This study reports on the quality of mental healthcare delivered to rural and urban Department of Veterans Affairs (VA) patients across COVID-19 pandemic. This is a retrospective study using VA medical records between 3/10/2019 and 9/22/2022. This study divided the COVID-19 pandemic into Eras based on significant historical events. Quality metrics represented core mental health services. Delivery modalities included on-site, telephone, and video. The study calculated the percentage of patients, by rural and urban strata, who met each quality metric throughout defined COVID Eras. This research used logistic regression to identify predictors of receiving quality mental healthcare. During the pre-COVID Era, primary care (PC) and mental health (MH) encounters using remote video were rare making up a fraction of all care (Rural PC = 0.1%, Urban PC = 0.1%; Rural MH = 0.2%, Urban MH = 0.3%). There was a dramatic increase in remote video encounters during the Early COVID Era, but urban patients experienced a much larger increase versus rural counterparts (Rural PC = 0.9%, Urban PC = 2.0%; Rural MH = 1.3%, Urban MH = 2.8%). The effect of COVID Eras on quality was mixed depending on the metric examined. Across all Eras, rural patients and patients receiving remote care only received substantially lower quality mental health care compared to urban patients and patients who received a combination of remote and on-site care. Overall, there were dramatic changes to service delivery modalities across the COVID-19 pandemic. Quality of mental health care remained persistently lower among rural patients.

Telepsychiatry presents a transformative opportunity to address Africa's significant mental health challenges. With a high prevalence of psychiatric disorders and limited access to care, particularly in rural and marginalized communities, innovative solutions are urgently needed. This paper has explored the potential of telepsychiatry to overcome geographical barriers and address the shortage of mental health professionals in Africa. Despite its potential, telepsychiatry faces challenges such as technological barriers, stigma, and regulatory issues. However, these challenges can be addressed with concerted efforts from governments, healthcare organizations, and communities. Developing robust regulatory frameworks, investing in infrastructure, and promoting cultural sensitivity are essential steps towards realizing the full potential of telepsychiatry in Africa. Looking to the future, telepsychiatry holds promise for revolutionizing mental healthcare delivery on the continent. Through continued research, evaluation, and innovation, telepsychiatry can become a cornerstone of mental healthcare provision, ensuring that no one is left behind in accessing the care they need.

Objective: This study examined behavioral health clinician perceptions at the beginning stages of the COVID-19 pandemic regarding their preparedness, training, and effectiveness in delivering telehealth to adults and adolescents in substance use and mental health settings. Methods: Data were collected through an anonymous online survey of 241 behavioral health practitioners in Pennsylvania from November 17, 2020, to January 3, 2021. Quantitative descriptive and qualitative analyses on survey results are presented. Results: Clinicians believed they were effective in their delivery of therapeutic services through telehealth modalities. However, they noted key training needs for delivering telehealth. Results indicate greater difficulty in delivering telehealth to adolescent clients and those with substance use. Practitioners indicate that telehealth allows greater access to treatment. Conclusions: Researchers recommend increasing training for practitioners and conducting training for patients. Policies should be reconsidered and address the changing landscape of behavioral health service provision.

Most individuals with disabilities live in low-and middle-income countries (LMICs) where healthcare services such as speech-language therapy are limited. The challenge of accessing services was compounded by the COVID-19 global pandemic, leaving many people who use augmentative and alternative communication (AAC) vulnerable. The aim of this study was to investigate the nature of tele-AAC across three LMICs as described by speech-language therapists (SLTs). Although studies have been published about speech-language therapy services provided via telepractice, some specifically on AAC services, none of these have examined the impact of having to rapidly pivot to tele-AAC in LMICs. Semi-structured interviews were conducted with 15 SLTs from three LMICs to explore their experiences. SLTs shared the impact that tele-AAC had on their work, their experiences, benefits and challenges including broader challenges of service provision in LMIC contexts.

Objectives: Telemental health via videoconferencing (TMH-V) can overcome many of the barriers to accessing quality mental health care. Toward this end, in 2011, the U.S. Department of Veterans Affairs (VA) established the National Bipolar Disorders TeleHealth (BDTH) Program to provide expert mental health consultation and treatment to Veterans with bipolar spectrum disorders. Methods: Initial analyses of BDTH services suggested that participants had positive changes in quality-of-care indices and clinical outcomes; however, that evaluation was based on a limited sample of both participants and VA medical centers. We were able to confirm and expand upon those early results by using nearly eight times the number of participants and more than twice as many medical centers. Results: For the 2,456 Veterans who completed the intake to our program, there were significant improvements in some of the quality metrics (e.g., lithium use) and a 54% reduction in positive suicide screens (p < 0.05). The Veterans who completed the initial and postprogram assessments (n = 815) reported a 16.6% reduction in manic symptoms (p < 0.001), a 29.3% reduction in depressive symptoms (p < 0.001), and a 21.2% reduction in mood episodes (p < 0.001). Additionally, these Veterans demonstrated significant improvements (p < 0.001) in mental health-related quality of life between the two assessments. Conclusions: These analyses provide further support for the general effectiveness and safety of telemental health via videoconferencing. Future research should examine the generalizability of these findings across various subgroups (e.g., minority patients, patients in rural areas), populations, and health care systems.

This cross-sectional study aimed to assess the demographic and geographic variations in the visit rate for first-episode psychosis (FEP), identify trends and diagnostic patterns, and explore factors associated with FEP visits in Nebraska. Inpatient and emergency department data spanning 2017-2021 were collected by the Nebraska Hospital Association (NHA). The study focused on Nebraska residents aged 14-35 admitted for FEP, identified through specific ICD-10 codes. The sample was derived using a multi-step process, and the data included patient demographics, Behavioral Health Regions, rural vs. urban residency, and neighborhood characteristics. Mann-Kendall tests were used to test for significant trends over time. T-tests and chi-squared tests were used to assess differences in each of the measures between patients with and without psychotic disorders. The study findings revealed a significant increase in visits related to psychotic disorders from 2017 to 2021. In 2021, the FEP visit rate was 116 per 100,000 individuals, varying considerably by age, gender, and Behavioral Health Region. Schizoaffective disorder bipolar type was the most frequent psychotic disorder. Patients with psychotic disorders tended to be older, predominantly male, and treated in acute care settings. The rising trend underlines the need for continued investment in early intervention programs and highlights challenges in rural areas, necessitating targeted interventions. The findings provide valuable insights to inform planning, advocate for funding, and address the specific needs of diverse populations. Future research should explore additional influencing factors and extend the study period to understand FEP trends comprehensively.

Suicide rates in rural areas are higher than urban areas and growing, with current treatment developments only exacerbating this discrepancy. Within individual factors, both age and gender relate to and intersect with personal values related to self-reliance and attitudes toward mental health difficulties and treatment to increase suicide risk. The lethality ubiquitous in rural environments and occupations is a leading factor in rural suicide rates, with other factors such as race alternately noted to be a key factor but with more mixed findings. The cultural values of rural communities as typically negative toward mental health disclosure and treatment contribute to the disengagement of rural communities from treatment that may otherwise prevent suicides, exacerbating the physical lack of treatment access many rural communities experience. Working within the primary care system alongside increased telehealth utilization are suggested to reduce rural suicide rates.

