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VA Telehealth Services — Reducing Health Care Disparities for Veterans With Mental Health Challenges

By Anna Panzo, MSW, LCSW

In the 21st century, constant improvements in technology have reshaped the provision of mental health supports. With a plethora of apps, YouTube videos, and websites, there are a wide variety of self-help services and resources available to anyone with a smartphone or an internet connection. Nevertheless, these resources cannot replace the benefits of clinical treatment. Unfortunately, those with a mental health diagnosis often face multiple barriers to obtaining that treatment. Contributing factors preventing them from seeking mental health care can include social stigma, transportation or distance, and family responsibilities. Furthermore, symptoms caused by the diagnosis can also present a challenge—people with high anxiety, for example, could struggle to leave their home.

The VA has leveraged 21st century technological advances to assist in overcoming treatment barriers and decreasing disparities in mental health care provision for veterans. VA medical centers utilize telehealth video-to-home (VTH) services to provide care to veterans with mental health diagnoses. Through the use of this technology, VA clinicians are able to conduct at-home therapy and evaluation sessions with veterans.

Breaking Down Barriers
Jan Lindsay, PhD, director for TeleBehavioral Health at the South Central Mental Illness Research Education and Clinical Center, a licensed psychologist at the Michael E. DeBakey Veterans Administration Medical Center, and a research health scientist at the Center for Innovations in Quality, Effectiveness, and Safety, is on the frontier of telehealth implementation programming and research at the VA. Lindsay is based out of the VA Medical Center in Houston, which currently is a national leader in the provision of telehealth services. She is passionate about decreasing access disparities for veterans. “Roughly half of veterans who need mental health treatment don’t access care, and those who do access mental health care do not receive an adequate dose,” Lindsay says. Her work at the VA has helped to provide increased access to mental health care for veterans who are in crucial need of that support.

Terri Fletcher, PhD, a clinical research psychologist and the evaluation lead for Lindsay’s team, speaks to some of the challenges veterans face when accessing in-person care at VA locations. “There are many logistical barriers to receiving psychotherapy services in person at the VA, such as travel time, parking, arranging child care and/or time off from work … some female veterans, particularly those who experienced military sexual trauma, are uncomfortable coming in person to the VA and prefer to receive their care from home. Additionally, veterans with PTSD, obsessive-compulsive disorder, or anxiety disorders may experience severe anxiety in a large hospital setting which makes it difficult for them to receive in-person care.” Recent research conducted by Fletcher and her colleagues found that VTH services had similar outcomes as in-person care for clinical effectiveness, patient and provider satisfaction, and treatment adherence, among others. By making therapy available through at-home video sessions, veterans who otherwise might not access treatment are able to receive high-quality care.

On the Telehealth Forefront
Currently, telehealth is considered standard practice within the VA; the majority of VA medical clinics have clinicians on staff who are trained in the use of video technologies to provide VTH mental health treatment services to veterans. Lindsay acknowledges that integrating a telehealth program into complex medical systems can have its challenges. Her interdisciplinary team facilitates the provision of telehealth services through offering support in developing infrastructure, providing training, and troubleshooting these challenges. “You need to have so much support to make these changes,” she says.

Nevertheless, the changes are well worth it. In addition to increasing access to care, at-home treatment offers unique advantages and insights that traditional on-site treatment does not provide. “Psychotherapy delivered via video to the home offers patients an innovative way to engage in evidence-based mental health care they might not otherwise receive,” Fletcher says.

Veronica Siffert, LCSW, who provides VTH psychotherapy services to veterans, describes working with a veteran who struggled with hoarding: “The use of a web-based camera helped the veteran feel that I was there with them during treatment as we worked together sorting, discarding, and cleaning.” Video technology allows therapists to see and experience the veteran’s home environment, giving them a window and opportunity to provide crucial support.

Telehealth is also being used by the Veteran’s Justice Outreach (VJO) program in Houston. The VJO works with veterans who are involved in the legal system. Through the outreach program, veterans required by the veteran’s court to obtain treatment are able to receive at-home care. “Many of these veterans live far distances from the VA or clinics and must maintain employment as part of their court agreements, which makes it difficult to attend in-person appointments that are also part of their agreements. VJO has used telehealth to address these requirements to attend case management and various mental health appointments,” Lindsay says.

Mark Norris, LCSW, an outreach specialist in the program, describes telehealth as “very practical and effective.” For him, “It’s a much better assessment tool as far as my case management sessions in the veterans treatment courts, rather than a phone call … it’s much easier to remain treatment compliant using telemedicine.” Norris uses video-on-demand, which can be conducted on any device with cellular data, such as iPads and smartphones. He says, “I’ve encouraged other social workers to utilize telehealth who are dealing with veterans in outlying areas. It’s a tool to provide the services we do to veterans who cannot reasonably access the clinic or medical center here.”

The Veteran’s Health Administration (VHA) is the largest integrated health care system in the United States, and is a leader in providing telehealth services; however, less than 1% of all veterans are receiving telemental health services. However, Lindsay points out, “The VHA’s telehealth infrastructure is far more developed than the private sector. The overall number of veterans being served through telehealth services grows by huge percentages annually.”

Fletcher says, “We expect growth to continue as more providers begin to use telemedicine and more patients begin to request it.”

For clinical social workers, providing therapy through virtual care resources such as telehealth services has its benefits. Siffert describes some of the advantages that telemedicine provides to both veterans and social workers. “It increases access to care, reduces burdens for the veteran, and reduces appointment no-shows … it helps the social worker to ‘meet them where they’re at.’” Siffert shares that telemedicine also served as a bridge to in-person care for a veteran she worked with: “Behavioral activation over telehealth enabled the veteran to feel well enough to leave their home and come to the VA for appointments.”

Telemedicine is valuable not only because it makes mental health treatment more accessible to veterans but also because it provides critical support for clinicians in more remote areas, who may not have access to their peers in the same way a clinician in a major city would. The VA in Houston uses video technology to connect clinicians in rural areas to other VA mental health care providers. The Houston VA offers what they call a virtual community of practice, where clinicians virtually connect for peer consultation and support, and discuss challenges and unexpected situations that they may face. This helps providers obtain access to the professional support they need to serve their patients. Lindsay views this as helping to reduce disparities not only for veterans but also for providers. “You can’t do one without the other,” she says.

On telehealth resistance, Lindsay says, “I think sometimes people are afraid of technology because they think it’s going to take over, and rural providers will be replaced with telehealth. I do not use that approach at all; we know there’s a value to sitting in person with someone.” Instead, Lindsay sees telehealth technology as a means of augmenting the supports that rural social workers or clinicians have, and further empowering them to provide their services.

VTH telehealth care and virtual peer supports are expanding the capacity of the largest integrated health care system in America to provide crucial care to an extremely vulnerable population. As such, the VA sets a high standard for other providers seeking to reach individuals and clinicians who would not otherwise have access to mental health care or peer support. It is an exciting field and important step to providing services that are at the advancing frontier of 21st-century technology.

— Anna Panzo, MSW, LCSW, is a writer with a background in clinical social work.