TY - JOUR
AU - Rowland, Jared, A
AB - Abstract Purpose To describe the implementation and initial outcomes of a pilot interdisciplinary telehealth clinic, Allied Transitional Telehealth Encounters post-iNpatient Discharge (ATTEND), providing clinical pharmacy specialist follow-up for veterans transitioning from inpatient to outpatient mental healthcare in a Department of Veterans Affairs (DVA) hospital. Summary The ATTEND clinic’s primary intervention was providing medication management appointments through clinical video telehealth (CVT) to patient discharge locations through a DVA-provided tablet. An interdisciplinary team supported care through on-unit inpatient training, secure messaging, and self-help applications. Clinical outcomes were measured through readmission rates, wait times, self-report measures, and follow-up interview at the completion of ATTEND services. Twenty patients completed on-unit training, and 16 unique patients were seen for at least 1 outpatient appointment. Inpatient readmission rates were lower for ATTEND patients than with standard care (5% versus 19%, respectively). Wait times until first postdischarge mental health appointment were reduced by a mean of 18.6 (S.D., 8.8) days. The pharmacist made medication interventions, including dosing changes, education on incorrect administration, and medication discontinuation. Self-reported psychological symptoms decreased during ATTEND participation. Post-ATTEND interviews indicated high levels of acceptance and interest in continued tablet-based care. Primary challenges included unique technological limitations and effective care coordination. Conclusion The ATTEND telehealth clinic provided postinpatient mental health follow-up that was more prompt and convenient than conventional on-site appointments. Psychiatric self-report improved during ATTEND-facilitated transition to outpatient care, and the recidivism rate for ATTEND patients was lower than the general inpatient rate during the same time period. access, mental health, mHealth, remote, telemedicine, veterans KEY POINTS This allied telehealth clinic provided veterans with tablet computers to aid in the transition between acute inpatient mental health treatment and outpatient treatment. The clinical pharmacist conducted medication management appointments through clinical video telehealth to the veteran’s discharge locations. Veterans who participated in the clinic were seen more promptly for their postdischarge medication management appointment, were less likely to be readmitted to the inpatient unit relative to unit recidivism rates over the same period, and reported a decline in their psychiatric symptoms. The clinic helped veterans overcome barriers to care, including transportation issues, work conflicts, and travel-related anxiety. The importance of follow-up outpatient care after acute inpatient mental health treatment has been well established, with a lack of attendance at postdischarge appointments being associated with a twofold increase in readmission rate and decreased quality of life.1 Research has suggested that a variety of factors decrease participation in follow-up care, including housing instability, transportation problems, distance from clinic, forgetting to attend appointments, driving-related anxiety due to posttraumatic stress disorder (PTSD), poor referral communication, and difficulty arranging time off work.2 These barriers to treatment can be at least partially circumvented by reducing a veteran’s need to travel to postdischarge appointments by providing them access to care from a distance. Clinical video telehealth (CVT) makes this possible by allowing veterans to participate in virtual health appointments from any location with sufficient privacy, such as their home.3 At the W.G. (Bill) Hefner Veteran Affairs Health Care System (VAHCS) in North Carolina, mental health clinical pharmacy specialists provide comprehensive medication management services under an approved scope of practice and a care coordination agreement between the pharmacy and mental health department. The mental health clinical pharmacy specialists have supervising psychiatrists and provide direct patient care services for the mental health department. The outpatient mental health clinical pharmacy specialists have a postdischarge mental health clinic to improve access to care.4,5 The no-show rate of veterans prompted an exploration of CVT services for patients following acute inpatient mental health treatment through the development of an interdisciplinary team. The primary goal of the team was to create a pathway for patients to access their postacute inpatient clinical pharmacy appointments remotely. Background The W.G. (Bill) Hefner VAHCS serves over 92,000 veterans. It is composed of