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:
- Webinars and other virtual trainings, continuing education, professional development, and telementoring programs for:
- Implementing integrated behavioral health care (e.g., UMass Medical School Certificate Course in Primary Care Behavioral Health, American Psychiatric Association Collaborative Care Model training program)
- Developing the behavioral healthcare skills of care team members (e.g., Project ECHO, Providers Clinical Support System, American Society of Addiction Medicine Criteria Course, and National Network of Child Psychiatry Access Programs)
- Incorporating shared decision making and facilitating patient engagement via telehealth (e.g., AHRQ's SHARE Approach Workshop Curriculum and Tools)
- Web and mobile-based patient health education for supporting treatment and recovery and preventing adverse events (e.g., self-harm, suicide, overdose, overdose death, and relapses)
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
Management and Monitoring
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
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)
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.
Ways To Incorporate Telehealth
Outcomes with Telehealth
Collaborative Care Model (CoCM)
Office-Based Opioid Treatment with Buprenorphine (OBOT-B) Collaborative Care Model (also known as the Nurse Care Manager Model or the Massachusetts Model)
Primary Care Behavioral Health (PCBH)
Hub and Spoke Model (H&S) / H&S Health Homes
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
- 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
- Depending on the specific approach taken, the implementation of telehealth may require hardware (e.g., computers, smartphones, or tablets), broadband Internet connection, and compatible telehealth software (e.g., programs, platforms, and applications).
- There are disparities in smartphone and tablet ownership, as well as home broadband internet service, between lower and higher-income Americans, rural and urban adults, and adults living with a disability versus those without a disability. There are programs working to address these inequities.
- Practices attempting to integrate behavioral health and primary/ambulatory care using telehealth should consider instituting universal screening to determine the digital accessibility of patients. By understanding the technologies patients have available to them, practices can assess their offerings and implement care plans that are adapted to patient needs.
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
- There are several Federal and State regulations for protecting the privacy and security of protected health information, including patient health data.
- Key Federal regulations:
- The Health Insurance Portability and Accountability Act (HIPAA) requires transmitted PHI to be encrypted. – Enforcement of this regulation has been amended (PDF – 70 KB) during the COVID-19 emergency, such as for video communication technologies.
- The Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR Part 2) prohibits SUD treatment programs that are federally assisted from disclosing information about a patient's SUD treatment without their written consent. – This rule has been recently revised to facilitate better care coordination and has new guidance for telehealth (PDF – 168 KB).
- Practices attempting to integrate behavioral health and primary/ambulatory care using telehealth needs to ensure that the consent forms and technologies they use are compliant.
Licensing, Credentialing and Privileging Regulations
- For telehealth services, the location of the patient is considered the place of care (or originating site). Practices using telehealth must comply with the licensing rules and regulations of the State in which the patient is located. Licensing requirements vary across States, and some States waived requirements during the COVID-19 pandemic.
- Practitioners using telehealth to provide remote services to a healthcare organization must also go through the credentialing and privileging process for that organization, even though they are not physically located there.
- Healthcare organizations can use a credentialing-by-proxy process (PDF – 196 KB) or complete the full credentialing and privileging process to verify the qualifications of the practitioner using telehealth.
- 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.
