5.3  Lessons learned in the telepsychology transition

5.3.1  Presenting issues
Though we anticipated that patients would be primarily focused on COVID‐19 once we resumed services, many were ready to “get back to work” on their primary issues and were not as focused on the pandemic as we had been anticipating. For new referrals, however, a primary driver was often the current pandemic (anxiety, panic attacks, worry about COVID‐19 risk, etc.). Common stressors for our lower‐income patients included loss of employment, or being furloughed, and financial strain. The increased presence of children in the home was stressful for some families. Many of our patients also had chronic health conditions and had been worried about being more vulnerable to the worst COVID‐19 outcomes. In addition, some of our patients included those without consistent housing or food sources, and one reported being homeless and living out of their car. They worried about the risk of a total shutdown (e.g., not being allowed to be on the street at all, even in their car) and being unable to find shelter.
Even when working on the primary behavioral health issues that preceded the pandemic, there were new twists and problems that were exacerbated. Of significant concern was the exacerbation of intimate partner violence as a result of the additional risk factors associated with being unable to leave the home as often and increased stress. For our patients with substance use and depression particularly, discussing engaging in behavior substitutions and enjoyable or pleasurable activities was especially difficult with the stay‐at‐home orders. Individuals who were trying to quit smoking often found themselves returning to a higher level of smoking. Similarly, individuals who were working on a plan to lose weight by reducing calorie consumption and increasing exercise tended to have more difficulty adhering to those plans.
It became clear that our underserved patients with chronic conditions were being dissuaded by social distancing policies and the crisis mode of the medical community from having routine care visits with their physicians at their primary care clinics. Combined with the reduced availability of other safety‐net services in the community (e.g., social services, food banks), many of our patients began reporting a feeling that they had been left behind or deemed a lower priority during the pandemic. Our clinicians noted that patients often expressed relief and gratitude that we continued to be available for our usual level of services—and that we were even more accessible now that they did not need to travel to the appointment.
We found that a subset of patients actually preferred telepsychology services to the in‐person visits we had only formerly offered. That meant we were able to reach patients who had previously declined services because of transportation issues. One partner clinic, in particular, focuses on high utilizing patients who have a high number of chronic medical conditions (at least seven to qualify for the clinic). Our trainees at that clinic historically had trouble getting patients to come in for longer, behaviorally focused sessions, and no‐shows were common. After the shift to telepsychology, the number of appointments soared and no‐shows became a non‐issue. Similarly, another clinic where the physicians are very invested in making referrals to behavioral health saw an increase in the number of patients accepting referrals because the barriers became lower for attending these sessions. As a result of this lesson, we already plan greatly to increase our telepsychology offerings after the pandemic recedes. We have discussed how it is probably best to have the first session occur in person, where rapport can be built and assessment instruments can be easily filled out, and then offer to hold future session on the phone or videoconferencing.

5.3.2  Supervision
Supervision, which also shifted to strictly telephone or videoconferencing, also had to change substantially. One of the distinct advantages of integrated primary care is the efficiency of the real‐time formal and informal peer and team supervision that occurs for trainees. Clinicians often sit in the same space between patient visits and discuss patients among themselves, with the supervisor who is often present on site, and with the medical providers who also typically sit in the same space. The notes of new referrals are reviewed before the session and there is a discussion with members of the trainee's “support team” about what approach might be taken. Due to the norms of primary care, there is also the one‐of‐a‐kind opportunity to interrupt a session to step out for real‐time consultation with peers or other medical providers. All of the advantages were upended by the shift toward a virtual team with only videoconference contact with the supervisor and other peers and team members.
With trainees operating in more of a silo when delivering care, the antithesis of what is best about integrated care, we found a need for more supervisor time per trainee and case. We also adapted to this loss of team support by developing a parallel virtual team meeting before each shift. Trainees connected through Zoom videoconferencing for shift check‐ins at the beginning of each shift, discussing shift responsibilities (e.g., responding to clinic messages), and ensuring that we followed through with our commitments to each clinic.
Given that the effects of the pandemic were reaching everyone across the world, we knew that our own graduate student therapists might be experiencing their own challenges. Indeed, there was some initial anxiety about transitioning so quickly to telepsychology, but that anxiety was generally outweighed by the desire to provide services to our patients. One strategy, which we feel aided in the transition to telepsychology, was the gradual start‐up of graduate student therapists delivering telepsychology. We started with our most senior (fourth‐year) graduate students providing the initial telepsychology services and then started our more junior therapists. Our staggered training plan allowed the senior graduate student therapists to work through any wrinkles in the initial plan and to decrease their own anxiety around telepsychology before starting our more novice trainees. Additionally, it was helpful for our team to discuss the ways in which face‐to‐face and telepsychology provision of services are similar (e.g., teaching a new parenting skill and then having a caregiver brainstorm how they could use it at home).

