Sample characteristics
Of the 391 respondents, 59.3% were SUD providers, and 40.7% were MH providers. The sample consisted of 46.3% counselors, 45.0% administrators, 2.8% physicians/prescribers, 2.6% recovery coaches, and 3.3% other (Table 1). As respondents were answering on behalf of their organization, they were not asked to provide socio-demographic data. Respondents were predominantly in specialty care settings and represented a mix of urban, suburban, and rural areas.
Table 1
Sample characteristics
|
|
Frequency
|
%
|
|
|
|
|
Organization setting
|
|
|
|
Rural
|
101
|
25.8
|
|
Small city
|
74
|
18.9
|
|
Suburban
|
75
|
19.2
|
|
Urban
|
140
|
35.8
|
|
Blank
|
1
|
0.0
|
|
|
|
|
Organization type
|
|
|
|
Specialty treatment
|
269
|
68.8
|
|
Health system
|
58
|
14.8
|
|
Opioid treatment programs
|
25
|
6.4
|
|
Recovery community
|
18
|
4.6
|
|
FQHC
|
17
|
4.4
|
|
Other
|
4
|
1.0
|
|
|
|
|
Respondent job function
|
|
|
|
Counselor
|
181.0
|
46.3
|
|
Administrator
|
176.0
|
45.0
|
|
Physician/Prescriber
|
11.0
|
2.8
|
|
Recovery coach
|
10.0
|
2.6
|
|
Other
|
13.0
|
3.3
|
|
|
|
|
|
Overview of qualitative emergent themes
Overall, three major themes emerged in the data: COVID-specific experiences with telehealth, general experiences with telehealth, and recommendations to continue telehealth delivery. Each of these themes contained multiple sub-themes, as elaborated in the following sections.
COVID-specific telehealth themes
Multiple providers expressed the view that their organizations would not have begun to use telehealth if not for the onset of the COVID-19 pandemic. Within those responses that specifically commented on the pandemic, three subthemes emerged pertaining to COVID-specific advantages of telehealth adoption: continued provision of services during the pandemic, the ability to adhere to safety and social distancing guidelines, and experiences related to having children at home. Another COVID-specific sub-theme was the easing of regulatory restrictions, which facilitated providers’ adoption of telehealth.
Continued provision of services during the pandemic
Many providers appreciated that virtual services could be used in place of in-person treatment once stay-at-home orders and social distancing requirements began. Responses conveyed a sense of relief that providers were able to continue providing services to clients during COVID-19. Some respondents felt that the substitution of telehealth for in-person treatment “saved lives,” “kept our patients out of the ED and psychiatric hospital” and was an “incredible lifeline” to clients. One provider stated that increased accessibility over the telephone was beneficial for clients, writing that “for clients to be able to access help before going into a full-blown crisis is priceless.” Respondents also expressed gratitude that telehealth allowed them, as individual providers and as a field, to continue performing their jobs. Several comments credited the ability to provide virtual services with having “saved my job” and having “literally saved our organization and likely our clients.”
Safety and social distancing
Respondents reported satisfaction with how telehealth adhered to social distancing guidelines and allowed clients and providers alike to minimize exposure to COVID-19. Telehealth was reported to be particularly beneficial for providers and clients at high personal risk of severe illness from COVID-19.
Children at home
To reduce COVID-19 exposure, schools began to conduct learning remotely. As many childcare centers remained closed, this left many parents with the additional challenge of caring for children at home during the day. Providers appreciated that telehealth allowed them (and their clients) to engage with treatment while balancing childcare needs.
Easing of regulatory restrictions on telehealth
Many respondents credited the easing of telehealth regulations during COVID-19 with their ability to maintain their use of telehealth. The responses referenced COVID-era policy generally, as well as reimbursement policy specifically. Many of the providers referred to the use of telehealth as “completely dependent” upon the eased regulations becoming permanent. Some of the respondents expressed uncertainty about how long eased regulations would last, and several noted that the uncertainty “makes it difficult to do long-term planning/workflow development that includes [telehealth].”
