With the rush to virtual services in the face of the pandemic crisis, there is wide agreement that the increased use of telehealth and virtual visits will remain a fundamental part of the service delivery system after the crisis fades (see Telehealth—Be Careful What You Wish For and Going ‘Virtual Service’ – Reaching Consumers Where They Are At With Telehealth & More – An Overview).
But in recent discussions with our team and our advisory board members, it has become clear—based on their experience in the field over the past seven weeks—that telehealth is not the optimal solution for every consumer. In this discussion, we’re not talking about access to broadband internet or digital literacy issues. We’re talking about consumers with characteristics that make virtual interaction with clinical professionals a less than optimal treatment modality. This is a challenge for the current crisis period and also a factor for planning for post-crisis recovery.
So who is in this group of consumers? Our discussions have resulted in a short list—including consumers with autism, intellectual and developmental disabilities (I/DD), paranoia, anxiety disorders, and consumers with sensory and communication difficulties. Over ten weeks, Alan Bragwell, a practicing professional counselor and OPEN MINDS advisory board member, saw about 85% of consumers in his practice accept tele-counseling. “Of those that would not transition, the pattern of refusal seems to include past struggles with paranoia, resistance to major changes (autism spectrum), and surprisingly, adolescents with anxiety disorders who worry about how they look on screen,” he explains.
Autism. Think about the world of a child with autism in the COVID-19 era, says Mordechai Meisels, chief clinical officer of Encore Support Services. “It’s a world with extreme isolation, lack of structure and schedule, and increased stress levels at home,” he points out. Not being among peers hurts these children and the lack of concrete reinforcements from their clinical professionals is limiting. His comments were part of a recent web briefing, Caring For Vulnerable Populations In A Social Distance World: Autism Service Providers Implement Virtual Care Delivery, led by OPEN MINDS Senior Associate Deb Adler. Mr. Meisels, along with Colin Davitian, chief executive officer of Gateway Learning Group and Yagnesh Vadgama, vice president, clinical care services, autism, Magellan—shared strategies they are implementing to make telehealth more effective for children with autism and their families.
Encore Support Services was quick to train parents to work with the clinical professionals to engage children at home, provide structure to calm the children, and clarify and align everyone’s expectations from telehealth. Mr. Meisels also led the development of the Social Pal model to enable virtual group interaction for children, with oversight by parents and clinical professionals. Children with autism in diverse locations across the country are paired so they can “Distance socialize in a socially distanced world.” This model has been greeted with enthusiasm by families.
At Gateway, Mr. Davitian’s team is letting consumers and families drive the care process. Whether families of children with autism want shorter virtual visits, multiple sessions a day, or some level of in-person care, clinical professionals accommodate them knowing that the effectiveness of telehealth varies by consumer. At the same time, “Virtual socialization will become the norm in the future so giving our consumers social skills virtually is important,” says Mr. Davitian
Treatment plans and protocols must be adjusted, says Mr. Vadgama, to accommodate what can be effective on a virtual platform. For example, clinical professionals must weigh the benefits of the different dimensions (effectiveness vs. generalization) of applied behavior analysis (ABA) for autism treatment and perhaps focus more on training parents to manage behaviors and situations when clinical professionals are not present. As telehealth for autism care is new territory, the Magellan team has reached out to provider organization clinical leaders to understand what they are learning on the ground and to enable sharing of best practices.
Intellectual and developmental disabilities. Consumers with I/DD, especially those with limited cognitive abilities, could be confused by telehealth, says OPEN MINDS Senior Associate Lori Schmidt. They may have trouble understanding if they are talking to a television or a real person. Routine and structure are critical to maintain independence and minimize disturbing behaviors. Virtual care cannot replace the benefits they get from being at their day programs or in jobs. These consumers may also have high sensitivity to sound or light, making it difficult to communicate through digital devices. Others communicate in non-traditional forms, using hand signs or assistive technology—and telehealth has not evolved to the point where such forms of communication can be effectively factored in. Comorbid physical and behavioral health conditions might necessitate care from multiple specialty provider organizations, which is hard to accept in the virtual space.
In many instances, telehealth for consumers with I/DD would work better if a “collateral”—a family member, caregiver, or clinical professional—is present at the visit, says OPEN MINDS Senior Associate Leon Hoover. When someone “accompanies” the consumer on the telehealth visit, they can help to navigate technology and also provide other valuable information that the consumers may find it harder to articulate on-line.
Remember that every consumer is different, cautions Mr. Braunstein. Clinical professionals need to assess consumers’ ability to interact and provide information via video before providing therapy. It is also possible to miss nonverbal cues with telehealth, he says. Often, telehealth may be an adjunctive tool, and not the only one, in caring for vulnerable populations, he says.
Anxiety disorders. Consumers with anxiety disorders—or depression and schizoaffective disorder mental health challenges that present as anxiety—are never comfortable with change and the introduction of telehealth adds additional levels of anxiety, says Mr. Bragwell. “I’ve never done that before,” is the immediate reaction when consumers have to get on a new platform for their telehealth visits. It’s worse when the change is unexpected, as with the COVID-19 crisis. Mr. Bragwell has seen otherwise tech-savvy consumers become more anxious when they need to do something as simple as download an app on their smartphones. In addition to change, consumers with anxiety have trouble with telehealth because of a sense of lack of control, problems with privacy, trouble with image, and inability to focus. He had three teenagers push back on tele-counseling because “they did not want to look at themselves on screen.” There are also many distractions on screen and consumers could be texting friends or reading work emails while in a therapy session, greatly reducing the effectiveness of the encounter.
