Mental and behavioral healthcare is one of many resident care needs that transitioned to telehealth (i.e., telephone or video visits) in nursing homes during the COVID-19 pandemic. The U.S. Department of Health and Human Services, via the Centers for Medicare & Medicaid Services (CMS) and other agencies, heavily promoted the switch to telehealth as an infection prevention and control measure across the healthcare spectrum for the duration of the public health emergency, going so far as to create a new telehealth website that offers a Telehealth for Behavioral Health Best Practice Guide, a Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit, and other telehealth guidance.
“One of the silver linings of the pandemic is that it cracked the door open a little wider for the use of telehealth in nursing homes,” says Deb Paauw, MS, RN, NE-BC, executive director of Quality and Data Integration-Senior Services for Avera Health, a four-state integrated health system based in Sioux Falls, SD. Avera has run telehealth pilot programs in several of its long-term care facilities during the pandemic to offer residents suffering from depression and isolation ongoing one-on-one counseling with psychologists in addition to its existing suite of on-demand telehealth options for urgent care situations and care planning for difficult behaviors.
“The pandemic has helped overcome the perception that ‘We don’t do high-tech in long-term care,’” explains Paauw. “Nursing homes proved that wrong, successfully handling virtual physician visits, as well as other types of virtual visits, including mental health providers.”
The following lessons learned can help directors of nursing services (DNSs) continue to reap the benefits of telehealth mental health services for their residents as the pandemic winds down:
Know that telehealth can work
Using telehealth for mental health services is very doable and relatively low-tech, says Paauw. “Set-up is pretty easy if you have basic technical abilities. Our nursing homes had iPads, and we offered them a variety of software platforms to make the program as stress-free as possible. So, it doesn’t take a lot of fancy equipment and software. DNSs should feel confident that they can offer telehealth mental health services to residents.”
Assess telehealth options
Some resident mental health concerns adapt extremely well to telehealth visits, says Lisa Lind, PhD, a licensed psychologist and the chief of quality assurance with San Antonio, TX-based Deer Oaks, a behavioral health company with a national practice in long-term care. Lind is also president of the provider association, Psychologists in Long-Term Care (PLTC).
These include the following possibilities:
| – Emergent situations, such as risk assessment related to suicidal ideation, may be well-suited to telehealth as a resident can often be seen—and a safety plan can be put in place—much more quickly. – When an acute change in a resident’s behavior or emotional status occurs that can’t wait for the next routine visit from the mental health provider, telehealth may be an option. – Common mental health conditions, such as depression, anxiety, and adjustment disorders, have been found to be well treated via telehealth. – Telehealth can open up opportunities for providing culturally appropriate treatment accommodations by increasing access to a larger network of providers. – Residents who reside in facilities where there is a shortage of treatment providers, such as rural areas, may benefit from having access to telehealth services as a means of ensuring consistent psychological services. Source: Lisa Lind, PhD, a licensed psychologist and the chief of quality assurance with San Antonio, TX-based Deer Oaks, a behavioral health company with a national practice in long-term care. Lind is also president of the provider association, Psychologists in Long-Term Care (PLTC). |
Consider resident barriers to telehealth
A resident’s diagnosis, clinical needs, and physical functioning can impact how well telehealth visits may work for them, says Paauw. In particular, nursing homes may want to consider the following concerns:
| – For residents with symptoms of psychosis, such as paranoia, delusional thinking, or auditory hallucinations, and especially if there is cognitive impairment involved, mental health service delivery via telehealth may not be the most ideal situation. If a resident who may be experiencing psychosis then hears voices coming from the telehealth device, that may lead to confusion and/or possibly reinforce delusional thinking. However, this is just based on anecdotal observations and not research data. – Residents with significant cognitive impairment and/or dementia may have more difficulty with telehealth, depending on the circumstances. Telehealth involves planning, multitasking, and managing technology, which can be more difficult for some residents with cognitive impairment unless they are receiving more hands-on assistance from staff. – Residents with hearing or visual impairment may initially be more anxious while using telehealth devices until they become more familiar with ways to adapt the device (e.g., manage the volume or use headphones for auditory issues, and increase the picture size on screens for visual issues). Source: Lisa Lind, PhD, a licensed psychologist and the chief of quality assurance with San Antonio, TX-based Deer Oaks, a behavioral health company with a national practice in long-term care. Lind is also president of the provider association, Psychologists in Long-Term Care (PLTC). |
Establish a mental health first culture
A successful mental health program of any kind may hinge on establishing the right culture, says Paauw. “Mental health may be a new service for nursing homes that don’t have local or regional mental health providers available. Especially at these facilities, DNSs may want to build that foundational culture up-front.”
