Tele-Health’s place in healthcare continues to evolve.
As government-mandated school closures and voluntary office shutdowns continue to mount across the country in response to the coronavirus (COVID-19) pandemic, the presence of technology and its convenience is planting yet another societal flag: Tele-Health. For a minimum of 2-4 weeks, the anticipated incubation period for the virus, students and teachers will overwhelmingly interact online through various virtual options, as will executives and colleagues who primarily conduct business digitally, in a growing number of regions across the country.
It’s time like these that the benefits of technology become most evident, especially for healthcare personnel who can utilize tele-health services to keep a safe distance from patients who may be ill while still being able to deliver effective care. Among these providers are a growing number of licensed counselors who have been seeing an increased number of patients through tele-health means, even before considering the recent dramatic impact of COVID-19. Tele-counseling (or tele-therapy) is becoming a more sought out option for those living with mental health conditions for a litany of reasons, only one of which is associated with the global health scare. With more Americans becoming more accustomed to technology having its place in essentially every aspect of their lives, and as more “digital natives” populate the healthcare space with each passing year, the rise is expected to continue.
According to statistics from the Association for University and College Counseling Center Directors, this type of service was almost unheard of among college students, whereas nearly 60 percent of today’s campuses can justify the need for tele-therapy providers. This does not appear to be a generational trend however, for a service that was once most typically utilized for acuity screening for mental healthcare. The Centers for Disease Control & Prevention (CDC) reports that since 2004, the number of tele-health “visits” among rural Medicare recipients alone increased from about 7,000 to nearly 108,000 in 2013. Additionally, the CDC anticipates the tele-health industry being a $30 billion dollar niche of the healthcare market in the near future. Growing “acceptance” and trust of technology is being credited for the growth, as is continued focus and promotion of mental healthcare as well as a perceived decreasing stigma among the population for mental health services. Those providers may be inclined to suggest tele-therapy for their patients, though various parameters should be considered.
Tele-Therapy’s Place In The Tele-Health Continuum
Lisa Henderson, LPC, a licensed professional counselor and chair with the American Counseling Association, said that a few specific set of circumstances come to mind when she thinks about how impactful tele-counseling can be in today’s environment. “One patient who is now seeing a counselor via tele-health said that between having a high-pressure job, three active children, and a clinician who was often running behind schedule due to increasing demand for counseling services, she had to stop going to counseling even though she knew she was not finished with treatment. But when she started with tele-health, all of those barriers were resolved.”
From a clinical standpoint, tele-counseling has reportedly been effective for patients who’ve been diagnosed with a variety of conditions, from mood disorders and anxiety to depression and personality disorders, depending on severity and the patient’s preferences. Henderson, who also serves as adjunct faculty at Vanderbilt Peabody College and is past president of the Tennessee Counseling Association, believes that a few key parameters exist for determining an individual’s appropriateness for tele-therapy versus in-person treatment, when allied professionals are considering referral for tele-health. “The three things that need to be considered are 1) patient preference; 2) access to technology; and 3) appropriateness for outpatient care.” A patient’s preference could be born out of a variety of reasons, including a willingness to share more intimate, personal thoughts when there’s a screen to “buffer” the experience or a less-intense example as an actual transportation barrier. “One patient recently told us that the closest mental health provider was more than an hour away and there was no way she could attend regular sessions,” Henderson said. “With tele-health, she has access to a pool of clinicians, not just the closest one, and so she has been able to attend sessions regularly.”
Tele-Health’s Pros & Cons For Patients & Providers
With the market for tele-counseling services still being established, providers and researchers are weighing various positives and negatives related to both patients and providers. “Tele-health saves patients time and money, making mental healthcare more accessible,” Henderson said.
From the provider perspective, Henderson believes there is reduced the potential of a “no-show” or reschedule appointments with tele-health, among other benefits. “In-person no-show rates average 20 percent, which is lost income for the clinician in private practice or lost revenue for the organization a clinician works in,” she said. Tele-health companies report no-shows and missed sessions in the single-digit percentages. This improves continuity of care and protects the financial health of the provider.” Henderson said she personally notices a more comfortable atmosphere when it comes to note-taking during tele-counseling. “Because you are already looking at your computer screen, it’s less distracting to the patient to take notes,” she said. “I can say to my client, ‘Here’s how I’ve captured that, does it sound right to you?’ It’s reflective listening in a way that is administratively efficient and demystifies for the patient what goes into their notes. This saves time outside of session, increases the accuracy of your notes, and turns notes into a clinical tool rather than an administrative burden.”
Mutually, both sides will see less of a time commitment, Henderson estimates. “A 45- or 60-minute [in-person] session can take 2-3 hours out of someone’s day by the time they stop what they are doing, drive to the office, park, wait for the session to start, drive back to home or office, and get back to what they were doing,” she said.
Other advantages that some see to the tele-health option include the immediate and spontaneous ability to reach out when in crisis and not generally having to wait periods of days or even weeks to get a scheduled session. Gary Vonk, president of Keiser University’s campus in West Palm Beach, FL, a school that has reportedly entered into a tele-therapy contract, has been quoted as saying that he believes the speed at which a supportive provider can be accessed can be a source of needed comfort in and of itself.
There are some reported tradeoffs and difficulties associated to meeting with patients online, of course. “There are interpersonal and logistical challenges in meeting a patient strictly through tele-health,” Henderson said. “The interpersonal challenges can be overcome with training and practice, by putting yourself in the position of the patient.” Still, some patients will not be comfortable with tele-health, and if they don’t have access to a device for tele-therapy, that can be very restricting. “If someone uses a shared phone and might not have access to it at the time of a session, or they are on a limited data plan, clinicians should consider if tele-health is a dependable means,” Henderson said. “They might determine that tele-health is not the best option. Otherwise, if the patient is appropriate for outpatient care, they are most likely appropriate for tele-health care.
There are also purely technical considerations that have to be made in order for tele-therapy to be effective, Henderson said. “Things like the angle of the camera, movement of the camera, internet and network connections, lighting, having enough battery power, and ensuring a confidential environment where the recording is happening [are all factors],” she said. “The patient needs to know that they are in a private, confidential location.” Advocates of tele-therapy might see the service as supplement, or steppingstone, even when considering it’s an alternative for those who are uninterested in in-person meetings due to such reasons as stigma.
What The Future Holds for Tele-Health
Henderson envisions a few potential scenarios moving forward for tele-therapy. “I see the most effective technologies being used to support the work of counselors. In the education and training area, some universities are already building virtual reality and simulation programs to give counseling students experiences of dangerous or high-pressure clinical situations. Patient care delivery might include support tools for diagnosing and guiding care plans, accessing available community resources that are part of that plan, connecting vetted peer-support networks, delivering interventions to when and where they are needed, artificial intelligence that can look at unstructured data across health service lines and detect mental health conditions, and augmented reality to prepare for discharge or transition to another level of care.
Henderson does not suspect that in-person counseling will be replaced. “What makes counseling effective is the relationship between the person delivering care and the person receiving it,” she said. “As technologies continue to advance, we’ll see incredible innovation and efficiencies in delivering mental health services and counseling. However, we’ll also see some missteps and abuses of these technologies. We’ll see patients who have been harmed in some way through technology or the abuse of it. We’ll see people who aim to go ‘off the grid,’ not be more connected to technology. For them, in-person counseling will always be the best form of care. She also anticipates that demand for this modality will continue to increase. “There does seem to be a greater demand for counseling services today for several reasons,” she said. There are many initiatives to meet the increasing demand including recruiting more people into the mental health field, expanding mental health providers, including peer support and certified coaches, and innovation in mental health care.