For years, telemedicine has been touted as a way to address mental health provider shortages in Greater Minnesota or as an option that could help stave off the looming mass retirement of the state’s aging psychologist workforce. But, despite the promise offered by technology, most mental health providers in Minnesota avoided making the move to telemedicine, instead preferring to see their patients face-to-face.
Then COVID-19 hit Minnesota and everything changed. Within weeks of Gov. Tim Walz’s statewide stay-at-home order, mental health providers across the state were forced to embrace telemedicine: Sticking with the old ways of doing business would mean turning patients away and shutting down their practices.
This rapid switch went surprisingly quickly, said Teri Fritsma, senior research analyst for the Minnesota Department of Health Office of Rural Health and Primary Care. With an eye on keeping their practices alive, mental health providers made the switchover en masse, and many are now embracing their new reality.
“This change probably would have happened naturally over the course of a decade, but COVID provided this opportunity — or forced this opportunity — on providers,” Fritsma said. “Otherwise they wouldn’t have been able to stay open or earn a living.”
Curious to measure the impact of the telemedicine switchover on Minnesota’s mental health workforce, Fritsma and her colleagues polled licensed mental health care providers across the state. What they learned leads them to believe that even after the pandemic subsides, telehealth will remain a permanent part of mental health care in Minnesota.
It’s not just mental health providers that have adopted telemedicine practices, Fritsma added: “It is across the board. Primary care and every health specialty that you can imagine is doing this sort of thing because it is necessary. It needed to happen, and providers across the state somehow made it happen.”
When she compared the percentage of mental health providers who offered telehealth services during 2019 to the number who offered the option during COVID-19, Fritsma said, “There has been a gigantic increase in the share that are using telehealth for their clients.”
Licensed mental health counselors are a good example. During the calendar year of 2019, the MDH survey discovered that 23 percent offered telehealth options for patients. During the first wave of the COVID crisis (between May-August 2020), that number jumped to 77 percent. The biggest jump was seen among Minnesota psychologists, who moved from just 17 percent offering telehealth to their clients in 2019 to 80 percent offering the option during the COVID crisis.
Jonathan Neufeld is program director of Great Plains Telehealth Resource & Assistance Center, an organization that helps health care providers develop and implement telehealth programs. He said that he can understand why the majority of mental health providers in the state were slow to offer telehealth services pre-pandemic: For many providers, the old way worked just fine. There was little incentive to make a major change.
Then a worldwide crisis forced action, and local providers stepped up to the challenge.
“These are people and organizations that get paid by the widget,” Neufeld said. “They had to deliver services during a pandemic. During any sort of lockdown or shelter-in-place order, the only way they can deliver their services is telehealth. Out of necessity some of these groups that have been inching toward telehealth for years, that have been dragging their feet, initiated a rapid deployment of telehealth when COVID hit. That’s what we’re seeing now.”
Richard Sethre, Psy.D., retired from his longtime psychology practice this spring. As he was nearing retirement, he made the decision to transition most of his practice to telemedicine. An early adopter to technology, he saw the benefits of virtual counseling sessions, and most of his patients, after initially expressing concern that telehealth could limit the therapeutic relationship, got on board with the change.
“At first, several of my patients commented, ‘This is really different,’” Sethre said. “Later, they also commented in effect, ‘Gee, this is going great. I love the convenience. I want to keep doing this.’ They reported very little negative difference between in-person treatment and telehealth.”
No going back
The cat is out of the bag: Now that patients and mental health care providers have experienced the benefits of telehealth, it is impossible to imagine ever going back to the old ways of providing care. While some providers and patients may prefer to meet face-to-face, too many have experienced for themselves the convenience of online appointments to ever shut down that option.
Fritsma sees this as a positive development.
“This is good news,” she said. “I think it’s one of the solutions that policy people have often talked about.” And even after the pandemic subsides, she hopes that providers statewide will continue to expand options for telehealth: “If telehealth is more widespread, it could be a solution to some of the provider shortages we see in rural areas.”
As part of their survey, Fritsma’s team asked mental health providers if they intended to continue offering telehealth treatment as an option after the days of COVID-era social distancing are over.
“Of the providers that are using telemedicine right now, a huge majority of them told us they plan to continue using telemedicine after the pandemic ends,” she said. “Most believe that it is here to stay.”
When asked if they intend to continue offering at least some services via telemedicine post-COVID, the majority of the state’s mental health providers — 75 percent of licensed alcohol and drug counselors, 85 percent of psychologists, 88 percent of mental health counselors and 79 percent of social workers — said they would. Once they had a taste of the convenience and options that telehealth offers, it appears hard to look back.
Fritsma compared the experience of offering telemedicine to her own work-from-home life during the pandemic: “Think about how easy it is in so many ways to not go into the office. The telehealth option encourages all sorts of providers to be able to offer care who might otherwise have to be out of the market, like new moms or people who are getting ready to retire but would like to continue to work full time.”
And with telehealth now established as a viable option, many providers who might have been considering retirement before may now be rethinking their futures. “This could allow people to keep a foot in the door and reach potential patients more broadly, too,” Fritsma said.
