Greene, Rosen, Mauldin, & Frueh, 2009; Morland et al., 2010). Over the past 15 years, in response to the mental health needs of veterans in rural areas, TMH has become increasingly utilized in VHA (Deen et al., 2012; Godleski, Darkins, & Peters, 2012; Wallace, Weeks, Wang, Lee, & Kazis, 2006; Weeks et al., 2004). VHA providers deliver TMH interventions via the VHA’s secure real-time, interactive clinical videoconferencing systems, which provide high definition, two- way communication between providers and veterans. The system is Federal Information Processing Standards (FIPS) 140 –2 com- pliant and part of a larger data management protocol that is HIPAA compliant.

VHA TMH Hub Initiative

The VHA TMH Hub initiative began in 2002 with the inception of a national clinical leadership group consisting of regional rep- resentatives and the Veterans Affairs (VA) National Offices of Telehealth and Mental Health Services (Godleski, 2014). The goal of the initiative was to leverage changes in technology-facilitated care by developing a model in which a facility “hub” could expand mental health resources to remote “spoke” clinics and veterans’ residences. In 2010, VHA established the National Telemental Health Center (NTMHC) to oversee and coordinate national TMH activity, with the continued purpose of connecting veterans to mental health experts, regardless of veteran residence (Godleski, 2014). The NTMHC clinicians provide expertise in the treatment of affective, psychotic, anxiety and substance use disorders and operate out of the VA Boston, VA Connecticut Health care Sys- tem, Philadelphia Veterans Affairs Medical Center (VAMC), and Providence VAMC (United States Department of Veterans Affairs, Office of Connected Care [OCC], 2018).

VHA TMH services are provided through multiple treatment modalities, including individual, group, couples and family psy- chotherapies, as well as medication management (Deen et al., 2012). Additionally, VHA TMH services are available to multiple sites, including VHA Medical Centers, VHA community-based outpatient clinics (CBOCs), residential treatment facilities, student health centers, homeless shelters and veterans’ residences (God- leski, 2014). Since 2002, VHA has provided more than 2.7 million TMH health encounters with service delivery increasing over time. In 2017, more than 151,600 veterans received TMH services. While most of the services were delivered at CBOCs, approxi- mately 8,700 veterans received mental health services in their homes, representing a significant additional expansion of access particularly critical in rural areas (OCC, 2018).

VA New York Harbor Health care System—Manhattan (VA NYH) – with its track record of providing tele-psychiatry services, density of mental health providers in the New York City area, range of clinical expertise among its staff, and established infra- structure for training and research—was selected by the VHA Office of Rural Health (VHA ORH) to serve as a “Hub” for TMH service delivery and was provided with resources to add psychol- ogy services to the facility’s existing TMH psychiatry services. Our current paper describes the implementation of TMH psychol- ogy services at the VA NYH TMH Hub in New York City. We describe the rationale for TMH services, the VA NYH TMH Hub’s mission, and future directions for our program.

The VA NYH TMH Hub Psychology Service

The VA NYH TMH Hub was one of six programs funded by the VHA ORH in September 2016 as part of an expansion of the original Hub initiative. In addition to increasing veteran access to mental health services, the mission of the VA NYH TMH Hub also includes providing training to students and other VHA clinicians in the delivery of TMH and conducting program evaluation as well as research to advance knowledge and promote innovation in TMH services.

VA NYH TMH providers use Cisco DX80 devices or Logitech webcams to administer TMH treatment. The DX80 devices are 23-in. liquid crystal display monitors with a 1920 � 1080 resolu- tion. The Logitech webcams are connected to Dell personal com- puters with 19-in. light emitting diode monitors that have 1440 � 900 resolution. Providers use Cisco Jabber software to provide treatment to veterans seen at CBOCs, VHA medical centers, or on a VHA-issued tablet at home. For veterans seen at home via their personal computers, providers used Virtual Medical Room (VMR) software. CVT connection is made through the VHA telehealth infrastructure, and data are transmitted at a speed of 100mb and encrypted per (FIPS) data-encryption guidelines.

Services

The VA NYH TMH Hub Psychology Service utilizes a “net- work” model in which any provider has the capacity to deliver services to any of our spoke sites or to the homes of veterans receiving services at our spoke sites. As areas of expertise vary across individual providers, this model maximizes the breadth of services available to veterans at any spoke facility. The current range of evidence-based psychotherapy treatments being offered by clinicians of the VA NYH TMH Hub via CVT is shown in Table 1.

