Background: The use of telemental health via videoconferencing (TMH-V) became critical during the Coronavirus disease 2019 (COVID-19) pandemic due to restriction of nonurgent in-person appointments. The current brief report demonstrates the rapid growth in TMH-V appointments in the weeks following the pandemic declaration within the Department of Veterans Affairs (VA), the largest healthcare system in the United States. Methods: COVID-19 changes in TMH-V appointments were captured during the six weeks following the World Health Organization's pandemic declaration (

Rosen served as lead for writing -original draft and writingreview and editing. Leslie A. Morland contributed equally to writing -review and editing and served in a supporting role for writing -original draft. Lisa H. Glassman served as lead for writing -review and editing and served in a supporting role for writing -original draft. Brian P. Marx served in a supporting role for conceptualization and writing -review and editing. Kendra Weaver served in a supporting role for conceptualization, data curation, and writing -review and editing. Clifford A. Smith served as lead for data curation and served in a supporting role for conceptualization and writing -review and editing. Stacey Pollack served in a supporting role for writing -review and editing. Paula P. Schnurr served in a supporting role for conceptualization and writing -review and editing. Craig S. Rosen, Leslie A. Morland, and Lisa H. Glassman contributed to conceptualization equally. Craig S. Rosen and Clifford A. Smith contributed to formal analysis equally. Craig S. Rosen and Leslie A. Morland contributed to project administration equally. The views expressed are those of the authors and do not necessarily reflect the position of the U.S. Veterans Health Administration or the government of the United States.

BackgroundOutcome for mental health conditions is suboptimal, and care is fragmented. Evidence from controlled trials indicates that collaborative chronic care models (CCMs) can improve outcomes in a broad array of mental health conditions. US Department of Veterans Affairs leadership launched a nationwide initiative to establish multidisciplinary teams in general mental health clinics in all medical centers. As part of this effort, leadership partnered with implementation researchers to develop a program evaluation protocol to provide rigorous scientific data to address two implementation questions: (1) Can evidence-based CCMs be successfully implemented using existing staff in general mental health clinics supported by internal and external implementation facilitation? (2) What is the impact of CCM implementation efforts on patient health status and perceptions of care?Methods/designHealth system operation leaders and researchers partnered in an iterative process to design a protocol that balances operational priorities, scientific rigor, and feasibility. Joint design decisions addressed identification of study sites, patient population of interest, intervention design, and outcome assessment and analysis. Nine sites have been enrolled in the intervention-implementation hybrid type III stepped-wedge design. Using balanced randomization, sites have been assigned to receive implementation support in one of three waves beginning at 4-month intervals, with support lasting 12 months. Implementation support consists of US Center for Disease Control’s Replicating Effective Programs strategy supplemented by external and internal implementation facilitation support and is compared to dissemination of materials plus technical assistance conference calls. Formative evaluation focuses on the recipients, context, innovation, and facilitation process. Summative evaluation combines quantitative and qualitative outcomes. Quantitative CCM fidelity measures (at the site level) plus health outcome measures (at the patient level; n = 765) are collected in a repeated measures design and analyzed with general linear modeling. Qualitative data from provider interviews at baseline and 1 year elaborate CCM fidelity data and provide insights into barriers and facilitators of implementation.DiscussionConducting a jointly designed, highly controlled protocol in the context of health system operational priorities increases the likelihood that time-sensitive questions of operational importance will be answered rigorously and that the outcomes will result in sustainable change in the health-care system.Trial registrationNCT02543840 (https://www.clinicaltrials.gov/ct2/show/NCT02543840).

Key Points Question Collaborative chronic care models for mental health conditions are supported by extensive randomized clinical trial data, but what is the evidence that these models can be implemented and can have beneficial effects in general clinical settings? Findings In this randomized clinical implementation trial of 5596 veterans, a collaborative chronic care model was shown to be effectively implemented with practical, scalable facilitation support for clinicians. Effects on self-reported health outcomes were limited, but mental health hospitalization rate improved. Meaning These findings suggest that collaborative chronic care models can be exported to general clinical practice settings using implementation facilitation and, at least for individuals with complex mental health conditions, can improve health outcomes.

