Table 4 Implementation strategies and outcomes for each study included in this review
From: Implementation strategies for telemental health: a systematic review
Author (year) | Implementation strategies used (ERIC Categories) | Implementation outcomes |
|---|---|---|
Adler et al (2013) b [20] | Provide Interactive assistance Staff had monthly communication with therapists and met with clinical leaders every other month to discuss progress Train and educate stakeholders Therapists completed online training and attended a video presentation by a psychotherapist with experience of TMH | Acceptability (Clinician views) Adopters reported that TMH was not as difficult or disruptive as they thought and were surprised by veteran acceptance of the approach. However, some clinicians reported little interest in using TMH Feasibility Reported barriers included clinical demands, staff shortages, scheduling problems and equipment failures Sustainability Two clinicians were offering TMH after 10 months. In many cases, clinical leaders had not acknowledged TMH as a priority |
Baker-Ericzén et al. (2012) b [21] | Adapt and Tailor to the Context The model used centrally located bilingual, bicultural Mexican–American mental health advisors to adapt to the cultural context and address barriers Develop Stakeholder Interrelationships The model was designed to facilitate communication between primary care and mental health services using a mental health advisor | Acceptability (Service user and carer views) 97% of mothers reported overall satisfaction with the intervention and 100% rated the quality of the mental health advisor as high Fidelity Mental health advisors were trained using standardized procedures and followed a written treatment manual and study protocol. Fidelity ratings were 83% |
Chen et al (2021) b [22] | Use Evaluative and Iterative Strategies Quality improvement data was gathered to allow rapid identification of problems and adjustments to be made Adapt and Tailor to the Context Services were developed for TMH delivery based on a review of the literature and consultation with clinicians with previous experience of TMH Train and Educate Stakeholders TMH was integrated into the existing Psychology training programmes, with the goal of offering TMH training to all existing Psychology training programmes within the next three years Support Clinicians Five new psychologists were hired for the main hub, weekly calls were set up between spoke sites and hub staff to establish the services. One staff member served as the primary point of contact for each spoke | Adoption Within five months the service reached its preestablished productivity goals of 80 veteran encounters per month, per provider for the first year Penetration From March 2017 to January 2018, 377 consults were received for TMH psychology services and 252 veterans engaged in TMH services. However, 32% did not receive treatment due to a variety of reasons, such as disengagement or discharge prior to services being offered |
Felker et al. (2021) [23] | Provide Interactive Assistance Training courses and workshops to address the specific practical aspects of providing TMH. Clinicians were encouraged to engage in TMH with at least 2 patients and attend at least 10, 1-h consultation calls to ask questions related to TMH (clinical or implementation issues) Adapt and Tailor to the Context Internal facilitators from each team provided consultation to external facilitators regarding the unique clinical and cultural aspects of their team (e.g. patients served, types of services provided, administrative needs, technological needs). External and internal facilitators tailored the TMH training programme to address clinic specific culture and barriers and meet unique clinic goals Train and Educate Stakeholders Clinical champions and team leads supported training and implementation of TMH | Acceptability (Clinician views)a Following the training, 95% of providers agreed (n = 42) or strongly agreed (n = 35) that they were satisfied with the training provided Adoptiona Providers reported increased knowledge, skills and interest in TMH after training Appropriatenessa 95% of providers agreed (n = 50) or strongly agreed (n = 28) that the amount of information covered was sufficient to begin using TMH. 76% of participants agreed (n = 45) or strongly agreed (n = 17) that they felt confident using TMH after receiving training Feasibility Barriers identified included: lack of patient interest (45%), administrative burden (20%), preference for in-person appointments (18%), concern about increased workload (11%), not completed all of the training components (6%), lack of supervisor support (4%), lack of provider interest (4%), and other reasons (4%) |
Hensel et al. (2020) [24] | Adapt and Tailor to the Context Initial survey of barriers allowed implementation to be tailored to the specific challenges identified by staff Develop Stakeholder Interrelationships Worked with emergency departments to establish support staff available to assist with referral. Implementation leads were appointed at site and leadership at all levels were engaged in the programme. Clinical champions with TMH experience encouraged staff engagement Train and Educate Stakeholders Education, anecdotes and evidence review from experienced providers. Initial training of a core group to develop expertise was conducted to build group confidence before engaging a larger cohort of providers. Training was offered to inexperienced providers Engage Consumers Clear explanations were given to patients and families regarding the TMH programme Utilize Financial Strategies Existing fee schedules were reviewed to support physicians and psychiatrists were salaried to avoid renumeration challenges. They also worked with regional authorities and hospitals to secure funding when needed Change Infrastructure They worked with participating emergency departments to install dedicated equipment where possible or make arrangements regarding existing equipment | Adoption In the first year of operation, 243 assessments were completed Workload increased by 42% between the 6 months pre-programme and the second 6 months of programme operation. There was a 2% increase in presentations at the hub, and some increase in workload from the spokes which saw declines in on-site support and an 8% increase in total mental health and addiction presentations. The percentage of transfers avoided increased from 0% pre-programme to 65% in December 2018 |