Additionally, our program is working to develop and adapt a range of new services for TMH delivery. For example, neuropsy- chological testing is also being offered as a service by the VA NYH TMH Hub based on a review of the literature on feasibility, reliability, validity, and practice recommendations for teleneuro- psychology, as well as consultation with VHA neuropsychologists with experience in this domain (Cullum, Hynan, Grosch, Parikh, & Weiner, 2014; Cullum, Weiner, Gehrmann, & Hynan, 2006; Galusha-Glasscock, Horton, Weiner, & Cullum, 2016; Grosch, Gottlieb, & Cullum, 2011; Grosch, Weiner, Hynan, Shore, & Cullum, 2015; Harrell, Wilkins, Connor, & Chodosh, 2014). Group psychotherapies, such as CBT Skills, DBT Drop in Distress Tolerance, CPT, and CBT-I, are also being offered to maximize veteran access to these psychological services. Our providers also collaborate with spoke site clinicians and interdisciplinary teams, as well as with TMH psychiatrists regarding shared patients within our program.

Training

In pursuing the Hub’s training mission, we are integrating of TMH into the existing Psychology training programs at VA NYH. Currently the Psychology Service coordinates predoctoral extern- ship, internship, as well as postdoctoral fellowship programs in Health Psychology, Geropsychology, and PTSD. In total, 20 psy-

2 CHEN ET AL.

chology trainees rotate through the VA NYH Manhattan Campus each year. We have developed didactic materials for trainees on the delivery of TMH and piloted the delivery of CBT-I via TMH as part of the psychology externship. We anticipate offering TMH training to all existing Psychology training programs at VA NYH within the next three years.

Quality Improvement

As a new program, we gather quality improvement (QI) data to allow us to identify problems and adjust processes quickly. Em- bedding QI protocols within our TMH Hub is critical to better understand the effectiveness of our services and for their continued development, sustainability, and future growth. We describe our QI protocols to veterans during initial orientation sessions to TMH and make clear that their participation in these efforts is voluntary and does not impact the care they receive. Moreover, veterans are made aware that any QI data is de-identified and cannot be linked to any personally identifying health information. Similarly, we inform staff that their participation in our QI efforts is voluntary and their participation or decision not to participate has no bearing on their employment. All TMH Hub staff have been integral in developing the QI protocols and participate voluntarily.

Research

We make a clear distinction between QI activities and research activities as guided by our human subjects committee, as QI activities are not conducted to produce generalizable knowledge or necessarily for publication purposes. Given the constantly evolv- ing technologies and the expanding range of interventions offered through TMH, continuing research is critical for evaluating the effectiveness of TMH and its application to a complex veteran population that often presents with co-occurring conditions. More- over, this modality provides tremendous opportunity for further innovation. All ongoing TMH research protocols have been ap- proved by the VA NYH Institutional Review Board (IRB) and either informed consent is obtained by study participants or we obtained a waiver of informed consent when appropriate (e.g., studies involving a chart review of standard care).

Implementation

Following the award of funding by the VHA ORH TMH Hub Initiative, the first five months of the program focused on staffing, establishing partnerships with spoke sites, evaluating the needs and resources available at each site, and planning the logistics for a

Table 1 “Menu” of Mental Health Services Offered by VA NYH TMH Hub

Condition/Disorder Treatment

Depression or Anxiety Cognitive Behavior Therapy (CBT) Behavioral Activation (BA) Acceptance and Commitment Therapy (ACT) Brief Dynamic Interpersonal Therapy (DIT) Interpersonal Psychotherapy (IPT) Long Term Psychodynamic Therapy (1 year) CBT Skills Group (CBT)

Posttraumatic Stress Disorder (PTSD) Prolonged Exposure (PE) Cognitive Processing Therapy (CPT) Skills Training in Affect and Interpersonal Regulations (STAIR) Cognitive Processing Therapy Group

Obsessive-Compulsive Disorder (OCD) Exposure and Ritual Prevention (ExRP) Mental Health Needs of Lesbian, Gay, Bisexual, Transgender,

Questioning (LGBTQ) Veterans Cognitive Behavioral Therapy (CBT) LGBTQ Affirmative Psychotherapy Eating Disorders Enhanced Cognitive Behavioral Therapy (CBT-E) Personality Disorders Schema Therapy for Personality Disorders Psychosis Cognitive Behavioral Therapy (CBT-P) ADHD/Executive Functioning Deficits Cognitive Behavioral Therapy (CBT)/Cognitive Remediation Pain Cognitive Behavioral Therapy (CBT-CP) Insomnia Cognitive Behavioral Therapy for Insomnia (CBT-I)—Group and individual forms Smoking Cessation Cognitive Behavioral Therapy (CBT) Weight Loss Cognitive Behavioral Therapy (CBT) Diabetes Management Cognitive Behavioral Therapy (CBT) Adjustment to Illness (e.g., cancer) Meaning Centered Psychotherapy (MCP) Traumatic Brain Injury Cognitive Behavioral Therapy (CBT) Family Caregiving for Dementia and Alzheimer’s Disease Resources for Enhancing Alzheimer’s Caregiver Health (REACH VA) Family Caregiving for Cancer Protocol Developed at Mount Sinai Grief/Bereavement Grief-Focused Psychotherapy Interpersonal Psychotherapy (IPT) Couples and Family Distress Cognitive Behavioral Therapy (CBT)

