Analyzing Telemental Health Service Modality Effects on Treatment Engagement Using Electronic Health Record Claims Data

Background and Purpose: Amidst the COVID-19 pandemic, Telemental Health (TMH) emerged as a critical avenue for delivering mental health services. While the pandemic's ebb has allowed for a return to in-person services, interest in maintaining TMH alongside traditional care models has increased. Existing research indicates that TMH has no known negative effects and offers numerous benefits, including improved treatment engagement, comparable outcomes to in-person therapy, and improved accessibility. This study was part of an internal program evaluation project at a large community mental health organization in Southern California and its aim was to inform organizational leadership on the sustainability of TMH services post-pandemic. Specifically, the study compares traditional mode of service delivery and TMH on treatment engagement.

Methods: Secondary analysis was conducted with administrative claims data from January 2021 to June 2023. Service modality was recorded for each clinical service as in-person (clinic-based or field-based) or TMH (telephone or video-based). Client disengagement in treatment was defined as increases in client missed appointments (no-shows) and premature termination (withdrawing before completing treatment). Two separate analyses were conducted to test the association between service modality and no-shows and premature termination. For the no-show analysis, a binomial linear mixed model was conducted on the level of clinical service claims (sessions; n = 93,621) with a random intercept for individual clients (n = 2,587). For the premature termination analysis, a logistic regression was conducted on those who discharged (n = 786) using total sessions by modality as the main predictor. Client age, service division, and program were included as covariates in both models.

Results: The no-show model revealed that clients were approximately 2.22 times more likely to no-show for clinic-based sessions compared to field-based and 2.04 times more likely to no-show for clinic-based compared to telephone. Clients were 1.11 times more likely to no-show for video sessions compared to clinic-based. The premature termination model found a significant association between TMH usage and premature termination. Specifically, with every additional TMH service, the odds of premature termination were reduced by approximately 3.9% over and above the effect of total sessions.

Conclusion and Implications: The study uncovered the unexpected increased odds of no-show for video-based services. Potential reasons for this finding might be related to technological barriers, privacy concerns, or the perceived impersonality of video interactions. Additionally, the convenience of video sessions might inadvertently contribute to client forgetfulness or lack of preparation, making it easier to miss but also to reschedule. This latter interpretation may be supported by the findings of lower no-show rates for field-based and telephone sessions. Both modalities require the provider to initiate contact with the client, whereas video and clinic-based services require the client to initiate contact with the provider. An encouraging finding was the reduced odds of premature termination for TMH, emphasizing its potential in enhancing treatment continuity. TMH services can improve access to care for diverse client populations. These findings underscore the nuanced landscape of TMH and the imperative for organizations to establish best practices that address technological, privacy, and engagement challenges.