Some members of the Anxiety and Depression Association of America reiterated the challenges in a conversation with The Wall Street Journal (see Your Video Therapist Will See You Now). Privacy is a key issue and consumers have retreated to their cars and closets for their telehealth sessions. With everyone being home during lockdown, interruptions—from children and pets—can be frequent. Others find it “jarring” to go from work to therapy in the same space with no time in between. One consumer found video visits to be “pretty disjointed” and misses the nonverbal body language. The “cacophony” of on-line interaction at group sessions is another issue and people may have to be broken into smaller groups. For children and young adults with social anxiety disorder, it’s hard to replace pre-pandemic group therapy that involved “exposures”—ordering food at local restaurant, role playing talking to strangers—to learn how to deal with anxiety.
For consumers whose challenges include paranoia that involves technology, “talking to them through the same technology from which they likely hear voices” is a significant concern says Ms. Schmidt. We don’t want to exacerbate their delusions. Telehealth for these consumers before they are stabilized is not recommended. And for consumers with anxiety and paranoia, it would be best to give them control on a virtual visit, says Mr. Hoover. For example, consumers should know they can end a session whenever they like.
Sensory and communication difficulties. Even in normal times, consumers with special needs—such as vision, hearing, and speech impairments—have difficulties accessing any health care and are extremely inconvenienced if they have to change health care professionals for any reason, says OPEN MINDS Senior Associate Stephen Holoviak, Ph.D. Consumers over 65 years of age, who may have partial vision and hearing loss, can’t engage effectively with their clinical professionals. A child with attention deficit hyperactivity disorder won’t connect with a therapist by staring at a monitor. In general, consumers who need nonverbal cues can’t get the most out of virtual care yet. Telehealth shifts the onus for effectiveness of care to the consumer, says Dr. Holoviak, which does not work for many vulnerable populations.
So why is it important to understand what consumer groups are not a ‘best fit’ for virtual services? These will be the ‘niches’ in the market that will be immune from a pending era of out-of-area, price-based competition for therapy services delivered on-line. The likely winning market positioning is to develop deep expertise in specific specialty populations—and demonstrate superior performance.
But market positioning around specific specialties is not enough. Virtual care for special needs populations has a strong future but we’re going to have to consider what will make care more effective, says Dr. Holoviak. The key is to understand the needs, preferences, and outcomes of each consumer cohort. And this goes beyond thinking about every consumer with a particular diagnostic condition as the same. The health and human service field needs to adopt consumer segmentation practices now common in retail and hospitality businesses—what are the subgroups of consumers (by age, geography, education, comorbid conditions, etc.) that have specific preferences and what market opportunities do those segments present?
In addition to this marketing approach, there are clinical practice initiatives that are likely to happen in the months and years ahead. Licensing and accreditation groups will likely develop more stringent standards, guidelines, and training programs to make virtual care effective for special needs populations. Mr. Meisels’ team has started to develop evidence-based practices (see Evidence-Based Telehealth Practice In The Time Of COVID-19) and we will see more such practices evolve. Provider organizations and payers are already collaborating to develop effective models of care—as Mr. Vadgama explained at the OPEN MINDS web briefing—and we will see more collaboration. Telehealth has opened up a ‘Pandora’s Box,’ says Ms. Schmidt. “It opens up possibilities but there are also limits that we must address.”
We’ll continue to track the evolution of the use of virtual care beyond this crisis-induced tipping point. For more, check out these resources in The OPEN MINDS Industry Library:
- CMS State Medicaid & CHIP Telehealth Toolkit
- Making The Strategic Shift From Telehealth To Virtual Care
- Developing The Consumer & Staff Training & Guidelines Needed To Expand Your Telehealth Services Quickly
- The Definitive Guide To Leveraging Telehealth
- Jump-Starting Telehealth & Home-Based Care: An OPEN MINDS Resource
- New Telehealth Service Helps Reduce Relapse Risk For Those In Recovery
- About 10% Of Medicaid Beneficiaries With Behavioral Health Disorders Made Telehealth Visits In 2017
- Improving Access To Care: The Benefits, Best Practices & Lessons Learned Implementing Telehealth Services
- Telehealth Best Practices: How To Build A Successful, Sustainable Program
- Telehealth Lessons Learned
And for more on developing your recovery strategy and innovation in the post-crisis era, I invite you to join us on-line for The 2020 OPEN MINDS Virtual Strategy & Innovation Institute, June 1 – 5, 2020. The agenda includes sessions such as Leveraging Technology To Improve Services For Consumers With I/DD and Emerging Models & New Benefits For Individuals Dually Eligible For Medicare & Medicaid that address some of the issues in caring for vulnerable populations. From the comfort of your home or office, you can learn from the experts and exchange ideas with your peers to ensure that you keep your doors open while serving vulnerable populations in the ‘new normal.’ Learn more and register at https://strategy.openminds.com/