Behavioral Family Therapy (BFT) Communication Skills Workshop Emotion-Focused Therapy (EFT)

Emotion Dysregulation Dialectical Behavior Therapy (DBT) Drop-In Distress Tolerance Skills Group Assessment Neuropsychological Testing

PTSD Evaluation

3IMPLEMENTATION OF TMH SERVICES

rollout of clinical services. Five psychologists were hired to staff the VA NYH TMH Hub. Four out of five were external hires and all were hired to dedicate 100% of their time to the program. Initially, plans were established to rollout services to four VAMC spoke sites (Albany, Bath, Canandaigua, and Iowa) that had ex- pressed interested in receiving TMH services once the program was announced within the local Veterans Integrated Service Net- work (VISN). Each VAMC identified programs and CBOCs that (a) needed additional mental health services, and (b had with the space and technical support resources required to receive TMH services (see Table 2). We initially scheduled weekly calls be- tween VA NYH TMH Hub staff, spoke site leadership, clinical and technical staff to establish services. The frequency of the meetings decreased as we finalized logistics and adequately addressed bar- riers to implementation. One staff member served as a primary point of contact (POC) for each spoke. The POC allowed hub and spoke sites to efficiently communicate and address emergent is- sues. A standing weekly VA NYH TMH Hub Psychology Staff meeting was held to address logistical issues across sites. Addi- tionally, a standing weekly VA NYH TMH Hub Psychology Staff Peer Supervision/Case Conference was held to address clinical issues that arose and to discuss the unique aspects of delivering services via TMH.

Within five months of beginning to offer mental health inter- ventions, the service reached its preestablished productivity goals of 80 veteran encounters per month, per provider for the first year. In response to the demand from spoke sites for additional services, in October 2017 VHA ORH provided the VA NYH TMH Hub with additional funding to expand the psychology staff by two additional full-time psychologists. New staff were recruited and on staff with the program in January 2018. Our most recent produc- tivity data (third quarter of Fiscal Year 2018) showed mean work relative value units (wRVU) of 395.6 and median wRVU of 440.5. The work relative value unit is a measure of specialty provider productivity utilized by VHA to provide guidance on the staffing of specialty services.

Standard Operating Procedures

TMH Hub staff psychologists developed emergency procedures, initial intake evaluation templates, and standard operating procedures (SOPs) for: (1) initiating services with spoke sites, dual-site docu- mentation, tracking routine clinical screening measures, scheduling patients, and delivering CVT-to-Home services. Through iterative collaboration, the team also developed an intake protocol and tem- plate to ensure a comprehensive and uniform initial evaluation that captures relevant clinical and TMH information (more details below).

We also established detailed risk procedures in collaboration with suicide prevention coordinators and clinical staff at each site prior to the delivery of services. These included on- and off-site contacts and contingency plans for possible risk scenarios includ- ing safety concerns related to veteran risk to self or others, medical emergencies, and problems with technology. For each scenario, staff developed a decision tree with contact information (on-site staff members as well as local police precinct and hospital infor- mation) and preferred method of contact (i.e., phone number(s), instant messaging, e-mail, etc.). Additionally, staff established specific procedures for responding to a group therapy participant’s endorsement of suicidal ideation on the PHQ-9. We also solicited feedback from the consultation service of the VA Rocky Mountain Mental Illness Research Education Clinical Centers of Excellence (MIRECC) for Veteran Suicide Prevention on our risk protocols.

We developed all protocols through preliminary brainstorming in VA NYH TMH Hub Psychology staff meetings. Individual staff members then volunteered to take primary responsibility for out- lining the ideas discussed, which were then reviewed and edited by all team members. Upon consensus, procedure and intake docu- ments were saved in a shared electronic folder to which all team members have access. As staff piloted these procedures, feedback was obtained during staff and peer supervision meetings, which allowed the protocols to continue to evolve in response to staff and clinical needs.

Referral Process

Spoke site clinicians refer veterans for TMH therapy and as- sessment services through an interfacility consult. Information in the consult includes: reason for referral, diagnosis, relevant stres- sors, risk factors, and referring provider’s contact information. Psychologists receive consults and screen veterans via chart re- view for appropriateness for our program (e.g., level of risk, clinical presentations or physical limitations that would interfere with delivery of treatment) and then assign veterans to a clinician based on the psychologists’ clinical specialties and availability. Prior to intake, psychologists attempt to contact veterans by phone to provide a brief introduction to TMH services. Psychologists use an initial intake template to assess the appropriateness of the referral and collaboratively develop the initial treatment goals and plan.

