In early March, because of the COVID-19 pandemic, thousands of skilled nursing facilities restricted access to residents. These restrictions included, but were not limited to, essential care providers, such as neuropsychologists and psychologists.

THE PROBLEM

For Executive Mental Health in Los Angeles, California, and the clients served by Executive Mental Health, these restrictions created two significant problems related to the continuation of patient care and the safety of clinicians and ancillary staff.

“With regard to patient care, Executive Mental Health primarily provides mental health care to skilled nursing facility residents, and that care was abruptly cut off,” said Dr. Ari D. Kalechstein, president and CEO of Executive Mental Health.

“That was problematic because 40%-60% of skilled nursing facility patients are diagnosed with a mental state condition, such as depression and/or anxiety. Moreover, these are statistics that were generated prior to the onset of COVID-19; hence, it would be reasonable to assume that the prevalence of mental state conditions was similar to or greater than these numbers after the onset of the pandemic.”

Without appropriate mental health interventions and given the facility restrictions that precluded patients from seeing loved ones and all of their usual healthcare providers, it is likely that at least a subset of these residents would experience a worsening of their mental state symptoms, he added.

“Another concern was related to the safety and concerns of Executive Mental Health staff,” he said. “They were fearful about exposure to COVID-19 and how Executive Mental Health and the facilities would create procedures that would protect them. In addition, and not surprisingly, the staff were worried that they might be laid off.”

"It’s important to note that, in addition to the creation of a tech-forward solution, the transition to a successful telehealth model was possible through the creation of a new position at Executive Mental Health – device technician."

Dr. Ari D. Kalechstein, Executive Mental Health

Taken together, and in just a matter of hours, the immediate mental healthcare needs of thousands were put on a backburner, awaiting a solution that did not involve in-person therapy. If Executive Mental Health was unable to deliver a solution that allowed its clinicians to provide care to patients, then likely more than 60% of its workforce would have been laid off.

“Very few if any skilled nursing facilities used telemedicine as a method for treating patients, citing a series of concerns, for example, poor connectivity, assumptions that patients would not benefit, and a concern that they could not support the equipment,” Kalechstein explained.

PROPOSAL

Given the need to adapt to shelter-in-place policies, Executive Mental Health was faced with the following challenges: How would it transition from a face-to-face model of care to a tech model? How would it use technology in a way that its partner facilities would understand and see how and why a tech model is integral to the provision of sound mental healthcare?

From Executive Mental Health’s perspective, Kalechstein said, the technology would need to:

• Support the patients: Provide quality, direct mental healthcare to residents who need it more than ever and ensure that uninterrupted mental healthcare remains an integral component of the treatment regimen at these facilities.
• Support the facilities: Reduce foot traffic and time spent in patient rooms, and lower the likelihood that Executive Mental Health clinicians would be vectors of disease transmission to facility workers/residents.
• Support the clinicians/company: Address clinicians’ fears of contracting the virus and/or spreading the virus and keep the entire team employed, with no layoffs.

MARKETPLACE

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MEETING THE CHALLENGE

Executive Mental Health used the following technology to meet the challenge of providing mental healthcare during the pandemic:

• Apple iPad series 7 with 9.8-inch screens were chosen for their durability, excellent screen resolution and size, 10-hour battery life and quick recharge, and for the ability to program for single-purpose use. Through Executive Mental Health’s relationship with an AT&T representative, the team was able to source more than 70 iPads despite product shortages.
• Portable stands that clamped the iPad into place, which enabled the iPads to be viewed without having patients hold them or drop them, and to reduce any chances of disease transmission.
• Doxy.me as HIPAA-compliant telehealth software for the provision of mental health services using Google Chrome, with FaceTime and Zoom used as backup video conferencing platforms. Signing on and connecting with the clinician via Doxy.me took two steps: Clicking the personal link provided and typing in the facility name. This allowed patients to meet with their clinician in less than a minute.
• Go Bulk 4 portable earphones were used for those patients whose hearing deficits/impairments affected their capacity to hear the words spoken by the clinician.

“It’s important to note that, in addition to the creation of a tech-forward solution, the transition to a successful telehealth model was possible through the creation of a new position at Executive Mental Health – device technician,” Kalechstein noted. “The device technician minimized the likelihood that the device would become a vector of disease transmission by ensuring that only the device technician touched the tablet.”

In addition, because Executive Mental Health sourced, hired and trained the device technicians, it effectively relieved the facilities of the burden of hiring and training additional employees when they already were managing staffing shortages, he added. Because the device technicians are crucial for the success of the Executive Mental Health telehealth program, the team created a device-technician training handbook.

RESULTS

The transition to telehealth continues to be a success: As of March 1, 2020, Executive Mental Health was providing no remote care, had not purchased any equipment to offer this service and had not conceptualized the logistics of delivering an effective telehealth model. In just three weeks, the team had set up the system protocol and launched it to more than 100 partner facilities. Other hard results from April to the end of August (five months) include:

• Physicians have conducted more than 14,000 telehealth sessions.
• Treatment providers have effectively achieved just under 90% levels of productivity compared to pre-COVID-19 baseline performance.
• Executive Mental Health has not laid off a single mental healthcare provider or ancillary staff member.
• In a survey carried out last month with partner facilities, more than 95% said they are very satisfied or satisfied with the care provided by their Executive Mental Health clinician.

“Executive Mental Health demonstrated the efficacy of this method for service provision,” Kalechstein stated. “At this time last year, we worked out a possible telehealth option that we would offer to remote facilities where staffing was proving difficult. While the COVID-19 pandemic has been a challenge on most every front, the benefit of overcoming these challenges has been the broad acceptance of telehealth as a viable option for providing mental healthcare.”

ADVICE FOR OTHERS

When implementing any telehealth solution, Kalechstein advised peers it would be prudent to consider the following points:

• When choosing the technology for a telehealth solution, consider the availability and cost. Additionally, and depending on demand, consider when the solution can scale effectively to meet demand.
• What resources and support are available from that device/software supplier? Will staff be able to handle all requests for troubleshooting?
• Are the devices/software HIPAA-compliant? While the rules have and continue to change, it is best to consider options that allow one to comply with whatever current regulations dictate.
• Create simple protocols that team members can follow at each stage of use. As one starts implementing this technology, ask for on-the-ground feedback and adapt protocols based on this.
• Remember to partner for success. Change is hard for most companies, which underscores the importance of communicating the what, why and how before the transition is implemented. Additionally, create an inclusive dialogue and keep the lines of communication open with staff and partner facilities. This way, the implementation is seen as a team effort rather than an imposed solution.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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