a tertiary care facility with an acute psychiatric unit, healthcare centers located in Charlotte and Kernersville, and a community-based outpatient clinic in Charlotte. Mental health clinical pharmacy specialists provide services through postdischarge clinics located at the Salisbury VA Medical Center and the Kernersville healthcare center. Department of Veterans Affairs (DVA) policy mandates that veterans receive a face-to-face appointment after they are discharged from an inpatient mental health unit. The DVA has highlighted the need for prompt and convenient access to providers across the healthcare system, with the recent “My VA Access Declaration” specifically highlighting the value of telehealth for enhancing care provision options towards this end. With the goal of reducing no-show rates for postdischarge appointments, a proposal was formed through collaboration between a mental health clinical pharmacy specialist and a Mental Illness Research, Education and Clinical Center (MIRECC) fellow with expertise in technology-mediated intervention. The core of the intervention was the facilitation of CVT appointments for patients in their home or another private location while the provider was located at their medical site. The proposal, formally titled Allied Transitional Telehealth Encounters post-iNpatient Discharge (ATTEND), was awarded a clinical core grant through the Veterans Integrated Service Network 6 MIRECC program to perform a clinical quality improvement project. This project was confirmed to be nonresearch by the W.G. (Bill) Hefner VAHCS research office and was therefore exempt from institutional review board review. Veterans were loaned DVA-provided Android tablets with 4G wireless Internet access for the course of their participation in ATTEND services. These tablets were provided by the VA Denver Acquisition and Logistics Center (DALC). The clinical pharmacy specialist used standard CVT equipment furnished by the local telehealth office (desktop computer with a high-definition webcam and high-speed connection) to connect with the veteran. Using this technology, the pharmacist would “call” the veteran’s tablet and the veteran would accept the call. Synchronous (real-time) audio and video communication between the pharmacist and patient was viewed on the tablet and monitor, respectively. Implementation In the development of the ATTEND clinic, the team worked with the local telehealth coordinator to ensure adherence to local policies and procedures (including emergency/risk management procedures aligned with the institution’s current policy). The clinical team consisted of a clinical pharmacy specialist, clinical psychologist, registered nurse, and psychology technician. The clinic had a supervising psychiatrist who reviewed the clinical pharmacist’s notes and helped address relevant medical issues. The clinical pharmacy specialist provided CVT medication appointments and motivational interviewing to support movement towards established goals postinpatient discharge. The clinical psychologist managed technical training and intake processes and provided secure messaging/ATTEND discharge support. The registered nurse facilitated care coordination with the inpatient unit. The psychology technician trained the patient on the technology used in the clinic. All staff completed necessary telehealth trainings regarding relevant clinical challenges, risk management processes, and federal- and DVA-specific regulations. The local telehealth coordinator created a telehealth clinic, and the prescribing clinical pharmacy specialist obtained privileges to place DVA tablet consults. The local MyHealthEVet coordinator certified 2 members of the team to authenticate veterans for the service while on the inpatient unit (which facilitated secure messaging with the ATTEND team). A secure file system (SharePoint; Microsoft Corporation, Redmond, WA) was used to track tablets and the patients’ transitions of care. To be eligible for ATTEND services, veterans were required to be referred for outpatient mental health treatment within the W.G. (Bill) Hefner VAHCS catchment area, not be designated for transfer to a different inpatient unit, be discharging to a location with high-speed wireless local area networking or 4G cellular Internet access, demonstrate competence in the use of telehealth technologies through successful completion of on-unit training, and not have substantial legal problems noted in the medical record. ATTEND services included the following 3 phases: (1) on-unit screening, orientation, intake, and training; (2) postinpatient discharge appointments and support; and (3) transition to standard outpatient care and discharge from the clinic. Self-report measures were administered during phases 1 and 3 and