The opioid overdose crisis requires strengthening treatment systems with innovative technologies. How people use telehealth for opioid use disorder (OUD) is evolving and differs in rural versus urban areas, as telehealth is emerging as a local resource and complementary option to in-person treatment. We assessed changing trends in telehealth and medication for OUD (MOUD) and pinpoint locations of low telehealth and MOUD access.

We used national data from the Mental health and Addiction Treatment Tracking Repository (2016-2023) to identify specialty outpatient SUD treatment facilities in the United States (N = 83,988). We modeled the availability of telehealth using multilevel multivariable logistic regression, adjusting for covariates. We included a 3-way interaction to test for conditional effects of rurality, the number of MOUD medication types dispensed, and year. We included two random effects to account for clustering within counties and states.

We identified 495 facilities that offered both telehealth and all three MOUD medication types (methadone, buprenorphine, naltrexone) in 2023, clustered in the eastern United States. We identified a statistically significant 3-way interaction (p < 0.0001), indicating that telehealth in facilities that did not offer MOUD shifted from more telehealth in rural facilities in earlier years to more telehealth in urban facilities in later years.

Treatment facilities that offer both telehealth and all three MOUD medication types may improve access for hard-to-reach populations. We stress the importance of continued health system strengthening and technological resources in vulnerable rural communities, while acknowledging a changing landscape of increased OUD incidence and MOUD demand in urban communities.

Although telemental health can make suicide prevention treatments more scalable and accessible, limited evidence demonstrates successful reductions in suicidality when interventions are administered through telehealth platforms. To address this limitation, the current work investigated the effects of two suicide prevention treatments - a clinician-guided Crisis Response Plan and a self-guided Safety Planning approach.

After completing the screening process, 82 participants with high suicide ideation and/or a lifetime history of suicidal behavior were randomly assigned across the two groups. Trained research clinicians administered the interventions using a videoconferencing platform. After the intervention delivery was complete, participants reported the therapeutic alliance they experienced with their clinician using an online survey. Participants also reported their overall suicidality 45 days after receiving the intervention. In addition, participants' perceived usefulness of the received intervention and actual use of the plan were recorded. Linear and logistic regression models predicted how suicidality, perceived utility, and actual use of their intervention protocols varied depending on the high (Crisis Response Plan) versus low (self-guided Safety Planning) level of clinician-led collaboration the two treatments entailed.

Both Crisis Response Plan and self-guided Safety Planning were found to lower suicidality after receiving them via telehealth services. At the same time, those who received the Crisis Response Plan (the more collaborative form of therapy) reported experiencing a stronger therapeutic alliance with the clinician, utilizing the plan more often and perceiving it as more useful. These findings demonstrate the additional benefits of adopting a more collaborative approach because of its effectiveness and perceived utility, which has implications for suicide-related distress reduction in the short and long term.

Evidence from this randomized control trial suggests that Crisis Response Plan is a suitable candidate for delivering suicide prevention via telehealth platform because of its effectiveness in reducing suicidality and its collaborative approach to building a strong therapeutic alliance, perceived usefulness, and actual utility in everyday life.

This paper was part of a registered RCT: https://clinicaltrials.gov/study/NCT04888845 . Registration date: Date: 2021-04-22.

Military sexual trauma-related post-traumatic stress disorder (PTSD) is highly prevalent and costly among women veterans, making the need for effective and accessible treatment of critical importance. Access to care is a key mechanism of mental health disparities and might affect differential response to treatment. The goal of this study was to estimate an individualized treatment rule based on readily available individual characteristics related to access to care to optimize allocation to in-person vs. telehealth delivery of prolonged exposure for PTSD in military sexual trauma survivors. The following variables were used as prescriptive factors: age, race, disability status, socioeconomic status, rural vs. urban status, and baseline PTSD level. The rule was estimated using a machine-learning approach, Outcome Weighted Learning. The estimated optimal rule outperformed a one-size-fits-all rule where everyone is universally assigned to telehealth; it led to markedly lower mean PTSD levels following 6 months from treatment (Vdopt - VTelehealth = -14.55, 95% CI: -27.24, -1.86). However, the rule did not significantly discriminate for in-person therapy (Vdopt - VIn-person = -11.86, 95% CI: -25.83, 2.12). Upon further validation with larger and more diverse samples, such a rule may be applied in practice settings to aid clinical decision-making and personalization of treatment assignment.

Digital technology offers scalable, real-time interventions for mental health promotion and treatment. This systematic review explores the opportunities and challenges associated with the use of digital technology in mental health, with a focus on informing mental health system strengthening interventions in the United Arab Emirates (UAE). Following PRISMA guidelines, a systematic search of databases was conducted up to August 2023 and identified a total of 8479 citations of which 114 studies were included in the qualitative analysis. The included studies encompass diverse digital interventions, platforms, and modalities used across various mental health conditions. The review identifies feasible, acceptable, and efficacious interventions, ranging from telehealth and mobile apps to virtual reality and machine learning models. Opportunities for improving access to care, reducing patients' transfers, and utilizing real-world interaction data for symptom monitoring are highlighted. However, challenges such as digital exclusion, privacy concerns, and potential service replacement caution policymakers. This study serves as a valuable evidence base for policymakers and mental health stakeholders in the UAE to navigate the integration of digital technology in mental health services effectively.

There is limited research on the spatial distribution of eating disorders and the proximity to available eating disorder services. Therefore, this study investigates the distribution of eating disorders among adolescents and young adults in Ontario, Canada, with a specific focus on geographic disparities and access to publicly-funded specialized eating disorder services.

A community sample of 1,377 adolescents and young adults ages 16-30 across Ontario between November and December 2021 participated in this study and completed the Eating Disorder Examination Questionnaire. Utilizing Geographic Information System (GIS) technology, we mapped the geographic prevalence of eating disorders and examined proximity to specialized eating disorder services. Multiple linear and logistic regression analyses were utilized to determine the association between geographic region and eating disorder symptomatology. Additionally, t-tests were utilized to examine differences between time/distance to specialized services and clinical risk for eating disorders.

Applying geospatial analysis techniques, we detected significant spatial clusters denoting higher eating disorder scores in rural areas and areas with fewer specialized services. Likewise, our findings report disparities between rural and urban areas, suggesting that rural regions exhibit elevated rates of eating disorders. There were no associations between distance/time to services and eating disorder symptomology.

The discrepancies in eating disorder symptomology between urban/rural may stem from stigma and unique socio-cultural contexts in rural communities. The study underscores the need for targeted intervention, including telehealth, in addressing the eating disorder challenges faced by adolescents and young adults in rural regions.

