Kathleen T. McCoy, DNSc PMHNP-BC PMHCNS-BC FNP-BC FAANP, University of South Alabama, discusses the impact of the COVID-19 pandemic on quality of care and ability to perform mental health screenings, as well as appropriate uses and limitations to telehealth across practice settings.
Hi everyone. My name is Kathleen McCoy, and I am a Registered Nurse and licensed and certified Psychiatric Mental Health & Family Nurse Practitioner and Associate Professor at the University of South Alabama.
Like many of you, I’ve experienced the impact that the COVID-19 pandemic has had on how we deliver psychiatric mental health care to patients. At the beginning of the pandemic, practices had a rapid shift to telehealth over the course of just 2-3 weeks. Some of the dramatic changes we saw were: 1) On-site patient encounters were limited; 2) Patient encounters were no longer limited to on-site telehealth locations and 3) NP students could attain mandated face to face clinical experiences virtually in any appropriate setting rather than limited to on site encounters.
Now, more than a year later, it’s a good time for providers to take stock of the changes that have occurred to how we practice, whether that be in a primary care or psychiatric mental health care setting, and consider some of the better uses, and limitations, of virtual psychiatric mental health care.
First, let’s talk about the use of telehealth appointments in primary care or psychiatric mental health care settings. The last year has shown us that not all appointments need to be on-site. Patients who may benefit from improved access to care via telehealth include patients in rural or remote locations, those who lack access to transportation and would otherwise face barriers to attending appointments physically on-site, and those who prefer not being seen at a clinic for psychiatric mental health care and appreciate the anonymity of not attending physical appointments.
Provided patients have a smartphone or are digital savvy, telehealth appointments in these situations can work well on a variety of platforms. Before a virtual appointment happens, steps can be taken to help the process run smoothly. For example, at my practice, clinic staff work through troubleshooting connection issues and administrative work to help better prepare patients before their appointments.
There are challenges to address and expectations to be set ahead of virtual appointments versus in an on-site setting. You want to stress the importance of patients holding their appointment times. I try to always have an additional staff member on the line during appointments to intervene in a timely manner if patient safety is at stake or, more likely, to help manage connection issues. No matter what practice setting you’re in, virtual or in-person, it is important to be fully present with the patient. Make sure they know you’re there, you’re listening, and you’re going to do everything you can, even if there are connection issues, to help address their needs.
[02:41] In my experience, measurement-based care, in which validated clinical measurements are used to objectively assess symptoms, treatment, and clinical outcomes,1 still works well via virtual. Find what evidence-informed assessment screens work best for you and the patients, embed those in your electronic health records system, and use them as a norm in your practice.
Depending on your clinical site, it can be helpful to identify the population and risk factors that are common to the population you serve when determining which evidence-based screens you might want to use.
Screening in a virtual environment looks different across practice settings. In my practice, an additional staff member connects with a patient via telehealth before the appointment to complete screens before the patient is patched through to me. Most screens can be self-administered prior to encounters, using an iPad or paper version or emailing to the patient ahead of time in your practice can work.
[03:45] Now, there are certainly drawbacks to telehealth, and there are some things you just can’t do virtually. Distractions, technology issues, internet access, and bad weather all become factors that impact the quality of care your patient receives through telehealth.
An example of a technology flaw I’ve experienced is static on the call or a dropped call during a telehealth appointment. I confirm with the patient that I am listening and try to reconnect as soon as possible. Emergency plans for patients experiencing a psychiatric mental health episode need to be discussed beforehand if technical issues like this arise and can’t be addressed during appointments.
Privacy when patients are taking appointments at home with their families can also be a concern. Be sure patients know they need to assure privacy before connecting.
There are also limitations to the providers ability to engage and observe patients over video or phone that can impact ability to screen patients. I’ve found I must rely more heavily on a patient’s ability to communicate verbally about symptoms or treatment effects they may be experiencing. Body language and visual cues can be obstructed in a virtual setting.
[4:52] Based on what I’ve learned, here are my Top 5 Tips for practicing telehealth for psychiatric mental health:
1) Prepare patients for the encounter. Trial an encounter with staff for connectivity and linking to the established platform. We have found a mock trial encounter prepares all very well.
2) Have the patient self-administer screens prior to the encounter so all is ready for the start time. Adjust the appointment time to account for this.
3) Speak with patients about appropriate connectivity. They should be in a quiet setting, with privacy. Discourage calls from moving cars, public settings, and anywhere with background noise. Be advised that children and other family members being present can risk privacy violations, as sensitive information is expected to be discussed. For children, parents should be nearby, but privacy with the minor patient and provider should also be assured.
4) Patients should be in a setting where they can be visualized easily, with enough light to see the patient, and without hats or sunglasses if possible. This assists in connecting with the patient and the appropriate assessment of the patient.
5) Having another staff member join the appointment helps more with technical issues than anything else. Text messaging between the provider and staff can facilitate behind-the-scenes coordination to help move the encounter along in an unobtrusive manner. We always have a staff member as well as the patient and provider on every contact.
[06:21] Looking forward, as we start to have conversations around how we will practice in the long-term, there are questions about returning to in-person, on-site visits or taking a hybrid approach.
A good approach may be to triage patients to determine who needs to be seen in person on-site. Additionally, if all attempts to serve the patient with technology don’t work, we encourage patients to come in. In this regard, the adoption of telehealth has required a coordinated effort to plan and prioritize who can be a virtual appointment and who needs to come in on-site.
The COVID-19 pandemic has impacted the delivery of health care in a variety of ways, and the rapid transition to a virtual format has certainly been practice-changing. NPs touch patients in every setting and are very much at the forefront of what is happening. Capturing lessons from the last year, and honestly assessing what has worked and what hasn’t, will inform our approach moving forward to help improve screening and provide accurate diagnosis, as well as timely, high quality, and readily accessible care in any setting.
NP Psych Navigator is sponsored by AbbVie Inc. The contributor is a paid consultant for AbbVie Inc. and was compensated for her time.
The content presented here is provided for educational purposes only. It is not intended as, nor is it a substitute for medical care or advice. Healthcare professionals should use their clinical judgment when reviewing educational resources on NP Psych Navigator
- Aboraya A, Nasrallah HA, Elswick DE, et al. Innov Clin Neurosci. 2018;15(11-12):13–26.