included a questionnaire developed for the clinic to understand patient perceptions and familiarity with telehealth technology (Perceptions of Health Technology Questionnaire), the Hogan Drug Attitude Inventory to assess perceptions of pharmacological intervention, the Patient Health Questionnaire-9 and Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Level 2-Depression-Adult (DSM Level 2 Depression) to evaluate depressive symptoms, the Generalized Anxiety Disorder-7 and DSM-5 Level 2-Anxiety-Adult (DSM Level 2 Anxiety) to evaluate symptoms associated with anxiety, and the Posttraumatic Stress Disorder Checklist for DSM-5 to evaluate symptoms associated with PTSD. The overall level of psychiatric burden was estimated using the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure-Adult (DSM Level 1). All measures were consolidated into a single electronic survey. On-unit screening, orientation, intake, and training Preliminary patient enrollment was conducted on the unit weekly (typically by the ATTEND nurse) through attendance at inpatient treatment team meetings, communication with unit providers, and chart review of the admitted patients. Candidate patients were screened by an ATTEND staff member during an in-person visit on the unit. Eligible veterans completed clinically relevant self-report measures on a DVA-provided tablet using software approved for use within the DVA (after being approved by local privacy and information security officers). While on the unit, patients completed all paperwork required to participate in CVT appointments (i.e., identification of an alternate contact near the patient’s discharge/CVT appointment location and completion of waivers and telehealth technology disclosures), followed by a practice CVT call from the unit to an ATTEND clinician. While on the inpatient unit, ATTEND staff (typically the psychology technician) also introduced ATTEND patients to MyHealthEVet (the DVA patient portal), assisted in related account creation and authentication processes, and provided an opportunity for patients to practice using MyHealthEVet secure messaging on the DVA-provided tablet (e.g., reading a secure message or sending a message to the care team). Finally, patients were introduced to 2 government-developed applications that have been developed for use by DVA/Department of Defense patients (T2 Mood Tracker and Virtual Hope Box; Defense Health Agency Connected Health, Tacoma, WA).6–9 Both seek to facilitate recovery and wellness by increasing symptom awareness and self-management (e.g., guided relaxation) and can be used on patient-owned Apple and Android devices/phones. Upon completion of all on-unit training, tablets were either stored with the patient’s personal effects for patient pickup upon discharge or mailed directly to the patient’s discharge address. The DVA tablets used for veteran participation in the ATTEND clinic were acquired from the DALC through an electronic medical record consult managed by the local facility telehealth coordinator. Postinpatient discharge appointments and support Upon discharge from the unit, patients were greeted with a secure message from the ATTEND team reminding them of their first CVT appointment time and encouraging them to download and use the self-help mobile apps demonstrated on the unit with a personal smartphone or device (as Virtual Hope Box was not available on the DVA-provided tablet). The first CVT appointment with the clinical pharmacist was scheduled within 7 days of discharge from the inpatient unit. The appointment consisted of disease state management, risk assessment, evaluation of medication compliance, review of treatment goals, and discussion of upcoming mental health appointments. Medication adjustments were made when clinically indicated. Patients were offered medication reconciliation via secure message. New or changed medications were coordinated with the facility pharmacy and mailed to the patients (with overnight shipping when indicated). Follow-up appointments were scheduled based on patient needs. When patients were not seeing the clinical pharmacist on a regular basis, secure messaging was used to check in weekly with the patient to maintain contact and encourage ongoing use of self-help applications. The providers followed emergency procedures and missed-appointment procedures, developed in compliance with local medical center and national DVA policies. Transition to standard outpatient care and discharge from clinic Patients remained in the clinic until they established care with their mental health team’s prescribing provider. When feasible, patients were seen for a final on-site visit with an ATTEND clinician immediately prior to their first post-ATTEND outpatient mental health appointment. This visit was