key: cord-1004480-pbgajuxv
authors: Brodar, Kaitlyn E.; Hong, Natalie; Liddle, Melissa; Hernandez, Lisandra; Waks, Judy; Sanchez, Janine; Delamater, Alan; Davis, Eileen
title: Transitioning to Telehealth Services in a Pediatric Diabetes Clinic During COVID-19: An Interdisciplinary Quality Improvement Initiative
date: 2021-10-27
journal: J Clin Psychol Med Settings
DOI: 10.1007/s10880-021-09830-z
sha: 363653481ed96b4328473b93d6a2130d744b144a
doc_id: 1004480
cord_uid: pbgajuxv

COVID-19 necessitated a rapid shift to telehealth for psychologists offering consultation-liaison services in pediatric medical settings. However, little is known about how psychologists providing these services adapted to using telehealth service delivery formats. This report details how our interdisciplinary team identified declining psychosocial screener completion and psychology consultation rates as primary challenges following a shift to telehealth within a pediatric diabetes clinic. We utilized the Plan-Do-Study-Act (PDSA) quality improvement framework to improve screening and consultation rates, which initially declined during the telehealth transition. Screening and consultation rates dropped initially, but recovered to nearly pre-pandemic levels following three PDSA intervention cycles. During implementation, challenges arose related to the feasibility of patient interactions, interdisciplinary collaboration, patient engagement, and ethical issues. Clinics shifting psychology consultation-liaison services to telehealth should prioritize interdisciplinary communication, elicit perspectives from all clinic professionals, leverage the electronic health record, and develop procedures for warm handoffs and navigating ethical issues.

The COVID-19 pandemic necessitated a sudden shift to telehealth for many pediatric psychologists delivering consultation-liaison services in medical settings. By April 2020, 84% of psychologists in consultation-liaison roles identified telehealth as their primary modality for seeing patients (Steinberg et al., 2020) . Although the transition to telehealth presented several challenges, it also offered opportunities for increasing access and convenience of care and is likely to continue even after the pandemic ends (Kumar et al., 2020; Perrin et al., 2020) . However, how psychologists in consultation-liaison roles have adapted to these new service delivery models remains relatively unreported.

Past research indicates that psychological interventions delivered via telehealth in outpatient mental health settings can effectively treat common problems, including depression and anxiety, and that mental health providers typically express favorable views of telehealth (Connolly et al., 2020; Grist et al., 2019) . Although existing guidelines for conducting outpatient mental health services via telehealth are useful (e.g., Martin et al., 2020; McCord et al., 2020) , guidelines specific to providing psychology consultation-liaison services in medical settings via telehealth are not currently available. Psychologists in these settings occupy unique roles and typically see patients on an as-needed basis immediately following the medical portion of the patient encounter . As such, transitioning services to telehealth is more complicated than in general outpatient mental health. For example, consultation-liaison psychologists are typically unable to schedule patients in advance and are generally introduced to patients via a warm handoff from a medical team member. Additionally, they may conduct activities like routine mental health screening that do not easily translate to telehealth, particularly in clinics that do not have the capability to incorporate screening within the electronic health record (EHR) and are thus dependent on providing screening measures on iPads or paper to patients in waiting rooms (Cifuentes et al., 2015) . Likewise, while some work describing how inpatient psychiatry services adapted to telehealth during the COVID-19 pandemic (Kalin et al., 2020) , these services are different than the activities conducted by consultation-liaison psychologists in outpatient medical settings.

Preliminary research evaluating the adaptation of pediatric consultation-liaison psychology services at the beginning of the COVID-19 pandemic highlighted several reported benefits of the telehealth service modality, including reduced risk of infection for both patients and providers, more flexibility, better continuity of care, and increased efficiency during visits (Steinberg et al., 2020) . For example, psychologists were able to schedule appointments in advance rather than spending time finding patients in the clinic. Moving to telehealth also presented several challenges, including more difficulty establishing rapport and engaging families in care, fewer non-verbal cues during patient interactions, and reduced interdisciplinary communication and collaboration. Although early findings in this area are useful for informing the development of efficient and effective telehealth services (e.g., Barney et al., 2020) , additional work focused on the initial transition and continued delivery of psychology consultation-liaison services via telehealth in pediatric outpatient medical settings is critical.

