Virtual Care Works – But You Have to Be There

When the COVID-19 pandemic arrived in the U.S. in early 2020, things changed for almost all high school students across the country. We all watched as cities in California went first. They issued shelter-in-place orders and their schools switched to virtual learning over a matter of days. Students, teachers, and school administrators nationwide watched and wondered:

“Are we next?”

The answer was “Yes.”

By March, a majority of schools went virtual. Teachers scrambled to redesign all their lesson plans for the semester to adapt to the virtual milieu. Some parents scrambled to get childcare for kids now taking class at home. Others had to leave their jobs to help younger, elementary school children navigate the ins and outs of virtual learning. Still others – those lucky enough to be able to work from home – created work and school spaces for themselves and their kids in living rooms, kitchens, and bedrooms. Everyone did their best to find a daily schedule that met everyone’s needs while complying with COVID-19 mitigation measures.

The overwhelming consensus from people around the country – in various locations and in diverse fields of work and study – was we’re not ready for this.

However, organizations who provide mental health and addiction treatment for adolescents – like us here at Evolve – knew we had to be ready. We knew we were an essential service. We knew the teens we treated needed us. And we agreed with all the experts when they warned that pandemic-related disruptions could lead to mental health issues in teens who’d never had issues before and exacerbate problems for teens already diagnosed with an emotional, behavioral, or addiction disorder.

We kept our residential program open – following strict protocols – and we implemented virtual therapy programs for teens in our outpatient treatment programs. In our virtual programs, we had a 95% attendance rate, which we’re proud of because we knew our teens need the support we offered.

Around the country and around the world, we assumed other adolescent mental health treatment providers did the same thing. This article follows up on that assumption with two basic questions:

Did other providers go virtual?

Did their patients show up?

Telehealth During COVID-19: Rapid Implementation Around the World

To answer these questions, we’ll use data from four articles that collected information in four different locations. One thing that concerned us was that if providers didn’t switch to telehealth for teens quickly, then gaps in continuity of care would have an adverse effect on adolescent mental health in general. We knew that teens in depression and paranoia treatment stepping down from residential treatment needed immediate outpatient support, and virtual therapy for these teens could offer them the help they needed. The same was true for patients in substance abuse treatment: a virtual approach could help teens avoid relapse and maintain treatment momentum. This spanned beyond teen depression and anxiety but also crossed well into general health, forcing more Americans to seek out telehealth for flu, eczema, and even physical therapy training! Our screen-heavy society took a macro dose of tech during the pandemic and made life online even more normal. 

But let’s get to those studies. We can answer the first question right now, for all four locations:

Yes, providers in California, Connecticut, Pennsylvania, and Helsinki, Finland went virtual. They provided telehealth services for adolescents and young adults in the first months of the pandemic.

Now we can stay focused on the second question.

1^st Study: San Francisco, California

The article “The COVID-19 Pandemic and Rapid Implementation of Adolescent and Young Adult Telemedicine: Challenges and Opportunities for Innovation” reports on the implementation of telehealth at the Young Adult Medicine Clinic at U.C. San Francisco in the first month of the pandemic.

Did their patients show up?

Yes – but it took time. Here’s what they reported for the month of March, 2020:

• 1st week: Zero (0) telehealth visits in the Teen Clinic
• 2nd week: 56 telehealth visits in the Teen Clinic
• 3rd week: 44 telehealth visits in the Teen Clinic
• 4th week: 80 telehealth visits in the Teen Clinic

They also reported that overall visits – telehealth included – to the Teen Clinic for the month of March 2020 were similar to 2019: 332 in 2020, and 337 in 2019, respectively.

2^nd Study: New Haven, Connecticut

The article “Showing Up Is Half the Battle: The Impact of Telehealth on Psychiatric Appointment Attendance for Hospital-Based Intensive Outpatient Services During COVID-19” reports on “rapidly deployed telehealth services for psychiatrically high-risk individuals receiving intensive outpatient program (IOP)” at the Yale New Haven Psychiatric Hospital.

Did their patients show up?

Yes. The study examined data from October 2019 to July 2020. Here’s what they observed:

• Telehealth appointment increased for telehealth compared to in-person services for adolescents
• Appointment attendance increased for IOP groups across five diagnostic treatment programs
• There were differences in attendance by insurance types:
  • For adolescents with commercial insurance, telehealth appointment attendance increased
  • For adolescents with Medicaid, appointment attendance remained constant
• There were differences in attendance by race:
  • Telehealth appointment attendance increased for non-Hispanic white adolescents
  • Telehealth appointment attendance decreased for Hispanic/Latinx adolescents
  • Appointment attendance remained constant for non-Hispanic black youth

These researchers noted that telehealth was an “important tool for individuals with high levels of psychiatric acuity, particularly for group-based services” in the first months of pandemic-related public health measures.

3^rd Study: Philadelphia, Pennsylvania and Surrounding States

The article “Outcomes of a Rapid Adolescent Telehealth Scale-Up During the COVID-19 Pandemic” reports on “the first 30 days of rapid adolescent telehealth scale-up in response to the coronavirus (COVID-19) pandemic.” Researchers collected data on visit outcome – completed or not completed – and visit type for adolescents between March 16^th to April 15^th, 2020.

Here’s what they found:

• A total of 392 telehealth visits
• An 82% completion rate
• 39% of telehealth visits were for eating disorders
• 17% of telehealth visits were for gender-affirming care
• 15% were for general adolescent medicine
• 1% were for substance abuse
• 28% were for various other disorders/issues

Along with this data, researchers included case notes. The 1% substance abuse represented one person – a homeless teen in a shelter who received care via videoconference. Physicians had medication delivered to the shelter due to COVID-19 mitigation measures. In this instance, it’s likely that rapid deployment of telehealth prevented relapse to opioid use.

4^th Study: Helsinki, Finland

The article Adolescent Psychiatric Outpatient Care Rapidly Switched to Remote Visits During the COVID-19 Pandemic reports on “the outpatient services of adolescent psychiatry in the Helsinki University Hospital (HUH) from 1/1/2015 until 12/31/2020.” Researchers analyzed data comparing in-person and remote visits for adolescents with a variety of mental health disorders.

Here’s what they found:

• Total visits decreased slightly in Spring 2020
• Remote visits sharply increased starting in 3/2020
• Remote visits remained at a high level compared with previous years through 12/31/2020
• In-person visits gradually increased after the sharp decrease in March 2020

The study authors concluded that a “rapid switch to remote visits in outpatient care of adolescent psychiatry made it possible to avoid a drastic drop in the number of visits despite the physical distancing measures during the COVID-19 pandemic.”

Provide Telehealth and Teens Will Participate

The four studies we cite above tell the same story: telehealth is a viable option that teens will adopt rapidly. There are two reasons this does not surprise us. First, we know that most teens who stay in treatment want to be in treatment. They don’t want to stay forever. They want to heal and then go out into the world and discover their new normal. That’s why they show up. Second, they’re digital natives. With very few exceptions, adolescents in the U.S. navigate the digital landscape with ease. That’s why they show up so much: they know how and it’s easy for them.

The coronavirus pandemic showed us that we were ready. Providers scaled-up immediately, and teen patients – with depression, anxiety, substance use, and other disorders – showed up soon thereafter. There are important issues to address, however, such as ensuring open access with regards to the social determinants of health and guaranteeing total privacy and confidentiality. These are critical concerns to address. When they’re resolved, we may learn that the telehealth infrastructure we created during the pandemic will ultimately engage more teens in mental health treatment than ever before.