Preliminary Access to Services (as of January 31, 2018)

From March 2017 to January 2018, the VA NYH TMH Hub received 377 consults for TMH psychology services. Of those consults received, 252 veterans engaged in TMH services through our Hub. We provided individual psychotherapy to 65 veterans,

Table 2 VA NYH TMH Hub Spoke Sites

VA Medical Center (VAMC) Spoke sites Rurality

Bath VAMC Domiciliary program RURAL Bath VAMC RURAL Wellsville CBOC RURAL Elmira CBOC URBAN Wellsboro CBOC HIGHLY RURAL

Albany VAMC Glens falls URBAN Plattsburg CBOC RURAL Bainbridge CBOC RURAL Fonda CBOC RURAL Saranac Lake CBOC RURAL

Canandaigua VAMC Canandaigua VAMC URBAN Rochester CBOC URBAN Domiciliary program URBAN

VA Central Iowa Health Care System Fort Dodge CBOC RURAL

Western New York Healthcare System Jamestown CBOC RURAL

Note. Adapted from “VAST Snapshot 2 — VHA Station Listing” by United States Department of Veterans Affairs Health Administration, VHA Support Service Center, 2018.

4 CHEN ET AL.

group psychotherapy to 193 veterans, and couples therapy to 7 veteran couples. Additionally, we provided 9 PTSD evaluations and 18 cognitive evaluations.

The demographic characteristics, clinical presentation of the veterans seen via CVT, and services provided by the VA NYH TMH Hub are shown in Tables 3 and 4. Given that many veterans present with multiple complex problems, many veterans seen through the program receive more than one intervention over the course of their treatment and intervention protocols frequently require adaptation to the veteran’s individual presentation.

Overall, 32% of patients referred to the program were not ultimately seen for treatment by VA NYH TMH Hub psychology staff. Reasons included: veterans’ lack of response to outreach,

inability to commit to demands of treatment, lack of availability during provider appointment times, lack of interest or indication that services were no longer needed, or discharged from the facility prior to services offered. Additionally, veterans were also not seen due to incorrect consult submissions, inappropriate referrals due to risk management issues, and services requested not being offered through the Hub. Data on the characteristics of veterans seen through the program and those not seen for individual and couples treatment are shown in Table 5. Overall, the characteristics of veterans seen and not seen by the program were similar, with the exception of age, veterans referred to the program but not seen tended to be younger than the population of veterans seen.

Our data was consistent with other findings indicating that psychotherapy delivered by TMH was well tolerated (Bouchard et al., 2004; Fortney et al., 2007; Gehrman et al., 2016; Gros et al., 2013; Gros et al., 2011; Morland et al., 2009; Morland et al., 2010). Overall, only 16.9% of patients who initiated individual or couples’ psychotherapy dropped out of treatment. The average number of sessions attended for individual treatment among those

Table 3 Characteristics of Veterans Seen Through NYH TMH Hub for All Services

Characteristic N

(% of veterans)

Age Mean 49.3 Median 50.5 Range 21–88 Standard Deviation 14.5

Gender Male 226 (89.7%) Female 26 (10.3%)

Ruralitya

Rural 128 (50.8%) Highly Rural 8 (3.2%) Urban 116 (46.0%)

Race/Ethnicity White Non-Hispanic 182 (72.2%) Black/African-American 40 (15.9%) Hispanic/Latino 4 (1.6%) Asian/Pacific Islander 4 (1.6%) Unknown 22 (8.7%)

Era (Vietnam, Gulf War, OEF/OIF/OND, other) Pre-Korean 1 (.4%) Korean War 2 (.8%) Post Korean 2 (.8%) Vietnam 44 (17.5%) Post-Vietnam 62 (24.6%) Persian Gulf War 134 (53.2%) Other 3 (1.2%) Unknown 4 (1.6%)

Diagnosis Depression 106 (42.0%) Trauma 77 (30.6%) Substance 51 (20.2%) Anxiety 37 (14.7%) Sleep Disorder 25 (9.9%) Bipolar 20 (7.9%) Adjustment 20 (7.9%) Persistent Mood Disorder 9 (3.6%) Relationship Problems 7 (2.8%) Generalized Anxiety Disorder 6 (2.4%) Neurocognitive Disorder 6 (2.4%) Phobia 5 (1.9%) Unknown 4 (1.6%) OCD 2 (.8%) Panic 2 (.8%) Impulse Disorder 1 (.4%)

a Adapted from “ZIP code rural-urban commuting areas geographic tax- onomy” data file by G. Hart and J. Cromartie, 2014.

