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Telehealth Training Considerations in a Community Healthcare Setting

Many articles have been written about the logistical transition to telehealth in training as a result of COVID-19 (Bell et al., 2020; Hames et al., 2020; Rosen, Glassman & Moreland, 2020; Perrin et al., 2020; Scharff, et al., 2020, Tarlow et al., 2020).  Chenneville and Scwartz-Mette (2020) as well as Desai et al., (2020) write about the ethics of practicing outside of one’s competence during a state of emergency, noting that attention needs to be directed to determining competent practice over telehealth long term for all clinicians.  Springer et. al (2020) reflect on how there is limited information regarding how to train individuals effectively in the provision of telehealth, which presents a challenge for training sites, given that telehealth is now a part of standard practice throughout many clinical settings. Determining competencies related to proficient use of telehealth becomes a priority, which is a consideration for not only trainees but for staff, who are new to the modality as well.

Prior to March of 2020, all behavioral health care at Community Health Center, Inc (CHC), in Connecticut, United States, was delivered in face-to-face in-person sessions, with the exception of a small pilot for telehealth programming. When Connecticut moved to lockdown in March 2020, like many organizations, all behavioral health services were transitioned to telehealth almost overnight.   CHC moved to telephone and video sessions and Connecticut quickly approved temporary Medicaid payment for these modalities, crucial for CHCI’s operations since about 70% of CHC clients participate in state insurance programs.  Administrative, operational, and clinical leadership staff figured out how to meet ethical and regulatory standards while providing remote services, and CHC continued to serve clients in an integrated care setting while some disciplines provided care off site.

The transition initiated new processes and policies in the psychology training program which was fully remote for the duration of the 2020-2021 training year. The remote activities included orientation, didactics, meetings, training, supervision, and clinical work. The focus of this study was to examine the processes of providing telehealth training to psychology trainees across levels (doctoral practicum student, doctoral intern, postdoctoral resident) to determine how to do so more effectively moving forward.

Methods:

Participants

All participants were involved in psychology training at Community Health Center, Inc., a Federally Qualified Health Center providing integrated co-located primary care to about 110,000 patients annually at 17 hub sites across the state of Connecticut.

In the 2020-2021 academic year, CHCI had 28 behavioral health trainees, all who completed on-boarding, orientation, training, supervision, and direct patient care remotely.   All participants were at the graduate and postgraduate level in the fields of social work, marriage and family therapy, counseling, and psychology.  During the 2020-2021 academic year, CHCI’s behavioral health trainee cohorts included five doctoral psychology practicum students, 13 masters level practicum students, four doctoral psychology interns, and six postdoctoral psychology residents.  All behavioral health trainees in the 2020-2021 training year (N=28) were invited to participate in the study, designed to elicit feedback regarding their experiences with- and the impact of- telehealth training.

11 trainees participated in the study; however, one individual requested to opt-out following participation and is excluded from this data (N=10). Participants were primarily female (n=7), and all were between the ages of 21 and 40. Participants included five postdoctoral residents, two doctoral interns, two doctoral practicum students, and one masters level practicum student.  Half of the participants provided telehealth services during their training year in a language other than English, either by using translation services or speaking that language fluently, three of whom endorsed Spanish as that language.  Half of the participants endorsed receiving training in telehealth prior to the training year, with a range of three to eight hours of didactic training, and a range of 32-612 clinical hours delivered

Procedures

After Institutional Review Board approval was obtained, an email was sent to all eligible participants of the 2020-2021 training year to invite them to participate in a survey related to their telehealth training experiences as well as an additional focus group experience (N= 28).  Trainees provided consent to participate in the initial survey, and two individuals participated in qualitative interview sessions to better understand current trainees’ telehealth training experiences and improve future training initiatives. Participation in the survey was entirely voluntary and optional. Consent forms and surveys were distributed through Qualtrics, and the interviews took place over Zoom. The consent form was obtained by asking respondents to read the terms and conditions and provide their permission to be part of the study. The initial survey consisted of 33 questions regarding telehealth training experiences. Questions included closed-ended type, open text responses, and Likert-scale.  Questions on competency and confidence in providing various aspects of telehealth services and using technology were assessed using the Dreyfus model of clinical problem skills acquisition, using the anchors of novice, beginner, competent, proficient, and expert (Pena, 2010).  The consent form and initial survey took approximately 15-20 minutes to complete. Each interview lasted about 90 minutes and was scheduled based on the trainees’ availability.  All data was collected by a research associate not affiliated with any of the psychology training programs at CHC, and de-identified data was provided to the research group. The interviews were conducted in English, then recorded and stored in the secure CHC server, and subsequently transcribed.