The COVID-19 public health emergency (PHE) caused significant disruptions in the delivery of care, with in-person visits decreasing and telehealth use increasing. We investigated the impact of these changes on mental health services for Medicaid-enrolled adults and youth in Washington State. Among enrollees with existing mental health conditions, the first year of the PHE was associated with a surge in specialty outpatient mental health visits (13% higher for adults and 7% higher for youth), returning to pre-PHE levels in the second year. Conversely, youth with new mental health needs experienced a decline in specialty outpatient visit rates by ∼15% and 37% in the first and second years of the PHE, respectively. These findings indicate that while mental health service use was maintained or improved for established patients, these patterns did not extend to Medicaid-enrolled youth with new mental health needs, potentially due to barriers such as difficulty in finding providers and establishing new patient-provider relationships remotely. To bridge this gap, there is a need for a multi-faceted approach that includes improving service accessibility, enhancing provider availability, and optimizing initial care encounters, whether in-person or virtual, to better support new patients.

Background: Telemental health (TMH) offers a promising approach to managing major depressive disorder (MDD). The objective of our work was to evaluate TMH usage among a vulnerable population of MDD Medicare beneficiaries and its association with health care utilization and expenditures. Methods: This cohort study analyzed 2019 Mississippi Medicare fee-for-service data for adult beneficiaries with MDD. Subjects were matched by the use of TMH following 1:1 propensity score matching. Comparisons between TMH and non-TMH cohorts were made on health care utilization and expenditure outcomes, adjusting for provider types postmatching. Results: Among 7,673 identified beneficiaries, 551 used TMH and 7,122 did not. Prematching, TMH cohort showed greater proportions of dual beneficiaries, rural residents, subjects with income below $40,000, those with disability entitlement, and higher Charlson comorbidity index scores, compared to the non-TMH cohort (all p < 0.001). Moreover, the TMH cohort had fewer outpatient visits, but more inpatient admissions, emergency department (ED) visits, and higher medical, pharmacy, and total expenditures (all p < 0.001). Postmatching, TMH was associated with a 25% reduction in outpatient visits (p < 0.001) and a 20% reduction in pharmacy expenditures (p = 0.01), with no significant effect on inpatient admissions, ED visits, medical expenditures, or total expenditures. Conclusions: These results underscore the potential of TMH in enhancing accessible health care services for vulnerable populations and affordable services for Medicare. Our results provide a robust baseline for future policy discussions concerning TMH. Future studies should consider identifying barriers to TMH use among vulnerable populations and ensuring equitable and high-quality patient care.

The use of telehealth for mental health-related encounters has increased exponentially since the COVID-19 pandemic. However, little is known how nurse practitioners (NPs) in rural areas establish connection and presence with patients through telehealth.

To leverage web-camera eye-tracking technology coupled with qualitative interviews to better understand rural NPs' perceptions, beliefs, experiences, and visual cues of connection and presence during mental health-related telehealth encounters.

This mixed-methods study employed web-camera eye-tracking technology to measure eye contact, facial/body movements with microexpressions, and auditory expressions during a simulated mental health-related telehealth visit. A qualitative descriptive methodology was used to conduct semistructured interviews with participants regarding utilization of telehealth in rural mental health care delivery. Sticky software, R, and STATA were used for the quantitative eye-tracking and demographic data analyses. Qualitative findings were analyzed using inductive thematic analysis.

Ten NPs participated in the eye-tracking aspect of the study; among them, three completed semistructured interviews. Eye-tracking areas of interest were significant for the number of fixations ( p = .005); number of visits ( p < .001); time until notice ( p < .001); and time viewed ( p < .001). The category Workflow had the greatest number of thematic units ( n = 21) derived from semistructured interviews.

Although an accessible means of obtaining data, web-camera eye tracking poses challenges with data usability. This prompts further attention to research, optimizing the telehealth milieu to lessen patient and provider frustrations with technological or environmental issues.

Nurse practitioners provide a key voice in the design and deployment of telehealth platforms congruent with the comprehensive assessment and presence of remote care delivery.

Introduction As primary care practices transition to a post-pandemic system of healthcare, it is important to recognize the benefits of offering telehealth services. Little research is available on the effectiveness of telehealth visits for managing acute illnesses or conditions in primary care practice. Methods Using the reporting functionality in the Epic™ electronic health record (EHR) (Epic Systems Corporation, Verona), a report was generated to identify all telehealth visit encounters that were completed in a family medicine clinic from March 1, 2020, to June 30, 2020. The report identified patients who had an acute complaint and required an in-office visit within 60 days of the telehealth encounter. If the patient required a face-to-face visit, that was not directed by the provider, the chart was reviewed to determine whether the diagnosis changed. The primary outcome was returning for a face-to-face visit within 30 days of the telehealth visit for the same acute need. Results The cohort included 349 telehealth visits for 303 patients. For patients who had more than one telehealth visit, only the first one was included in the analysis. Among the 303 patients, 50 (16.5%) returned for a face-to-face visit within 30 days of the telehealth visit (95% confidence interval: 12.5%-21.2%), and 71 (23.6%) returned for a telehealth visit within 60 days (95% confidence interval: 18.9%-28.8%). Furthermore, 19 of the 50 patients (38%) that returned for a face-to-face visit did not have a change in diagnosis, and, in some instances, the diagnosis made on the telehealth visit was only slightly different from the face-to-face visit. Discussion and conclusion Telehealth, specifically two-way, synchronous, interactive patient-provider communication through audio and video equipment, for acute care needs in a primary care practice helps reduce the need for in-person visits and can address patient complaints without the need for in-person follow-up.

Utilization of telemedicine care for vulnerable and low income populations, especially individuals with mental health conditions, is not well understood. The goal is to describe the utilization and regional disparities of telehealth care by mental health status in Texas. Texas Medicaid claims data were analyzed from September 1, 2012, to August 31, 2018 for Medicaid patients enrolled due to a disability.

We analyzed the growth in telemedicine care based on urban, suburban, and rural, and mental health status. We used t-tests to test for differences in sociodemographic characteristics across patients and performed a three-way Analyses of Variance (ANOVA) to evaluate whether the growth rates from 2013 to 2018 were different based on geography and patient type. We then estimated patient level multivariable ordinary least square regression models to estimate the relationship between the use of telemedicine and patient characteristics in 2013 and separately in 2018. Outcome was a binary variable of telemedicine use or not. Independent variables of interest include geography, age, gender, race, ethnicity, plan type, Medicare eligibility, diagnosed mental health condition, and ECI score.

Overall, Medicaid patients with a telemedicine visit grew at 81%, with rural patients growing the fastest (181%). Patients with a telemedicine visit for a mental health condition grew by 77%. Telemedicine patients with mental health diagnoses tended to have 2 to 3 more visits per year compared to non-telemedicine patients with mental health diagnoses. In 2013, multivariable regressions display that urban and suburban patients, those that had a mental health diagnosis were more likely to use telemedicine, while patients that were younger, women, Hispanics, and those dual eligible were less likely to use telemedicine. By 2018, urban and suburban patients were less likely to use telemedicine.