Table 4 Services Provided by NYH TMH Hub

Treatments

N (% veterans receiving)

Individual Psychotherapy Treatments Cognitive Behavior Therapy for Anxiety or

Depression (CBT) 29 (46%) Behavioral Activation (BA) 1 (1.6%) Acceptance and Commitment Therapy

(ACT) 5 (7.9%) Brief Dynamic Interpersonal Therapy (DIT) 1 (1.6%) Dialectical Behavior Therapy (DBT) 4 (6.4%) Prolonged Exposure (PE) 2 (3.2%) Cognitive Processing Therapy (CPT) 3 (4.8%) Skills Training in Affect and Interpersonal

Regulations (STAIR) 1 (1.6%) Exposure and Ritual Prevention (ExRP) 3 (4.8%) Enhanced Cognitive Behavioral Therapy

(CBT-E) 1 (1.6%) Cognitive Behavioral Therapy for Chronic

Pain (CBT-CP) 5 (7.9%) Cognitive Behavioral Therapy for Insomnia

(CBT-I) 8 (12.7%) Cognitive Behavioral Therapy for TBI

(CBT) 1 (1.6%) Cognitive Behavioral Therapy for Smoking

Cessation (CBT) 1 (1.6%) Grief-Focused Psychotherapy 1 (1.6%) Emotion-Focused Therapy (EFT) 7 (11.1%) Trauma-Focused Psychodynamic

Psychotherapy (TFPP) 3 (4.8%) Assessment Neuropsychological Testing 18 (66.7%) PTSD Evaluation 9 (33.3%) Group Psychotherapy Treatments Cognitive Behavioral Therapy Skills Group

(CBT) 75 (38.9%) Cognitive Behavioral Therapy for Insomnia

(CBT-I) 18 (9.3%) Cognitive Processing Therapy Group (CPT)

for Military Sexual Trauma 12 (6.2%) Dialectical Behavior Therapy (DBT) Drop-In

Distress Tolerance Skills Group 88 (45.6%)

5IMPLEMENTATION OF TMH SERVICES

who have completed treatment was 12.0. Among those in active individual treatment as of January 2018, the mean number of sessions attended was 15.0. Among those actively receiving cou- ples’ treatment, the mean number of sessions attended was 12.5.

Given the uncertainty regarding timing of discharge from the domiciliary program where the VA NYH TMH Hub’s psychother- apy groups have been implemented, most groups have been de- signed as drop-in skills groups. This format is designed so skills taught in each session do not require background from prior sessions. Each individual session is thus able to “stand alone,” which provides the greatest flexibility in the timing for veteran entry into the groups. The mean number of group session attended by veterans ranged from 2.9 to 3.8 varying by group.

Quality Improvement

The program is engaged in ongoing quality improvement ef- forts. To facilitate these efforts, as part of the program’s protocols for routine clinical care, we implemented standardized assessments and developed a standardized intake to ensure consistent collection of clinical information (see Appendix A). The intake includes an interview where demographic information, military history, med- ical history, functional capacity, pain, social history, psychiatric history, and substance use history are collected. Depression and anxiety are measured weekly with the PHQ-9 and GAD-7 and other measures are utilized when relevant to the veteran’s treat- ment goals (e.g., PCL-5 for PTSD, YBOCS for OCD). Staff at the spoke site administer measures to veterans at the time of their arrival for their appointment and then send the measures via fax or encrypted e-mail to psychologists at the VA NYH TMH Hub. We plan to analyze and review this data quarterly to track treatment quality.

We also established procedures to evaluate the experience of a) veterans receiving TMH services, (b) VA NYH TMH Hub psy- chologists, and (c) spoke site leadership, technical support, and the clinical staff who refer patients to VA NYH TMH Hub psychology services. All participants from whom we gather QI data are in- formed that their participation is entirely voluntary and will not

impact the care they receive or their employment status. Following the final therapy session, patients complete an 8-item measure of satisfaction (Consumer Satisfaction Questionnaire) and a 10-item measure of factors specific to TMH treatment (e.g., experience with technological difficulties, privacy concerns, veteran’s other options for psychotherapy, and why they selected TMH over other available options). Following a literature review of patient satis- faction measures, program psychologists were unable to find an existing measure that assessed the specific domains of interest to our program (i.e., specific factors related to veterans’ selection of TMH and issues that may have negatively impacted their TMH experience). We collaboratively developed a 10-item measure designed to help the program better understand veterans’ experi- ence with our services and identify potential systematic issues that could be addressed to improve the delivery of services (see Ap- pendix B). Veterans who receive individual psychotherapy also complete a 20-min qualitative telephone interview about their experiences using TMH, which is conducted by staff specifically trained to carry out these procedures within one month of treat- ment completion. The interview asks about aspects of TMH that patients found useful as well as areas for improvement, perceived impact of TMH on the therapy relationship, and patients’ satisfac- tion with technology, privacy, and access. Patients who prema- turely drop out of treatment are also contacted via telephone and given the option to complete this interview. As an additional aspect of our QI protocols, staff also record and transcribe the interviews, but only with written consent from veterans in accordance with VA policy. Interviews for veterans receiving other services are currently being developed.