The interdisciplinary team needs to understand the importance of mental health to resident quality of life, explains Paauw. “They also must have the education and skills to identify those residents who may need a mental health provider. Identifying and referring at-risk residents before they reach a crisis that requires an intervention with urgent care mental health services benefits the resident and ultimately may save staff time as well.”
Understand when nurses need to be involved
For residents who have acute mental illness to use telehealth mental health services, more is required from DNSs and nursing staff than they originally may expect, says Amber Givens, RN, BSN, director of nursing at Cashmere Care Center in Cashmere, WA. The SNF offers a mental health placement program, as part of an expanded community service (ECS) contract with the state, for residents who don’t require inpatient psychiatric care but cannot live in the community due to safety concerns. Cashmere has used telehealth mental health services for these residents throughout the pandemic.
“Telehealth is amazing for these residents, but it also can be frustrating for nursing staff. Nurses have to be there for the whole visit, not just to facilitate the visit,” stresses Givens. “In addition, the mental health provider relies on the nurses to point out issues and provide assessment information.”
Givens offers the example of a resident she felt was overmedicated. “I wanted the provider to watch the resident walk and watch their rigidity,” she explains. “So, I had to pre-empt what the provider was looking for and then provide those opportunities via telehealth for them to see what I thought needed to be addressed for that resident.”
Sometimes, the mental health provider only sees the resident’s face, not their total body, adds Givens. “Nurses have to share issues that they identify so that the mental health providers can know to direct their observations and their conversations to areas of concern. So, telehealth definitely places a significant responsibility of more complete knowledge and assessment on the nursing staff. However, it’s also beneficial because it allows for collaborative care. As the eyes and ears of the mental health provider, nurses can advocate for the care of their residents.”
Define the mental health provider’s responsibilities
In the Avera pilot programs, the mental health clinics took on the bulk of the responsibility for coordinating the scheduling, double-checking that the equipment was in place, and ensuring that their counselors were credentialed through each clinic, says Paauw. “However, one of our nursing homes did require counselors to go through the credentialing process at the facility to be able to provide care there. So there were facility-level idiosyncrasies that we dealt with as we rolled out this project.”
Set up an internal process
Prior to launching a telehealth mental health program, nursing homes need to identify their internal process—and practice it before involving any residents, suggests Paauw. “That process will need to be tailored to the facility culture, but duties do need to be assigned because the workload is more than you may anticipate and will take some staff time.”
The facility’s internal process should include:
- A staff liaison. To have a successful telehealth mental health program, someone in the facility needs to serve as the staff liaison who spearheads the process of identifying residents who may need mental health services and scheduling a visit with the mental health provider, says Paauw. “It doesn’t necessarily need to be the same staff person at every facility. It just needs to be someone who has eyes and ears on the residents so that problems don’t go under the radar for too long.”
During the Avera pilot programs, the liaison tended to be the social worker, says Paauw. “For general non-acute mental health services, the social worker at the facility often was the real liaison with the mental health provider and the clinic rather than the nursing staff or the physicians. However, it could be a certified nursing assistant (CNA) who has a knack for identifying subtle changes.”
- Visit facilitators. The staff liaison can also facilitate visits, but nursing homes may need to have several staff members identified and trained as facilitators. “These staff members not only need to do the physical set-up for each visit on the nursing home side, but in some cases they must provide assistance holding the iPad or computer during the visits,” says Paauw.
For residents with acute mental illness, the visit facilitator may need to be someone on the nursing management team, adds Givens. “With these residents, the person hosting the telehealth visits should have access to the broadest level of information. There will be questions about lab and test results or referral appointments. Floor staff may not have access to that type of information, so the facilitator must be someone who can look up information in the facility’s system and give the mental health provider the most complete picture of the resident so that there are no barriers to care. You don’t want the facilitator to have to say, ‘I don’t know.’”
