The COVID-19 pandemic prompted sweeping changes to behavioral health (BH) care delivery, and the Military Health System (MHS) faced challenges similar to those of other health care systems. The MHS needed to minimize disruptions and ensure continuity of BH care for service members, leading to a rapid increase in the use of telehealth. The objectives of the work presented in this report were to assess the perspectives and experiences of military BH staff regarding their use of telehealth following the onset of the pandemic. The findings informed recommendations to guide the MHS in better integrating telehealth into BH care. We interviewed staff who delivered or oversaw BH care at military treatment facilities (MTFs) between July and October 2020 to help the MHS assess how these facilities and individual providers adapted to providing BH care in the midst of a pandemic, their experiences with telehealth as a BH care delivery method, and the feasibility of using telehealth for this type of care in the post-pandemic future.
The COVID-19 Pandemic May Have Increased Demand for Behavioral Health Care in the MHS
Posttraumatic stress disorder (PTSD), depression, and substance use disorders (SUDs) are all common among U.S. service members. Prior RAND Corporation research analyzing MHS administrative data identified several differences in BH care access and quality across service members with these conditions. Specifically, access to and receipt of recommended BH care was generally found to be lower among reserve-component service members than active-duty service members and lower among service members who lived in areas remote from an MTF compared with those who lived near such a facility (Hummer et al., 2021; Hepner et al., 2021; Hepner et al., 2017). The MHS aims to provide high-quality care for service members with BH conditions, and the recommendations from those studies—which included the increased use of telehealth—highlighted opportunities to address these differences and ensure that all service members receive the BH treatment they need.
However, the pandemic may have affected MHS efforts to improve service members’ access to BH care and the quality of care they received. At the same time, increased distress related to the pandemic may have increased demand for BH care among service members and their dependents who are eligible for TRICARE. Nationally representative longitudinal survey data from the Centers for Disease Control and Prevention and RAND showed sharp increases in mental health symptoms and psychological distress as a result of the pandemic (Breslau et al., 2021; Czeisler et al., 2020), particularly among younger adults and racial/ethnic minorities. Preliminary data suggest that this trend held true for service members as well: A survey conducted from March to May 2020 found that 15 percent of active-duty service members experienced worsening symptoms of an existing anxiety or depressive disorder diagnosis (Strong, Akin, and Brazer, 2020). Another 18 percent reported experiencing anxiety or depressive symptoms with no preexisting diagnosis, suggesting new onset of these symptoms.
Telehealth for Behavioral Health Care in the MHS
In the MHS, telehealth has been defined as “the use of technology to provide health care consultation, education, assessment, treatment, care coordination and support for health care providers and patients separated by distance” (Military Health System, undated).1 The MHS has used telehealth—whether real-time interaction (synchronous) or non-simultaneous information exchanges between patients and providers (asynchronous)—for more than 20 years. It has been used for numerous conditions, but its most common application has been for BH care. There are many different models of telehealth, but most have similar benefits, including convenience for patients who need to schedule appointments around work and child care obligations. Telehealth can also increase access to BH care for service members who live in remote areas or require care in deployed settings. Research also suggests that telehealth is an effective means of care delivery for PTSD, depression, and SUDs. For the MHS, telehealth has the potential to address surges in demand for BH care, provided that procedures are in place to flexibly reassign workloads across providers or care teams and to overcome challenges associated with a shortage of BH care providers.
Prior to the pandemic, telehealth use was low in the MHS: A RAND study of MHS administrative data found that less than 3 percent of service members treated for PTSD, depression, or SUD in 2016–2017 received synchronous (real-time) telehealth care (Hepner et al., 2021).
