During the first session, the provider obtains consent from the veteran to engage in TMH services, conducts an assessment, and establishes rapport. The provider works with the veteran to develop a treatment plan for PTSD or other mental health diagnosis that will include the type of EBP. At the end of the first session, the next appointment is scheduled, and treatment materials are either mailed to the veteran or given to him or her onsite. After completing EBP, the VISN TMH center works with the referring provider to find follow-up services for the veteran.
The various steps necessary to begin an interfacility TMH clinic are summarized in Table 1.
Provider Training
Despite strong evidence of success, many providers remained skeptical about the efficacy of TMH. One study indicated that several providers in VISN 16 rarely used the established TMH programs because they were not familiar with them and applied TMH only for medication checks and consults. 11 This skepticism was present in providers preparing to offer TMH as well as in providers referring veterans for TMH services. However, once providers better understood the TMH programs and had more experience using them, they were significantly more likely to use TMH for initial evaluations and ongoing psychotherapy. For these reasons, proper training and educational opportunities for practicing providers are vital to TMH implementation. 9,11
To be proficient, providers need to become familiar with various TMH applications. 10 Health care networks implementing TMH must ensure that their providers are well trained and prepared to give and receive proper consultation and support. Providers must also acquire several skills and familiarize themselves with available tools. 9 In educating providers on the process and use of TMH, the authors suggest the following steps for TMH application:
- Learn new ways to chart in multiple systems and know how to troubleshoot during connectivity issues.
- Have an established administrative support collaborator at outpatient clinics to fax and exchange veteran homework. 12
- The TMH clinic culture must be embedded where the veteran is being served in order to allow for a more realistic therapeutic feel. This type of clinic setting will allow for referrals at the veteran site and the availability to coordinate emergency procedures in the remote clinic.
Clinical Issues
Ongoing clinical issues need to be addressed continuously. Initially, referrals may be plentiful but not always appropriate. It is important to have an understanding with referring providers and remote sites about what constitutes a “good referral” as well as alternate referral options. It is imperative to outline inclusion and exclusion criteria that are clear and concise for referring providers. It is often helpful to revisit these criteria with potential referral sources after initiating services.
With the ability to provide inhome services, it is important to identify specific inclusion/exclusion criteria. Recommendations are based on research and clinical applications for exclusions, which are available on the Office of Technology Services website. These include imminent suicidality or homicidality, serious personality disorder or problematic character traits, acute substance disorders, psychotic disorders, and bipolar disorder. It is important to use sound clinical judgment, because the usual safeguards present in a remote clinic are not available for inhome services. Emergency planning is one of the most important aspects of the in-home TMH health services that are provided. The information for the emergency plan is obtained prior to initiation of services.