Growth in telemedicine care was strong in urban and rural areas between 2013 and 2018 even before the COVID-19 pandemic. Those with a mental health condition who received telemedicine care had a higher number of total mental health visits compared to those without telemedicine care. These findings hold across all geographic groups and suggest that mental health telemedicine visits did not substitute for face-to-face mental health visits.

The number of clinics offering telemedicine in Japan has been increasing. Regional characteristics such as population density and the number of physicians may be associated with the provision of telemedicine. This study investigated the relationship between clinics offering telemedicine and such regional characteristics for each prefecture in Japan.

Data were collected from publicly available information that included the percentage of clinics offering telemedicine (real-time synchronous type) among all clinics (in 2022), population density, and the number of physicians for each of Japan's 47 prefectures. An ecological study was carried out to determine the correlation between the percentage of clinics offering telemedicine and regional characteristics for each prefecture, and Pearson correlation analysis and multiple regression analysis adjusted for regional characteristics were performed.

The min-max and mean levels were, respectively, 3.4-39.2% and 15.6% of clinics offering telemedicine, 66.6-6402.6 and 657.1 people per square kilometer of population density, and 185.2-356.7 and 274.0 physicians per 100,000 people. Geographically, the northeastern regions appeared to show a high percentage of clinics offering telemedicine relative to the southwestern regions. There was a significant negative correlation between the percentage of clinics offering telemedicine and population density (r = -0.31, p < 0.05; β = -0.31, p < 0.05).

The negative relationship of the provision of telemedicine in clinics with population density throughout Japan might be a reflection to ensure residents' access to clinics in less populated areas. Although further detailed studies are needed to confirm this, population density might be a useful measure for considering whether to offer telemedicine in clinics in Japan.

There is a paucity of population-level data on marijuana use and mental health and functioning in older adults.

We analyzed cross-sectional data (n = 910) from a well-characterized cohort, the Monongahela-Youghiogheny Healthy Aging Team (MYHAT) study. MYHAT is an age-stratified random sample of the population age 65 years and older from a small-town in the USA. Half the sample was female and half were over 75 (Mean age = 77). Most participants were non-Hispanic White. Marijuana use was assessed by self-report and symptoms of mood disorders were screened using the modified Centers for Epidemiological Studies-Depression Scale and the Generalized Anxiety Disorder screener. Cognition was assessed by the Mini-Mental State Examination and a neuropsychological test battery; functioning using the OARS Activities of Daily Living and Instrumental Activities of Daily Living; and overall assessment using the Clinical Dementia Rating (CDR®).

One in five MYHAT participants had a history of marijuana use and 5% reported recent use, primarily for pain (41%) and recreation/relaxation (37%). Recent use was associated with cigarette and alcohol use, symptoms of depression or anxiety, and impairments in attention.

Twenty-percent of community-dwelling older adults living in a US state where recreational marijuana use is illegal had a history of marijuana use. Recent marijuana use was less common but, consistent with prior research, associated with other substance use and poorer mental health.

Some policymakers are concerned that expanding telehealth coverage may increase Medicare expenditures. However, there is limited evidence on the association of telehealth use with utilization and spending among Medicare beneficiaries with major depression.

To examine the differences in spending and utilization among telemental health users and non-telemental health users with major depression.

We examined 2014-2019 traditional Medicare claims data for beneficiaries aged ≥50 years with major depression in Texas. Multivariable generalized linear models were used to assess the relationships between telemental health use and Medicare spending and utilization while adjusting for patient demographics and programmatic and clinical factors.

In each of the years between 2014 and 2019, an average of 4.6% Medicare beneficiaries with major depression had at least 1 telemental health visit. Compared with beneficiaries without a telemental health visit, those who had a telemental health visit were significantly more likely to be enrolled in Medicaid, be Medicare eligible due to a disability, live in a lower income area or in a rural area, and have a higher comorbidity index. Beneficiaries utilizing telemental health services incurred higher unadjusted Medicare spending than those not receiving telemental health services. However, this difference appeared due to beneficiary and programmatic characteristics rather than telemental health use. Adjusting for model covariates, the telemental health group had lower overall per member per year predicted spending, inpatient admissions, and emergency department visits than non-telemental health users.

Our findings suggest that telemental health care use may improve access to mental health care without increasing Medicare spending among telemental health users in Texas.

Mental health is a significant public health challenge globally, and one anticipated to increase following the COVID-19 pandemic. In many rural regions of developing nations, little is known about the prevalence of mental health conditions and factors that may help mitigate poor outcomes. This study assessed the impact of the COVID-19 pandemic on mental health and social support for residents of rural Haiti. Data were collected from March to May 2020. The Patient Health Questionnaire subscales for anxiety and depression, and the Perceived Stress Scale were utilized in addition to tailored questions specific to COVID-19 knowledge. Half (51.8%) of the 500 survey respondents reported COVID-19-related anxiety and worrying either daily or across a few days. Half (50.2%) also reported experiencing depression daily or across several days. Most (70.4%) did not have any social support, and 28.0% experienced some stress, with 13.4% indicating high perceived stress. Furthermore, 4.6% had suitable plumbing systems in their homes. The results were immediately actionable, informing the implementation of a mental health counseling program for youth following a loss of social support through school closures. Long-term investments must be made as part of public health responses in rural communities in developing nations, which remain under-studied.

The COVID-19 public health emergency (PHE) led to increased mental health (MH) concerns among Medicare beneficiaries while inhibiting their access to MH services (MHS). To help address these problems, the federal government introduced temporary flexibilities permitting broader telehealth use in Medicare. This study compared rural versus urban patterns of change in telemental health (TMH) use among adult MHS users in fee-for-service Medicare from 2019 to 2020, when PHE-related telehealth expansions were enacted.

In this cross-sectional investigation based on 2019-2020 Medicare claims data, we used chi-square tests, t-tests and adjusted logistic regression to explore how year (pre-PHE vs. PHE), rurality, and beneficiary characteristics were related to TMH use.

From 2019 to 2020, the proportion of MHS users who used TMH rose from 4.8% to 51.9% among rural residents (p < 0.0001) and from 1.1% to 61.3% (p < 0.0001) among urban residents. Across study years, adjusted odds of TMH use grew more than 18-fold for rural MHS users (OR = 18.10, p < 0.001) and nearly 120-fold for their urban counterparts (OR = 119.75, p < 0.001). Among rural MHS users in 2020, adjusted odds of TMH use diminished with increasing age.

TMH mitigated PHE-related barriers to MHS access for rural and urban beneficiaries, but urban residents benefited disproportionately. Among rural beneficiaries, older age was related to lower TMH use. To avoid reinforcing existing MHS access disparities, policies must address factors limiting TMH use among rural beneficiaries, especially those over 75 and those from historically underserved communities.

This study investigated how mental health providers' use of telemedicine has changed since the coronavirus disease (COVID) 2019 pandemic and their expectations for continuing to use it once the pandemic ends.

