At the start of the COVID-19 pandemic, the department of psychiatry and behavioral health at Geisinger began experiencing a significant increase in demand for behavioral health services.
THE PROBLEM
The demand for services was most noticeable for adult psychotherapy services, with waits as long as several months and several thousand outstanding orders. Simultaneously, the department was beginning to shift much of its care to telemedicine, ultimately resulting in more than 80% of outpatient visits for behavioral health services being offered virtually.
At the time, the department had several group therapy offerings.
“Historically, these services were not offered virtually due to the complexity of offering groups via telemedicine,” said Benjamin C. Gonzales, operations manager II, virtual care, behavioral health, at Geisinger. “This created a significant challenge given the important role groups can play in treating mental illness and the access they create.
“The department, and Geisinger as a whole, did not have a solution for virtual groups,” he continued. “Geisinger’s service area is also rural. While in-person groups would be ideal, this would be difficult given how far some patients might need to travel. In fact, some groups saw poorer utilization due to having multiple options when consolidation was needed.”
Further, Geisinger’s behavioral health team saw significant growth among its provider group, adding more than 70 providers to the team over the course of the pandemic. Much of this growth was accomplished via telemedicine providers, including virtual psychotherapists.
Many of these providers were trained to offer therapy, but without a virtual group platform, this service could not be provided.
PROPOSAL
Virtual group therapy was meant to solve a number of problems. The most important was service continuity during the pandemic; with many in-person services on hold, there was no possibility of running groups at the clinic.
“Groups serve as an important component for many with mental health and substance use disorders, including some of Geisinger Behavioral Health’s sickest patients who often are enrolled in the intensive outpatient program,” Gonzales explained. “Simultaneously, the department received an average of 180 referrals per day, with roughly half being for adult psychotherapy.
“In many cases, patients could be supported in a group setting, but options were limited as most groups were offered in person,” he noted. “Many providers were also transitioning to remote work, making in-person groups a challenge to operate. Virtual groups would allow our team to see patients remotely while leveraging our remote workforce. This in turn would help the department keep up with the overwhelming demand for services.”
Additionally, virtual groups were meant to provide a safe and secure way of scheduling patients for group sessions. For example, the department could not simply send a Zoom invite because this would share the patient’s email with other invitees. The team also needed a way of sharing content with patients before and after groups meet, in a seamless manner, to ensure patients could prepare for sessions.
MEETING THE CHALLENGE
Virtual groups were ultimately implemented by the Center for Telemedicine at Geisinger. The system used Microsoft Bookings for Groups due to its ability to send invites for groups securely without sharing patient emails.
The platform also allowed teams to create templates for groups, including providers/staff on the invite, the name and time of the group, as well as the maximum number of participants. The invite itself contained a Teams invite without displaying the contact information of other invites; Teams is also used widely at Geisinger for nonclinical purposes, which made implementation easy given the staff’s and provider’s comfort with the application.
“The platform was accessible to all departments at Geisinger,” Gonzales said. “In behavioral health, the platform was largely used by providers and staff to schedule and hold groups. At this time, scheduling groups and documentation are not integrated. Geisinger uses Booking for Group scheduling, while patients are also scheduled in Epic.
“This allows providers to use Epic for clinical documentation while leveraging Microsoft Teams for actual connection with their patients,” he added.
RESULTS
The most important outcome of this work was service continuity.
“We were able to offer nearly every group we offered in person via telemedicine, including our highest acuity offering, intensive outpatient program,” Gonzales reported. “This was important for us given the important role the group process can play in recovery from mental health and substance use disorders.
“We were also able to increase when compared to individual psychotherapy,” he continued. “At this time, we offer 16 groups, creating capacity for 172 patients each week. With the same capacity, we would only be able to care for 64 patients via individual psychotherapy. At one time, we were unable to offer any groups due to the restrictions during the COVID-19 pandemic.”
Wait times for groups are significantly shorter. Most groups can accommodate new patients within a week, while individual psychotherapy can take several months to access. This is largely due to the increased capacity created by groups.
“Along with the increased capacity, we are able to offer variability among group offerings, creating redundant offerings of the same service,” Gonzales explained. “This allows any patient to access services at their preferred day and time, rather than being forced to choose from one option.
“Lastly, we were able to add over a dozen remote providers to group coverage,” he noted. “This could not have been accomplished without telemedicine given the geographic spread of our team. Ultimately, this will allow us to further scale the capacity created by groups.”
ADVICE FOR OTHERS
“I would encourage healthcare leaders to consider what services they can offer in a group setting and how they can be supported via telemedicine,” Gonzales advised. “We have found that patient needs can often be met in a group setting, preserving individual therapy access for patients who need it the most.
“I would also invite leaders to consider how this technology can allow them to leverage talents outside of their service area,” he continued. “We’ve been able to add several providers to our team, creating redundancy and creating more opportunities for patients to join group while also scaling access.”
Lastly, leaders should be mindful of the operational need to support groups, he added.
“While we’ve created more capacity despite the geographic distribution of our patients and workforce, we have found that groups take more support from our staff,” he concluded. “Most of the extra comes in the form of managing referrals and scheduling groups given the larger number of patients served within the same encounter.”
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