Between shelter-in-place orders and a general fear of going to hospitals and clinics for treatment and care, the COVID-19 pandemic has transformed the way the healthcare industry delivers care. While much of the focus remains on the clinical side, behavioral health providers similarly needed to rapidly innovate in response to the crisis and to meet their patients’ new needs.
For many in the mental health field, the transition to virtual care during COVID-19 was an easier adjustment compared to other specialties. But as the pandemic continues to unfold, will mental health visits remain virtual? Sean Boileau, Ph.D., director of behavioral health services at APLA Health—a Los Angeles-based federally qualified health center (FQHC) that originally started out in the 1980s as an HIV services organization—discusses with Healthcare Innovation his team’s experience in switching to virtual during the pandemic, how behavioral health patients are taking to the transition, and more. Below are excerpts of that interview.
At a high level, can you describe APLA Health and its vision in this current healthcare environment?
The acronym APLA initially stood for AIDS Project Los Angeles. In the early 1980s, in light of the Reagan administration’s egregious mishandling of the HIV crisis response when it seemed like it was initially only impacting gay men, a whole bunch of grassroot organizations that were privately funded by mostly local folks with resources sprung up. Every major metropolitan city in the U.S., and really in the world—depending on how their national response was—did fundraising and threw resources together to help take care of folks that were unfortunately dying of HIV at that time.
We have since evolved a lot [in our ability to care for HIV patients]; in the 1990s it was very much like palliative care, and by the 2000s it was about taking care of people who had some medical consequences to HIV treatment, but the treatments were relatively effective. And in the 2010s, and now the 2020s, one thing that shocks a lot of people is that a person diagnosed with HIV who engages successfully in healthcare lives on average three months longer than an HIV negative person by virtue of the fact they’re getting preventive visits and routine lab work that the average American is not.
Eventually, APLA wanted to make sure to not misrepresent who we were, to not suggest wrongfully that we only treat those with an AIDS diagnosis. Most of our HIV positive patients are not diagnosed with AIDS; they are simply people living with HIV. We also became a federally qualified health center about six-and-a-half years ago, so we’re not solely focused on folks living with HIV or solely on the LGBT communities of Los Angeles. While those are still areas of focus, we are also generalists and provide community healthcare. A good 50 percent of my caseload does not have HIV and a good 25 percent of my caseload doesn’t presently identify with LGBT.
We have stayed the course during [the pandemic] and try to offer every [service] that we offered in February in March in April and May, while making sure the quality of healthcare adapted to this new environment. We have evolved to a largely telehealth environment; we just weren’t willing to sacrifice quality as an accommodation. The idea is to still have patients get 100 percent of their needs met as they would have in February, albeit stylistically different in many ways.
To that end, what has the transition to virtual care for behavioral health during the pandemic been like for your department at APLA?
Overall, looking at the big picture, since the start of COVID, we have seen a 16-times increase in healow tele-visits. Using the eClinicalWorks’ platform, in terms of my department, there has been a literal infinitive increase in these visits since we weren’t offering telehealth for behavioral health prior, but now we are 100 percent telehealth. We really don’t have anyone going to the office except for isolated crisis incidents. We actually have a little bit of an issue now with availability since there were patients who “tagged out” at the beginning of the pandemic, and said they would wait for in-person to open back up. So we took new patients in those timeslots, but then two months later those folks who tagged out decided to give telehealth a chance. The patients and staff have been pleasantly surprised, even those who cringed and flinched in March about doing this. I recently asked my team what they would want this to look like in the future: 80 percent said they preferred a hybrid option of both telehealth and in-person; 20 percent said they want 100 percent telehealth; and not a single person said they want to go back to 100 percent in-person visits.
What type of skepticism to virtual behavioral health existed early on?
My team’s resistance was a little lower than other teams’ resistance, and it just so happens that my team is a little bit on the younger side; the average age of my providers is mid-30s to mid-40s. But there was some skepticism and concern that they wouldn’t be as effective doing telehealth as they were with in-person. The elements that get “lost” when you switch to telehealth—greeting someone in person, shaking their hand, walking them in and sitting them down—were palpable losses that many of us had feelings about. But we have been pleasantly surprised about how much of that actually translates to a telehealth environment.
Even pre-COVID, it could be stressful sitting in a waiting room with people who look like they are dealing with physical illnesses. There are also factors such as parking, someone scratching your car, maybe panhandlers approaching you as you park your car and walk to the clinic, and the hustle and bustle of waiting in line and checking in. People aren’t doing that anymore; they are sitting on their couches with a cup of coffee and click two buttons to get their provider up on the screen. I had patients who relied on public transportation and it took them 90 minutes each way to get to me—and it was a very stressful 90 minutes. It’s a three-and-a-half hour chunk of their day for a 30-minute appointment.
And have you noticed that for some behavioral health patients, not only is the convenience factor there, but they are actually more comfortable not being physically in the room with their provider?
I have seen this in about 50 percent of my patients. There are those social phobias and that could lead to them being on-guard or anxious. For one patient, the act of taking transportation to get to me caused him extreme anxiety when he got here, but now I log in and once my face pops up on the screen, I see a smile on his face. For some folks, this is how they interact with the world—via social media. They are used to utilizing technology to engage with people in their everyday lives, so even when they have to do so on a professional level, it’s comfortable and familiar for them. Sitting in an office with a person in a tie feels unnatural to folks, but wearing a T-shirt and talking to a face on the phone is something they are familiar with, so that comfort level gets some folks to a place where they’re ready to delve deeper into unpacking things from their past.
How do you see the future, especially in areas such as getting more qualified behavioral health specialists, as well as training and adequately paying providers for behavioral health components?
Hopefully, the governor and president sign off on legislation allowing telehealth to become more permanent than it is right now when we’re operating in a state of emergency. In Los Angeles, it’s been a running gag for 30 years that you don’t ask someone how many miles they live away since that’s completely irrelevant; you ask them how far away they are, time-wise.
We have a ton of patients who are bilingual Spanish speakers, and I have a friend who is a psychiatrist, also a native Spanish speaker, and is a member of the LGBT community, but he lives two hours away from APLA during the wrong time of the day. But a Spanish-speaking LGBT psychiatrist is a unicorn of unicorns, and that is someone who would be of massive value to our staff. He isn’t going to commute to APLA every day, but depending on how things go next, this could be a person who I could incorporate to do telehealth psychiatry for us. That’s a benefit we have been looking to [add to our team]. So our ability to track and retain staff, and get people who are in line with our mission, who culturally and linguistically add [value] to us, from a greater than five-mile radius, is something we can hopefully [make happen].