This report details how an interdisciplinary team employed multiple cycles of the Plan-Do-Study-Act (PDSA) quality improvement (QI) framework to improve psychological service utilization in an outpatient pediatric diabetes clinic during the transition to telehealth services at the start of the COVID-19 pandemic. Authors include two psychologists (AD & ED), three psychology trainees (KB, NH, & ML), two diabetes educators (LH & JW), and one endocrinologist (JS), who worked collaboratively within an endocrinology clinic in a South Florida academic medical center serving a diverse patient population (65.2% White, 19.9% Black, 14.9% Other race; 58.5% Hispanic/Latinx, 41.5% Non-Hispanic/Latinx).

On average, in the several months prior to the World Health Organization declaring COVID-19 a pandemic (i.e., December 2019 through early March 2020), 60% of eligible patients within our clinic completed a psychosocial screener and 25% participated in a psychology consultation (see Fig. 1 ). On March 17th, 2020, all in-person services were suspended due to safety concerns, requiring all team members to shift to providing services exclusively via telehealth. This shift was followed by an immediate decrease in both screener completion rates (down to 36%) and consultation rates (down to 9%). We aimed to restore psychosocial screening and psychology consultation rates to prepandemic levels within 3 months. Our clinic's psychosocial screening procedures and psychology consultations play an important role in identifying youth in need of additional support (Brodar et al., 2021) . As such, it was critical to address the declining screening and consultation rates, particularly given the increase in mental health concerns in youth related to the pandemic, especially among youth with chronic illnesses (Hawke et al., 2020) . Herein, we describe various interventions we employed to meet these goals and report on their effectiveness. Additionally, we note challenges encountered, solutions identified, and recommendations for future practice.

In May 2018, our clinic adopted routine psychosocial screening procedures. This change corresponded to a 24.9% increase in psychology consultation rates within the clinic over the following 10 months, with consultations specifically for mental health concerns (versus diabetes management or health behavior-related issues) increasing by 71.9% (see Brodar et al., 2021, for details) . The screening protocol included measures of life satisfaction, depression and suicide risk, anxiety, eating disorders, and diabetes-specific measures of self-management behaviors, family conflict, stress, and intrinsic motivation. Adolescents (ages ≥ 12 years) completed the screener on iPads via Qualtrics-a secure survey platform-annually or more often, if indicated, prior to meeting with their endocrinologist. Qualtrics scored the measures automatically, and the psychology team shared results with medical providers orally in-person during clinic and later via summary tables emailed at the end of the clinic day for documentation purposes. Individuals with elevated scores received same-day consultation with a psychology team member who conducted additional assessment, offered brief interventions, and provided appropriate referrals at the end of the medical visit. The psychology team also provided consultations to families of younger youth or those without elevated scores, as needed. Endocrinologists and/or diabetes educators introduced the psychology team to patients and their families, offering a bridge that presented psychology as a routine part of care.

Clinic team members shared a huddle room, which facilitated interdisciplinary collaboration and consultation requests. Medical providers documented their portion of the patient encounter in our institution's electronic health record (EHR)-Epic-accessible to all clinic team members.

However, due to a lack of infrastructure and development at the time, medical providers were precluded from viewing psychology notes within the EHR. Thus, the psychology team documented their portion of the patient encounter in a separate, secure, cloud-based storage system-Box-accessible to all clinic team members. Given the predominant reliance on in-person contact for consistent interdisciplinary collaboration and coordination of care, the suspension of all in-person services highlighted the importance of optimizing communication among team members to continue delivering services effectively.