optional, due to many patients receiving care at off-site outpatient clinics. During this visit, the self-report measures administered during the clinic screening were readministered, and patients were interviewed regarding their experiences in the clinic and their use of clinic interventions. A primary goal of this visit was to gather feedback regarding how ATTEND services might be improved. The DVA tablet was also collected from the patient during this appointment. For patients who did not participate in the final on-site appointment, a tablet return kit was mailed to the patient’s address on file. Outcomes Clinical data were analyzed to better understand associations between clinic participation and reduction in wait times, improvements in accessibility, and changes in relevant clinical variables, such as self-report symptoms. Psychiatric measures completed during phases 1 and 3 were included. Not all patients completed measures during phase 3 due to clinic scheduling and transportation difficulties. The completeness and accuracy of the data collected were ensured through review by the first 3 authors prior to analysis. Patient participation and demographic characteristics Between August 2016 and May 2017, 20 patients successfully completed the screening process and ATTEND clinic on-unit training, and 16 unique patients were seen by the ATTEND clinic for at least 1 postdischarge CVT appointment and were transitioned to their outpatient mental health team. Of the 4 patients who did not complete the program, 2 patients completed the screening and training process but were removed from the clinic prior to discharge due to their direct transfer to another inpatient unit (e.g., substance abuse treatment). The other 2 patients did not participate in an ATTEND CVT appointment after discharge; 1 patient was unable to successfully use the tablet at home (likely due to a diagnosed neurocognitive disorder), and 1 patient was admitted to a different inpatient facility prior to the first scheduled ATTEND appointment. One patient was readmitted to the inpatient unit after completing ATTEND and participated in the clinic a second time. Eight patients completed an optional on-site visit and postdischarge measures upon transition to their outpatient care team. The primary documented reason for initial inpatient admission was depression with suicidal ideation (9 patients). Three ATTEND patients were flagged as being at high suicide risk in the medical record. Primary mental health diagnoses included major depressive disorder (11 patients), PTSD (4 patients), bipolar disorder (3 patients), and alcohol use disorder (1 patient). Additional mental health diagnoses that were a secondary focus of treatment while on the unit, and not previously mentioned, included substance use disorders, generalized anxiety disorder, and panic disorder. Included patients were prescribed an average of 4.4 mental health medications upon inpatient discharge. Additional relevant patient characteristics and demographics are detailed in Table 1. Table 1. Patient Characteristicsa Characteristic n % Age, yr 20–29 3 15 30–39 3 15 40–49 7 35 50–59 7 35 Sex (per medical record) Male 19 95 Female 1 5 Ethnicity Black 5 25 American Indian 1 5 White 14 70 Military service era OEF/OIF/OND 14 70 Persian Gulf 4 20 Other 2 10 Characteristic n % Age, yr 20–29 3 15 30–39 3 15 40–49 7 35 50–59 7 35 Sex (per medical record) Male 19 95 Female 1 5 Ethnicity Black 5 25 American Indian 1 5 White 14 70 Military service era OEF/OIF/OND 14 70 Persian Gulf 4 20 Other 2 10 an = 20. OEF = Operation Enduring Freedom, OIF = Operation Iraqi Freedom, OND = Operation New Dawn. Open in new tab Table 1. Patient Characteristicsa Characteristic n % Age, yr 20–29 3 15 30–39 3 15 40–49 7 35 50–59 7 35 Sex (per medical record) Male 19 95 Female 1 5 Ethnicity Black 5 25 American Indian 1 5 White 14 70 Military service era OEF/OIF/OND 14 70 Persian Gulf 4 20 Other 2 10 Characteristic n % Age, yr 20–29 3 15 30–39 3 15 40–49 7 35 50–59 7 35 Sex (per medical record) Male 19 95 Female 1 5 Ethnicity Black 5 25 American Indian 1 5 White 14 70 Military service era OEF/OIF/OND 14 70 Persian Gulf 4 20 Other 2 10 an = 20. OEF = Operation Enduring Freedom, OIF = Operation Iraqi Freedom, OND = Operation New Dawn. Open in new tab Clinical outcomes ATTEND clinic participation substantially reduced the wait time for a follow-up appointment compared to the time until each patient’s first scheduled appointment with their standard outpatient treatment team (Table 2). Recidivism rates were lower than the inpatient unit’s overall rates during the same time period (5% versus 19%, respectively), with only 1 ATTEND patient readmitted. Table 2. Reduction in Postdischarge Wait Timesa Outcome Mean ± S.D. 95% CI Days from