Access to high-quality behavioral health (BH) care is essential to the readiness of the U.S. armed forces and the health of their families. The U.S. Army has made significant improvements to its BH care delivery system over the past ten years, but it now faces the challenge of integrating lessons learned from the dramatic and unanticipated shift to virtual behavioral health (VBH) that occurred in the context of the coronavirus disease 2019 (COVID-19) pandemic. Three years since the onset of the pandemic, the optimal role of VBH as part of overall BH care delivery for soldiers and their dependents remains unclear. To inform policy and planning related to VBH, the Office of the Surgeon General, U.S. Army, asked RAND Arroyo Center to assess the expansion of VBH services and its relationship with overall BH service utilization and soldier perceptions of VBH, to inform recommendations on the role of VBH in military BH care in the future.
Background and Methods
BH conditions include a range of mental health and substance use disorders. VBH, also referred to as telehealth or telebehavioral health, is remote patient access to visits with a BH provider using technology such as a computer or cellular phone. VBH can be conducted as video visits using audio and visual communication technology, or as audio visits (also called audio-only or telephone) using audio technology with no video. Literature suggests that VBH can improve access to care, especially for patients who face barriers that involve work commitments, transportation, or child care (Donelan et al., 2019; Kruse et al., 2017). Systematic reviews suggest that VBH is similarly effective to in-person care for assessment and diagnosis of BH conditions (Greenwood et al., 2022; Hilty et al., 2013; Krzyzaniak et al., 2021; Scott, Bakhit, et al., 2022; Scott, Clark, et al., 2022). Research is favorable yet inconclusive on the comparative effectiveness of treatment through VBH and in-person care, as many studies were limited in their size, duration of follow-up, and the number of populations or BH conditions studied (Barnett et al., 2021; Ekeland, Bowes, and Flottorp, 2010). Therefore, it has been difficult to generalize the findings about effectiveness of VBH across populations, treated conditions, modalities (e.g., video, audio), and models (e.g., hybrid use of VBH and in-person BH care). For instance, some studies have concluded that video visits are superior to audio visits for the treatment of depression and trauma (McClellan et al., 2022). Patient satisfaction with VBH tends to be high, especially when patients can see their usual provider, and tends to increase with more use of VBH (Fischer et al., 2022; Kruse et al., 2017). Yet greater understanding is needed of patient experiences with and preferences regarding VBH and how those might change under a variety of conditions, treatments, and circumstances.
In this study, we examined patterns of VBH care delivery to active-component soldiers and their spouses and their receipt of VBH by different sources of care (i.e., direct care versus private-sector care). We also analyzed soldiers’ perceptions of and experiences with VBH.
- Administrative data analyses included visit-level analyses of trends in the proportion of BH visits that were by VBH from October 2019 through March 2022 and VBH visits by soldiers (N = 78,797) and their spouses (N = 49,705) who had at least one BH visit through primary or specialty care between October 2021 and March 2022. Administrative data analyses also included person-level analyses of VBH visits among a subset of soldiers (n = 22,614) and their spouses (n = 7,836) who received at least three specialty BH treatment visits at a military treatment facility (MTF) (or, for spouses, at an MTF or in private-sector care) between October 2021 and March 2022 (the BH treatment cohorts).
- A survey of soldiers assessed perceptions of VBH among those who received at least three BH specialty care outpatient treatment visits at an MTF between January and March 2022. The survey contained 70 items; was fielded between August 4 and September 23, 2022; and was completed by 419 soldiers.
We distilled the main findings from our administrative data analyses and the soldier survey into five themes.
Direct Care Providers Were Less Likely to Deliver Virtual Behavioral Health Than Private-Sector Providers and Relied Heavily on Audio Virtual Behavioral Health
For soldiers, the proportion of direct care VBH visits hit a peak of 74 percent in April 2020 and declined to 16 percent by March 2022. In contrast, private-sector care VBH visits among soldiers ranged from 61 percent to 46 percent during the same period. In direct care, between October 2021 and March 2022, primary care providers and psychiatrists were most likely to provide care by VBH, and evaluation and management/medication management visits were more likely to be by VBH than other types of visits. During the same period, in private-sector care, clinical psychologists and social workers were most likely to provide care by VBH, and individual psychotherapy was more likely to be by VBH than other types of visits. About 80 percent of direct care VBH visits were coded as audio visits, and nearly all private-sector VBH visits were coded as video-based, but guidelines on coding practices may partially account for these differences. Specifically, provider guidance varied regarding the definition of synchronous VBH (e.g., whether a video component was required), and codes used by direct care providers to designate audio visits were not used by private-sector providers. Survey findings indicated that, among those with any VBH, more soldiers reported receiving audio visits (79 percent) than video visits (58 percent). The majority of soldiers accessed VBH using their cell phone, though some used a computer or tablet or completed a visit from their vehicle; the home was the most common location for receiving VBH visits.
Soldiers Who Received Virtual Behavioral Health Typically Received a Mix of Virtual Behavioral Health and In-Person Visits
About half of soldiers in the BH treatment cohort received their treatment through a mix of VBH and in-person visits. Some small differences (just over 5 percentage points) were found in receipt of VBH across demographic groups within the BH treatment cohort. The largest difference in use of VBH was across age groups: VBH was used by 60 percent of those age 45–64 and 51 percent of those age 18–24. Almost all soldiers in the BH treatment cohort (98 percent) received at least some in-person care. Only 2 percent received all their visits through VBH.