Impact on psychologists significant
One category of mental health professionals that may benefit the most from telemedicine is Minnesota’s psychologists. With an aging workforce and a looming shortage of providers as more and more of the state’s psychologists contemplate retirement, telemedicine, with its potential for flexible scheduling and work from home, may be a way for some providers to extend the length of their career.
Among the state’s mental health providers, Fritsma said, “Psychologists are demographically the oldest group.” Pre-pandemic, she explained, the group appeared resistant to changing the way they did business, but they have since risen to the challenge: “Before COVID, psychologists were the least likely to use telemedicine. Now they are the most likely.”
In Fritsma’s survey, 85 percent of psychologists say they plan to continue providing at least some telemedicine post-COVID. This is good news to Sethre, who has made it a mission of sorts to help his fellow psychologists feel more comfortable with using technology as a way to expand and strengthen their practices.
When he was working to expand his own telehealth practice, Sethre discovered that information and tech support for this option was scattered and hard to come by. He decided to pull together the existing resources in one place and create a video designed to help other mental health professionals get their telehealth practices up and running.
“Some of us in the senior category were threatened by having to learn to use a new video program and dealing with the technology involved,” Sethre said, adding that he understood his colleagues’ trepidation and wanted to help them realize that they, too, can master the technology: “It is more complex than renting an office and chatting with a person in a room. You have a whole layer of technology you have to attend to — but I’m here to tell you it is something that can be achieved.”
Sethre found many benefits to seeing patients via telehealth. Like many of his colleagues, he had been concerned that virtual visits would feel impersonal, but in the end he said that both he and his patients found the experience to be a good option.
“I actually preferred telehealth,” said Sethre, who explained that his retirement date was pushed up when COVID restrictions meant that he could no longer conduct in-person mental health assessments on patients awaiting bariatric surgery in hospitals, a role that represented a large percentage of his practice. “The American Psychological Association has been advocating for the benefits of telepsychology for a couple of years. I just thought it made sense, and I like innovation. I asked myself, ‘How can technology make me a better therapist?’ I thought it would be easier for people to get in, easier to fill my schedule. I saw a lot of potential benefits.”
The rest of Sethre’s client caseload was made up of individuals with severe and persistent mental illness. He was concerned that they could be put off by telehealth or not have access to the technology needed to make a remote appointment work, but it turned out that, thanks to the ubiquity of smartphones, they all were able to make the required connections.
“You’d think that these would be the people who need more in-person connection and telehealth could be a serious barrier for them,” Sethre said of his former patients, “but every single one had the technology required. They all said that to their surprise they enjoyed the telehealth option and even preferred it.”
Because his experience with telehealth was so positive, Sethre hopes that many other psychologists will continue to build remote options into their practices even as the world returns to normal. He thinks that the technology will allow many to see patients longer and provide services for people who otherwise would have lacked care options.
“This is a great advancement for our profession,” he said. “I hope it continues to catch on.”
While most people believe that mental health care will never be the same post-pandemic, that the cat is out of the bag and telehealth is here to stay, there are still some advocates who point out that technology can never completely replace face-to-face human interaction.
Neufeld said that since the first panic of the pandemic has died down he has begun hearing from some providers who say they find the experience of treating patients with telehealth to be overwhelming.
“We are starting to hear from providers who are saying, ‘This is more exhausting than working in the office because it doesn’t have that aspect of respite. It is not a place I control,’” Neufeld said. “It is rare that a provider has a private office set up at their home, and finding a good place to conduct their practice can be challenging.”
Some mental health care providers have also told Neufeld that they miss having the option of leaving their homes and working from a private office.
“People are saying to me, ‘It is not the same being online. Instead of driving a few minutes and going to this nice, quiet space, I now have to yell at everybody in my family to stay out of my office,’” Neufeld said. “It’s not the same process.”
While Sethre said that his patients did not have a problem finding the technology needed to meet with him virtually, he does have some concern that telehealth could limit access to care for people who may need it the most.
“You could call it ‘the gentrification of telehealth,’” he said. “Telehealth works great for people who are prosperous and have a good computer and internet connections and a private space to do their appointments. People who are less prosperous might not have an internet connection or even a computer. This is a problem that will have to be figured out.”
Rural parts of the state with significant mental health provider shortages have the most to gain from telehealth, Fritsma said, but Greater Minnesota residents who lack access to adequate broadband services may not be able to realize the true benefits of telehealth.
While telehealth means that providers could see more patients without having to travel long distances, “There are rural areas where broadband is sketchy,” Fritsma said. “Certain populations don’t have access to the technology or can’t master it. If we want this to really take off statewide, this is something that has to be figured out.”
Neufeld said that some providers have told him they would much rather work with their patients in person and they will go back to that option as soon as it is viable. Still, he said, things will never be exactly like they were before.
“I think across the field of mental health I would be shocked if it ever went back to where it was simply because we found out a couple of things: One: Telehealth wasn’t as hard as we thought, and two: It’s extremely useful in certain situations among certain populations. That’s our reality now, and that’s the way things are going to be well into the future.”