Lindsay et al. (2015) b [25] | Provide Interactive Assistance Technical support was provided through weekly consultation calls with a facilitator to discuss technical and logistical issues specific to the delivery of TMH Adapt and Tailor to the Context Site-specific implementation plans were tailored to unique needs of the site including needs of stakeholders Train and Educate Stakeholders Intensive training in evidence-based practice for PTSD was provided to providers including an experientially orientated 2–3-day workshop and weekly consultations with experts | Acceptability (Clinician views)a Therapists reported a high degree of satisfaction and rated the external facilitation model as very helpful in their efforts to implement video telehealth (6.67 out of 7), viewing the regular facilitation calls as very important to establishing video telehealth services Penetration Compared to baseline, participating sites averaged a 6.5-fold increase in psychotherapy sessions conducted via TMH, whereas non-participating sites averaged a 1.7-fold increase |
Lynch et al. (2020) [26] | Use Evaluative and Iterative Strategies In response to reports of problems with maintaining attention in virtual sessions, clinicians problem solved with clients to minimise distractions, used screen sharing features and interactive activities, and provided additional brief breaks when needed Provide Interactive assistance Virtual training on the features and functionality of telehealth platforms were provided to staff Support Clinicians Factors to support and capture work from home productivity were considered for staff Engage Consumers Individualized instruction about telehealth platforms were provided to service users as needed | Adoption TMH acceptance rates indicated that 90% (n = 18) of the 20 patients enrolled at the time of conversion agreed to TMH sessions within ten days of the service transition and maintained their specific treatment plans virtually. An additional five service users began using TMH after the start of the study. There were no significant differences in attendance rates before conversation to TMH, and no differences in acceptance between the TMH and non-TMH group Feasibility Following conversion to TMH, participants and clinicians sought to maintain individualized treatment plans and group schedules whenever possible, which may have contributed to the high acceptance rates and unchanged service utilization |
Lynch et al. (2021) [27] | Use Evaluative and Iterative Strategies The service responded to challenges identified by staff with new implementation strategies Adapt and Tailor to the Context Group session material was adapted to be engaging on virtual platforms Develop stakeholder interrelations In addition to formal systems that were put in place to ensure consistent communication (e.g., end-of-day email debriefs), staff had increased support from supervisors to facilitate both client care coordination and opportunities for staff to “support each other as individuals.” Engage Consumers Through a collaborative approach some service users who were challenged by TMH helped the team to come up with web etiquette guidelines for other service users Change Infrastructure The proactive culture at the clinic helped rapid transition to TMH and aided continuity of care. Resources, workflows and infrastructure were developed in anticipation of regulatory change, rather than in response | Acceptability (Clinician views) Though staff perceived the shift to TMH as slightly more challenging for themselves than for clients, they reported learning to navigate the technology and virtual interaction fairly quickly However, TMH negatively impacted staff’s ability to communicate with each other, due to the lack of informal contacts. ‘Zoom fatigue’ and exhaustion were also reported by staff Acceptability (Service user and carer views) All respondents who completed the questionnaire (n = 18) provided a score > 23, suggesting satisfaction with the TMH services. However, 78% of respondents stated that they would still prefer in-person sessions if there were no health risks. Only 50% reported feeling that TMH was as good as in-person sessions Adoption 93% of service users enrolled at the time of conversion agreed to maintain their specific treatment plans virtually. 7% opted out. Session attendance did not significantly differ over time or between in-person and TMH formats. The mean no show/cancellation rate was 37% less at 13–18 weeks after implementation of TMH compared to in-person (B = -.47, p < 0.05) Appropriateness TMH was deemed appropriate because of its increased flexibility to adapt scheduling to client capacity for engagement, e.g. offering shorter, more frequent breaks, or reducing session duration but increasing frequency. However, staff raised concerns that for some service users, long-term TMH utilization may hinder recovery, as the routine and engagement associated with traveling to a clinic may enhance treatment investment and pro-health behaviours Feasibility Staff found TMH more challenging for clients who had technology or gaming addictions, or symptoms associated with attention deficit hyperactivity disorder or autism Fidelity Staff noted that group dynamics in virtual sessions were largely positive and similar to in-person sessions, with clients interacting with one another and not responding solely to the group leader |