We also gather quality improvement data on VA NYH TMH Hub psychologists and staff at the spoke site. TMH psychologists meet weekly for peer supervision to discuss complex cases, ob- servations about providing services via TMH, and personal reac- tions to providing clinical care via TMH. The content of these meetings is maintained for future analysis to direct further inno- vation in the NYH TMH Hub. Additionally, we collect informa- tion on the experiences of referring providers and spoke site leadership focused on satisfaction with the delivery of TMH ser- vices for further quality improvement. Referring providers include spoke site clinical staff from a variety of disciplines, including psychiatrists, psychologists, social workers, nurse practitioners, registered dietitians, and primary care physicians. We are also interested in the experiences of Telehealth Clinical Technicians (TCTs), who assist in the delivery of TMH at the remote site. Their responsibilities include bringing patients to clinical rooms at their appointment times, connecting the patients with their service pro- vider via CVT, transmitting copies of clinical measures and psy- chotherapy materials (e.g., handouts, homework) between patient and service provider, and assisting with scheduling TMH appoint- ments. We plan to conduct similar experience surveys with TCTs as described above.

Current Research

Additionally, the VA NYH TMH Hub is pursuing a research mission with two primary objectives: (a) evaluation of factors that impact structure, process, and treatment outcome, and (b) devel- opment and evaluation of new practices. As part of our efforts to advance the first aim, we have an IRB approved protocol to

Table 5 Characteristics of Veterans Referred for Individual and Couples Treatments

Characteristic Veterans seen by

Hub N (%) Veterans not seen

by Hub N (%)

Age Mean 49.6 41.41 Median 49 36 Range 23–81 26–76 Standard Deviation 14.75 17.05

Sex Male 62 (86%) 31 (84%) Female 10 (14%) 6 (16%)

Race White 67 (93%) 33 (89%) Black/African-American 2 (3%) 0 (0%) Unknown 3 (4%) 4 (11%)

Ethnicity Not Hispanic or Latino 70 (97%) 34 (92%) Unknown 2 (3%) 3 (8%)

6 CHEN ET AL.

conduct a chart review examining the quality of care provided through the TMH Hub with a goal of identifying factors that influence the effectiveness of TMH services. Toward the second aim, the Clinical Co-Director of the VA NYH TMH Hub serves as Principal Investigator (PI) on an IRB approved, VA Health Ser- vices Research and Development (HSR&D) funded pilot study to develop a TMH-based assessment and family intervention for family caregivers of individuals with dementia. VA NYH TMH Hub staff are providing input on the development of the assess- ment and intervention.

Future Directions

Aligning with its three areas of focus, the Hub will seek to continue to develop and pursue its clinical, training, and research missions. Clinically, the development of more rapid systems that can provide information to leadership as well as feedback to individual clinicians on productivity, patient outcome, and prog- ress could allow both the program and individual providers to adjust practices rapidly and improve the quality of services and care. Additionally, program staff are internally developing proto- cols to track clinical data in ways that will alert providers to patients who are not progressing as expected. Clinicians will discuss these patients at peer supervision meetings to determine potential modifications to their treatment plans.

We seek to eventually expand the training mission of the Hub beyond providing supervision and seminars to trainees who are onsite at the VA NYH. Ultimately, the training program will seek to develop curriculum for delivery of TMH services for specific patient populations that integrates with the VHA’s continuing education systems and could provide distance learning to anyone interested in developing skills in the delivery of TMH services.

Finally, in addition to the NYH TMH Hub’s engagement in quality improvement, the VHA’s TMH Hub initiative is ripe for addressing a vast range of research questions. TMH’s implemen- tation within the VHA health care system provides opportunities for examining differences in structure, process, and outcome in a systematic way. We plan to collaborate with other VHA TMH programs to pursue research funding to study the impact of struc- tural factors that form the context of care including equipment, setting (e.g., facility to facility, facility to home, facility to another location such as a veteran’s workplace via use of VHA tablets or video apps, etc.), human resources, scheduling, and organizational characteristics on patient and system outcomes. We hope to go beyond the question of “does it work?” and ask questions that evaluate who most benefits from TMH services, at what time in treatment, delivered by which providers, and in what types of settings.