5.3.3  Working with children and adolescents
Delivering telepsychology to a vulnerable population, such as children and adolescents, presented our team with a unique set of challenges, which compelled our pediatric behavioral health team to make a number of operational changes, adapting to the shifting service delivery landscape at our medical center. Our first steps in pediatrics were to check in with our medical team partners, to familiarize ourselves the new policies around pediatric well and sick visits, and to obtain their feedback on our tentative plan for telepsychology deployment. Generally, our plan was to offer telepsychology to families referred to us via their pediatrician, with an emphasis on prioritizing those presenting problems that have been a good fit for our behavioral health services thus far: adolescents and young adults with internalizing concerns (i.e., depression, anxiety) and children with home behavioral concerns. We hypothesized (and subsequently confirmed) that many of our patients' caregivers who had school‐related concerns would choose to pause their sessions with us, given the current school closures. For the time being, warm hand‐offs would be suspended as well. After conferring, our primary care psychology supervisors and medical team leaders (i.e., directors of the primary care clinics, nursing, and patient services) approved of the telepsychology plan to continue the provision of behavioral health services to pediatric patients and that we would check in regularly to discuss ongoing clinic needs and any feedback about the new pediatric primary care telepsychology services.
With the plan in place, we began to start the roll‐out of telepsychology services. Once their telepsychology training (detailed above) was complete, our graduate student therapists began calling all patients and their caregivers on our schedule for the upcoming week to inform them that we were moving to a telepsychology model of care during the pandemic and to gauge their interest in continuing care under this model. Many families were glad to hear from our team, but felt that behavioral health services for their child was no longer their top priority. Approximately half of our current patient load decided to continue care with us via telepsychology. Using a structured consent form, our team obtained and documented verbal informed consent to treat via telepsychology with these families. Thus, our pediatric primary care psychology team delivered telepsychology services to many of our teens with depression and/or anxiety, which for some, was exacerbated by the COVID‐19 pandemic and the social distancing and stay‐at‐home orders in our locale. Given the increased amount of time that caregivers and children were spending together due to school closings, many caregivers felt stressed and in need of stress management techniques and/or behavioral parent training. Our team also provided those therapeutic strategies via telepsychology. Additionally, while we had a very structured crisis management plan in place for any acute issues (e.g., suicidality), we have not yet had to use it. Communication with our medical colleagues went very well. We had some initial worries about not being colocated in the clinics during this time and losing some of the face‐to‐face time that had seemed vital to maintaining our presence as team members. However, communication via secure email as well as the electronic medical records were seamless as we all worked toward the common goal of providing good family‐centered care.
Despite our successes, there were some barriers to serving our pediatric families via telepsychology. For instance, as with our adult clinics, our patient load decreased, as many referrals were for school‐based concerns. Additionally, we were no longer obtaining referrals via warm hand‐offs. Also, there may have been some families who had other significant concerns (e.g., paying rent, losing their job, taking care of an ill family member). Given that our patient population is from the communities being hardest hit by COVID‐19 (i.e., low‐income, predominantly Black/African American families), it is no surprise to us that child behavioral health concerns were not at the top of the list of priorities for families.
Providing evidence‐based services via telepsychology through our pediatric clinics presented another challenge. It was difficult to have telepsychology sessions with caregivers who had young children, as those children were often in the room, making noise, needing their caregivers' attention. In clinic, we were able to have a graduate student therapist assist with childcare; that is not possible with telepsychology. Therefore, we are still navigating the best ways to provide telepsychology to parents who have more chaotic home environments (e.g., scheduling an appointment during a child's naptime).