General telehealth themes
The bulk of the verbatim responses shared general experiences with telehealth independent of the COVID-19 pandemic. These ‘general’ responses reflected four subthemes: organizational conditions affecting ability to adopt telehealth, access, perceived treatment effectiveness, and cost-effectiveness. Within each of these subthemes, respondents detailed both advantages and disadvantages of using telehealth.
Organizational conditions which affect ability to adopt telehealth
A handful of respondents reported positive experiences with the integration of telehealth into their organizational workflow, stating that their organization had made telehealth easy to adopt. Others shared positive feedback about their organization’s access to technology, which allowed them to easily download necessary platforms and navigate telehealth technology, even if they initially experienced a learning curve with setting up virtual services.
By contrast, multiple respondents reported struggles integrating telehealth into their organization’s usual operations. Concerns about confidentiality, security, and encryption on platforms like Zoom were common. Several providers complained that they received limited support and training from management on adjusting to telehealth, that they were not given the equipment necessary for seamless and proper use of telehealth, and that managing multiple platforms was difficult. This difficulty was in some cases exacerbated by limited staff literacy. One respondent remarked that they struggled to adapt to telehealth at first, prompting them to “take online courses and webinars to learn [how to use telehealth]” on their own, as “[t]he organization [doesn’t] offer any webinars or trainings.” Two others reported that co-workers were resorting to using HIPAA non-compliant platforms to treat patients due to lack of organizational infrastructure.
Access
Multiple providers remarked on client access to telehealth. Many respondents reported that telehealth removed barriers of access to transportation, distance to treatment, and access to childcare. As one provider put it, “No transportation — no problem! Gas is too expensive — no problem! No daycare — no problem!”
Several respondents shared their perspective that virtual services opened the door for new populations to access treatment, such as clients with severe anxiety and clients who wish to avoid stigma associated with seeking treatment. Telehealth was also perceived as allowing respondents to provide remote treatment to clients residing in locations distant from them, such as clients in rural areas. As one respondent wrote: “[T]o have telephonic and telehealth end would mean many clients leaving services. Accessibility is everything, especially for the clients in the upper peninsula that we serve electronically right now. We’d love to see telehealth and telephonic appointment reimbursement continue. We’ve seen such an influx in SUD self-referrals because it is now so much more accessible.” Some other providers observed that clients kept their telehealth appointments more often than they did with in-person appointments and that patients were generally more engaged in telehealth, with one provider noting that they “got better follow through and fewer no-shows.” In addition, numerous respondents reported that their number of admitted patients increased during telehealth.
While some respondents perceived telehealth as opening up treatment, others perceived telehealth as making treatment less accessible. Several providers noted that switching to virtual services cut them off from some clients altogether, such as those who have unstable housing, lack adequate privacy for appointments, or refuse to use telehealth. One respondent expressed worry that not enough people in the rural community were aware of telehealth as a treatment option. Additional concerns were that clients were harder to reach, made fewer appointments over telehealth, disengaged from services, or missed more appointments. Providers also perceived that new clients took longer to engage in virtual services than their preexisting clients. Some respondents reported that their clients missed and rescheduled telehealth appointments more frequently than they did with in-person appointments, while others reported that several of their clients had fully disengaged from telehealth.
The most common concern about access to care was clients’ limited access to technology. Many respondents complained that their clients did not have access to the internet, with a few citing poor broadband infrastructure in rural areas. Other providers reported that their clients did not have cell phones that could support telehealth platforms. Limited cell phone data and limited battery life were cited as problems, as sometimes clients would run out — or fear running out —of their cellular data or battery life if they used virtual services. In addition, respondents perceived some of their patients — such as clients from rural areas, low-income clients, cognitively impaired clients, and older adults — as more prone to having difficulty navigating technology. An overarching worry was that telehealth would exacerbate preexisting barriers to care, especially within historically marginalized patient populations and communities of color. Two respondents reported that technology issues raised barriers to continuous access and engagement during sessions, with one respondent adding that this situation posed unanticipated billing issues:
Cell phone quality & connection problems … can be a problem in meeting minimum session length requirements for billing. For example, I have a client whose phone frequently cuts out every 2 minutes. It gets frustrating for the client & counselor to have to keep calling each other back. It also raises an ethical issue if we’ve only talked for 15 minutes but need to bill for a 25-minute session. If we don’t bill for it, then it’s as if the client wasn’t seen for a session — not fair for the client to be penalized for having a poor-quality phone, or for the program not to get credit for trying to serve the client despite the phone limitations.
