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Telehealth: A Key Weapon

Telehealth in Older Adult Mental Healthcare: A key weapon in the fight against the COVID 19 pandemic
by Denise Meuldijka,b*, Viviana M. Wuthricha,b, Carly Johncoa,b, Daniella Kanareckc, Alexander Svenson c, Kristen Szulikd, Sharon Buxtond aCentre for Emotional Health, Department of Psychology, Macquarie University, Sydney, Australia, 2109
bCentre for Ageing, Cognition and Wellbeing, Macquarie University, Sydney, Australia, 2109

c Older Persons’ Mental Health Services, Euroa Centre, Prince of Wales Hospital, Sydney, Australia, 2031
dWestern NSW Local Health District, Specialist Older People’s Mental Health Services, Curran Centre, Orange, Australia, 2800


Key highlights:

  • Telehealth services can facilitate access to mental healthcare services during the COVID-19 pandemic, as it limits unnecessary exposure of patients and health professionals to virus transmission.
  • Challenges with video conferencing for healthcare provision with older people are broad, including lack of access to compatible devices, technology challenges and concerns about privacy.
  • Older clients preferred telephone-delivered psychological services over videoconferencing and using a telephone landline rather than their mobile telephone.
  • In rural and remote areas, unstable internet connections can make videoconferencing unfeasible.
  • Both staff and clients had reservations about adoption of telehealth; however, over time these barriers have reduced
  • New creative and innovative solutions, such as self-help resources for clients, have been developed during this pandemic with the intention of making care more convenient and more affordable.
  • As more people are encouraged to use telehealth options, healthcare providers need to further adjust their services to improve telehealth- enabled patient- centered models of care and streamline procedures accordingly.

In January 2020, the World Health Organization (WHO) declared the outbreak of a new coronavirus disease, COVID-19, to be a Public Health Emergency of International Concern. In March 2020, WHO made the assessment that COVID-19 can be characterized as a pandemic [WHO, 2020]. As WHO and public health authorities around the world have been acting to contain the COVID-19 outbreak, government restrictions have been put in place, including social and physical distancing, to help prevent disease transmission.

Although these restrictions help to limit the spread of the coronavirus, the confinement of the population during lockdowns and the impact on healthcare services has been profound. Mental health services for older people have been facing significant disruptions, even as restrictions ease, given these older clients are at higher risk of significant morbidity and mortality outcomes from COVID-19 [Howell et al. 2020]. In some contexts, this has included the complete cessation of all face-to-face and in-person assessments and treatments.

In this article, we explore how four Australian government-funded providers of mental health services for older people and people with age-related frailty have pivoted to continue providing vital care during ‘social distancing’ and quarantine requirements during the COVID-19 outbreak. The experience of clinicians and managers are described, as well as the barriers and facilitators of implementing online and telehealth interventions in Older People’s Mental Health (OPMH) services and older adults during the COVID-19 pandemic were explored.

Setting
In New South Wales (NSW), a southern-eastern Australian State, with Sydney as its capital, publicly funded mental health services for older people (Older People’s Mental Health (OPMH) Services), provide both inpatient and out-patient care to people aged 65 years and older, and Aboriginal and Torres Strait Islander people aged 50 years and older, with diagnosable mental health problems. The nature of the interventions offered at the specialist mental health care services are similar to those offered by general community services. They involve an initial mental health assessment, treatment and care planning by nurses, psychiatrists, physicians, psychologists, social workers and occupational therapists, or medication review. Inpatient care typically involves voluntary short-term management and treatment during an acute phase of mental illness. If necessary, the OPMH services will work with other services (e.g., community and residential care and support programs) to enable optimal care for the older adult. Given the remote location of many of these OPMH services in regional NSW, they are already well-equipped to use videoconferencing and telehealth approaches, and typically use these for the purposes of assessment, intervention, consultation, education and/or supervision. The experiences of one urban and three regional OPMH services in NSW are reported in the current article.

Impact on service provision

The OPMH services experienced significant disruption in usual mental health services delivery. In all OPMH services, in-person (i.e., face-to-face) services were being minimized or suspended. Regular mental health-care appointments and procedures scheduled to occur at the OPMH service or in client’s homes were delayed, discontinued or reduced to prevent the spread of the virus. Managers and clinicians indicated that in-patient services were greatly impacted by the physical and social distancing restrictions with group therapy sessions, leave requests and family visits suspended. For the regional services, enforced travel restrictions impacted their service provision. Large community mental health services in regional areas provide outreach services to several other smaller, remote and rural towns.

Older adults living in these regional areas are highly dependent on the care they receive from the healthcare professionals of these larger OPMH services, as no local services are available due to geographic isolation. The discontinuation of regional visits by the larger teams created some unique challenges for health service delivery. This was exacerbated by the inability of professionals who normally ‘fly-in/fly-out’ to provide services given travel restrictions, leaving some towns without access to professional services.

Finally, the staff reported mounting pressure to shift to telehealth as a tool to give support to or facilitate the treatment of older adult people remotely. Although most of the OPMH services already provided some of their services via the telephone before COVID-19, the rapid move to use telehealth for all elements of care created a general feeling of unpreparedness and uncertainty for the clients and staff. In addition, the increased use of telehealth highlighted the need for a bolstered IT infrastructure to accommodate telehealth in the OPMH services.