Results:

10 out of 28 trainees completed the post survey (5/6 postdoctoral residents, 2/4 doctoral interns, 2/5 doctoral students, 1/13 masters level students).   The survey assessed their perceived competence and confidence across several measures: using technology as a telehealth platform; delivering individual therapy via telehealth; and conducting telehealth groups.

Using Technology

Most trainees (N=8) indicated either maintenance or growth in their competency using technology over the course of the training year.  Likewise, confidence in using technology reflected improvement or maintenance with nine individuals.

Delivering Telehealth Therapy

Seven participants noted an increase in their competency in delivering telehealth individual therapy, with two participants retaining a high level of competency (a four or five out of five rating before and after their training year) and one participant not responding.  For endorsed confidence in delivering telehealth individual therapy, seven trainees reported an increase, and three trainees maintained their high levels of confidence.

Telehealth groups:

Most participants (N= 8) reported novice or beginner competency in conducting telehealth groups compared to other areas assessed.  Seven out of 10 trainees endorsed an increase in competency, and three trainees maintained their rating.   With confidence in conducting telehealth groups, seven trainees noted an increase, and three trainees maintained their level of confidence in running telehealth groups.

Telehealth training

Participants indicated that training about conducting groups over telehealth and constructing virtual playrooms were helpful.  Introductory trainings to conducting telehealth therapy, and general certification were also noted as helpful by some participants but were seen as redundant for others.

Role of experience

It was noted several times across training levels that participants learned by experience.  In the survey, when asked to clarify pre- and post- confidence and competence ratings, of those respondents who provided a clarifying answer, the majority connected their rating to either having experience or clinical exposure or not.  Participants rarely referenced previous training as a rationale for their competency or confidence scores.

Individual interviews

Two participants completed individual interviews to provide more information regarding their experience with training using telehealth.

Benefits and drawbacks of telehealth

How expectations impacted experience

One participant noted how their understanding about telehealth efficacy initially affected their comfort in using the modality.  “I felt uncomfortable at the start, and I feel much more comfortable now. But what contributed to it was…there's research showing that telehealth isn't as effective in …symptom reduction, as in person therapy. So, there was always a doubt in the back of my mind whether it's going to be as effective as in person.”

Mixed feelings about the use of telehealth

Trainees noted mixed feelings about the benefits of telehealth.  One shared the thought that, “In some ways that [telehealth] helped. In some ways it hindered.”  Overall, one trainee stated, “So I felt like telehealth helped them and some, it was like brought closer, other ones to kind of push away.”

Effects on intimacy

Trainees noted a mixed impact of conducting therapy over telehealth on the sense of connection with clients.  One trainee stated that “[b]eing able to work with a family in their home was an interesting experience that I think improved the intimacy in some ways, but the flip side of that is that it was too comfortable, it was too intimate for some patients, having a therapist in their bedroom with them made them uncomfortable.”  Additionally, “[y]ou had to worry more about HIPAA and people being in the room because it felt casual and almost put the therapist on guard more…. There are less boundaries.”

A trainee reflected on how personally for them, telehealth provided a buffer where they could be more direct with clients: “I felt like I had the tendency to respond back or like somehow try to … lessen the blow, like if I'm asking the question “Hey have you ever experienced trauma?  ’I felt like [on the computer] I was much more direct.”

Conversely, trainees reflected that not being face-to face at times hindered interpersonal connection.  Patient curiosity was noted to emerge toward termination, as patients introduced themes of loss in having never met the therapist in terms of the felt sense of not ever having been in the room physically with their therapist. “Termination was interesting because almost everyone that I terminate with has the comment of ‘I wish I would have met you. Or I wish I would have just seen you, or put like because they wouldn't know how tall I am … and I think that's a human component of just like, oh, there's a person. And I just want to see what that person looks like or what that person like is. So, I felt like termination was a little bit different here because it was just like okay bye See, like, I'll see you and we're going to close this. Whereas in person, it was like, I can touch you… and then it just seemed a little bit more genuine in terms of the termination.”

