Cover: Behavioral Health Care Delivery Following the Onset of the COVID-19 Pandemic

Behavioral Health Care Delivery Following the Onset of the COVID-19 Pandemic

Utilization, Telehealth, and Quality of Care for Service Members with PTSD, Depression, or Substance Use Disorder

Published Mar 20, 2023

by Kimberly A. Hepner, Carol P. Roth, Jessica L. Sousa, Teague Ruder, Ryan Andrew Brown, Layla Parast, Harold Alan Pincus

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Research Questions

  1. How did patterns of behavioral health care utilization change in the MHS following the onset of the COVID-19 pandemic among service members with PTSD, depression, or substance use disorder?
  2. Under what circumstances and to what extent was telehealth incorporated into behavioral health treatment during that period?
  3. Were there any changes in the quality of behavioral health care that service members received through the MHS following the onset of the pandemic?

The COVID-19 pandemic brought about restrictions on in-person care delivery and led to a marked increase in the use of telehealth. When the pandemic began, the Military Health System (MHS) was already exploring options to expand its use of telehealth, including for service members with behavioral health conditions. To inform this effort and to provide insights into the pandemic's impact, RAND researchers examined changes in behavioral health care delivered to service members with PTSD, depression, or substance use disorder by the MHS following the onset of the COVID-19 pandemic, including patterns of care, use of telehealth, and quality of care. Although the number of behavioral health visits in the MHS declined overall following the onset of the pandemic in 2020 compared with an equivalent period in 2019, the use of telehealth increased markedly, and service members who received care had more visits with providers. In addition, the quality of the care they received largely held steady or even improved.

The findings and recommendations can help guide the MHS as it takes steps to expand the use of telehealth, improve service members' access to behavioral health care and the quality of care they receive, and increase the resilience of behavioral health care in the MHS in the face of future disruptions.

Key Findings

Pandemic-related restrictions prompted changes in behavioral health care delivery in the MHS

  • Compared with a pre-pandemic period (2019), there were fewer behavioral health visits among service members with PTSD, depression, or substance use disorder following the onset of the pandemic.
  • Fewer service members started treatment for PTSD, depression, or substance use disorder in 2020 than in 2019. However, service members who started treatment for PTSD or depression in 2020 received significantly more visits than those who started treatment in 2019. There was no significant difference for those starting treatment for substance use disorder.

Telehealth use increased markedly after the onset of the pandemic but varied by type of treatment

  • Before the pandemic, more than 90 percent of behavioral health care visits among service members with PTSD, depression, or substance use disorder were in person. Immediately following the onset of the pandemic, telehealth accounted for around two-thirds of these visits.
  • Telehealth modality varied by treatment, with audio-only used most often for evaluation and management visits and a mix of video and audio-only for individual psychotherapy.

Behavioral health care quality largely held steady or improved following the onset of the pandemic, but fewer service members were seen for PTSD, depression, or substance use disorder

  • The quality of care that service members received was similar in 2020 and 2019 on ten of 21 measures, improved on seven measures, and declined on four measures.
  • Receipt of recommended care was lowest in both years on timely delivery of treatment and follow-up care.

Recommendations

  • The MHS should continue to expand its use of telehealth for behavioral health conditions and continuously monitor care access and quality. Despite the challenges of the pandemic and the rapid expansion of telehealth, findings suggest that the quality of behavioral health care was sustained or improved on 17 of 21 measures and that telehealth could support MHS efforts to improve care quality and access. Robust telehealth capability could increase the resilience of behavioral health care delivery in the event of future disruptions — from pandemics to natural disasters.
  • The MHS should assess behavioral health treatment outcomes among service members who receive telehealth services. Prior to the pandemic, routine collection of patient symptoms relied on the Behavioral Health Data Portal, a system that used waiting room kiosks and tablets — methods that were not feasible for telehealth visits. Thus, data were not available to compare treatment outcomes between in-person and telehealth care. The MHS plans to enable patient-reported measures to be collected remotely as part of telehealth care. This will be an important step in accurately tracking symptoms across modes of care delivery and providing essential data to compare outcomes for patients who receive care via telehealth.
  • The MHS should increase the clarity of its telehealth coding guidelines for providers. As the MHS continues to explore telehealth expansion, standardized coding guidance for telehealth visits will be essential to monitoring the quality of care that service members are receiving.

This research was sponsored by the Defense Health Agency and conducted within the Forces and Resources Policy Program of the RAND National Security Research Division (NSRD).

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