A 15-min online survey was completed by 175 practicing and licensed telemental health providers who use telemedicine. In addition to personal and professional demographic items, the survey included items about the frequency of telemedicine use, proportion of caseload served by telemedicine, comfort using telemedicine before and during the COVID-19 pandemic, and expectations to use telemedicine after the pandemic ends. A series of χ2 analyses, an independent samples t-test, and analyses of variance were conducted.

The pandemic resulted in a greater proportion of telemental health providers using telemedicine on a daily basis (17% before and 40% during the pandemic; p < 0.01) and serving more than half of their caseload remotely (9.1% before and 57.7% during the pandemic; p < 0.05). Also, there was a statistically significant increase in their comfort using telemedicine before and during the pandemic (p < 0.001). Providers reported expecting to use telemedicine more often after the pandemic ends (M = 3.35; SD = 0.99). Expectations to provide telemental health services after the pandemic were greater for mental health counselors, providers who practiced in rural regions, and providers who served patients through out-of-pocket payments.

Telemental health providers use telemedicine daily as a result of the COVID-19 pandemic, with expectations of continuing to use telemedicine in practice after the pandemic. This expectation is more prominent in certain segments of providers and warrants further investigation.

Rural residents face significant barriers in accessing mental health care, particularly as the demand for such services grows. Telemedicine has been proposed as an answer to rural gaps, but this service requires both access to appropriate technology and private space in the home to be useful. Our study documented longer travel time to mental health facilities in rural areas and greater barriers to digital devices for telemedicine access in those same areas. However, urban areas demonstrated greater household crowdedness than rural noncore areas when looking at private space within the home. Across ZIP Code Tabulation Areas located more than an estimated 30 minutes from the nearest outpatient care, 675 950 (13.1%) rural households vs 329 950 (6.4%) urban households had no broadband internet. The current Affordable Connectivity Program should target mental health-underserved communities, especially in rural America, where the scarcity of digital access compounds travel burdens to mental health care.

We sought to investigate temporal trends in telehealth availability among outpatient mental health treatment facilities and differences in the pace of telehealth growth by state urbanicity and rurality. We used the National Mental Health Services Survey (2015-2020) to identify outpatient mental health treatment facilities in the US (N = 28,989 facilities; 2015 n = 5,018; 2020 n = 4,889). We used logistic regression to model telehealth, predicted by time, state rurality (1 to 10% rural, 10 to < 20%, 20 to < 30%, or [Formula: see text] 30%), and their interaction, and adjusted for relevant covariates. We estimated the predicted probability of telehealth based on our model. We estimated effects with and without data from 2020 to assess whether the rapid and widespread adoption of telehealth during the COVID-19 pandemic changed the rural/urban trajectories of telehealth availability. We found that telehealth grew fastest in more urban states (year*rurality interaction p < 0.0001). Between 2015 and 2020, the predicted probability of telehealth in more urban states increased by 51 percentage points (from 9 to 61%), whereas telehealth in more rural states increased by 38 percentage points (from 23 to 61%). Predicted telehealth also varied widely by state, ranging from more than 75% of facilities (RI, OR) to below 20% (VT, KY). Health systems and new technological innovations must consider the unique challenges faced by urban populations and how best practices may be adapted to meet the growing urban demand. We framed our findings around the need for policies that minimize barriers to telehealth.

Objective: We sought to characterize patterns of utilization of telemental health among commercially insured individuals over the decade preceding COVID-19.

Methods: We developed telemental health service groups from the US PharMetrics Plus database, using diagnostic codes to identify those diagnosed with mental health conditions and procedure codes to capture mental health visits delivered via telehealth sessions. We analyzed 2 indicators of utilization between January 1, 2010, and December 31, 2019: (1) the percentage of patients with mental health needs who used telemental health services and (2) the percentage of all mental health services provided via telehealth. We stratified our analyses by year, patient gender, patient age, and geographic region.

Results: The proportion of mental health visits delivered via telemental health increased from 0.002% to 0.162% between 2010 and 2019. A larger proportion of males received telemental health services as compared to females; however, the proportion of mental health visits delivered via telehealth was higher for females than for males. Patients aged 18 to 34 years and those in the western US had the highest utilization compared to other age groups and geographic regions.

Conclusions: Telemental health utilization comprised a small fraction of overall mental health services and beneficiaries in the IQVIA PharMetrics Plus claims data, but increased over time, with differences documented in utilization based on patient gender, patient age, geographic region, and type of telemental health claim. Evidence from this study may serve as a pre-pandemic baseline for comparison against future evaluations of telehealth expansion policies.

Introduction: Telepsychiatry consultation for rural providers may help address local staffing needs while ensuring timely and appropriate care from behavioral health experts. The purpose of this study was to assess the implementation of a telepsychiatry consultation service within medical and psychiatry inpatient units of hospitals serving predominantly rural areas. Methods: A mixed-methods study with qualitative interviews of site personnel and quantitative assessment of electronic health record data was conducted across 6 facilities in 3 U.S. states between June 2019 and May 2021. We interviewed 15 health care professionals 6 months after telepsychiatry was implemented, and we identified emerging themes related to the inpatient telepsychiatry service implementation and utilization through an inductive qualitative analysis approach. We then applied the themes emerging from this study to existing implementation science theoretical frameworks. Results: Telepsychiatry consultation was utilized for 437 medical inpatient cases and 531 psychiatric inpatient units. Average encounters by site ranged from 1 to 20 per month. The three main domains from the qualitative assessment included the impact on the care process (the partnership between inpatient units and the telehealth hub, and logistical dynamics), the care provider (resource availability in inpatient units and changes in inpatient units' capability), and the patient (impact on patient safety and care). Discussion: Implementation of a telepsychiatry service in the inpatient setting holds the promise of being beneficial to the patient, local hospital, and the rural community. In this study, we found that implementing this telepsychiatry service improved the clinical care processes, while addressing both the providers' and patients' needs.

During the COVID-19 pandemic, the rapid scaling of telehealth limited the extent to which proactive planning for equitable implementation was possible. The deployment of telehealth will persist in the postpandemic era, given patient preferences, advances in technologies, growing acceptance of telehealth, and the potential to overcome barriers to serve populations with limited access to high-quality in-person care. However, aspects and unintended consequences of telehealth may leave some groups underserved or unserved, and corrective implementation plans that address equitable access will be needed. The purposes of this paper are to (1) describe equitable implementation in telehealth and (2) integrate an equity lens into actionable equitable implementation.

Telemedicine can increase access to care, but uptake has been low among people living in rural areas. The Veterans Health Administration initially encouraged telemedicine uptake in rural areas, but telemedicine expansion efforts have broadened since the COVID-19 pandemic.

To examine changes over time in rural-urban differences in telemedicine use for primary care and for mental health integration services among Veterans Affairs (VA) beneficiaries.

This cohort study examined 63.5 million primary care and 3.6 million mental health integration visits across 138 VA health care systems nationally from March 16, 2019, to December 15, 2021. Statistical analysis took place from December 2021 to January 2023.

Health care systems with most clinic locations designated as rural.

