Telepsych vs inperson

[TheTruckGuy]

Those of y'all that are doing a lot of telepsych during COVID, what limitations do you feel like you get from it? Do you think the patient gets the same experience? If someone was cluster A or B, do you think it would be hard to pick up on over the phone? Do you think we're going to see increased telepsych in the future, even after COVID has died down, purely due to convenience?

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[psych.meout]

Is this homework?

 

[MAClinician]

^posting history suggests he is a doctor/medical officer I. The military so maybe not homework.

Personally I have only had 1 or 2 clients where I had to do telephone/audio only sessions. The rest have been telehealth using a video platform. With the phone you miss the body language/facial expressions so that can be challenging especially when speaking to a client who has a risk history (previous SI/ SIB/ AH/VH etc). Video visits were better but when the connection froze I found I would ask a question, client would answer but I didn’t know because of the video freezing and it was repetitive. For some clients it works adequately compared to in person but for others it was used because the other option was no service at all so you do the best you can given the circumstances.

I think video visits will stay depending on the insurance but phone visits might get cut. I know several health systems in my state have stated telehealth will continue in the future but it will be interesting to see what reimbursement will look like.

My supervisor and I had a discussion this week about how people can “fall through the cracks” more so during the pandemic and how even with telehealth you can miss things. There was a disabled child who died of severe neglect several months back in my state and the state did an investigation into how things got missed considering DCF, special education, and several service providers were involved with the family. So many missed opportunities and questionable decisions made, especially given the ability to still service the family over telehealth/remote learning. Very sad report to read.

 

[jdawg2017]

There are tradeoffs for sure. I think it is here to stay (with the big caveat being assuming that insurance will allow it to be billable for providers). However, there are significant considerations, and the digital health divide (esp. problematic for older individuals and individuals of lower SES) may be a trade with traditional in-person health divides, or even more exacerbated.

Don't even get me started on this topic in neuropsych (e.g., teleneuropsych). It's a growing passion of mine, partially born out of necessity since *everything* I have done since March 2020 has been virtual, both clinically and in-research. It's a really interesting area of the field that is now rapidly growing, but there are a lot of problems the field urgently needs to address with research if the examinee will be anywhere but in a clinic in future evaluations. There are definitely things we can't see over virtual visits vs. in-person (e.g., motor behaviors, anything below the waist [e.g., RLS] unless you ask the patient to stand up or query specifically, etc.).

Happy to share some interesting tele-NP papers here or in PM if you want to know more about the cognitive testing angle.

 

[Spydra]

I am still in training, but have seen all of my therapy clients via telepsych (video not phone) since COVID started in March 2020. I like it so much more than in person treatment that when given the option to return to the campus clinic I just said no. With telepsych the no shows stopped entirely, "forgetting" to pay stopped entirely, seeing their environment provided way more clarity about their circumstances, and they were more forthcoming about everything. I could accommodate client requests for therapy times outside of the clinic's normal hours if I wanted. I was also able to completely control my environment and could make my space as relaxing and comfortable as I desired whereas the campus clinic is awful. This made me happier, more attentive, and better able to address their needs. There was also no time lost/wasted switching treatment rooms, getting supplies, dealing with paper files, or bumping into another student with a question or wanting to chat.

I also recognize I was lucky in a lot of ways. My clients were all very tech savvy, internet issues were rare, I had all of the equipment I needed to get started, and living alone meant I had total control over my home office. Regardless if I do any therapy post-internship year it will most likely be telepsych since I prefer it and am not aiming to take insurance.

 

[psych.meout]

I am still in training, but have seen all of my therapy clients via telepsych (video not phone) since COVID started in March 2020. I like it so much more than in person treatment that when given the option to return to the campus clinic I just said no. With telepsych the no shows stopped entirely, "forgetting" to pay stopped entirely, seeing their environment provided way more clarity about their circumstances, and they were more forthcoming about everything. I could accommodate client requests for therapy times outside of the clinic's normal hours if I wanted. I was also able to completely control my environment and could make my space as relaxing and comfortable as I desired whereas the campus clinic is awful. This made me happier, more attentive, and better able to address their needs. There was also no time lost/wasted switching treatment rooms, getting supplies, dealing with paper files, or bumping into another student with a question or wanting to chat.

I also recognize I was lucky in a lot of ways. My clients were all very tech savvy, internet issues were rare, I had all of the equipment I needed to get started, and living alone meant I had total control over my home office. Regardless if I do any therapy post-internship year it will most likely be telepsych since I prefer it and am not aiming to take insurance.