References

Bouchard, S., Paquin, B., Payeur, R., Allard, M., Rivard, V., Fournier, T., . . . Lapierre, J. (2004). Delivering cognitive-behavior therapy for panic disorder with agoraphobia in videoconference. Telemedicine Journal and e-Health, 10, 13–25. http://dx.doi.org/10.1089/1530562047736 44535

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

Cullum, C. M., Hynan, L. S., Grosch, M., Parikh, M., & Weiner, M. F. (2014). Teleneuropsychology: Evidence for video teleconference-based

neuropsychological assessment. Journal of the International Neuropsy- chological Society, 20, 1028 –1033. http://dx.doi.org/10.1017/S1355617 714000873

Deen, T. L., Godleski, L., & Fortney, J. C. (2012). A description of telemental health services provided by the Veterans Health Administra- tion in 2006 –2010. Psychiatric Services, 63, 1131–1133. http://dx.doi .org/10.1176/appi.ps.201100458

Fortney, J. C., Pyne, J. M., Edlund, M. J., Williams, D. K., Robinson, D. E., Mittal, D., & Henderson, K. L. (2007). A randomized trial of telemedicine-based collaborative care for depression. Journal of General Internal Medicine, 22, 1086 –1093. http://dx.doi.org/10.1007/s11606- 007-0201-9

Galusha-Glasscock, J. M., Horton, D. K., Weiner, M. F., & Cullum, C. M. (2016). Video teleconference administration of the repeatable battery for the assessment of neuropsychological status. Archives of Clinical Neu- ropsychology, 31, 8 –11. http://dx.doi.org/10.1093/arclin/acv058

Gehrman, P., Shah, M. T., Miles, A., Kuna, S., & Godleski, L. (2016). Feasibility of group cognitive-behavioral treatment of insomnia deliv- ered 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 cognitive behavioral therapy for pain Pt. 1. [PowerPoint slides]. Retrieved from https://www.hsrd.research.va.gov/ for_researchers/cyber_seminars/archives/869-notes.pdf

Godleski, L., Darkins, A., & Peters, J. (2012). Outcomes of 98,609 U.S. Department of Veterans Affairs patients enrolled in telemental health services, 2006 –2010. Psychiatric Services, 63, 383–385. http://dx.doi .org/10.1176/appi.ps.201100206

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

Gros, D. F., Morland, L. A., Greene, C. J., Acierno, R., Strachan, M., Egede, L. E., . . . Frueh, B. C. (2013). Delivery of evidence-based psychotherapy via video telehealth. Journal of Psychopathology and Behavioral Assessment, 35, 506 –521. http://dx.doi.org/10.1007/s10862- 013-9363-4

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

Grosch, M. C., Gottlieb, M. C., & Cullum, C. M. (2011). Initial practice recommendations for teleneuropsychology. The Clinical Neuropsychol- ogist, 25, 1119 –1133. http://dx.doi.org/10.1080/13854046.2011.609840

Grosch, M. C., Weiner, M. F., Hynan, L. S., Shore, J., & Cullum, C. M. (2015). Video teleconference-based neurocognitive screening in gero- psychiatry. Psychiatry Research, 225, 734 –735. http://dx.doi.org/10 .1016/j.psychres.2014.12.040

Harrell, K. M., Wilkins, S. S., Connor, M. K., & Chodosh, J. (2014). Telemedicine and the evaluation of cognitive impairment: The additive value of neuropsychological assessment. Journal of the American Med- ical Directors Association, 15, 600 – 606. http://dx.doi.org/10.1016/j .jamda.2014.04.015

Hart, G., & Cromartie, J. (2014). ZIP code rural-urban commuting areas (RUCAs) geographic taxonomy (Version 3.10) [Data file]. Retrieved from https://ruralhealth.und.edu/ruca

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

Morland, L. A., Greene, C. J., Rosen, C. S., Foy, D., Reilly, P., Shore, J., . . . Frueh, B. C. (2010). Telemedicine for anger management therapy in

7IMPLEMENTATION OF TMH SERVICES

a rural population of combat veterans with posttraumatic stress disorder: A randomized noninferiority trial. [doi]. The Journal of Clinical Psy- chiatry, 71, 855– 863. http://dx.doi.org/10.4088/JCP.09m05604blu

Morland, L. A., Greene, C. J., Rosen, C., Mauldin, P. D., & Frueh, B. C. (2009). Issues in the design of a randomized noninferiority clinical trial of telemental health psychotherapy for rural combat veterans with PTSD. Contemporary Clinical Trials, 30, 513–522. http://dx.doi.org/10 .1016/j.cct.2009.06.006

Seal, K. H., Bertenthal, D., Miner, C. R., Sen, S., & Marmar, C. (2007). Bringing the war back home: Mental health disorders among 103,788 U.S. veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine, 167, 476 – 482. http://dx.doi.org/10.1001/archinte.167.5.476

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

United States Department of Veterans Affairs, Office of Connected Care. (2018). Telemental health in the department of veteran affairs fact sheet. Washington, DC: Office of Public Affairs Media Relations.

United States Department of Veterans Affairs, Office of Mental Health and Suicide Prevention. (2017). Suicide among veterans and other Ameri- cans. Retrieved from https://www.mentalhealth.va.gov/docs/ 2016suicidedatareport.pdf

United States Department of Veterans 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

United States Department of Veterans Affairs, Veterans Health Adminis- tration Support Service Center. (2018). VAST [Veterans Affairs Site Tracking] Snapshot 2—VHA Station Listing. Retrieved from Organiza- tion’s Secure Intranet.