The current study examined patient and provider differences in use of phone, video, and in-person mental health (MH) services. Participants included patients who completed ≥1 MH appointment within the Department of Veterans Affairs (VA) from 10/1/17–7/10/20 and providers who completed ≥100 VA MH appointments from 10/1/17–7/10/20. Adjusted odds ratios (aORs) are reported of patients and providers: (a) completing ≥1 video MH appointment in the pre-COVID (10/1/17–3/10/20) and COVID (3/11/20–7/10/20) periods; and (b) completing the majority of MH visits via phone, video, or in-person during COVID. The sample included 2,480,119 patients/31,971 providers in the pre-COVID period, and 1,054,670 patients/23,712 providers in the COVID period. During the pre-COVID and COVID periods, older patients had lower odds of completing ≥1 video visit (aORs < .65). During the COVID period, older age and low socioeconomic status predicted lower odds of having ≥50% of visits via video versus in-person or phone (aORs < .68); schizophrenia and MH hospitalization history predicted lower odds of having ≥50% of visits via video or phone versus in-person (aORs <. 64). During the pre-COVID and COVID periods, nonpsychologists (e.g., psychiatrists) had lower odds of completing video visits (aORs <. 44). Older providers had lower odds of completing ≥50% of visits via video during COVID (aORs <. 69). Findings demonstrate a digital divide, such that older and lower income patients, and older providers, engaged in less video care. Nonpsychologists also had lower video use. Barriers to use must be identified and strategies must be implemented to ensure equitable access to video MH services.

Background: Extensive evidence indicates that Collaborative Chronic Care Models (CCMs) improve outcome in chronic medical conditions and depression treated in primary care. Beginning with an evidence synthesis which indicated that CCMs are also effective for multiple mental health conditions, we describe a multistage process that translated this knowledge into evidence-based health system change in the US Department of Veterans Affairs (VA). Evidence Synthesis: In 2010, recognizing that there had been numerous CCM trials for a wide variety of mental health conditions, we conducted an evidence synthesis compiling randomized controlled trials of CCMs for any mental health condition. The systematic review demonstrated CCM effectiveness across mental health conditions and treatment venues. Cumulative meta-analysis and meta-regression further informed our approach to subsequent CCM implementation. Policy Impact: In 2015, based on the evidence synthesis, VA Office of Mental Health and Suicide Prevention (OMHSP) adopted the CCM as the model for their outpatient mental health teams. Randomized Implementation Trial: In 2015-2018 we partnered with OMHSP to conduct a 9-site stepped wedge implementation trial, guided by insights from the evidence synthesis. Scale-Up and Spread: In 2017 OMHSP launched an effort to scaleup and spread the CCM to additional VA medical centers. Seventeen facilitators were trained and 28 facilities engaged in facilitation. Discussion: Evidence synthesis provided leverage for evidencebased policy change. This formed the foundation for a health care leadership/researcher partnership, which conducted an implementation trial and subsequent scale-up and spread effort to enhance adoption of the CCM, as informed by the evidence synthesis.

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Background The coronavirus disease 2019 (COVID-19) pandemic dramatically increased the use of telemental health via videoconferencing (TMH-V). While TMH-V has been found to be effective and satisfactory to both patients and providers, little is known regarding factors that influence site-level uptake. We examined facilitators and barriers to TMH-V uptake at higher and lower adoption sites within the US Department of Veterans Affairs (VA). Methods We conducted twenty-four semi-structured qualitative interviews at four northeastern VA medical centers (two with higher TMH-V adoption and two with lower adoption). Six interviews were conducted per site (one member of mental health leadership, one facility telehealth coordinator/technician, and four mental health providers per site). We performed directed content analysis, guided by the Consolidated Framework for Implementation Research (CFIR), followed by a matrix rating process to rank the degree of influence of each of the 19 included CFIR constructs at the four sites. Positive overall influences, negative overall influences, and differentiators were then identified based on patterns in ratings across sites. Results Five CFIR constructs had positive overall influences across sites: Relative advantage, Patient needs and resources, Relative priority, Knowledge and beliefs, and Self-efficacy. Complexity had a negative overall influence across sites. Four constructs significantly differentiated between higher and lower adoption sites with regards to TMH-V use: Quality, Compatibility, Leadership engagement, and Champions. Conclusions Several positive overall influences on TMH-V uptake were identified across sites; respondents acknowledged multiple advantages of TMH-V (e.g., convenience), and providers’ attitudes towards TMH-V improved as they gained experience. In contrast, complexity was a negative overall influence; TMH-V platforms and processes must be simple and user friendly to promote use. The emergence of Quality, Leadership engagement, and Champions as differentiators speaks to the importance of educating frontline staff and leadership at lower adoption sites about the evidence base demonstrating that TMH-V is high-quality care. Compatibility also emerged as a differentiator; if TMH-V is not easily integrated into provider workflows, uptake will falter. Future work should draw from these findings to develop implementation strategies aiming to increase TMH-V uptake at lower adoption sites, thereby increasing access to high-quality mental health care.