Increased consistency in treatment

It was also noted that telehealth provided increased consistency of attendance, which could help with rapport building.   A trainee noted: “With building rapport, I think the accessibility of telehealth helps consistency, which then helps build rapport. I think the fact that I was able to access most patients, most of the time, helped lay the groundwork for a therapeutic relationship, which then impacted their willingness to engage in [treatment].”  Another noted, “We could actually open that up as a way of talking about education and their mental health. And so, it opened up a space for us to really get deep down into what they were experiencing… If that was in person, those conversations wouldn't have happened because I can't go see my therapist every day of the week like it's crazy to drive over here. And so, for some folks I felt like it was really helpful to do internet based or telehealth where other folks that are like, I just can't grasp the phone, I can't grasp talking and looking at a screen.”

Trainees noted that for many clients, telehealth increased access that they would not have had if they had to come to treatment in person. A trainee noted, “I got the sense that some of these folks would not have gone to therapy had it not been telehealth. And I got the sense that some folks would not have shared as much if it wouldn’t have been in person.”  It was also noted: “And I saw almost every patient, every week. I strongly doubt that would have happened in person with or without a pandemic.”

Personal benefits

For trainees, personal benefits of training remotely were also noted,  specifically around the flexibility of scheduling.  One trainee noted: “I made a schedule where I was able to work [longer] a couple days a week so that I had a shorter days and other days that I could care for the kids and so I was able to do all the work that needed to do and parenting, which was exhausting but I don't know how would have gone otherwise you know so that flexibility that was afforded by doing telehealth was monumental, and I'm so grateful for that.”  Another trainee noted: “In terms of the trainings. I mean, it seemed like it was bulletproof because, hey, you can't make the training sessions great, you need to watch a video online. When do we watch it, figure it out, then it's like well hey there's different sessions that I want to go to different echo sessions. I can't go to it because this fulfills my hours here. Well great there's one that you could review online watch the recording every week. So it's like, Man, This is awesome.”

Telesupervision considerations and developing cohesion

Themes from qualitative data indicated a preference for in-person supervision. “Supervision itself felt normal, it didn't feel very different. Once you know that our own supervisions were actually beneficial in some ways because they're navigating the systems and things of that sort, you could just share your screen and do it. So that was beneficial. But I would prefer in person if we're not considering the pandemic.” Another trainee reflected, “I think being in person I could see his (the supervisor’s) books and [ask about them], whereas when we started doing online supervision, I didn't see those things I just saw the blank screen so I didn't know much about him. So, I think I would want supervision in person.”  Trainees also acknowledged some technological ways to mitigate not being in person to learn from their supervisors: “We pull up on screen here's your cases, let's work on this together so it was, it felt like it was more integrated, and it was more collaborative. And so, I don't know if that was her style versus previous supervision styles, but I felt like I got a lot out of it.”

In regard to making connections with trainees and staff, there was note of the loss of informal interactions through remote training.  “I wish we had more group cohesion. We just didn't.  Another noted: “What was useful to build group cohesion was [having]an hour set aside, just for us…we didn't have opportunities for informal gathering.”

Summary

Overall, participants reported feeling both competent and confident conducting telehealth services by the conclusion of the training year, even if they did not feel so at the beginning of the year.  Participants tended to rely upon amount of clinical exposure conducting telehealth services as the basis of their ratings of confidence and competence. This may suggest that trainees may enter a site with the notion that they are competent to conduct services via telehealth simply by nature of clinical exposure. Additionally, trainees in this sample had similar levels of exposure of providing clinical services over telehealth, as the majority transitioned to providing telehealth services at the same time during the previous year (March of 2020) which will not be the case in cohorts moving forward.  The considerations suggest the need for training programs to consider which competencies they will use to determine trainees’ telehealth proficiency, such as Maheu et al’s (2019) telebehavioral health competencies already established, as well as to cultivate a trainee’s sense of what it means to be proficient using telehealth.  Aside from using specific competencies, observing clinical work, and utilizing outcome measurement tools, are important to confirm proficiency of trainees providing clinical services over telehealth. Cassiday et. al (2020) speak to the role of using simulations as a standardized form of observation as another way of assessing competency in the provision of telehealth services.   Moving forward, if training sites have options for trainees to provide services over telehealth or in person, there may be times where it may be important to determine if telehealth is an appropriate modality for a trainee to use or not, by their preference and/or proficiency in utilizing the modality.

