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Telehealth and Behavioral Health Integration

Wide adoption and expansion of telehealth in primary care and behavioral health took place rapidly as a means to provide ongoing patient care during the COVID-19 pandemic. The implementation of telehealth continues to rapidly change and evolve, particularly with regard to policies, payment, regulations, and laws. To be able to provide patient-centered integrated behavioral healthcare in primary and ambulatory care practices, those actively engaged in behavioral health integration must keep up with these changes, with a keen focus on the importance of tailoring telehealth choices to the needs of patients, providers, and care teams.

This page presents the available research evidence, including peer-reviewed outcomes data and experiences shared via grey literature. This page is not comprehensive, nor does it provide the basics of general telehealth more broadly. This page aims to provide practical information and resources for using telehealth technologies to implement patient-centered integrated behavioral health care in primary and ambulatory care practices, including:

  • Various components of integrated behavioral healthcare that can be supported via telehealth technologies
  • Models of integrated behavioral healthcare that have been fully or partially implemented using telehealth technologies
  • Evidence for the use of telehealth technologies for behavioral health integration
  • Things to consider when using telehealth technologies for behavioral health integration

Telehealth involves using electronic information and telecommunications technologies to support delivery of clinical services, patient and professional health-related education, public health, and health administration. These technologies can include hardware (e.g., telephones, smartphones, tablets, computers, kiosks, wearables, and patient monitoring and testing devices) and software (e.g., computer programs, online platforms, and mobile applications).

Implementing integrated behavioral healthcare in primary or ambulatory care practices using telehealth technologies can provide patients with increased access to substance use, mental health, and recovery support services. Telehealth policy changes enacted in response to the COVID-19 pandemic have expanded the guidance, coverage, and flexibility for telehealth use in primary and behavioral healthcare practices.1,2,3

Additionally, the models of care for behavioral health integration can be fully or partially implemented using telehealth technologies, based on the needs and resources of patients and practices. The evidence base for using telehealth technologies for behavioral health integration though limited, is promising, with high patient preference and outcomes comparable to in-person care.

Telehealth technologies can support the implementation of integrated behavioral healthcare and allow primary and ambulatory care practices to offer comprehensive patient-centered care. Many patients have already adapted to telehealth and behavioral healthcare is easily adapted to telehealth. There may be times when in-person care is necessary, perhaps for acute conditions, but many of the functions of behavioral healthcare are similar in person and via telehealth.

Screening and Assessment: Practices should establish systematic protocols for screening and assessment of behavioral health conditions.4,5,6,7 Practices can use telehealth to implement standardized tools and instruments for identifying patients who may benefit from mental health or substance abuse treatment, understanding patient needs and how to tailor care delivery to meet those needs, and measuring patient experience. For assessments conducted in advance of visits, practices can establish workflows and standard procedures for monitoring and addressing patient responses in the time leading up to visits.

Additionally, practices can conduct virtual screening of patient digital health literacy and telehealth preferences, using tools such as the eHealth Literacy Scale and the Service User Technology Acceptability Questionnaire to inform which care delivery methods are best to meet patient needs.

Examples of telehealth technologies for screening and assessment include:

  • Mobile applications, kiosks, or web-based platforms and portals for virtual patient screening and assessment and clinical decision support
  • Screening, assessment, diagnostic interviewing, diagnostic confirmation, and testing for behavioral health conditions via video teleconferencing or telephone

Treatment: Practices can use telehealth for treatment, including prescribing medications, conducting therapy (counseling), and implementing other cognitive and behavioral interventions and psychosocial supports.

Examples of telehealth technologies for behavioral health treatment include:

  • Individual or group telepsychiatry, telepsychology, teletherapy or telepsychotherapy (also referred to as telemental health) e-visits for patients
  • Web or mobile-based digital therapeutics (i.e., digital health devices, software and mobile applications) delivering evidence-based therapeutic interventions for mental health and substance use disorders (SUDs) to patients
    • e-CBT (virtual cognitive behavioral therapy) and other e-therapies
    • Digital contingency management tools and programs
    • Virtual or tele-MAT (medication-assisted treatment) for opioid use disorder (OUD)
  • Teleprescribing medications for mental health and SUDs (e.g., medications for OUD, anti-psychotics, antidepressants) via e-prescribing software

Management and Monitoring: Practices can use telehealth for patient management and monitoring, including tracking patient progress and compliance with behavioral health treatment and making mid-course treatment adjustments when needed; tracking patient health outcomes; and collecting patient health-related data. These are standard practices (PDF – 1.24 MB) within the Collaborative Care Model and are used in other models of patient-centered integrated behavioral health care as well. Telepharmacies (PDF – 52 KB) also offer these services.