- AHRQ Views: Asking the Hard Questions About Telehealth
- American Society for Healthcare Risk Management: Telemedicine Risk Management Considerations (PDF – 235 KB)
- American Society of Addiction Medicine: Supporting Access to Telehealth for Addiction Services: Regulatory Overview and General Practice Considerations
- Maryland Health Care Commission: Medical Professional Liability Insurance Key Considerations for Telehealth (PDF – 388 KB)
- National Frontier and Rural Addiction Technology Transfer Center: Telehealth Capacity Assessment Tool (PDF – 1.69 MB)
- National Telehealth Technology Assessment Resource Center: Technology Assessment 101
- Pacific Southwest Mental Health Technology Transfer Center: Telehealth Clinical and Technical Considerations for Mental Health Providers (PDF – 703 MB)
- U.S. Department of Health & Human Services: Legal Considerations for Telehealth
- American Hospital Association: Redesigning Care - A How-To Guide for Hospitals and Health Systems Seeking to Implement, Strengthen and Sustain Telebehavioral Health (PDF – 3.55 MB)
- American Hospital Association: Telehealth - A Path to Virtual Integrated Care (PDF – 5.25 MB)
- American Medical Association: Digital Health Implementation Playbook
- American Medical Association: Telehealth Implementation Playbook (PDF – 9.23 MB)
- Great Plains Telehealth Resource & Assistance Center: Telehealth Quick Start Guide: Primary Care & FQHC/RHC Focus (PDF – 7.37 MB)
- Healthcare and Public Health Sector Coordinating Council: Health Industry Cybersecurity – Securing Telehealth and Telemedicine
- HealthIT.gov: Health IT in Health Care Settings - Behavioral Health
- Health Resources and Services Administration: Best Practices Guide - Telehealth for Behavioral Health Care
- Northeast Telehealth Resource Center: Roadmap and Toolkit for Implementing Primary Care and Behavioral Telehealth Services during the COVID-19 Pandemic (PDF – 1.39 MB)
- Rural Health Information Hub: Telehealth Models for Increasing Access to Behavioral and Mental Health Treatment
Finding Telehealth Service Providers
- Addiction Technology Transfer Center Network: Online Support Groups
- Alberta Health Services: Addiction and Mental Health Mobile Application Directory 2019 (PDF – 1.05 MB)
- Anxiety & Depression Association of America: Mental Health Apps
- Arizona Telemedicine Program: Telemedicine & Telehealth Service Provider Directory
- California Health Care Foundation: Innovation Landscape Series - Telehealth MAT
- National Telehealth Technology Assessment Resource Center: Clinician's Guide to Video Platforms
- AHRQ Patient Safety Network: Telehealth and Patient Safety During the COVID-19 Response
- HealthIT.gov: Patient Engagement Playbook
- National Action Alliance for Suicide Prevention: COVID Guidance - Screening for Suicide Risk during Telehealth Visits (PDF – 217 KB)
- American Academy of Family Physicians: Using Telehealth to Care for Patients During the COVID-19 Pandemic
- American Psychiatric Association: Telepsychiatry Best Practices
- American Psychological Association: Guidelines for the Practice of Telepsychology
- Digital Therapeutics Alliance: Understanding DTx
- Drug Enforcement Administration: How to Prescribe Controlled Substances to Patients During the COVID-19 Public Health Emergency (PDF – 141 KB)
- National Council for Mental Wellbeing: Supporting Telehealth and Technology-assisted Services for People Who Use Drugs: A Resource Guide (PDF – 1.74 MB)
- Substance Abuse and Mental Health Services Administration: TIP 60: Using Technology-Based Therapeutic Tools in Behavioral Health Services
Several organizations have online resource collections addressing using telehealth for behavioral health treatment.
- American Telemedicine Association Resources: Telehealth Resources
- Federation of State Medical Boards: COVID-19 State Telehealth Policy Resources
- Health Resources & Services Administration: Telehealth Resources for Providers
- National Consortium of Telehealth Resource Centers: Telehealth Resources
- ProviderBridge: Federal and State Telehealth Resources
- Integrating Behavioral Health and Primary Care Playbook
- Medication-Assisted Treatment for Opioid Use Disorder Playbook
- Telehealth Tools and Resources for Management of Unhealthy Alcohol Use
- Telehealth Tools and Resources for Medication Assisted Treatment for Opioid Use Disorder
- A Guidebook of Professional Practices for Behavioral Health and Primary Care Integration: Observations From Exemplary Sites (PDF – 1.24 MB)
- Provider- and Practice-Level Competencies for Integrated Behavioral Health in Primary Care: A Literature Review (PDF – 624 KB)
- AHRQ Primary Care Medication-Assisted Treatment for Opioid Use Disorder Grantees
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