While didactic training in telehealth group therapy provided at CHCI was consistent among trainees, group experience at CHCI comes with more variability in terms of trainee exposure, depending on access to actively running groups.  Trainee experiences varied greatly in terms of their access to groups to shadow and co-lead, and the telehealth group therapy experience levels of the supervisors they were working with. In assessing telehealth competencies, it is important to consider all modalities of treatment that are offered and proficiency across modalities (e.g., assessment, individual, group), particularly when experiences may not be able to be consistent across trainees, as often is the case with group experiences.

Developmentally, regardless of level of training, competency increased, even though some participants reported experiencing redundancy in training content.  Overall, participants noted pros and cons of each telehealth training they received, with variation between participants as to what aspects of the training were particularly beneficial to them.  With the nuances in trainees’ individual experiences in telehealth, programs should be attuned to these different experiences and keep this in mind in developing training. Though training in general in telehealth was received favorably, the most noted training was in specific areas rather than general training, such as developing virtual playrooms or conducting group therapy.  Rather than focusing on general telehealth training, agencies may want to consider training in specific areas in the provision of telehealth to which trainees may not be familiar.

The study also raised the need to reflect on supervisor competency on supervising trainees using telehealth services as a care delivery system.  Many supervisors were learning how to deliver care using telehealth, while simultaneously supervising and evaluating trainees in this modality, without formal training on how to do so ethically and systematically.   There is a considerable need to address this concern for supervisors and find ways to assess their competence.

Rosen et al (2020) noted the importance of starting to look to the future about when telehealth is appropriate to use and not to use.  Trainees reflected that in their experience, there were clients who thrived receiving telehealth, and those where telehealth did not feel like an appropriate modality.  Incorporating discussions with trainees in terms of considerations to when to use telehealth and how to do so effectively should be prioritized.

Limitations

At the time of data collection, limited telehealth research existed, and the questions were largely exploratory in nature, as noted by McCord et al. (2015).  Determining specific skill sets in telehealth and how to assess them is the future of research in this area.  A significant limitation of the study was the paucity of participants from the sample pool.  This was attributed to the timing that the data was collected.  The students and predoctoral interns were completing their training year or had just completed their year, rendering a reduction in participation in these cohorts. Additionally, since the data was gathered retrospectively, there is not a good way to discern what participants learned through training versus practice exposure.  To increase the participant group size, data could be gathered prior to trainees leaving, and could be gathered at more training sites aside from just one training location.  In gathering this data, there was the aspiration to be able to determine if there are similarities and differences in telehealth training experience across different levels of training.  With such a small sample, one is unable clear conclusions of this nature across the different training levels.  Additionally, since the data was gathered retrospectively, there is not a good way to discern what participants learned through training versus practice exposure.

In new aspects of training, such as telehealth, anchors assessing competency may not be as clear to trainees.  For example, they may not be able to identify their level of ability as they have limited context to compare it to.  Additionally, with newer trainees, it may be difficult to differentiate their perception of their competency in providing telehealth as compared to their perceived proficiency in providing clinical services in general.  Taking time to review new competency areas with trainees, the ways they are rated, and obtaining a qualitative sense of how trainees rate themselves, may be important. Consequently, the research team discussed the importance of selecting competency anchors where a trainee has a clear sense of what each anchor represents.  Casper et al speak to this importance, particularly in providing clear consistent intervals between anchors (2020).

 

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Cite This Article

McIntosh, C., Ringelheim, J., Fathi, D., R. Kearney, T., Orozco, L. D., & Oo, M. (2022, August). Telehealth training considerations in a community healthcare setting. Retrieved from http://www.societyforpsychotherapy.org/telehealth-training-considerations-in-a-community-healthcare-setting

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