Receipt of Virtual Behavioral Health Was Associated with More Positive Perceptions of Virtual Behavioral Health
Soldiers generally had positive perceptions of VBH convenience, regardless of whether they had received VBH as part of their BH care. About two-thirds of soldiers indicated that VBH visits saved time and were more convenient than in-person BH visits, and slightly less than half viewed VBH as requiring less time away from their military duties. About two-thirds of soldiers also saw VBH as an important option for care continuity during deployment or after moving to a new location. However, soldiers who had received VBH were more likely to endorse the advantages of VBH than those with no VBH experience (72 percent versus 48 percent, respectively, on the convenience of VBH, for example). Likewise, those with VBH experience were less likely to agree with statements about privacy concerns related to VBH (19 percent versus 34 percent, respectively, on concern about security of the connection). In addition, the “dose” of VBH experience also seemed to make a difference in perceptions of VBH: Soldiers with two or more VBH visits indicated significantly more positive perceptions of their providers, of visits, and of VBH technology (e.g., ease of use, protection of privacy) than those with only one visit.
Soldiers Who Received Virtual Behavioral Health Rated Their Military Behavioral Health Care Similarly to Those Who Received Only In-Person Behavioral Health Care
Comparing soldiers who received VBH and those who did not, we found no significant differences in perceptions of BH care quality, access, privacy, convenience, working alliance with providers, helpfulness of BH care, or global ratings of care. Some concerns arose regarding the scheduling of appointments in a timely manner, and a minority reported feeling concerned about their privacy during appointments, but those concerns did not differ by receipt of VBH. Because perceptions of BH care did not differ, these findings suggest that VBH integration did not negatively affect soldiers’ experience receiving BH care.
Few Soldiers Declined Virtual Behavioral Health in Favor of In-Person Care, but Nearly One-Third Were Not Offered Virtual Behavioral Health
While about half of surveyed soldiers received VBH in the prior six months, nearly one-third were not offered VBH, one-sixth were offered it but did not receive it, and the remainder did not receive VBH but could not be sure whether it was offered. This suggests that some soldiers may have been interested in VBH and may have chosen to use it had it been offered to them. The soldiers who were offered VBH but did not receive it were a small part of the sample (17 percent), but the majority (91 percent) of this small subgroup expressed a preference for in-person BH care.
We integrated our analyses of VBH use and the survey of soldiers to develop three recommendations on the role of VBH in overall BH delivered by the military.
Recommendation 1. Support the Expanded Delivery of Virtual Behavioral Health Among Military Treatment Facility Providers by Developing a Virtual Behavioral Health Care Strategic Plan
Our findings suggest that there is ample room to increase the use of VBH in direct care. The proportion of VBH visits in direct care was substantially lower than in private-sector care, and direct care providers relied heavily on audio visits. A subset of soldiers in our survey who did not receive VBH also indicated that they had not been offered VBH care, which suggests that they might have used it had it been offered to them. To expand the delivery of VBH, we recommend that the Military Health System (MHS) capitalize on its existing virtual health care strategic plan by developing goals and an implementation plan specific to VBH. These could include defining a target volume of VBH to be delivered through direct care and private-sector care, releasing guidance on appropriate situations for VBH delivery, and clarifying coding guidelines for video and audio visits in direct and private-sector care. A VBH implementation plan should establish minimum requirements for training and outfitting military BH providers with necessary technical equipment. Direct and private-sector providers should receive guidance on standardized coding for the VBH modality used (i.e., video versus audio) to ensure accurate data capture of the use of these modalities. These standards for VBH could be communicated to providers across service branches through an updated Defense Health Agency Procedural Instruction or similar document and through clinical, administrative, and technical trainings.
Recommendation 2. Assess Barriers to Virtual Behavioral Health and Ensure That Military Treatment Facility Providers Are Equipped and Trained to Deliver Virtual Behavioral Health
The high proportion of audio visits in direct care suggest that direct care providers may need additional support to carry out video visits. While the MHS currently has plans to fully equip all direct care providers with VBH equipment, conducting a baseline survey to assess perceived barriers related to technology and clinical training for VBH among MTF BH providers would provide a comprehensive needs assessment to guide these efforts. Survey findings could help identify content to incorporate into standardized trainings, current technology resources, and areas for which additional clinical guidelines or training protocols may be needed.
Recommendation 3. Evaluate the Utility of Virtual Behavioral Health in Supporting Continuity of Behavioral Health Care Across Military Treatment Facilities
Most soldiers indicated that they saw substantial value in being able to continue seeing their provider through VBH while deployed or after moving to a new location. Though the MHS has been developing a Virtual Medical Center to address access shortages in direct care settings in the United States and around the world, there are several barriers to keeping soldiers connected to providers regardless of location. These include administrative processes regarding MTF privileging and credentialing, existing systems for measuring provider productivity according to visits completed with service members at the provider's MTF, and a lack of guidance on how and when to implement VBH with service members after a move or deployment. If the MHS were to address these barriers through changes to administrative processes and the dissemination of updated guidance, it could be useful to then pilot and evaluate the utility of VBH in supporting continuity of care across MTFs. For example, the MHS could explore the feasibility of allowing time-limited use of VBH to support care continuity, such as for a period of six months or until BH care is established with a new provider. A rigorous evaluation could assess for differences in quality and cost of BH care and provide an assessment of the potential value of broader implementation of VBH to support care continuity in the future.
The rapid expansion of VBH during the pandemic provided an opportunity to learn about the potential for VBH to enhance access to BH care for soldiers and their spouses. The key findings and recommendations from this report may be used to inform policymaking and planning regarding the role that VBH will play as a permanent part of BH care delivery.