Interview Sample Selection and Methods
We interviewed 53 BH staff at ten MTFs. We identified facilities and staff to interview using a tiered stratified sampling approach. First, we selected MTFs to maximize variation by service branch; geographical location; proportion of BH visits by remote service members being treated for PTSD, depression, and SUDs; MTF size; quality of BH care; and types of telehealth services offered by the MTFs. The distribution included slightly more Army MTFs, larger MTFs, and MTFs offering higher-quality BH care. We then selected staff to interview using the following eligibility criteria: (1) a member of the U.S. military (Army, Navy, Air Force, or Marine Corps) in the active component, in the National Guard/reserve (active-duty or active status), or a government/U.S. Department of Defense civilian and (2) a provider or administrator who delivered or oversaw care at an MTF for service members with at least one of the target diagnoses (PTSD, depression, or SUD).2 A mix of provider types—including psychiatrists, psychologists, master's-level counselors, substance use counselors, and primary care practitioners—helped us capture a wide range of experiences with BH care delivery and telehealth.
We conducted interviews by phone or via a secure web-based video-conferencing platform between July and October 2020. The interviews used a semistructured protocol to collect details on providers’ use of telehealth following the onset of the COVID-19 pandemic, organizational and clinical factors associated with the use of telehealth, perspectives on patient satisfaction and the need for provider and patient familiarization with telehealth, and experiences providing telehealth to remote service members.
Use of Telehealth Increased Dramatically Following the Onset of the Pandemic, but It Varied Within and Across MTFs, and Many MTFs Were Already Returning to In-Person Care
Nearly all respondents noted a dramatic shift from in-person care to audio-only or video telehealth or to a combination of in-person and telehealth modalities early in the pandemic. Some described using audio-only telehealth for shorter visits or “check-ins,” while others mentioned attempting to deliver full-length psychotherapy sessions. More than half reported at least some integration of mobile apps into their BH care delivery. There was variation across sites and between providers in the proportion of telehealth visits relative to in-person care during the pandemic. At the time of our interviews, half of respondents across all MTFs told us they were getting “back to normal” and seeing more patients in person.
Most Providers Were Open to Using Video Telehealth, but Widespread Technological Challenges and a Lack of Clear Policy Guidance Impeded More-Frequent Use
Nearly all providers were using audio-only telehealth at the time of our interviews, yet only about a quarter indicated that they were open to continuing to use it. Most were not yet using video telehealth; among those who did, just over half indicated that they were open to continuing to use it. Overall, more than three-quarters expressed an interest in using video telehealth in the future. Reasons for low uptake of video telehealth included administrative and technological barriers, such as insufficient internet bandwidth and equipment, difficulty accessing telehealth platforms while teleworking, a lack of technical support, and concerns about reliability and data security. Staff at most MTFs also expressed frustration with bureaucratic barriers, unclear guidance, or a perceived lack of support for telehealth at the MTF or Defense Health Agency (DHA) level.
Staff Expressed Concerns About Using Telehealth with High-Risk Patients, Those Diagnosed with PTSD or SUD, and Those Receiving Group Therapy
Nearly all respondents shared opinions about the appropriateness of telehealth for specific patient populations. Around half expressed concerns about using telehealth—particularly audio-only telehealth—to treat high-risk patients or patients with high symptom severity. Reasons given included an inability to accurately assess certain symptoms. Most staff reported that high-risk patients were typically seen in person during the pandemic. In addition, nearly one-third and one-fifth, respectively, expressed some concern about using telehealth with any patient with PTSD or SUD. About one-quarter of respondents mentioned that group therapy sessions had stopped since the onset of the pandemic, and about one-fifth expressed concerns about using telehealth to deliver group therapy. Across nearly all MTFs, around one-third of respondents shared concerns about using telehealth to conduct intake assessments or suggested that it should be used with established patients only.
Staff Indicated That Both Patients and Providers Needed More Orientation to Telehealth
Just over half of BH staff reported that they believed patients liked telehealth, largely citing greater convenience. However, nearly one-third reported that some patients disliked telehealth and preferred to receive care in person. Reasons included a lack of trust in the technology or difficulty using it. Some staff described a “learning curve” for both providers and patients as they became more comfortable with telehealth modalities.