This is the operative part. Many lower SES and/or rural patients have poor quality connections (which complicate and frustrate teletherapy) and some lose access entirely if they're having trouble paying their bills. Hell, I've done phone therapy and some patients have financial difficulties maintaining a consistent phone, let alone broadband internet. That said, there are definitely benefits for these groups, who often live far from our sites or have transportation issues that hinder them being able to show up for therapy. Many of these people would never have access to some of the specialty care we provide without telehealth.

You also have age-related issues, both with older adults being unable to work the technology or feeling less comfortable with it (often preferring phone sessions, which are much more familiar to them), and with younger kids, who often have difficulty maintaining focus and attention on something like therapy (especially if they have something like ADHD, developmental delays, etc.) and being unable to do some of the therapeutic activities that usually keep them engaged. Phone therapy has been good for some of my less mobile older adult patients, who likely would have trouble coming in for sessions due to physical limitations and transportation issues. Telehealth has been good for teenagers, who are generally quite tech savvy, but there's still the issues (at least in the settings where I've worked) of needing an adult present in the home for therapy.

There's also the logistics of telehealth. I never had to deal with barking dogs, construction noises, my own internet woes, or other issues when I was in-clinic. I do like many things about telehealth, but there's definitely give-and-take.

 

[WisNeuro]

Yeah, I was working with an older, less tech savvy, low SES population in my clinical work last year. It was terrible. Had to essentially set aside at least 10% of my clinical time last year to dealing with tech issues. Also, was pretty much only doing brief testing where the chart review and interview pretty much confirmed the diagnoses, with the brief testing to get some tracking data. For my work, telehealth was not great. Refused to do IMEs via telehealth when asked a couple times.

 

[Ollie123]

Glad telehealth is going well for some. I do like that my show rate is much higher, but between the tech issues, difficulty reading body language, and increased distraction for both me and the patient I would jump back to in-person in a heartbeat. Instead I'm stopping clinical work entirely - at least for now! The other advantage I've found is that it is less awkward to chart during session (I try to avoid during in-person visits), but my notes are brief anyways so it isn't a huge deal.

Some of this is likely my frustration with circumstances though, so we'll see how that changes if teletherapy continues beyond the pandemic. I'm not in the business of treating minor, normative and arguably adaptive anxiety. Behavioral activation is just a PITA to try and do right now. Zoom mindfulness just feels awkward and somewhat counterintuitive. I haven't figured out a good way to do exposure for most things. Even reviewing worksheets/homework and the like is kind of a mess. Some of those (e.g. BA) will get better post-pandemic, but others (mindfulness) probably won't. I think the extremely straightforward/didactic-type interventions (e.g. BA, CBT-I, traditional CT with the right patient) translate a little better to a telehealth format but I'm struggling with many others.

 

[cara susanna]

One big issue with telehealth is that the patients seem more distracted. I even have telephone appts where people will be out grocery shopping or something.

Also, video appts are exhausting to me (and I'm not the only one apparently - look up Zoom fatigue).

 

[PsychPhDone]

For my particular speciality, telehealth is going great. I saw many of my patients via video prior to the pandemic and plan to have a mostly virtual caseload moving forward.

 

[Sanman]

One big issue with telehealth is that the patients seem more distracted. I even have telephone appts where people will be out grocery shopping or something.

Also, video appts are exhausting to me (and I'm not the only one apparently - look up Zoom fatigue).

Frame is definitely more difficult to keep with telephone and to some degree with tele-health. I have had an even more difficult time as my folks often cannot hold a phone or tablet due to physical debility and many are too old to know how to use the technology. For the traditional outpatient folks, I can see the benefit and convenience. For a population like the VA, I worry about some people losing the responsibility of getting dressed and showing up to an appt rather than sitting at home doing nothing other than picking up the phone.

 

[foreverbull]

I really miss in person sessions, but telehealth from home has had its perks. Never wear slacks, fewer no shows, can take care of things at home in between.

That said, I paid for an office that I haven’t used in a year and my lease is up soon. I’ve decided not to renew given the state of things still being in flux. I figure it’s not hard to go out and sublet an office at a moment’s notice if needed, but it IS hard to throw money away to a company without even being able to use the office or knowing when it’s safe to do so (I have no internet in there, so there really is nothing I can do there other than in person sessions).

I do have zoom fatigue at times, but it’s not necessarily because of clients but because of meetings I attend that are extremely draining.

Technological issues can really be a pain though. Occasionally there’ll be a delay/mismatch between audio and video or someone’s mic on their laptop won’t pick up sound at all if their voice gets quieter. Usually it’s the client’s internet that isn’t working in those cases.

And some clients will pass up therapists who refuse to see clients in person, but that has been rare.