discharge to first outpatient appointment 25.5 ± 10.8 20.0–31.0 Days from discharge to first ATTEND appointment 4.9 ± 5.5 2.1–7.7 Days reduction in wait time for first appointment 18.6 ± 8.8 14.1–23.1 Outcome Mean ± S.D. 95% CI Days from discharge to first outpatient appointment 25.5 ± 10.8 20.0–31.0 Days from discharge to first ATTEND appointment 4.9 ± 5.5 2.1–7.7 Days reduction in wait time for first appointment 18.6 ± 8.8 14.1–23.1 an = 17. One patient was readmitted to the inpatient unit and completed the program twice. ATTEND = Allied Transitional Telehealth Encounter(s) post-iNpatient Discharge, CI = confidence interval. Open in new tab Table 2. Reduction in Postdischarge Wait Timesa Outcome Mean ± S.D. 95% CI Days from discharge to first outpatient appointment 25.5 ± 10.8 20.0–31.0 Days from discharge to first ATTEND appointment 4.9 ± 5.5 2.1–7.7 Days reduction in wait time for first appointment 18.6 ± 8.8 14.1–23.1 Outcome Mean ± S.D. 95% CI Days from discharge to first outpatient appointment 25.5 ± 10.8 20.0–31.0 Days from discharge to first ATTEND appointment 4.9 ± 5.5 2.1–7.7 Days reduction in wait time for first appointment 18.6 ± 8.8 14.1–23.1 an = 17. One patient was readmitted to the inpatient unit and completed the program twice. ATTEND = Allied Transitional Telehealth Encounter(s) post-iNpatient Discharge, CI = confidence interval. Open in new tab The primary barriers to on-site treatment reported by patients are detailed in Table 3. Many patients reported multiple barriers; however, transportation-related difficulties predominated. The average distance from ATTEND patients’ postdischarge residence to their outpatient mental health clinic was 43.5 miles (range, 2.6–66.7 miles). Table 3. Primary Patient-Reported Barriers to On-Site Treatmenta Barrier n % Lack of transportation 4 23.53 Distance from clinic/driving time 5 29.41 Difficult to take time off work 1 5.88 Anxiety regarding driving/riding in car 3 17.65 Wait time 4 23.53 Barrier n % Lack of transportation 4 23.53 Distance from clinic/driving time 5 29.41 Difficult to take time off work 1 5.88 Anxiety regarding driving/riding in car 3 17.65 Wait time 4 23.53 an = 17. One patient was readmitted to the inpatient unit and completed the program twice. Open in new tab Table 3. Primary Patient-Reported Barriers to On-Site Treatmenta Barrier n % Lack of transportation 4 23.53 Distance from clinic/driving time 5 29.41 Difficult to take time off work 1 5.88 Anxiety regarding driving/riding in car 3 17.65 Wait time 4 23.53 Barrier n % Lack of transportation 4 23.53 Distance from clinic/driving time 5 29.41 Difficult to take time off work 1 5.88 Anxiety regarding driving/riding in car 3 17.65 Wait time 4 23.53 an = 17. One patient was readmitted to the inpatient unit and completed the program twice. Open in new tab CVT intervention was tailored to individual patient needs, and a variety of interventions were provided. ATTEND patients completed an average of 2.0 (range, 1–3) CVT appointments with the clinical pharmacist. During these appointments, nearly half (47%) of the patients received education focused on improving sleep hygiene, and this education was reinforced through secure messaging by the ATTEND team. All patients had a suicide risk assessment completed at each appointment. The pharmacist made 10 changes in the dose of medications and discontinued 1 medication. Two patients were taking a medication incorrectly, and this was identified and corrected (medication intervention rate per visit, 0.42). Participation in the ATTEND clinic was associated with reductions in symptoms on all pre-post psychological measures collected (Table 4). Table 4. Pre- and Post-ATTEND Psychological Outcomesa Measure Intake, mean ± S.D. 95% CI Discharge, mean ± S.D. 95% CI DSM Level 1 52.00 ± 15.03 41.58–62.42 41.38 ± 17.59 29.19–53.56 DSM Level 2 Anxiety 27.25 ± 4.80 23.92–30.58 26.13 ± 7.61 20.86–31.40 DSM Level 2 Depression 32.13 ± 5.33 28.43–35.82 23.88 ± 9.22 17.49–30.26 Generalized Anxiety Disorder-7 16.25 ± 4.92 12.84–19.66 12.25 ± 7.17 7.28–17.22 PTSD Checklist for DSM-5 54.50 ± 18.67 41.56–67.44 49.50 ± 21.13 34.86–64.14 Patient Health Questionaire-9 20.13 ± 6.01 15.96–24.29 15.63 ± 7.27 10.59–20.66 Measure Intake, mean ± S.D. 95% CI Discharge, mean ± S.D. 95% CI DSM Level 1 52.00 ± 15.03 41.58–62.42 41.38 ± 17.59 29.19–53.56 DSM Level 2 Anxiety 27.25 ± 4.80 23.92–30.58 26.13 ± 7.61 20.86–31.40 DSM Level 2 Depression 32.13 ± 5.33 28.43–35.82 23.88 ± 9.22 17.49–30.26 Generalized Anxiety Disorder-7 16.25 ± 4.92 12.84–19.66 12.25 ± 7.17 7.28–17.22 PTSD Checklist for DSM-5 54.50 ± 18.67 41.56–67.44 49.50 ± 21.13 34.86–64.14 Patient Health Questionaire-9 20.13 ± 6.01 15.96–24.29 15.63 ± 7.27 10.59–20.66 an = 8. ATTEND = Allied Transitional Telehealth