Staff Believed That Telehealth Was a Promising Approach for Service Members Who Lived Far from an MTF, but They Reported Barriers to Using Telehealth with These Patients
The majority of BH staff reported that they did not use telehealth with remote service members prior to the pandemic, and nearly half said that telehealth was not always used with this population during the pandemic. More than half acknowledged the unique value of telehealth for these service members, including increased access and continuity of care. Although most said that telehealth had ameliorated barriers for one or more remote service member patients, there was broad recognition that existing MTF staffing levels and referral practices did not support ongoing use of telehealth with this population. Respondents also cited concerns about treating high-risk or high-symptom-severity patients as a possible barrier.
The following recommendations can help the MHS continue to integrate telehealth to meet the BH needs of service members and guide decisionmaking regarding policies and practices for the adoption of telehealth for BH care at an enterprise scale.
Recommendation 1. Develop Policy Guidance on the Use of Telehealth for Patients with Specific BH Conditions
DHA released interim guidance on data security and privacy in March and August 2020 (Place, 2020; Cordts, 2020), along with standards of practice for BH during the pandemic period (Defense Health Agency, 2020), but, as of March 2021, there was no formal procedural instruction for telehealth. Policy guidance should address both the technological requirements and expectations for high-quality treatment delivery via telehealth. It might also be worthwhile to standardize policy guidance with clinical guidelines on the safe treatment of patients with various clinical issues. Allowances might be made for MTF- or command-level variation in telehealth implementation while still establishing minimum legal and regulatory requirements at the system level.
Recommendation 2. Develop and Implement a Strategic Plan to Ensure That Providers Have Adequate Technology to Support Video Telehealth
Across all the MTFs in our study, staff reported technological infrastructure barriers to telehealth adoption—including a lack of adequate technology to allow video telehealth, poor connectivity, inadequate bandwidth, and difficulty using telehealth platforms. It appears that the MHS would benefit from a strategic plan to address these limitations. Ideally, the MHS would adopt a user-friendly, reliable, and secure audio-only and video telehealth platform that is compatible with multiple types of devices; interoperable with GENESIS, the electronic medical record system being deployed across MTFs; and adaptable to both individual and group treatment. It might be beneficial to first evaluate existing platforms and identify potential improvements to meet these needs.
Recommendation 3. Provide Clinical and Technical Training on the Use of Telehealth
Recommendation 3a. Provide Training on the Clinical Aspects of Telehealth
Staff expressed concerns about using telehealth in a variety of clinical situations (e.g., with high-risk patients), suggesting a need for additional training on the clinical aspects of telehealth. Training that targets providers’ specific concerns and competency levels would increase comfort, knowledge, and skills and would potentially improve attitudes toward telehealth. Providers also need standardized, empirically based guidance to identify which patients are appropriate candidates for telehealth, how to assess patients and deliver evidence-based psychotherapy using telehealth, and how to respond when there are concerns about patient safety. They would also benefit from materials to socialize patients to telehealth.
Recommendation 3b. Provide Technical Training and Support for Telehealth
Staff expressed a desire for access to technical support and training specific to telehealth implementation. Training on the technological elements of telehealth modalities and best practices for interacting with patients this way could help mitigate this barrier. It might be worthwhile to identify existing technical support staff and conduct an initial assessment of potential scalability at a given MTF. At the system level, it may be useful to increase information technology staffing to ensure that someone is on site at each MTF to troubleshoot or provide in-home assistance (for providers who are teleworking).
Preliminary evidence indicates that the COVID-19 pandemic increased demand for BH care among service members, just as it did for civilian populations. Furthermore, pandemic-related restrictions affected the ability to deliver BH care to service members in person. Telehealth filled a gap for some MTFs and providers early on in the pandemic, but there was some uncertainty about its future utility at the time of our interviews. The findings and recommendations in this study illustrate how telehealth can—with the appropriate training, technology, guidance, and policies—increase access to BH care and help the MHS meet the needs of all service members.