Post COVID-19 Re-entry with Blended/Hybrid Telehealth

By Eugene F. Augusterfer and Richard F. Mollica

First, let us start by defining blended or hybrid telehealth. As the name suggests, blended or hybrid telehealth is a combination of traditional face-to-face clinical encounters blended with virtual or telehealth encounters. When possible, it is best to have an initial meeting face-to-face, then move to telehealth meetings. Studies and experience have demonstrated that while using telehealth, occasional face-to-face meetings mixed with telehealth meetings is more efficacious. “New patient visits, even those that perhaps are safe to perform virtually, may benefit from face-to-face encounters to familiarize patients with their care and build a trusting relationship”.1 (Reeves JJ, Ayers JW, Longhurst CA, Telehealth in the COVID-19 Era: A Balancing Act to Avoid Harm, J Med Internet Res, 2021 Feb; 23(2): e24785).

The authors fully recognize that certain circumstances, such as, the COVID-19 pandemic, often precluded face-to-face meetings. As we hopefully begin to exit the COVID protocols which required mostly telehealth meetings, the blended/hybrid model is one that has merit.

The use of telehealth in the mental health field had its start in 1959 with the Nebraska Psychiatric Institute using early videoconferencing to provide group therapy, long-term therapy, consultation-liaison psychiatry, and medical student training at the Nebraska state hospital in Norfolk. In 1969, Massachusetts General Hospital at Harvard provided psychiatric consultations to adults and children at a Logan International Airport health clinic, mostly for anxiety related to fear of flying. During the 1970s-80s the use of telehealth became increasingly common, expanding to most diagnostic and therapeutic patient encounters. Telehealth continued to grow reaching under-served and difficult to reach populations during the 1990s and early 2000s. However, the use of telehealth expanded rapidly with the arrival of the COVID-19 pandemic. The pandemic brought a rapid pivot to the use of telehealth for most medical and mental health providers. For many providers, and patients, this was their first use of telehealth. Studies of the use of telehealth during the pandemic indicate that telehealth was a useful and satisfactory substitute for face-to-face therapy. “A study of 596 telehealth users, the majority of respondents (n=369, 61.9%) stated that their telehealth experience was “just as good as” or “better than” their traditional in-person medical appointment experience. On average, respondents perceived that telehealth would be moderately useful to very useful for medical appointments after the COVID-19 pandemic ends”.2 (Isautier JM, Copp T, Ayre J, Cvejic E, Meyerowitz-Katz G, Batcup C, Bonner C, Dodd R, Nickel B, Pickles K, Cornell S, Dakin T, McCaffery KJ People’s Experiences and Satisfaction With Telehealth During the COVID-19 Pandemic in Australia: Cross-Sectional Survey Study, J Med Internet Res 2020;22(12):e24531 doi: 10.2196/24531(link is external)).

As we move out of the isolation brought on by COVID-19 lockdowns, we need to consider best-practices in terms of blended, or hybrid, models of telehealth. Moving back to face-to-face encounters with our patients/clients is welcome for a number of reasons, however, one can argue that telehealth should continue to have an important role in the delivery of care, especially as a blended, or hybrid model. Long before the pandemic, studies have supported the blended/hybrid model of mental health care.3 (Augusterfer EF, Mollica RF, Lavelle J. Leveraging Technology in Post-Disaster Settings: The Role of Digital Health/Telemental Health. Current Psychiatry Reports, 2018 Aug 28;20(10):88. doi: 10.1007/s11920-018-0953-4).

While a complete review of the literature on the use of telehealth in the mental health and primary care fields during the pandemic is beyond the scope of this brief article, there are a large number of studies supporting the important use and lessons learned regarding the use of telehealth for mental health care during this extraordinary time. To state the obvious, none of us have lived through a period like the current pandemic while doing our best to care for our patients/clients. Telehealth has been an important tool to help us stay connected with our patients/clients during these troubled times.

In terms of the use of blended or hybrid telehealth, a question often is asked, is there a recommended ratio of face-to-face and telehealth visits. There is no simple answer as the frequency of visits is determined by the patient/client’s condition. For example, a highly anxious person may benefit from more frequent visits, including face-to-face. Whereas a person who is more clinically stable may do well with less frequent face-to-face visits. It is also important to remember that persons with certain conditions are not as suitable for telehealth visits as others, for example, a patient with acute paranoid delusions may have difficulty trusting a telehealth/virtual visit. However, for most people, telehealth is a very good alternative to face-to-face, as supported in the published literature.

In conclusion, a number of thoughts to keep in mind as we move towards the post-COVID environment, such as, telehealth is an effective tool for meeting the clinical needs of our patients/clients, telehealth allows providers to reach a broad geographic population4 (The Death of Distance, Frances Cairncross, 1997), the time and money saved by patients/clients is an important factor 5 (Shore JH, Brooks E, Savin DM, Manson SM, Libby AM. An economic evaluation of telehealth data collection with rural populations. Psychiatry Services. 2007 Jun;58(6):830-5. doi: 10.1176/ps.2007.58.6.830. PMID: 17535944), and telehealth has helped us connect with colleagues and it assisted in providing supervision and/or consultation when needed.6 (Augusterfer EF, O’Neal CR, Martin SW, Sheikh TL, Mollica RF. The Role of Telemental Health, Tele-consultation, and Tele-supervision in Post-disaster and Low-resource Settings, Current Psychiatry Reports, 2020 Nov 28;22(12):85. doi: 10.1007/s11920-020-01209-5. PMID: 33247315; PMCID: PMC7695585).

Lastly, here are links to a few papers on telehealth during COVID.

• State Medicaid & CHIP Telehealth Toolkit(link is external) 
• Telehealth: Delivering Care Safely During COVID-19(link is external)
• A Systematic Literature Review on e-Mental Health Solutions to Assist Health Care Workers During COVID-19(link is external)
• Realising the Potential of Digital Psychiatry(link is external)

References:

1. Reeves JJ, Ayers JW, Longhurst CA, Telehealth in the COVID-19 Era: A Balancing Act to Avoid Harm, J Med Internet Res, 2021 Feb; 23(2): e24785.
2. Isautier JM, Copp T, Ayre J, Cvejic E, Meyerowitz-Katz G, Batcup C, Bonner C, Dodd R, Nickel B, Pickles K, Cornell S, Dakin T, McCaffery KJ People’s Experiences and Satisfaction With Telehealth During the COVID-19 Pandemic in Australia: Cross-Sectional Survey Study, J Med Internet Res 2020;22(12):e24531 doi: 10.2196/24531(link is external)
3. Augusterfer EF, Mollica RF, Lavelle J. Leveraging Technology in Post-Disaster Settings: The Role of Digital Health/Telemental Health. Current Psychiatry Reports, 2018 Aug 28;20(10):88. doi: 10.1007/s11920-018-0953-4.
4. Cairncross F, The Death of Distance, 1997, Harvard Business School Press.  
5. Shore JH, Brooks E, Savin DM, Manson SM, Libby AM. An economic evaluation of telehealth data collection with rural populations. Psychiatry Serv. 2007 Jun;58(6):830-5. doi: 10.1176/ps.2007.58.6.830. PMID: 17535944.
6. Augusterfer EF, O’Neal CR, Martin SW, Sheikh TL, Mollica RF. The Role of Telemental Health, Tele-consultation, and Tele-supervision in Post-disaster and Low-resource Settings. Current Psychiatry Reports, 2020 Nov 28;22(12):85. doi: 10.1007/s11920-020-01209-5. PMID: 33247315; PMCID: PMC7695585.