Perceived treatment effectiveness
Another key subtheme pertained to the perceived effectiveness of telehealth. Respondents reported mixed opinions about whether telehealth improved or decreased the effectiveness of the care they were able to offer to clients. As an example, one provider wrote, “Truly a mixed bag. Works beautifully for some folks and want to continue even after COVID. For others, it is deeply frustrating and they long to come back face-to-face.”
A handful of respondents reported that clients seemed more open or trusting over telehealth than during in-person sessions, while only respondents whose clients had preexisting trust issues reported lower trust levels. Providers also appreciated that clients’ engagement in video care from home gave them insight into the client’s home environment.
Several providers shared their perspective that telehealth was valuable if necessary but could never be an equally effective replacement for in-person treatment. “It is not an adequate substitute for in-person therapy,” one respondent wrote, “but it is better than nothing.” One of the key trepidations about effectiveness was missing important “body language cues” from clients during sessions. For example, one respondent noted, “without seeing them in person, it is hard to tell [when] they are struggling.” Several others similarly felt that the “personal touch” was missing over telehealth, citing concerns with “rapport,” “depth,” and “connection,” as well as experiences of “disconnect.” One respondent shared that they were missing out on the “genuine transformation you see when the person comes to the office weekly.” Other providers felt that the rigor of assessment was diminished over telehealth and that holding clients accountable was more difficult.
Cost-effectiveness
Another subtheme pertained to perspectives of the cost-effectiveness of telehealth. These perspectives were mixed. Some respondents felt that telehealth was more productive and efficient. One respondent commented that “the more I use it, the more I like it because it saves me time, money, and energy.” Another said that “administratively it is cost effective because I do not have staff with as much ‘windshield time’ as they drive across 4 rural counties to provide services.” Others said that telehealth required a greater investment of work and time, citing technology setup and building rapport with clients.
Recommendations to continue telehealth delivery
Three subthemes emerged related to recommendations to advance telehealth: continuing to ease or change telehealth restrictions, investing in broadband infrastructure and institutional support, and combining telehealth and face-to-face intervention.
Continued easing of regulations
The most frequent suggestion was to continue telehealth reimbursement and relaxed regulations. “It would be a shame,” one respondent said, “to again implement the limitations.” Beyond continuation of eased regulations, some respondents took it a step further and advocated for changed regulations. One respondent suggested, “Let’s change the previous regulations to facilitate the use of telehealth by non-licensed professionals such as recovery coaches, case managers and counselors.” Another echoed this, saying that “we need to continue to allow bachelor level and recovery support services staff to use telehealth post-pandemic.”
Investing in broadband infrastructure and institutional support
Another popular suggestion was to invest in expanding access to infrastructure in rural areas to increase access to telehealth services. “Internet service providers need to MAJORLY step up availability and affordability of internet services in rural areas,” one respondent said. Meanwhile, another provider noted that ensuring equitable access to care would require large-scale changes. “These barriers,” they said, “are too large for our non-profit agency to address.” Institutional support was also viewed as critical. Multiple providers expressed a desire for more training, technical support, and equipment for staff, as well as increased security and improvement of telehealth platforms.
Combining telehealth and in-person care
Finally, several respondents explained that they intended to continue using a combination of telehealth and in-person care after the end of the COVID-19 pandemic. Many providers shared their perspective that although they do not prefer telehealth to in-person care, it should continue as an option for clients. However, it was commonly acknowledged that the ability to offer a hybrid combined model would depend on reimbursement. As an example, one respondent wanted their care model to integrate telehealth, but explained that “without reimbursement ability, it is not an option at all.”
One respondent took it a step further and argued that telehealth should be viewed as a key part of the future of treatment, explaining: “I think it’s time to not see telehealth only as an alternative in times of urgent need, but rather as a necessity that requires thorough training, development of sound policies and implementation of secure telehealth systems.”