Examples of telehealth technologies for patient management and monitoring include:

  • Remote patient monitoring
    • Web, mobile, and app-based symptom tracking, medication adherence, and self-management tools for providing automated notification reminders
    • Smart pill boxes, bottles, dispensers, bio-ingestible sensors, and live video monitoring of medication adherence
    • At-home/remote bio-specimen sample collection kits for substance use testing (e.g., oral swab kits for saliva samples, blood collection devices for dried blood samples)
    • Smart devices monitoring substance use (e.g., Bluetooth-enabled breathalyzers)
    • Smart devices monitoring weight, vital signs, blood pressure, blood sugar, blood oxygen, heart rate, physical activity, sleep, and other health indicators
  • Virtual clinical supervision and observation
    • Video teleconferencing to observe medication use and remote bio-specimen sample collection for substance use testing
  • Virtual patient check-ins

Continuing Care: Practices can use telehealth for continuing care, including support services for patients who have completed treatment.

Examples of telehealth technologies for continuing care include:

  • Web and mobile-based e-recovery platforms and mobile applications for virtual coaching, self-help, and peer support groups to assist in relapse prevention
  • Virtual meetings and other online programming from behavioral health peer support programs (e.g., 12-step recovery programs and mental health support groups)
  • Predictive analytics using patient data transmitted by Smart devices to identify patients at risk for adverse health events

Education: Practices can use telehealth for educational purposes, including participating in professional development training and technical assistance and providing health education and information to patients.

Examples of telehealth technologies for education include:

Collaboration: Practices can use telehealth to support collaboration, including communication, coordination, and consultation between care team members and patients.

Examples of telehealth technologies for collaboration include:

  • E-consultations between care team members
  • Web and mobile-based electronic health records (EHRs), patient registries, other health information exchange (HIE) platforms, and care and case management tools for supporting secure video teleconferencing, messaging, file and screen sharing, shared documentation and notetaking between care team members and patients

Engagement: Practices can use telehealth to meaningfully engage patients as active participants with ownership and influence in their treatment and care.

Examples of telehealth technologies for patient engagement include:

  • Online resources and tools:
    • Breaking down the available telehealth offerings and how to access and use them
    • Explaining how telehealth can help patients
    • Addressing challenges, risks, fears, and other concerns
    • Answering frequently asked questions
    • Describing the integrated behavioral healthcare approach
    • Defining the roles of each care team member
    • Demonstrating how to engage with the care team using telehealth
    • Assisting patients in evaluating their options and making informed decisions
  • Web-based or call-in request systems supporting telehealth access and use based on the needs of the patient (e.g., customized telehealth home kits or the delivery of specific health record information)
  • Virtual meetings and web and mobile-based collaboration tools for patient and family involvement in advisory councils
  • Remote patient monitoring platforms and programs providing customization for design, goals, and technology options based on patient needs

These technologies can augment in-person care or replace it. Practices and health systems can pick and choose what to try to implement. Additional information, tools, and resources for the implementation process, such as sample protocols for introducing telehealth to patients (PDF – 703 MB), can be found in the Resources for Using Telehealth for Integrated Behavioral HealthCare section.

Using telehealth technologies to support integrated behavioral health care

Type of Telehealth

Components of Integrated Behavioral Health Care (IBHC)

Screening and Assessment

Treatment

Management and Monitoring

Continuing Care

Education

Collaboration

Engagement

Synchronous
Live, real-time telehealth via video conferencing, telephone, livechat, mHealth technologies

Virtual diagnostic interviewing and confirmation

Individual or group patient e-visits

Virtual observation of BH medication use or sample collection for SU testing; virtual patient check-ins

Virtual recovery support programs

Virtual IBHC telementoring, training, and continuing education for care team members; virtual BH education and coaching for patients and families

E-consultations; electronic communication for case management and care coordination

Virtual patient and family advisory council meetings

Asynchronous
Store-and-forward telehealth via health information exchange technologies and mHealth, SMS text- or web-based technologies

Web-based or computerized BH screening, assessments, and clinical decision support

E-prescribing; digital therapeutics; automated appointment reminders

Automated medication adherence and self-management reminders

Virtual peer and recovery support; BH chatbots; BH text lines

Web-based engagement tools and resources; web-based or call-in request systems supporting telehealth access and use

Remote Patient Monitoring (RPM)
Real-time, electronic transmission of patient health data via smart biometric and diagnostic devices

Smart devices to monitor health indicators

Smart devices to monitor medication adherence

Smart devices to monitor symptoms

Smart devices connected to platforms that identify patients at-risk for adverse patient events

Smart devices connected to platforms that automate or prompt responsive patient education

Smart devices connected to platforms that provide automated alerts to care team members based on patient health data

RPM platforms and programs providing customization capabilities in design, use, and technology options based on patient needs

Models that can incorporate telehealth technologies to deliver integrated behavioral health care

Telehealth can be incorporated into several of the models of care used to implement integrated behavioral health care (IBHC) in primary and ambulatory care practices, including:

  • Collaborative Care Model
  • Office-Based Opioid Treatment with Buprenorphine (OBOT–B) Collaborative Care Model
  • Primary Care Behavioral Health
  • Hub and Spoke Model (H&S) / H&S Health Homes.