- A clear workflow. Cashmere usually does visits for six to seven residents in succession per mental health provider, notes Givens. “Our policy is to maintain a provider list of residents. I go through that list with the mental health professional prior to rounding. Residents are often in shared rooms or they are in the hall, and there is not a quiet, private spot for them to have a visit. So, having that conversation in my office with the mental health provider to discuss some of the issues that we are seeing and want them to address with the resident is very helpful. Then, I take the iPad and round the building so that they get a chance to connect with each resident who is on the list.”
Customize and individualize when mental health providers are local
A telehealth-only approach to mental health services may not be as popular in the long-term care setting after the pandemic ends, says Lind. “Providing telehealth mental health services in nursing homes can be challenging and unpredictable for mental health providers,” she notes. “Reliance on nursing home staff, who are often busy with a multitude of patient care activities, to facilitate telehealth often results in inconsistent follow-through with telehealth scheduling and facilitation.”
Absent another pandemic that requires stringent infection prevention and control protocols, providers may want to consider some combination of in-person and telehealth visits when mental health providers are available locally, adds Paauw. “There are pros and cons to both in-person and telehealth visits, so we are considering the best path forward.”
To achieve maximum productivity and scheduling flexibility for the mental health provider and the nursing home, a combination of visit types may be ideal, she explains. “For example, the mental health provider could do an initial in-person visit to establish the relationship and start the journey with the resident, and then they could transition to telehealth visits or perhaps telehealth every other visit.”
It’s especially important to consider scheduling flexibility for the resident when deciding how to structure mental health visits, says Paauw. “The entire interdisciplinary team is there to serve the resident and help them be the best they can be. If, for example, the resident wants to go to bingo and do their counseling later, you should have a process that is flexible enough to allow them to do that. Finding the right balance of virtual and in-patient visits for each resident will be critical.”
The flexibility offered by using telehealth in conjunction with face-to-face services potentially could decrease the rate of missed sessions, adds Lind. “For example, mental health providers often round at a specific facility on a certain day of the week, and often some patients are missed because they may be at dialysis, at an outpatient appointment, or in the hospital. Allowing for the option of having telehealth as an adjunct method of delivery could potentially assist with continuity of service delivery.”
Create a system for between-visit communication
Especially for residents with acute mental health concerns, establishing a line of communication with the mental health provider outside of the visit process is critical, says Givens. “For some residents, a weekly or biweekly telehealth visit with the provider may not be sufficient. You want to establish ahead of time a line of communication with the provider that has the potential to be on a daily basis so that they can be kept up-to-date. For example, I may text a resident’s provider if I need to talk to them about a possible change in medication before the next scheduled visit.”
The following chart offers additional insights that DNSs may want to consider when setting up a program:
| Telehealth Mental Health Best Practices: Suggestions From a Licensed Psychologist – Ensure that the mental provider has remote access to the electronic health record (EHR) system so that they can review recent nursing and physician notes, medication changes, and other pertinent information prior to the session. – Be respectful of the mental health provider’s time. If they set aside a certain portion of a day for residents, ensure that the nursing home follows through with the commitment of having a facilitator available. – Communicate recent issues or concerns to the mental health provider ahead of time so they may address issues during session. – If facilitator time is limited, prioritize residents’ needs based on pertinent circumstances and communicate that priority to the mental health provider. – Ensure that multiple staff members are available to serve in the role of facilitator, and ideally have multiple telehealth devices available for use in case there are unexpected technological or staffing challenges. – Ensure psychological services are conducted in a private area. The mental health provider may have limited ability to see who may be able to hear the information being shared on the other end, and they depend on the facilitator’s help to ensure that privacy is respected. Hanging a “session in progress” or similar sign on the resident’s door during the session may be a cue for staff not to interrupt unless absolutely necessary. – If the residents are able to use communication devices themselves, allow them to speak with their mental health provider alone. There is no need for staff to stand there waiting while private information is being shared. Have a communication system in place for the provider and the facilitator to communicate with each other when a session is about to end so the facilitator can retrieve the device and bring it to the next resident. – Ask residents for feedback about their telehealth experience. What were perceived barriers? What are areas that could be improved on? Source: Lisa Lind, PhD, a licensed psychologist and the chief of quality assurance with San Antonio, TX-based Deer Oaks, a behavioral health company with a national practice in long-term care. Lind is also president of the provider association, Psychologists in Long-Term Care (PLTC) |
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