Myers et al. (2021) [28] | Provide Interactive Assistance TMH champions assisted with enrolment into the TMH system, procurement of equipment and completion of a systems check (e.g., test calls, quality check of audio and visual issues) Develop Stakeholder Interrelationships Site champions (with previous experience or trained for leadership roles) were utilised to support implementation Train and Educate Stakeholders The TMH champions assisted with mandatory training of policy and procedures, and with selection criteria for determining appropriateness of treatment via TMH | Adoption The site failed to address lack of internet or phone access for service users, which affected implementation. However, use of TMH was increased by 42% Appropriateness TMH was considered appropriate other than for suicidal or psychotic individuals. Lack of appropriateness for these service users, however, limited the ability to provide crisis support Feasibility Providers reported concerns about the feasibility of TMH: 1) it reduced their ability to respond to emergencies (e.g., responding to suicidal patients); 2) it may not be feasible for some veterans considered “too high risk” or unstable; 3) some veterans were not respecting therapeutic boundaries (e.g., trying to engage in treatment sessions while driving); 4) too much time was lost attending to technical issues; and 5) difficulty in delivering measurement-based care Implementation Costa The main cost was time-related (the role of site champion was unpaid) Sustainability Sustainability of TMH may vary by site, depending on organisational constraints (administration, other role commitments which may inhibit implementation and ongoing support) It is unclear if all providers should be “telehealth generalists” or if TMH should be a speciality |
Owens & Charles (2016) [29] | Use Evaluative and Iterative Strategies Clinicians and service users worked closely with the research team and software developers through a series of three iterations or feedback loops to optimise the intervention and assess whether it was sufficiently likely to normalise to be worth evaluating in a full trial Develop stakeholder interrelations Three clinicians in each team supported and mentored each other for the duration of the study and cascaded knowledge through the team, influencing others to adopt the intervention | Acceptability (Clinician views) Clinicians saw it as a potentially valuable tool to help young people manage their self-harming behaviour Adoption The most significant barrier to adoption was the need for buy-in at management levels and the time it took to obtain this Feasibility CAMHS teams reported being under very high pressure which negatively affected their ability to be involved in new projects Appropriateness In the context of very heavy caseloads, high stress levels and exhaustion, the effort involved in mastering a new technology and incorporating it into everyday practice was perceived to be too much by clinicians. Although some reported that they were using apps of various kinds with their clients, others appeared to be resistant to technological interventions. Nearly all informants believed that CAMHS was not the ideal delivery setting as clinicians see only the most acute and complex cases and duration of contact with CAMHS is typically short |
Puspitasari et al. (2021a) [30] | Train and educate stakeholders Counsellors attended weekly consultation meetings facilitated by a clinical psychologist to ensure treatment adherence and fidelity. All disciplines attended daily meetings to discuss safety management and patient progress Engage Consumers Service users who were accepted into the programme received assistance from programme staff and information technology support staff to prepare for the first TMH session. Each group was led by two counsellors: one as the primary facilitator leading the presentation and group discussion, the other assisting patients with any technological issues | Adoption The completion rate of the programme was 70/76. This completion rate was higher than typical completion rates for psychiatric Intensive outpatient or partial hospitalization programmes Feasibility Zoom features (including chat, whiteboard, shared screen and waiting room) improved feasibility. It was also feasible to conduct psychotherapy experiential exercises via videoconferencing, e.g., performing guided group mindfulness exercises, completing psychotherapy forms, and watching psychotherapy skills videos |