Wallace, A. E., Weeks, W. B., Wang, S., Lee, A. F., & Kazis, L. E. (2006). Rural and urban disparities in health-related quality of life among veterans with psychiatric disorders. Psychiatric Services, 57, 851– 856. http://dx.doi.org/10.1176/ps.2006.57.6.851

Weeks, W. B., Kazis, L. E., Shen, Y., Cong, Z., Ren, X. S., Miller, D., . . . Perlin, J. B. (2004). Differences in health-related quality of life in rural and urban veterans. American Journal of Public Health, 94, 1762–1767.

Appendix A

Initial Intake Evaluation

CHIEF COMPLAINT

MILITARY HISTORY

Branch: Years served: Military Occupational Specialty: Combat: Highest rank: Discharge rank: Disciplinary action:

SOCIAL HISTORY

Geographic area born/raised: Education: Marital status: Children:

Social support: Current residence: Employment: Legal history: Domestic violence history: Religion/spirituality:

PSYCHIATRIC HISTORY

Overview of current symptoms: Current treatment: Current psychiatric medications: Overview of past psychiatric symptoms: Past psychiatric treatment: Past psychiatric hospitalizations: Past psych medications: Description of depressive symptoms:

(Appendices continue)

8 CHEN ET AL.

Description of anxiety symptoms: Description of PTSD symptoms: History of trauma: History of Military Sexual Trauma: Description of mania symptoms: Description of psychotic symptoms:

SUBSTANCE USE

Alcohol: Tobacco: Recreational drugs: Prescription drug misuse: History of substance use treatment:

RISK/SAFETY

Current suicidal ideation: Past suicidal ideation: Past suicide attempts: Past self-injurious behavior: Current homicidal ideation: Past homicidal ideation: History of violence: Access to weapons/firearms: Risk factors for harm to self/others: Protective factors for harm to self/others:

MEDICAL HISTORY

Relevant medical diagnoses: Do you currently have any pain? Where: Current medications:

COGNITIVE FUNCTIONING

Prior head injury/TBI: Recent cognitive changes: Information provided by collaterals regarding cognitive changes:

MENTAL STATUS/BEHAVIORAL OBSERVATIONS

Approach to evaluation: Orientation: Appearance: Eye contact: Sensory deficits: Speech/language: Mood/affect: Thought process: Thought content: Insight/judgment: SCORES FOR RELEVANT ASSESSMENT MEASURES SUMMARY/FORMULATION DIAGNOSIS RECOMMENDATIONS PLAN

Appendix B

Addendum to Satisfaction Survey

1. How did your telehealth therapy compare to your expectations?

a. Much worse than I expected b. A little worse than I expected c. About what I expected d. A little better than I expected e. Much better than I expected

2. What type of in-person therapy have you done before? (select all that apply)

a. None b. Individual therapy

c. Group therapy d. Couples therapy e. Family therapy f. Other: ________________________________

3. What type of telehealth therapy have you done before? (select all that apply)

a. None b. Individual therapy c. Group therapy d. Couples therapy e. Family therapy f. Other: ________________________________

(Appendices continue)

9IMPLEMENTATION OF TMH SERVICES

4. Did you experience any technical problems while

using telehealth?

a. No (skip to question 5) b. Yes (select all that apply)

i. Problems with sound ii. Dropped calls

iii. Poor video quality iv. Other: ____________________________

4a. If you experienced technical problems, were those issues resolved?

a. No b. Yes

4b. If you experienced technical problems, was your therapist aware of the issues?

a. No b. Yes

5. Did you have any concerns about your privacy or confidentiality while using telehealth?

a. No (skip to question 6) a. Yes

5a. If you had concerns about privacy or confidentiality, was your therapist aware of your concerns?

a. No b. Yes

6. Did you have options for therapy other than telehealth?

a. No

b. Yes (select all that apply)

i. In-person at VA medical center (VAMC) ii. In-person at community-based outpatient center (CBOC)

iii. In-person community provider (outside of the VA) iv. Other telehealth options v. Other: ______________

7. If you had other options for therapy, why did you choose telehealth? (select all that apply)

a. Reduced travel time b. Reduced travel cost c. Availability of specialized therapy d. Availability of a therapist who could see me more

frequently e. Availability of a therapist who could see me more

quickly f. Ability to do therapy at home g. Other______________________

8. Where were you located during your telehealth therapy sessions? (select all that apply)

a. VA Medical Center b. VA Community-Based Outpatient Clinic (CBOC) c. In my home d. In a location other than my home (Please specify:

___________________________)

Received May 6, 2018 Revision received November 2, 2018

Accepted November 9, 2018 �

10 CHEN ET AL.