Telemental Health Linked to Greater Post-Hospitalization Follow-up

Kelli Whitlock Burton

July 06, 2022

High use of telemental health services by patients with serious mental illness (SMI) who live in nonmetropolitan US counties is associated with improvements in key outcomes, including greater post-hospitalization follow-up, new research suggests.

In a nationwide study, researchers drew on Medicare data from nearly 3000 counties covering the period from 2000 to 2018. Results show that counties in which there was greater use of telemental health services reported higher increases of clinical visits and better follow-up after hospitalization among patients with bipolar 1 disorder and schizophrenia or other psychotic disorders.

In the study, "clinical visits" referred to both in-person and telemental health visits.

Dr Haiden Huskamp

"These findings really support the idea that telemental health can be safe and effective and beneficial for in-person care for people with severe mental illness," co-investigator Haiden Huskamp, PhD, professor of healthcare policy at Harvard Medical School, Boston, Massachusetts, told Medscape Medical News.

The findings were published online June 27 in JAMA Network Open.

Continuing Trend?

Past studies have pointed to a sharp increase in the use of telepsychiatry services for patients with SMI. As reported by Medscape Medical News, this is a trend some clinicians say is likely to continue after the pandemic.

Use of telemedicine during the pandemic received a boost by the temporary suspension of certain Medicare rules that restrict telehealth use. Debate continues at the federal and state levels on whether to make that suspension permanent. Huskamp said more information is needed about the efficacy and accessibility of telemental health.

To investigate, researchers used Medicare fee-for-service data from 118,170 patients in 2916 counties. More than two thirds of the patients were aged 65 years or younger.

During the study period, telemental health service increased from 0.03 visits per patient with SMI in 2010 to 0.19 visits per patient in 2018. This increase was broad, with the number of counties reporting high use of telemental health increasing from 2% in 2010 to 17% in 2018.

Compared with counties in which there was no telemental health services, those with high use were less densely populated and had fewer healthcare professionals and hospital beds.

The number of overall visits with a mental health professional increased slightly in high-use counties compared to no-use counties, from 4.65 visits in 2010 to 4.79 visits in 2018. The number of in-person visits during that period declined from 4.55 visits in 2010 to 3.73 visits in 2018, which suggests that the overall increase was due to higher use of telemental health.

In the high-use group, the number of patients who had at least four mental health care visits increased 8%, and the number of patients who had a follow-up visit within 30 days of a hospitalization increased 20.4%.

A "Helpful Option"

"Telemedicine doesn't address the national shortage of providers, but it definitely helps in underserved areas [and] rural areas," Huskamp said.

"We need more mental health providers and need to develop new models of care that can leverage the providers we have in the best way possible. This is at least a helpful option, especially when you're thinking about the maldistribution of providers across the country," she added.

The study results showed that there was no difference in medication adherence between low- and high-use counties.

There was greater contact with mental health care providers in counties with high use of telemental health, and patients in the high-use group were 7.6% more likely to be hospitalized within a year compared with their peers in counties that had no telemental health use.

"We did see modest increases in inpatient use in counties that shifted the most to telemental health services, but that's not typically viewed as a measure of quality because it can mean so many different things," Huskamp said.

For example, it could mean that counties with greater telemental health use did a better job of identifying and responding to patients' need for acute care, she noted. It could also be a reflection of the loss of psychiatric inpatient care in low-use communities.

Another Tool

Commenting on the findings for Medscape Medical News, Robert Caudill, MD, director of Telemedicine and Information Technology Programs at the University of Louisville School of Medicine in Kentucky, called the increase in hospitalization in high-use counties "surprising." However, he noted it might be a reflection of the need to fine-tune telemental health for patients with SMI.

"I think that more time and experience with telehealth will further normalize the practice and help to narrow, if not close, the gap," said Caudill, who was not involved with the research.

"There are so many side benefits to doing things via telehealth which can be properly done via telehealth that it is a simple matter of continuing to learn how to do those things better," he added.

Caudill noted a multidisciplinary approach that includes psychiatric care and case management is generally considered to be the gold standard in treating patients with the types of mental illness included in this study.

While some of that care can be delivered effectively via telemedicine, it is possible other aspects, such as case management, are better handled in person, he said.

"I don't think it is the role of telehealth to make in-person care obsolete. It is simply a tool to be used when appropriate," said Caudill, who is a past chair of the American Telemedicine Association's Telemental Health Special Interest Group.

"Surgeons did not abandon scalpels when laser surgery became possible," he added.

The study was funded by the National Institutes of Mental Health. Huskamp and Caudill report no relevant financial relationships.

JAMA Netw Open. Published online June 27, 2022. Full article

Kelli Whitlock Burton is a reporter for Medscape Medical News who covers psychiatry and neurology.

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