For every system, monthly visit counts for primary care and mental health integration specialties were aggregated from 12 months before to 21 months after pandemic onset. Visits were categorized as in person or telemedicine, including video. A difference-in-difference approach was used to examine associations in visit modality by health care system rurality and pandemic onset. Regression models also adjusted for health care system size as well as relevant patient characteristics (eg, demographic characteristics, comorbidities, broadband internet access, and tablet access).

The study included 63 541 577 primary care visits (6 313 349 unique patients) and 3 621 653 mental health integration visits (972 578 unique patients) (6 329 124 unique patients among the cohort; mean [SD] age, 61.4 [17.1] years; 5 730 747 men [90.5%]; 1 091 241 non-Hispanic Black patients [17.2%]; and 4 198 777 non-Hispanic White patients [66.3%]). In fully adjusted models for primary care services before the pandemic, rural VA health care systems had higher proportions of telemedicine use than urban ones (34% [95% CI, 30%-38%] vs 29% [95% CI, 27%-32%]) but lower proportions of telemedicine use than urban health care systems after pandemic onset (55% [95% CI, 50%-59%] vs 60% [95% CI, 58%-62%]), signifying a 36% reduction in the odds of telemedicine use (odds ratio [OR], 0.64; 95% CI, 0.54-0.76). The rural-urban telemedicine gap was even larger for mental health integration (OR, 0.49; 95% CI, 0.35-0.67) than for primary care services. Few video visits occurred across rural and urban health care systems (unadjusted percentages: before the pandemic, 2% vs 1%; after the pandemic, 4% vs 8%). Nonetheless, there were rural-urban divides for video visits in both primary care (OR, 0.28; 95% CI, 0.19-0.40) and mental health integration services (OR, 0.34; 95% CI, 0.21-0.56).

This study suggests that, despite initial telemedicine gains at rural VA health care sites, the pandemic was associated with an increase in the rural-urban telemedicine divide across the VA health care system. To ensure equitable access to care, the VA health care system's coordinated telemedicine response may benefit from addressing rural disparities in structural capacity (eg, internet bandwidth) and from tailoring technology to encourage adoption among rural users.

The purpose of this study was to examine geographic variation in the availability of and barriers to school-based mental health services.

A weighted, nationally representative sample of U.S. public schools from the 2017-2018 School Survey on Crime and Safety was used. Schools reported the provision of diagnostic mental health assessments and/or treatment as well as factors that limited the provision of mental health services. Availability of mental health services and factors limiting service provision were examined across rurality, adjusting for school enrollment and grade level. The analysis was conducted in December 2021.

Half (51.2%) of schools reported providing mental health assessments, and 38.3% reported providing treatment. After adjusting for enrollment and grade level, rural schools were 19% less likely, town schools were 21% less likely, and suburban schools were 11% less likely to report providing mental health assessments than city schools. Only suburban schools were less likely than city schools to provide mental health treatment (incidence rate ratio=0.85; 95% CI=0.72, 1.00). Factors limiting the provision of services included inadequate access to professionals (70.9%) and inadequate funding (77.0%), which were most common among rural schools.

Significant inequities in school-based mental health services exist outside of urban areas.

As telebehavioral health continues to advance and become part of routine care, there is a need to develop effective training methods. While a consensus on how to best train telebehavioral health has not yet been achieved, this commentary will describe how evidence-based implementation strategies were used to develop a framework to create and implement a telebehavioral health training program that is relevant and enduring for a given audience. Evidence-based implementation strategies included the PARiHS criteria which were used to organize the project. Re-AIM criteria was used to organize chosen outcome measures. Important partnerships were formed to help support infrastructure as well as regional and national reach. A series of Plan-Do-Study-Act loops were used to inform progressive training series. Since April 2020, the Behavioral Health Institute has developed and offered 6 unique telebehavioral health training series, employing both webinar and online formats, and addressing core components as well as more advanced concepts. These series have provided over 19,100 accredited continuing education hours of training through June 2022, to almost 3000 unique learners via webinar and nearly 6800 unique online learners, across 45 states. Evaluations rated these trainings as high quality, relevant, and that material would likely be implemented. Feedback from attendees was considered vital in series planning. This commentary discusses how evidence-based implementation strategies can be used to create a framework upon which to base a training program for health care providers. An example is given on how this framework was used to create successful, relevant, and enduring telebehavioral health training.

Telehealth is the use of electronic information and telecommunication technologies to provide care when the patient and the provider are not in the same room at the same time. Telehealth accounted for less than 1% of all Medicare Fee-for-Service outpatient visits in the United States in 2019 but grew to account for 46% of all visits in April 2020. Changes in reimbursement and licensure policies during the COVID-19 pandemic appeared to greatly facilitate this increased use. Telehealth will continue to account for a substantial portion of care provided in the United States and globally. A better understanding of telehealth approaches and their evidence base by public health practitioners may help improve their ability to collaborate with health care organizations to improve population health. The article summarizes the Centers for Disease Control and Prevention's (CDC's) approach to understanding the evidence base for telehealth in public health practice, possible applications for telehealth in public health practice, and CDC's use of telehealth to improve population health.

The goal of this paper is to provide a comparative review of using phone (audio-only) or video for mental health treatments. Our review includes evidence of phone and video's effectiveness in terms of reduced symptomology, retention, satisfaction, therapeutic alliance, and other outcomes of interest. This review also discusses how patients and providers' experiences and attitudes differ between these two modalities. Finally, we present information on different usage rates of phone and video across patient populations and mental health provider types, and different implementation strategies.

Treatments through phone and video are both able to reduce symptoms related to mental health conditions and have both been found to be non-inferior to in-person care. Both phone and video are more convenient to patients. Video offers important visual information that can be important to diagnosing mental health conditions. Phone, however, is more broadly accessible and may come with fewer technological issues. In the context of mental health care, where non-verbal cues are tied to symptomology and diagnosing, and a strong relationship between patient and provider can enhance treatment, we encourage the use of video, especially for psychotherapeutic services. However, as phone is more accessible, we ultimately recommend an accommodating approach, one that flexibly makes use of both phone and video. Future studies on telehealth should focus on direct, head-to-head comparisons between phone and video and conduct more rigorous testing on whether clinical differences exist.

Early in the COVID-19 pandemic, states implemented temporary changes allowing physicians without a license in their state to provide care to their residents. There is an ongoing debate at both the federal and state levels on whether to change licensure rules permanently to facilitate out-of-state telemedicine use.

To describe out-of-state telemedicine use during the pandemic.

This cross-sectional study of telemedicine visits included all patients with traditional Medicare from January through June 2021.

Telemedicine visits from January through June 2021 where the patient's home address and the physician's practice address were in different states.

