Project Summary The response to COVID-19 in the U.S. has generated a transformative shift in telehealth policies for mental health care, including expansion of provider reimbursement, licensure portability, and permitted telehealth platforms. Against the backdrop of COVID-19, it remains unanswered to what extent U.S. mental health facilities have transitioned to telehealth, as well as effects on access, equity and quality of care. We propose a longitudinal, mixed-methods evaluation of the effects of telemental health expansion on access, equity and quality of mental health care—according to provider and patient perspectives. First, using a secret shopper approach, we simulate the patient experience of attempting to access telemental health services with a nationally representative sample of 1,500 mental health treatment facilities in Years 1 and 2, creating a longitudinal repository of the evolution of service availability for a wide array of telemental health services. Second, we will generate a unique, longitudinal secondary dataset that merges facility-, county- and state-level characteristics to investigate key factors that predict telehealth availability along three axes: (i) facility characteristics such as type of facility and facility management structure; (ii) county-level socioeconomic, racial/ethnic, and geographic disparities; and (iii) state-level COVID-related legislation. Third, following an explanatory sequential mixed-methods design, we will use responses from the secret shopper survey to guide key informant (KI) interviews with providers at 20 facilities—stratified by whether the facility offers telehealth services, and whether this occurred following onset of COVID-19. KI interviews will provide key insights on provider perspectives on barriers and facilitators to telehealth, quality of care, and feedback they have received from patients. Our three specific aims are: Aim 1: Conduct a longitudinal secret shopper survey of 1,500 mental health treatment facilities to assess an array of patient barriers to accessing specific telemental health services during the COVID-19 pandemic. Aim 2: Create a national database that synthesizes facility-, county-, and state-level characteristics to examine three sets of predictors of telemental health service availability from 2015-2022: (i) facility characteristics—including forms of management and accepted insurance; (ii) county-level racial/ethnic, socioeconomic, and geographic composition; and (iii) state-level COVID-19 related policies. Aim 3: Record key facilitators and barriers to offering telemental health services, provider perspectives on quality of care, and feedback from patients, drawing from KI interviews with a stratified sample of providers. The proposed study will shed light on the rapidly changing landscape of telemental health services— including with regard to access, equity and quality of care. Building from this, we will pursue an R01 in which we link our completed dataset to claims data to examine telehealth utilization and patient-related outcomes.

Project Narrative COVID-19 has catalyzed a dramatic shift in the landscape of telemental health, driven by the sudden disruption of in-person care and extensive state and federal regulatory changes. As a result, public health officials and policymakers will need rigorous evaluations of the evolving healthcare landscape to determine whether telemental health uptake and associated policies have affected access, equity and quality of care—both from provider and patient perspectives. In this longitudinal mixed-methods evaluation, we aim to increase our understanding of: (i) patient barriers to accessing telemental health by mental health treatment facilities (using primary data collection), (ii) facility-, county- and state-level characteristics—including COVID-related policies— influencing access and equity of telemental health care (using secondary data aggregation), and (iii) barriers, facilitators, and quality of telemental healthcare according to providers (using qualitative data collection).