I think telehealth in the mainstream is here to stay, and some therapists in my area have said they plan to go fully telehealth and never look back. I am not one of those people, but then I think back to last year when my client showed up to session and told me in my office that they’d just been to a huge tourist event that involved close body contact and had a “cold” in late February last year. That client exposed me to whatever they had, because this was before masks were in use—and my spouse and I immediately got sick afterward. After that incident, I realized that I can’t rely on clients to do what’s best for themselves and others when it comes to spreading illnesses. So it’s tempting at times to go full telehealth just for that reason alone.

 

[cara susanna]

For a population like the VA, I worry about some people losing the responsibility of getting dressed and showing up to an appt rather than sitting at home doing nothing other than picking up the phone.

I definitely agree with this.

 

[ClinicalABA]

Have any of you run into funders putting deadlines on how long they will pay for remote services? I've had one insurer initially say 3/31, but revise to 6/30 when pushed.

 

[Ollie123]

Have any of you run into funders putting deadlines on how long they will pay for remote services? I've had one insurer initially say 3/31, but revise to 6/30 when pushed.

I'm not directly involved in those discussions (large AMC so this is all handled wayyyy up the chain), but absolutely yes. I believe we had varying insurers continuing though September, October, December, March and now beyond. To my knowledge all insurers have ended up extending telehealth coverage, but I won't know for sure until someone yells at me for not doing the thing that was only discussed at the meeting I wasn't invited to attend and no one told me about.

 

[TheTruckGuy]

Is this homework?

No, not homework. As another poster pointed out, I'm an MD. Just curious, as around here I see a lot of telephone telehealth with occasional zoom calls. Even when I see mental health patients, in my amateur mental status exam, I feel like there's a lot I would miss if it was on video, and certainly a lot I'd miss if it was solely over the phone. There are some borderline anti-social people that I've sent to formal mental health and they do their encounters over the phone, and I feel like there's no way the psychologist is getting the full picture.

I can see the convenience factor for both patients and providers, but I think we need to we need to get back to seeing patients in the flesh. Or maybe I'm just old and think you can't really connect with a person via telehealth compared with in person, and most young people these days feel the opposite.

 

[Spydra]

I can see the convenience factor for both patients and providers, but I think we need to we need to get back to seeing patients in the flesh. Or maybe I'm just old and think you can't really connect with a person via telehealth compared with in person, and most young people these days feel the opposite.

I do not think you being however old you are has anything to do with it. I think there are a variety of reasons telepsych/telehealth may or may not work for practitioners and may or may not work for clients. I think its human nature to wonder if something we aren't accustomed to doing is going to be effective. I discussed this a lot in supervision.....what is or isn't working and why or why not. Before everything shifted to telepsych/telehealth there was a lack of suitable options for everyone who needed treatment and that won't go away if everything returns to in person only. I think there needs to be both options so that more people who need treatment have more options to get it. I am also wondering if there might be more practitioners willing to provide treatment if telepsych/telehealth stays. Before this global experiment I was firmly in the 'last day of internship, no more therapy' camp, now I'm happy to devote a little time via telepsych and am pondering research I can conduct to see what may or may not work and how training/supervision can be improved.

 

[PsychPhDone]

No, not homework. As another poster pointed out, I'm an MD. Just curious, as around here I see a lot of telephone telehealth with occasional zoom calls. Even when I see mental health patients, in my amateur mental status exam, I feel like there's a lot I would miss if it was on video, and certainly a lot I'd miss if it was solely over the phone. There are some borderline anti-social people that I've sent to formal mental health and they do their encounters over the phone, and I feel like there's no way the psychologist is getting the full picture.

I can see the convenience factor for both patients and providers, but I think we need to we need to get back to seeing patients in the flesh. Or maybe I'm just old and think you can't really connect with a person via telehealth compared with in person, and most young people these days feel the opposite.

In my specialty, I have really liked the ability to see my patients' home environments. Just another point I forgot to mention before.

 

[WisNeuro]

Have any of you run into funders putting deadlines on how long they will pay for remote services? I've had one insurer initially say 3/31, but revise to 6/30 when pushed.

Yes, we have. This is a major lobbying effort we're currently pushing at the state and federal levels.

 

[MiniLop]

In my specialty, I have really liked the ability to see my patients' home environments. Just another point I forgot to mention before.

Same. Doing mostly OCD work, it's been great being with clients while they do exposures at home, since that's where most of their triggers tend to be (rather than at an office, where we're usually trying to approximate what they experience at home).

That said, I miss being able to take my socially anxious clients for walks outside the office and having them do their social anxiety exposures with strangers on the street, local businesses, etc.

 

[PsyDr]

Have any of you run into funders putting deadlines on how long they will pay for remote services? I've had one insurer initially say 3/31, but revise to 6/30 when pushed.