In describing which patients and specialties were using out-of-state telemedicine, we focused on the period between January to June 2021. We chose this period because it was after the turmoil of the early pandemic, when vaccines became widely available and the health care system had stabilized, but before many of the temporary licensing regulations began to lapse by mid-2021. In the first half of 2021, there were 8 392 092 patients with a telemedicine visit and, of these, 422 547 (5.0%) had 1 or more out-of-state telemedicine visits. Those who lived in a county close to a state border (within 15 miles) accounted for 57.2% of all out-of-state telemedicine visits. Among the out-of-state visits in this time period, 64.3% were with a primary care or mental health clinician. For 62.6% of all out-of-state visits, a prior in-person visit occurred between the same patient and clinician between March 2019 and the visit. The demographics and conditions treated were similar for within-state and out-of-state telemedicine visits, with several notable exceptions. Among those with a telemedicine visit, people in rural communities were more likely to receive out-of-state telemedicine care (33.8% vs 21.0%), and there was high of out-of-state telemedicine use for cancer care (9.8% of all telemedicine visits for cancer care).

The findings of this cross-sectional study suggest that licensure restrictions of out-of-state telemedicine would have had the largest effect on patients who lived near a state border, those in rural locales, and those who received primary care or mental health treatment.

Throughout the COVID-19 pandemic, there has been increased interest in telehealth as a means of providing care for depression. In this article, we provide an overview of telehealth utilization for the treatment of depression and provide some insight into the rapid shift made to quickly implement these telehealth services into our everyday practices due to COVID-19 personal distancing requirements. We review the application of telehealth in the treatment of depression during the COVID-19 pandemic. The multiple advantages and disadvantages of telehealth in treatment of depression are summarized through the literature, and we analyze the methods to improve the effect and quality of telehealth in depression treatment. It has been highlighted in the current research that against its proven capacity for convenience, its relative cheapness, and its ability to overcome geographic barriers, telehealth has its own shortfalls, including disparities in rural-urban infrastructure and an alleged inability to be exhaustive when intensive interventions are needed. Recommendations for the improvement of telehealth during the COVID-19 pandemic also presuppose that it is infrastructure and human resource intensive and that short-term improvements in its efficiency are largely dependent on the creativity and resourcefulness of physicians to provide custom solutions for patients.

The coronavirus disease 2019 pandemic has contributed to growing demand for mental health services, but patients face significant barriers to accessing care. Direct-to-consumer(DTC) telemedicine has been proposed as one way to increase access, yet little is known about its pre-pandemic use for mental healthcare.

To characterize patients, providers, and their use of a large nationwide DTC telemedicine platform for mental healthcare.

Retrospective cross-sectional study.

Mental health encounters conducted on the American Well DTC telemedicine platform from 2016 to 2018.

Patients and physicians.

Patient measures included demographics, insurance report, and number of visits. Provider characteristics included specialty, region, and number of encounters. Encounter measures included wait time, visit length and timing, out-of-pocket payment, coupon use, prescription outcome, referral receipt, where care otherwise would have been sought, and patient satisfaction. Factors associated with five-star physician ratings and prescription receipt were assessed using logistic regression.

We analyzed 19,270 mental health encounters between 6708 patients and 1045 providers. Visits were most frequently for anxiety (39.1%) or depression (32.5%), with high satisfaction (4.9/5) across conditions. Patients had a median 2.0 visits for psychiatry (IQR 1.0-3.0) and therapy (IQR 1.0-5.0), compared to 1.0 visit (IQR 1.0-1.0) for urgent care. High satisfaction was positively correlated with prescription receipt (OR 1.89, 95% CI 1.54-2.32) and after-hours timing (aOR 1.18, 95% CI 1.02-1.36). Prescription rates ranged from 79.6% for depression to 32.2% for substance use disorders. Prescription receipt was associated with increased visit frequency (aOR 1.95, 95% CI 1.57-2.42 for ≥ 3 visits).

As the burden of psychiatric disease grows, DTC telemedicine offers one solution for extending access to mental healthcare. While most encounters were one-off, evidence of some continuity in psychiatry and therapy visits-as well as overall high patient satisfaction-suggests potential for broader DTC telemental health use.

Access to specialty mental health care remains challenging for people with serious mental illnesses, such as schizophrenia and bipolar disorder. Whether expansion of telemedicine is associated with improved access and quality of care for these patients is unclear.

To assess whether greater telemedicine use in a nonmetropolitan county is associated with quality measures, including use of specialty mental health care and medication adherence.

In this cohort study, the variable uptake of telemental health visits was examined across a national sample of fee-for-service claims from Medicare beneficiaries in 2916 nonmetropolitan counties between January 1, 2010, and December 31, 2018. Beneficiaries with schizophrenia and related psychotic disorders and/or bipolar I disorder during the study period were included. For each year of the study, each county was categorized based on per capita telemental health service use (none, low, moderate, and high). The association between telemental health service use in the county and quality measures was tested using a multivariate model controlling for both patient characteristics and county fixed effects. Analyses were conducted from January 1 to April 11, 2022. Before the COVID-19 pandemic, telemedicine reimbursement was limited to nonmetropolitan beneficiaries.

Receipt of a minimum of 2 specialty mental health service visits (telemedicine or in-person) in the year, number of months per year with medication, hospitalization rate, and outpatient follow-up visits after a mental health hospitalization in a year.

In 2018, there were 2916 counties with 118 170 patients (77 068 [65.2%] men; mean [SD] age, 58.3 [15.6] years) in the sample. The fraction of counties that had high telemental health service use increased from 2% in 2010 to 17% in 2018. In 2018 there were 1.08 telemental health service visits per patient in the high telemental health counties. Compared with no telemental health care in the county, patients in high-use counties were 1.2 percentage points (95% CI, 0.81-1.60 percentage points) (8.0% relative increase) more likely to have a minimum number of specialty mental health service visits, 13.7 percentage points (95% CI, 5.1-22.3 percentage points) (6.5% relative increase) more likely to have outpatient follow-up within 7 days of a mental health hospitalization, and 0.47 percentage points (95% CI, 0.25-0.69 percentage points) (7.6% relative increase) more likely to be hospitalized in a year. Telemental health service use was not associated with changes in medication adherence.

The findings of this study suggest that greater use of telemental health visits in a county was associated with modest increases in contact with outpatient specialty mental health care professionals and greater likelihood of follow-up after hospitalization. No substantive changes in medication adherence were noted and an increase in mental health hospitalizations occurred.

Because of limited access to psychiatrists, patients with acute mental illness in some emergency departments (EDs) may wait days for a consultation in the ED or as a medical-surgical admission. The study assessed whether telepsychiatry improves access to care and decreases ED wait times and hospital admissions.

ED visits with a primary diagnosis of mental illness were identified from 2010-2018 Medicare claims. A total of 134 EDs across 22 states that implemented telepsychiatry between 2013 and 2016 were matched 1:1 with control EDs without telepsychiatry on several characteristics, including availability of in-person psychiatrist consultations. Outcomes included patients' likelihood of admission to a medical-surgical or psychiatric bed, mental illness spending, prolonged ED length of stay (LOS) (two or more midnights in the ED), 90-day mortality, and outpatient follow-up care. Using a difference-in-difference design, changes in outcomes between the 3 years before telepsychiatry adoption and the 2 years after were examined.

