Factors influencing uptake of telemental health via videoconferencing at high and low adoption sites within the Department of Veterans Affairs during COVID-19: a qualitative study

Abstract

Background: The coronavirus disease 2019 (COVID-19) pandemic dramatically increased the use of telemental health via videoconferencing (TMH-V). While TMH-V has been found to be effective and satisfactory to both patients and providers, little is known regarding factors that influence site-level uptake. We examined facilitators and barriers to TMH-V uptake at higher and lower adoption sites within the US Department of Veterans Affairs (VA).

Methods: We conducted twenty-four semi-structured qualitative interviews at four northeastern VA medical centers (two with higher TMH-V adoption and two with lower adoption). Six interviews were conducted per site (one member of mental health leadership, one facility telehealth coordinator/technician, and four mental health providers per site). We performed directed content analysis, guided by the Consolidated Framework for Implementation Research (CFIR), followed by a matrix rating process to rank the degree of influence of each of the 19 included CFIR constructs at the four sites. Positive overall influences, negative overall influences, and differentiators were then identified based on patterns in ratings across sites.

Results: Five CFIR constructs had positive overall influences across sites: Relative advantage, Patient needs and resources, Relative priority, Knowledge and beliefs, and Self-efficacy. Complexity had a negative overall influence across sites. Four constructs significantly differentiated between higher and lower adoption sites with regards to TMH-V use: Quality, Compatibility, Leadership engagement, and Champions.

Conclusions: Several positive overall influences on TMH-V uptake were identified across sites; respondents acknowledged multiple advantages of TMH-V (e.g., convenience), and providers' attitudes towards TMH-V improved as they gained experience. In contrast, complexity was a negative overall influence; TMH-V platforms and processes must be simple and user friendly to promote use. The emergence of Quality, Leadership engagement, and Champions as differentiators speaks to the importance of educating frontline staff and leadership at lower adoption sites about the evidence base demonstrating that TMH-V is high-quality care. Compatibility also emerged as a differentiator; if TMH-V is not easily integrated into provider workflows, uptake will falter. Future work should draw from these findings to develop implementation strategies aiming to increase TMH-V uptake at lower adoption sites, thereby increasing access to high-quality mental health care.