Puspitasari et al. (2021b) b [31] | Use Evaluative and Iterative Strategies A staged implementation strategy was used where the TMH group intervention was first piloted in one site, which indicated readiness for TMH implementation, openness among clinicians and availability of resources. Challenges faced during the TMH rollout were informally assessed and communicated to team members for efficient problem solving Provide Interactive Assistance A multi-disciplinary TMH committee coordinated the change to TMH and ensured clinicians had access to necessary technology. All clinicians had 24/7 access to the IT help desk for additional support. An operations manager coordinated the preparation, adoption, and implementation phase. This individual was responsible for managing the workflow and engaging other stakeholders within and outside of the department to ensure a smooth transition to teletherapy. Quick reference guides were also created for clinicians to help them adapt to TMH Adapt and Tailor to the Context The committee met twice weekly for the first month during the most rapid phase of implementation to review, update and expand upon existing training resources, guidelines, and policies. Due to the closing of many behavioural health services in the surrounding area and increased need for intensive outpatient care, the service expanded capacity and added an additional intervention for patients suffering with mood and anxiety disorders Develop Stakeholder Interrelationships TMH champions were identified (including directors, an operations manager, committee members, IT specialists, and several clinicians with TMH experience or enthusiasm). These champions were fully integrated into the team to provide adequate support for its other members. Daily virtual meetings attended by all staff allowed discussion of patient progress and issues Train and Educate Stakeholders Education, training, and ongoing supervision were integral implementation strategies prior to TMH adoption | Adoptiona Education, training, and ongoing supervision were of particular importance at the start of teletherapy implementation to support clinicians’ successful engagement with the technology, as well as to establish an effective practice for virtual therapy Feasibility Data on patient attrition indicated that TMH was feasible to assure patient retention, since many service users completed the programme and the average number of sessions attended was high Penetration A plan was established by the pilot site to initiate full implementation following the pilot |
Sharma et al. (2020) b [32] | Use Evaluative and Iterative Strategies Pilot tests were conducted with three small groups of parents, with satisfaction surveys resulting in a change of platform Provide Interactive Assistance A brief technical guide was provided to all clinicians after group TMH training sessions to assist in their subsequent TMH clinics. A “cheat sheet” was developed to help the clinician guide families through the process of setting up their home systems and responding to the e-invite for a TMH session Adapt and Tailor to the Context Each day the faculty analysed and adapted to latest government rules regarding stay-at-home mandates and patient and staff needs Train and Educate Stakeholders Videoconferencing training sessions were run to quickly train staff on the online platform and clinical aspects of TMH Engage Consumers If a family was not able to participate in TMH due to lack of internet access, then a phone appointment was offered to ensure equity | Adoption Failure of the outpatient videoconferencing platform delayed full home-based TMH adoption Feasibility This study demonstrates the feasibility of rapidly building upon an existing telemedicine infrastructure to train a large group of multidisciplinary providers to deliver urgent home-based TMH services. However, the key message is that even with a well-established telemedicine infrastructure, programmes must expect to encounter serious challenges during crises. Planning for the next crisis should start now Implementation Cost Funding fell dramatically after transitioning patients from clinic to home. Interim phone appointments while awaiting full implementation of TMH services yielded less revenue per appointment than in-clinic or TMH appointments, although required the same amount of time and almost the same level of documentation by the faculty Penetration After 1 month, TMH was offered to all established outpatients for individual visits and the clinic started a trial process for enrolling new patients. Continued work on expanding TeleGroups occurred. Only the crisis clinic continued a regular in-clinic presence Sustainability The faculty’s relatively rapid but complex development of clinic-wide home-based TMH and TeleGroups was reported to help to advance and increase access to psychiatric care. Authors argued that in the future, home-based TMH may help overcome barriers to treatment such as distance, transportation and scheduling |
Taylor et al. (2019) [33] | Use evaluative and iterative strategies A pilot project established the efficacy of the intervention in improving the skills and knowledge of local health service providers but identified a need for additional clinical support in specialist areas. This was therefore integrated into the model Develop Stakeholder Interrelationships As a result of the pilot project, General practitioners (GPs), mental health professionals and other service providers were offered access to secondary consultations with perinatal and infant psychiatrists. The service also employed a clinical facilitator who was responsible for service promotion, site visits, staff education and training, co-ordinating case conferences and video consultations | Acceptability (Clinician views) Mental health workers who had used TMH were unanimously complimentary about the service, reporting that it allowed expert input into care planning, reduced professional isolation, upskilled remote workers and provided a sense of security for remote care providers Appropriateness The study showed that TMH can help address unmet need for specialist mental health services in regional, rural and remote areas Sustainabilitya Clinical facilitation is likely to be more important in intermittent compared with high-volume services where regular clinics can make TMH more visible. Ongoing facilitation is necessary for the sustainability of TMH services due to intermittent demand and local impediments, such as fragmentation of service providers and transiency of the workforce |