There were 172,708 ED mental illness visits across the 134 matched ED pairs in the study period. Telepsychiatry adoption was associated with increased admissions to a psychiatric bed (differential increase, 4.3 percentage points; p<0.001), decreased admissions to a medical-surgical bed (differential decrease, 2.0 percentage points; p<0.001), increased likelihood of a prolonged ED LOS (differential increase, 3.0 percentage points; p<0.001), and increased mental illness spending (differential increase, $292; p<0.01).

Telepsychiatry adoption was associated with a lower likelihood of admission to a medical-surgical bed but an increased likelihood of admission to a psychiatric bed and a prolonged ED LOS.

A statewide COVID-19 quarantine order forced an abrupt shift for Louisiana's behavioral health providers who provide mental health and substance abuse treatment services. The Center for Evidence to Practice conducted a study of this unprecedented shift to better understand the disruption and continuation of care during early statewide adoption of telemental health. The Center performed a mixed-method assessment including a series of focus groups and key informant interviews followed by a survey of over 300 responding providers. Over 85% of providers reported sustaining behavioral health services using a variety of telemental health strategies. While traditional referral networks and client volume were significantly disrupted, temporary relaxation of Medicaid regulatory and reimbursement policies appeared to be a key facilitator of telemental health adoption and continued services. Shifting to telemental health relied on provider's quick adaptations, engaging clients with a hybrid of teleconferencing platforms, calls/texts, and socially-distanced in-person visits. Larger multi-clinician providers and evidence-based practice (EBP) providers were better equipped to support the adoption of telemental health. Rural and EBPs providers disproportionately discontinued services. Although many practitioners viewed the original COVID-19 pandemic as a short-lived condition, the recent emergence of Delta and other variants has shown the impact on the BH care system may be lasting. Flexibility across policies and a variety of telemental health platforms are keys to telehealth adaptation. However, the contraction of the client base raises concerns of increasing disparities among vulnerable and hard-to-reach populations if telemental health becomes a sustained approach in response to future COVID-19 variants.

Advance practice registered nurses (APRNs) play an increased role in mental illness treatment. Health services research that uses claims to study mental health is often limited because behavioral health nurse practitioners (i.e., APRNs who specialize in mental illness also known as psychiatric mental health APRNs) cannot be easily identified in claims data. We describe a methodology to identify behavioral health APRNs in administrative claims. DATA SOURCES/STUDY SETTING (W/ HOSPITAL/INSTITUTION SETTING ANONYMIZED): We use 2010-2018 claims from the traditional Medicare fee-for-service program along with 2010-2019 commercial claims and Medicare Advantage data from the OptumLabs® Data Warehouse (OLDW). Self-reported specialty data from the National Plan & Provider Enumeration System (NPPES) were used for validation.

For each APRN, we calculated the percentage of visit diagnoses and of prescriptions in each database that were for mental health and classified those with ≥80% as behavioral health APRNs. We validated our definition with NPPES self-reported specialty for Medicare data.

Not applicable.

Among APRNs with 10+ visits, 10,978 (8.1%) in Medicare and 9829 (11.7%) in commercial claims data met our visit-based criteria as behavioral health APRNs. Among APRNs with 10+ prescriptions, 8160 (6.2%) in Medicare and 16,538 (9.0%) in commercial claims data met our prescription-based criteria as behavioral health APRNs. Among the APRNs who self-reported they were behavioral health APRNs, 92.8% and 90.5% met our visit-based and prescription-based criteria respectively.

We present and validate two methods of identifying behavioral health APRNs in claims that can be used by other researchers.

Despite the growth of palliative care (PC), access to PC remains challenging for rural Americans living with chronic diseases. Given the demand and benefits of PC, a comprehensive view of PC access would inform policymakers in developing PC services in rural areas.

This scoping review aimed to understand the barriers and facilitators to PC access in rural areas from the voices of service users and service providers during the past decade.

A scoping literature review was conducted from 2010 to 2020 using MEDLINE, CINAHL, and PsychINFO databases. Results: Twenty-eight studies met inclusion criteria. Barriers to PC access in rural areas mostly arose in structural issues: (1) the inadequate knowledge and awareness of PC among both service users and providers and (2) the poorly structured PC system. Other barriers included communication gaps/challenges between providers and patients/families and cultural barriers. The facilitators mainly originated in patients/families' connectedness with local providers and with other social networks such as friends.

These findings highlight the need for funding support to increase provider competency, service availability and accessibility, and the public knowledge and awareness of PC in rural areas. A holistic and tailored PC model that standardizes care delivery, referral and coordination, including family caregiver support programs, can improve care access. Future practice and research are warranted to implement and evaluate innovative approaches, such as a coordinated community-based approach, to the successful integration of PC in rural communities.

Timely and comprehensive treatment in the form of early psychosis intervention (EPI) has become the standard of care for youth with psychosis. While EPI services were designed to be delivered in person, the COVID-19 pandemic required many EPI programs to rapidly transition to virtual delivery, with little evidence to guide intervention adaptations or to support the effectiveness and satisfaction with virtual EPI services.

This study aims to explore the adaptations required to deliver NAVIGATE, a model of coordinated specialty care used in EPI, in a virtual format. This study will evaluate implementation of the NAVIGATE model delivered virtually by describing the nature of the adaptations to the intervention, assessing fidelity to the EPI model and the satisfaction of clients, family members, and care providers. We will investigate barriers and facilitators to virtual NAVIGATE implementation, service engagement, and health equity impacts of this work.

The Centre for Addiction and Mental Health (Toronto, Ontario, Canada) transitioned to delivering NAVIGATE virtually early in the COVID-19 pandemic. The Framework for Reporting Adaptations and Modifications for Evidence-Based Interventions will be used to describe the adaptations required to deliver NAVIGATE virtually. Fidelity to the EPI model will be measured using the First Episode Psychosis Services Fidelity Scale and fidelity to NAVIGATE will be assessed by investigating adherence to its core components. Implementation facilitators and barriers will be explored using semistructured interviews with providers informed by the Consolidated Framework for Implementation Research. Satisfaction with virtually delivered NAVIGATE will be assessed with virtual client and provider experience surveys and qualitative interviews with clients, family members, and providers. Service engagement data will be collected through review of medical records, and potential impacts of virtually delivered NAVIGATE on different population groups will be assessed with the Health Equity Impact Assessment.

Virtual clinical delivery of NAVIGATE started in March 2020 with additional adaptations and data collection is ongoing. Data will be analyzed using descriptive statistics and survival analysis for quantitative data. Qualitative data will be analyzed using thematic content analysis. Integration of qualitative and quantitative data will occur at the data collection, interpretation, and reporting levels following a convergent design.

This study will provide information regarding the type of intervention adaptations required for virtual delivery of NAVIGATE for youth with early psychosis, ensuring access to high-quality care for this population during the pandemic and beyond by guiding future implementation in similar contexts.

DERR1-10.2196/34591.