Encounter(s) post-iNpatient Discharge, DSM = Diagnostic and Statistical Manual of Mental Disorders, DSM Level 1 = DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure-Adult, DSM Level 2 Anxiety = DSM-5 Level 2-Anxiety-Adult, DSM Level 2 Depression = DSM-5 Level 2-Depression-Adult, PTSD = posttraumatic stress disorder, CI = confidence interval. Open in new tab Table 4. Pre- and Post-ATTEND Psychological Outcomesa Measure Intake, mean ± S.D. 95% CI Discharge, mean ± S.D. 95% CI DSM Level 1 52.00 ± 15.03 41.58–62.42 41.38 ± 17.59 29.19–53.56 DSM Level 2 Anxiety 27.25 ± 4.80 23.92–30.58 26.13 ± 7.61 20.86–31.40 DSM Level 2 Depression 32.13 ± 5.33 28.43–35.82 23.88 ± 9.22 17.49–30.26 Generalized Anxiety Disorder-7 16.25 ± 4.92 12.84–19.66 12.25 ± 7.17 7.28–17.22 PTSD Checklist for DSM-5 54.50 ± 18.67 41.56–67.44 49.50 ± 21.13 34.86–64.14 Patient Health Questionaire-9 20.13 ± 6.01 15.96–24.29 15.63 ± 7.27 10.59–20.66 Measure Intake, mean ± S.D. 95% CI Discharge, mean ± S.D. 95% CI DSM Level 1 52.00 ± 15.03 41.58–62.42 41.38 ± 17.59 29.19–53.56 DSM Level 2 Anxiety 27.25 ± 4.80 23.92–30.58 26.13 ± 7.61 20.86–31.40 DSM Level 2 Depression 32.13 ± 5.33 28.43–35.82 23.88 ± 9.22 17.49–30.26 Generalized Anxiety Disorder-7 16.25 ± 4.92 12.84–19.66 12.25 ± 7.17 7.28–17.22 PTSD Checklist for DSM-5 54.50 ± 18.67 41.56–67.44 49.50 ± 21.13 34.86–64.14 Patient Health Questionaire-9 20.13 ± 6.01 15.96–24.29 15.63 ± 7.27 10.59–20.66 an = 8. ATTEND = Allied Transitional Telehealth Encounter(s) post-iNpatient Discharge, DSM = Diagnostic and Statistical Manual of Mental Disorders, DSM Level 1 = DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure-Adult, DSM Level 2 Anxiety = DSM-5 Level 2-Anxiety-Adult, DSM Level 2 Depression = DSM-5 Level 2-Depression-Adult, PTSD = posttraumatic stress disorder, CI = confidence interval. Open in new tab Patient perceptions During the ATTEND clinic discharge interviews, patients provided qualitative feedback regarding interventions. All interviewed patients expressed enthusiasm for the convenience of attending appointments remotely, with a common theme being the lack of driving/transportation time required. Appreciation regarding the promptness of medication adjustments and the opportunity to receive additional support were noted by several patients, with 1 patient reporting that they “appreciated the time the pharmacist spent listening to [them].” Two patients reported that seeing a provider remotely allowed for unique opportunities, such as visually showing the provider their home context and having increased feelings of comfort/safety due to the familiarity of their surroundings. Several patients reported that they preferred CVT to phone interaction because they “felt more connected” or like “[the provider was] there.” Notably, all queried patients reported a preference to continue receiving care through the tablet from outpatient providers, and half of these patients reported that they would be willing to change treatment teams if it would allow access to care in this manner. Two patients reported that although they would like to be able to attend some appointments (e.g., psychiatry, pharmacy, and group therapy) using CVT, they would prefer to travel to the clinic for individual psychotherapy. Some patients indicated that it would be beneficial if they could use a combination of both CVT and on-site appointments to participate in care rather than always receiving only 1 form or the other. Most patients appreciated the availability of secure messaging on the tablet, with several noting the convenience of accessing it through a dedicated app icon (rather than a Web browser). Two patients specifically noted that they appreciated the secure message response time from ATTEND providers in comparison to communicating by phone message (“playing phone tag”). One patient appreciated the ability secure messaging provided to “formulate thoughts” in message form rather than being “on the spot” during a phone call. Though the ATTEND training did not explicitly include hands-on use of MyHealthEVet features beyond secure messaging, some patients reported benefiting from the available medication list and appointment scheduling features. However, secure messaging was not without its challenges for some patients, consistent with previous work.10,11 Reported challenges included limited screen size when typing messages using the on-screen keyboard, lack of MyHealthEVet website-responsive design (making it difficult to click links and small buttons), and some initial confusion regarding how to initiate a new secure message to the ATTEND team (rather than only responding to those received). Nearly all patients queried found the T2 Mood Tracker application to be helpful in improving awareness and management of symptoms. Several