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story.lead_photo.caption Heather Johns uses her phone to telecommunicate with Barbara Price-Boucher, who is sitting across the room from her, to demonstrate how a teleconference between a patient and a therapist could go on Friday at Capital Region Medical Center's Southwest Campus in Jefferson City. Teleconferenced therapy sessions can be held over the phone, on a smart device like an iPad or via laptop or computer.

As the COVID-19 pandemic took hold in Missouri, Jefferson City hospitals shifted to a behavioral health-delivery model that relied on telehealth programs.

Along with the pandemic, social distancing and stay-at-home orders fostered a rapid increase in telehealth for use in both primary and specialty health care, according to Mike Misko, president of SSM Health Medical Group in Mid-Missouri.

"The providers in our SSM Health outpatient Behavioral Health Clinic here in Jefferson City converted many visits to the virtual platform, and we continue to offer that service when appropriate," Misko said. "With regards to inpatient care, we had already implemented the utilization of telehealth for behavioral health/psychiatry consultations, which has worked well and increased efficiency of evaluations and care."

Mental health care providers at Capital Region Medical Center had also implemented the technology to treat patients. They found that when the pandemic began, they treated more patients.

There was a lot of fear about being exposed to the novel coronavirus, said Heather Johns, manager of Capital Region's Center for Mental Wellness. The pandemic only enhanced the anxiety for patients the center was already seeing.

"People were fearful of going to their primary care doctor initially. They didn't want to get out and be exposed," Johns said.

But there was also a lot of anxiety about income and job loss. Maybe, because of social distancing restrictions, people were forced to spend too much time with their families, she said.

"It's taken a toll emotionally. Some have been hit financially and emotionally," Johns said.

People needed to — and continue to — receive mental health care.

There may have been a slight dip in patients the first week of the pandemic, she continued.

An issue was that insurance wasn't paying for telehealth services.

"We were already set up in the behavioral health world to provide telehealth care," Johns said. "We had already been set up and had the training."

Despite insurance companies' initial hesitance, physicians and nurse practitioners at CRMC reached out to patients and told them they could receive care via telehealth.

Shortly after the pandemic started, insurance companies said they wanted patients to stay home for their health and began supporting programs.

"A lot said they'd pay the co-pay," Johns said.

As federal restrictions eased, insurance companies also agreed to support telephonic services — done over a land line.

Using the technology to provide mental health services for its clients isn't new to CRMC. The hospital has offered counseling for corporate clients of its Employee Assistance Program for several years.

The service offers a free, voluntary and confidential counseling and referral service designed to help people with job-related problems. The counseling could be done virtually.

By 2018, the hospital was developing processes for other specialties, including therapy services and specialty providers. And, with the need for medical care in rural communities growing, it has worked with rural health clinics to implement telehealth services over the past few years.

So, as the COVID-19 pandemic began to take hold in Missouri in late March, CRMC was prepared.

At the time, it announced patients could see their health providers for almost any appointments that didn't require an in-person physical examination. They could either use apps on their smartphones or go to crmc.org/televisit to participate in visits using their personal computers equipped with webcams.

CRMC said it could view the health event as an opportunity to expand access for patients, with the goal of having every provider using online technology to improve patient experiences.

A psychologist with SSM Health Medical Group, Laurel Kramer said the pandemic has intensified stresses patients had already asked for help with. It also created new stresses.

"Family problems like care giving for family members in their homes and nursing homes without visits, divorce, parenting stress with schools closed; coping with their own behavioral health problems — depression and anxiety worsened with the pandemic and especially with sheltering at home," Kramer said. "Telehealth was necessary to reach all these patients to help them cope with the ongoing stress and the intensified strain of the pandemic."

On Wednesday, U.S. Sen. Lamar Alexander, R-Tennessee, who is chairman of the Senate Health, Education, Labor and Pensions Committee, said three changes (of more than 30) made to telehealth during the pandemic should be made permanent. He said physicians should be reimbursed for telehealth regardless of the patient's location; feds should allow Medicaid and Medicare to reimburse providers for more services, including emergency department visits, nursing facility visits and therapy; and feds should allow doctors to conduct appointments using common apps like FaceTime, texting or speaking over land line phones.

He also expressed some willingness to allow physicians to continue to offer health care across state lines through interstate compacts.

"I believe there would have been more emotional problems without telehealth. All my patients said telehealth is helpful in a crisis situation and for immediate needs," Kramer said.

Johns said she sees only one or two patients in person each week. That's by their choice, she explained.

"We see a lot of patients who drive from outside (the community)," Johns said. "One or two people who we have worked with for a while — I'm their only trip out. They feel safe coming in here."

The patients' only other trips out of their home may be to a grocery store.

There is a limited number of people at the center, she said, which makes it easy to remain socially distant.

Telehealth, patients say, is convenient. It keeps them healthier. Insurance now supports it. And it's a different level of confidentiality because patients don't have to leave their homes, Johns said.

A large percentage of the center's visits — 50-65 percent — were done electronically during April and May.

"Patients were comfortable using it with us," Johns said, which translated to other services. "People who had chronic illnesses weren't being neglected. We saw a rise in other clinics."

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