IBHC Model

Key Elements

Ways To Incorporate Telehealth

Outcomes with Telehealth

Collaborative Care Model (CoCM)

  • Care managers foster collaboration between care team members
  • Care managers provide patient monitoring and management, education,brief intervention, treatment support, and/or care coordination
  • Care managers serve as a point of contact for patient and care team
  • Virtual brief behavioral health (BH) interventions
  • Patient e-visits
  • Virtual patient education
  • Virtual BH treatment (digital therapeutics, e-prescribing)
  • Virtual care coordination and collaboration by care team
  • CoCM is effective through remote telehealth delivery, and works as well or better than in-person collaborative care in a federally qualified health center setting.8,9,10

Office-Based Opioid Treatment with Buprenorphine (OBOT-B) Collaborative Care Model (also known as the Nurse Care Manager Model or the Massachusetts Model)

  • Drug Addiction Treatment Act of 2000 (DATA)-waived physicians, nurse practitioners, and physician assistants prescribe buprenorphine
  • Care managers (or other care team members, if needed) conduct patient screening and assessment for OBOT-B, supervise medication induction, monitor stabilization, and provide treatment support, patient education, follow up, and referral for continued care
  • Virtual patient screening and assessment with DATA-waived care team members
  • Patient e-visit(s) with DATA-waived care team members
  • Virtual patient education
  • Virtual BH treatment (digital therapeutics, e-prescribing)
  • Virtual care coordination and collaboration by care team
  • The OBOT-B Collaborative Care (on and off-site) is feasible in primary care settings and produces patient outcomes comparable to those derived from other physician-centered approaches.11,12

Primary Care Behavioral Health (PCBH)

  • BH practitioner is onsite at a primary or ambulatory care practice for patient visits and care team consultations
  • BH practitioner is a full member of the care team (in-practice or third-party consultant)
  • BH practitioner provides BH education and training to other care team members
  • Patient e-visits
  • Virtual patient education
  • Virtual BH treatment (digital therapeutics, e-prescribing)
  • Virtual care coordination and collaboration by care team
  • Integration of BH practitioners in primary care practices, using a mix of face-to-face and telehealth visits, decreased medical utilization rates and psychiatric and crisis visits.13

Hub and Spoke Model (H&S) / H&S Health Homes

  • Centralized practices (hubs) provide intensive services for screening, assessment, and stabilization for patients with complex needs (e.g., Opioid Treatment Programs where care team members can dispense methadone, buprenorphine, and naltrexone)
  • Care team members at the hub refer patients to satellite, community-based practices (spokes) for treatment, maintenance, education, continuing care, care management, and/or wraparound services (e.g., OBOTs where care team members can supervise buprenorphine induction)
  • Nurses and care managers from patient-centered medical homes are deployed to spoke practices to monitor treatment adherence, provide patient education, follow up, and referral for continued care
  • Patient e-visits with care team members at hub practices
  • Virtual patient education
  • Virtual BH treatment (digital therapeutics, e-prescribing)
  • Virtual care coordination and collaboration by care team
  • Telemental health services at spoke locations are not inferior to face-to-face services at hub locations.14

Generally, patients and practices have had positive experiences with telehealth visits, and health outcomes for patients have been comparable with in-person care.15,16,17 While the evidence for using telehealth for the integration of behavioral and physical health is limited, there is a strong evidence base supporting the effectiveness of telehealth for:

  • Remote patient monitoring, communication, and counseling for patients with chronic conditions18
  • Psychotherapy as part of behavioral health treatment18,19
  • Psychiatry in acute care8,9,10,12,20
  • Consultations as part of outpatient, inpatient, and emergency care21

Digital therapeutics are an emerging field, and the evidence base continues to develop. Generally, websites, forums, social networking sites, mobile applications, and short messaging service (SMS) texting programs have had positive effects, are feasible, and have high acceptability for people in recovery or with mental health conditions.22,23,24 Systematic and meta-reviews of digital therapeutics have found promising potential for adjunctive treatment, monitoring, and/or management of a wide range of mental health conditions and SUDs:25,26,27,28

  • Alcohol use disorder29,30
  • Anxiety and depression31,32,33,34
  • Nicotine35,36
  • OUD37,38,39
  • Post-traumatic stress disorder40

SUD interventions using real-time, electronic transmission of patient health data via smart biometric and diagnostic devices have been shown to reduce cravings and/or substance use, and have high acceptability.41