Approaches used by OPMH Services to manage COVID 19

In response to the COVID-19 pandemic and its impact on service provision, the OPMH services indicated that they adjusted triage, evaluation, and care for patients. The OPMH services embraced telehealth, primarily using telephone consultations or videoconferencing in the provision of mental health care. Psychological services and internal staff meetings rapidly transitioned into telephone or videoconferencing consultations. The team managers and clinicians noticed an initial skepticism in patients about using telehealth technology, with client preferences for telephone-delivered psychological services over videoconferencing, and preferences for landline telephone calls over mobile phone calls.

They reported that proposals to use videoconferencing for patient assessment and care created anxiety and stress among both clients and staff. Lack of knowledge and confidence in using the technology, privacy and confidentiality concerns, and concerns about the loss of social interaction, were common concerns reported by clients. Whilst some staff were able to adapt to use headsets to make telephone calls, some older people experienced physical difficulties holding a telephone for (longer) consultations.

Although the use of telehealth services is an established component in most OPMH services. The sudden increase and almost exclusive use of telehealth during the coronavirus pandemic identified some shortcomings in the infrastructure of these services. Limited availability of rooms and resources to conduct telehealth sessions while adhering to physical distancing, maintenance of equipment, internet connection instability in remote locations, and difficulties troubleshooting technical problems were frequently reported as challenges to the use of telehealth. In order to resolve some of these challenges, the three regional OPMH services, set up dedicated videoconferencing rooms at their services. These facilities enabled easy access to modern and efficient telehealth services for both mental health staff and clients, and the use of a reliable internet/telephone connection.

At the urban OPMH service, virtual waiting rooms were introduced to facilitate administrative processes and set up client’s visits prior to the appointment between the client and their clinician. Virtual waiting room interventions allowing clients to interact, engage, and learn about mental health topics, are currently being explored as an opportunity to offer a variety of telehealth interventions within the current infrastructure. To increase access to videoconferencing technology for the patients, the regional OPMH services facilitated the purchase of iPads from clients’ Home Care package funds. Since some services or support provided through a Home Care Package has discontinued due to the COVID-19 crisis, clients had more money available to allow the purchase of an iPad or other electronic devices for the purpose of telehealth.

In addition, in response to limitations in client contact and discontinuation of other supportive services for the older adult, the OPMH services developed a number of resources aimed to support improved care of older adult clients. Self-help resources, tips and information sheets – tailored to the needs of the individual patient, were sent to clients, encouraging them to practice therapeutic strategies between sessions. In addition, the urban OPMH service started sending out fortnightly newsletters, providing all clients involved in their service with general information about how to look after their own mental health, and up-to-date information on the implications of the COVID-19 crisis on receiving mental health care at their service. Furthermore, as geriatric neuropsychological testing is an essential service in older adult mental health care, services have developed resources to enable remote neuropsychological assessment, which are currently being finalized for implementation.

Directions for the future

The COVID-19 pandemic rapidly increased the focus on technology-enabled mental health provision in OPMH services across Sydney. While telehealth technology and its use are not new across the OPMH services, widespread adoption among healthcare staff and clients beyond simple telephone correspondence has been challenging. The over-dependence on IT systems as a result of the COVID-19 constraints, illustrated the insufficiency of telehealth system coordination and the technical challenges implementing telehealth as the primary modality in OPMH services. Although feelings of uncertainty and unpreparedness were some other unintended consequences of telehealth, the constraints also provided creativity amongst clients and healthcare staff. Staff and clients self-initiated education focused on developing foundational skills in the use of technology, enhancing independence and confidence.

Furthermore, several innovative self-help resources were developed by the OPMH services to provide personalized support and will continue to be used as normal services resume. The OPMH services have strengthened their connections with other older adult support services by using the limited resources available in the most effective way, thereby adapting to a constantly changing environment. To enable continued access to mental health services and to overcome barriers to services associated with the COVID-19 restrictions, the OPMH services have embraced telehealth approaches during the coronavirus pandemic. Although initial steps have been taken to implement these models in clinical practice, developing greater capacity and support to provide technology-enabled older mental health care is still needed.

References

  1. World Health Organization (WHO) (2020). Mental health and psychosocial considerations during the
  2. COVID-19 outbreak. Retrieved from: https://www.who.int/publications/i/item/mental-health-and-psychosocial-considerations-during-the-covid-19-outbreak
  3. Morrow- Howell, N., Galucia, N., Swinford, E. (2020). Recovering from the COVID-19 Pandemic: A Focus on Older Adults. Journal of Aging and Social Policy, 32:4-5, 526-535, DOI:10.1080/08959420.2020.1759758

Denise Meuldijk, Centre for Emotional Health, Centre for Ageing, Cognition and Wellbeing, Faculty of Medicine, Human and Health Sciences, Macquarie University, Sydney, Australia, 2109

Acknowledgements

Acadia Pharmaceuticals Avanir Pharmaceuticals Cambridge University Press Otsuka Pharmaceuticals
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