patients reported that they used the application daily, with 1 patient reporting use multiple times daily and another reporting increased use on “bad days.” Reported benefits included the review of graphs of symptom ratings over time to compare the current mental state with the past to “see improvements.” Multiple patients reported that the app assisted them in understanding/expressing their current mood. However, 1 patient reported that he felt the app “missed the complexity of feelings,” and another patient expressed some frustration regarding an application flaw that erased rated symptoms if a device was rotated before saving. Nearly half of the interviewed patients made use of the Virtual Hope Box app, though most did not use it daily. There was a tendency to use the application more often early in clinic participation until the skills taught (e.g., deep breathing and progressive relaxation) were learned, at which point use would decrease. Several patients expressed a particular appreciation for the “distraction” games included in the app and reported their usefulness in “calming thoughts,” “narrowing focus,” and “[reducing] stress.” Two patients reported that they found the distraction games to be more beneficial than other games available through public app stores. Most indicated that it would have been helpful to be able to use the Virtual Hope Box app on the DVA tablet rather than only through their personal smartphone/device, and several patients were unable to use the app, as they did not have a personal device. Challenges The coordination between inpatient treatment and outpatient care presented several challenges involving the distribution of tablets, coordination of follow-up appointments, and transition of patients to their outpatient mental health team. The first challenge in the ATTEND process was related to providing patients with the DVA-owned tablet. DVA-owned tablets were used according to local telehealth policy at the time, which prohibited use of non–DVA-managed tablets for the provision of clinical care. Regardless, many patients did not own a personal tablet with reliable Internet access, and the use of a DVA tablet allowed hands-on experience on the unit consistent with the tablet that the patient would be using at home. Patients were not able to receive their tablet before they were discharged from the inpatient unit due to safety policies. Initially, the tablets were stored at the nursing station, or an ATTEND staff member would bring the tablet to the patient at discharge (when this could be coordinated). However, clinic staff were not always able to be present upon discharge to coordinate tablet distribution, and some patients were discharged without a tablet. Alternately, tablets were mailed to the patient discharge location, though this resulted in a delay of care on 2 occasions. The current process is that whenever feasible, tablets are stored with patients’ personal belongings for retrieval upon their departure from the hospital. After completing the program, veterans were asked to return the tablet to the provider or use a return kit to mail the tablet back to the DALC. As a result, the number of lost tablets was not directly tracked. However, the ATTEND team was only contacted once by the DALC in regards to a lost tablet. The technology itself presented minimal challenges. Software issues did prevent care in 1 instance, when a patient with a diagnosed neurocognitive disorder was unable to remember how to adequately operate the tablet. Finally, the transition from ATTEND to outpatient mental healthcare was often difficult to coordinate. The ATTEND team used warm handoffs whenever feasible, such as when patients would be receiving care at the primary medical center housing the inpatient unit. For patients seen at community clinics, providers were notified through alerts in the electronic medical record. Finally, time limitations of staff limited participation in the clinic during the 10-month enrollment period. The research coordinator’s time was allocated to the project due to grant funding; however, the ability of all other team members to participate in the clinic varied based on their existing responsibilities. However, as a result of the promising findings of this new clinic, the mental health administration decided to incorporate these activities into the clinical pharmacy specialist’s clinical practice. Discussion Technology provides unique opportunities for increasing access to follow-up care after inpatient mental health treatment, particularly for patients who have historically faced significant barriers to participating in on-site appointments. The use of CVT and other DVA-supported technologies has allowed the ATTEND team to increase participation in prompt