The evidence on effective technical methods for implementing integrated behavioral health care via telehealth, including technical, relational, and procedural dimensions, is limited. Emerging evidence on telementoring models show improvements in provider knowledge and self-efficacy.42,43,44,45,46

The Project Extension for Community Healthcare Outcomes (ECHO) telementoring model, for example, improves provider knowledge and self-efficacy to treat mental health and substance use, patient access to behavioral healthcare, and the number of DATA-waived practitioners.47,48,49,50,51 Key features of Project ECHO include:

  • Behavioral health practitioners perform telementoring and telemedicine to build the behavioral healthcare knowledge and skills of primary care physicians.
  • Behavioral health practitioners provide virtual clinics on how to screen, diagnose, and initiate brief interventions, and make referrals for several mental health disorders and SUDs.
  • Primary care physicians present anonymous cases to behavioral health practitioners for review and consultation.

Several factors require consideration when using telehealth for integrated behavioral healthcare, some related to patient experience and others regulatory in nature.

Adapting In-Person Care

  • Operational changes associated with incorporating telehealth technologies can increase the workload of care team members if not streamlined and interoperable.
  • Care team members can experience fatigue (PDF – 2.23 MB) from decreased physical movement between e-visits, increased time using videoconference technology, and ergonomic and technical distractions that can arise from equipment setups.
  • Building trust and rapport and establishing a patient-provider relationship requires adapting communication strategies to virtual care, such as looking into the camera during e-visits to maintain eye contact, and using audio cues like “mm-hmm” to verify attentiveness and active listening.
  • Before an in-person care visit, care team members typically collect updates, vital signs, and other health data, and patients typically have time to prepare before entering an exam room. Patient activation and engagement before and after e-visits also requires adapting.

Patient Needs and Safety

  • There are additional clinical considerations for patient needs and safety (PDF – 703 MB) when providing virtual care. For example, patients with anxiety or paranoia may not trust the video teleconferencing software and have concerns about who is present in the care team member's setting during virtual care. Patients may prefer audio-only or telephone-based care due to a lack of privacy or security in their home.

Inequities in Telehealth Access

Lack of Reimbursement Parity Laws

  • Healthcare services via telehealth are not always reimbursed at the same rate as in-person healthcare services. Reimbursement rates for telehealth vary by State and payer type (i.e., Medicaid, Medicare, private), and are often less than those for in-person visits.
  • Additionaly, some States and payers require initial patient visits to be in-person. Payer policies have been made more flexible during the COVID-19 emergency, but these changes may be temporary.
    • The Centers for Disease Control and Prevention released interim guidance for increased use and coverage of telehealth.
    • The Centers for Medicare & Medicaid Services (CMS) has expanded the flexibility of Medicare and Medicaid coverage for telephone and video health visits.
    • The Drug Enforcement Administration (DEA) adopted policies allowing DEA-registered practitioners to prescribe buprenorphine without an initial in-person consultation as long as the prescriber is following certain guidelines outlined in the policy.
    • SAMHSA has also temporarily waived (PDF – 202 KB) the requirement for an in-person physical evaluation for new OUD patients that are being treated with buprenorphine.
    • Many States requested that private payers expand coverage and reimburse for telehealth using the same rates as for in-person care.

Privacy and Security Regulations

Licensing, Credentialing and Privileging Regulations

Prescribing Regulations

  • There are several Federal and State regulations for telehealth prescribing. Under the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 (the Ryan Haight Act), providers who wish to use online prescribing for a controlled substance, such as methadone, must have an in-person medical exam with the patient at least once every 24 months.
    • There is an exception (PDF – 625 KB) to in-person exam requirement for DEA-registered MAT providers.
    • There is also an exception (PDF – 140 KB) for when the U.S. Secretary of Health and Human Services declares a public health emergency in concurrence with the DEA Administrator – such as with COVID-19 emergency.
  • Practices must also comply with State regulations, some of which prohibit or restrict prescribing of controlled substances via telehealth. Some States have similar public health emergency exceptions; others do not.

Malpractice and Liability

  • Malpractice law related to telehealth is not fully settled and varies by State.
  • Practices should confirm that their current malpractice insurance adequately covers services provided via telehealth and that coverage extends into the States where patients are located.
  • Additional or alternative insurance coverage may be needed. For instance, practices may also want to consider liability coverage to protect against data breaches.

Considering Implementation

Planning Implementation

Finding Telehealth Service Providers

Engaging Patients

Providing Treatment

Several organizations have online resource collections addressing using telehealth for behavioral health treatment.

References

  1. Medicare Telemedicine Health Care Provider Fact Sheet. Baltimore: Centers for Medicare & Medicaid Services; 2020. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet. Accessed June 28, 2021.
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