Pick the largest hospital group you can think of. Now pick the second largest, and the third largest. Now add that to every other state. Imagine their lobbyists dollars. All of those resources are dedicated to making sure telemedicine continues.

 

[smalltownpsych]

From what I gather from this conversation, telehealth can provide some benefits and in-person can as well. Prior to pandemic when a suicidal patient or a family member would contact me by phone, I couldn't even bill for it and if I had a patient who couldn't make it to their appointment because of a legitimate reason, I couldn't use videoconferencing. During the pandemic, I have used both virtual and in-person depending on what made the most sense in my clinical judgement while relying on our medical team for guidance and consultation. I would love it if the field continued to let the clinicians determine what made sense for their cases going forward.

 

[TheTruckGuy]

From what I gather from this conversation, telehealth can provide some benefits and in-person can as well. Prior to pandemic when a suicidal patient or a family member would contact me by phone, I couldn't even bill for it and if I had a patient who couldn't make it to their appointment because of a legitimate reason, I couldn't use videoconferencing. During the pandemic, I have used both virtual and in-person depending on what made the most sense in my clinical judgement while relying on our medical team for guidance and consultation. I would love it if the field continued to let the clinicians determine what made sense for their cases going forward.

I think this makes sense. As an outsider, I feel like the average patient benefits from in-person sessions. Of course if they can't make it then they can't benefit at all, but for those that can it makes sense to me.

 

[WisNeuro]

I think this makes sense. As an outsider, I feel like the average patient benefits from in-person sessions. Of course if they can't make it then they can't benefit at all, but for those that can it makes sense to me.

Yeah, we;ll need more data in the long-term to start answering this empirically. The corporate telehealth companies throw out some research, but it's fairly weak at the moment. There may be something there, but we just don't know yet, particularly long-term data.

 

[tr]

Yeah, we;ll need more data in the long-term to start answering this empirically. The corporate telehealth companies throw out some research, but it's fairly weak at the moment. There may be something there, but we just don't know yet, particularly long-term data.

The sudden shift from in-person to tele occasioned by the pandemic actually offered an excellent opportunity for real-world clinical comparisons.
I'm writing up data right now comparing clinical improvement in an affiliated PHP that abruptly switched to 100% tele due to pandemic. Shockingly the improvement from entry to exit was statistically somewhat *greater* with the remote program, while baseline characteristics remained similar. Can't figure out why but apparently none of the physical amenities associated with on-site attendance had any major clinical relevance.

 

[WisNeuro]

The sudden shift from in-person to tele occasioned by the pandemic actually offered an excellent opportunity for real-world clinical comparisons.
I'm writing up data right now comparing clinical improvement in an affiliated PHP that abruptly switched to 100% tele due to pandemic. Shockingly the improvement from entry to exit was statistically somewhat *greater* with the remote program, while baseline characteristics remained similar. Can't figure out why but apparently none of the physical amenities associated with on-site attendance had any major clinical relevance.

When you get it published, I'd be interested in reading. Does your program do any longer-term follow-ups, either in-person or planning to look at it for the remote data?

 

[tr]

When you get it published, I'd be interested in reading. Does your program do any longer-term follow-ups, either in-person or planning to look at it for the remote data?

I can PM you when it's out. There isn't currently a plan or structure for obtaining long-term f/u but it's definitely something I'd like to work on setting up for the future.

 

[WisNeuro]

I can PM you when it's out. There isn't currently a plan or structure for obtaining long-term f/u but it's definitely something I'd like to work on setting up for the future.

Please do. And hopefully you can make the f/u collection feasible. It's something we don't do enough of in healthcare, but sorely needed.

 

[TheTruckGuy]

So, what about manipulative, cluster B types. Do you think you can get a gauge of that better in person, or about the same as over the phone? I feel like body language is huge for them. But for your average depression/anxiety patient it's probably not as big of a deal.

 

[WisNeuro]

So, what about manipulative, cluster B types. Do you think you can get a gauge of that better in person, or about the same as over the phone? I feel like body language is huge for them. But for your average depression/anxiety patient it's probably not as big of a deal.

Oh, you'll get enough of a feel of it with the communications that occur between sessions.

 

[PsyDr]

IME, telepsych misses the a significant portion of psychotherapy. Psychotherapy isn't just what happens in session. Patients have to consider that they have a problem that is significant enough to make some phone calls, set aside a weekly time, tell people in their life why they are missing for an hour a week, think about what they are going to say on the drive to the office, spend an hour, then think about that on the drive back, and think about how they would describe the session to others if asked.

And neuropsych is completely different without touching people.

But telepsych isn't going anywhere.

 

[MAClinician]

And now you can asses for Zoom Exhaustion and Fatigue

https://stanforduniversity.qualtrics.com/jfe/form/SV_5w2JruIAQzOgiTI