follow-up care and reduce patient burden in obtaining that care. The ATTEND clinic was able to substantially reduce wait times and recidivism in patients recently discharged from an acute psychiatric facility. Clinical pharmacist–led intervention by CVT during the ATTEND pilot was associated with high levels of patient satisfaction, apparent reduction in psychiatric symptom burden, and the prompt addressing of treatment needs, including medication management. As has been reported elsewhere, providing services to a patient’s place of residence has both direct (e.g., increased access and engagement, increased satisfaction, and increased convenience) and less obvious benefits (e.g., increased access to information regarding psychosocial context, increased patient comfort/openness), many of which have been observed in the ATTEND clinic.6 The ATTEND clinic continues to provide postdischarge CVT appointments to patients and is now accepting direct referrals from inpatient providers within the W.G. (Bill) Hefner Veterans Affairs Health Care System. With the recent DVA release of the DVA Video Connect app, the scheduling and performance of CVT appointments continue to grow in efficiency. For instance, when a visit is scheduled through the app, both the provider and patient now receive an email with a link. At the time of the scheduled visit, the provider and patient click on the link and enter the virtual medical room where they are able to conduct the secure clinical session. DVA Video Connect circumvents the previous need for providers to directly call patients and does not require installation of telehealth software, reducing the complexity of implementing ATTEND and other similar services. Veterans are also able to participate in the service using their personal iOS devices (i.e., iPhone and iPad) if available, reducing reliance on DVA-owned tablets. In sum, the ATTEND clinic provides a pilot model for leveraging a variety of technical resources and a multidisciplinary clinical pharmacist–led team to increase access and reduce outpatient wait times for veterans discharging from inpatient treatment. Recent improvements in DVA telehealth software offerings have reduced some of the barriers to implementing a clinic such as this on a large scale. Continued implementation of this and similar clinics is encouraged, as well as the development of research protocols to further validate preliminary quality improvement findings. Conclusion The ATTEND telehealth clinic provided postinpatient mental health follow-up that was more prompt and convenient than were conventional on-site appointments. Psychiatric self-report improved during ATTEND-facilitated transition to outpatient care, and the recidivism rate for ATTEND patients was lower than the general inpatient rate during the same time period. Disclosures This work was supported by the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness, Research, and Treatment and the Mid-Atlantic Mental Illness Research, Education, and Clinical Center (Veterans Integrated Service Network 6 MIRECC) of the Department of Veterans Affairs Office of Mental Health Services. Facilities and resources were also provided specifically by the W.G. (Bill) Hefner Veterans Affairs Health Care System. The authors have declared no potential conflicts of interest. Additional information The contents of this publication do not represent the views or official policy of the Department of Veterans Affairs, the Department of Army/Navy/Air Force, the Department of Defense, or the U.S. Government. References 1. Nelson EA , Maruish ME , Axler JL . Effects of discharge planning and compliance with outpatient appointments on readmission rates . Psychiatr Serv. 2000 ; 51 : 885 - 9 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Mitchell AJ , Selmes T . Why don’t patients attend their appointments? Maintaining engagement with psychiatric services . Adv Psychiatr Treat. 2007 ; 13 : 423 - 34 . Google Scholar Crossref Search ADS WorldCat 3. Shore P , Goranson A , Ward MF , Lu MW . Meeting veterans where they’re @: a VA home-based telemental health (HBTMH) pilot program . Int J Psychiatry Med. 2014 ; 48 : 5 - 17 . 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Google Scholar Crossref Search ADS PubMed WorldCat Published by Oxford University Press on behalf of the American Society of Health-System Pharmacists 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.
TI - Improvement of postinpatient psychiatric follow-up for veterans using telehealth
JO - American Journal of Health-System Pharmacy
DO - 10.1093/ajhp/zxz314
DA - 2020-02-07
UR - https://www.deepdyve.com/lp/oxford-university-press/improvement-of-postinpatient-psychiatric-follow-up-for-veterans-using-UNEIO0mxBw
SP - 288
VL - 77
IS - 4
DP - DeepDyve
ER -