Approximately 1 week after the start of the COVID-19 pandemic (mid-March 2020), all patient encounters shifted to telemedicine. After approximately 3 months, the clinic began seeing some patients in person who were unable to do telemedicine visits. These patients were offered the option to come in person to the clinic to use an iPad to complete their virtual visit (see Table 2 ). However, more than 90% of visits continued to be completed via telehealth until June 2021. The overall number of patient visits to the clinic was approximately the same during the pandemic as it had been prior to the pandemic. Some patients came in only to download clinical information from their devices (e.g., continuous glucose monitor) and to be assessed for vitals and HbA1c values. The clinic's diabetes educators contacted patients on the day before their appointment to address any concerns about completing the telehealth visit. Any patient who did not show up for their appointment was contacted repeatedly until they were able to have an appointment.

The PDSA approach was our selected continuous improvement method, as it has been shown to be highly effective at improving clinical process outcomes (Hill et al., 2020) . This pragmatic approach (Speroff & O'Connor, 2004; Taylor et al., 2014) facilitated the use of complex and multi-faceted interventions that were responsive to the rapidly changing needs of our clinic and patients during the transition to telehealth services necessitated by the COVID-19 pandemic. Our interdisciplinary team identified two problematic areas-(a) psychosocial screening rates and (b) psychology consultation rates-which both decreased substantially during the initial transition to telehealth service delivery. We employed three PDSA cycles to address these issues (Table 1) . Psychology became increasingly proactive • Reviewed chart notes from all interdisciplinary team members and examined prior psychosocial screening data for potential consults • Emailed medical providers at start of clinic day with names of patients who may benefit from consult Initiated informal needs assessment in June 2020, which supported renewed interdisciplinary collaboration Uncertainty navigating the identification and coordination of care • Medical providers were not initially provided with full list of youth to be screened or seen for consults each day and were initially uncertain how or with whom to initiate contact with psychology team • Diabetes educators and endocrinology fellow felt less informed about psychology's procedures than physicians, wanted to be included in communication about patients Psychology presented findings from needs assessment and procedural updates during interdisciplinary team meeting Psychology began emailing physicians and nurse educators a list of patients to be screened prior to the start of each clinic day Limited review of psychology documentation by medical providers due to separate platforms • Accessing separate system added to medical providers' workload • Written documentation to facilitate interdisciplinary communication about patient concerns and progress became integral once no longer sharing space

In needs assessment, medical providers indicated they would be more likely to review notes if integrated in the EHR Psychology began documenting directly in the EHR and routing notes to physicians

Psychology screening information not available to physicians until following their portion of the visit • Many patients failed to complete the screening measures before medical visit, were instead reminded to complete during visit by physician • Screening data obtained after visit were less useful for physicians' clinical decision-making Patients with elevated scores had to be re-contacted to schedule a consult outside of medical visit time, and were sometimes lost to follow-up until next visit

Results sent to physician as soon as screening was complete Screening questionnaires sent earlier in the week Psychology team contacted families individually on the morning of their visits to prompt them to complete screener as needed

Separate endocrinology and psychology team patient encounters led to a decrease in patient acceptability of consults, particularly when patients/parents were uncertain of the reason for referral and/or experiencing perceptual barriers to participation (e.g., stigma about mental health care)

Physicians asked psychology team to join virtual visit before patient left encounter; provided summary of visit and recommendations as warm handoff to psychology, parallel to in-clinic handoffs (facilitated by switch to using Zoom integrated in Epic) Psychology encounters documented in EHR and routed to provider to view facilitated closure in communication loop that arose related to feasibility of patient interactions, interdisciplinary collaboration, patient engagement, and ethical issues, as well as our corresponding responses. These are reviewed in more detail in the discussion section.

During Cycle 1, which was initiated during the onset of the pandemic (early March 2020; see Fig. 1 ), the psychology 

On telehealth, patients no longer a "captive audience"

• Patients/parents occasionally ended encounter early, declined to see psychology • Whereas families previously may have reserved more time for in-person visit, on telemedicine, patient/parent at home, expected to return to virtual school/work as soon as medical visit ended, less willing to extend visit • Lower completion rates on psychology screener (see Table 1 ) Physicians framed psychology consult as part of medical visit/routine part of care rather than optional offering Warm handoff procedure instituted (see Table 1) COVID-19 pandemic presented new challenges for many patients; required a shift in type of services offered and how psychology team met patient needs • COVID-19-related adjustment, fears and worries, isolation, family stress • Parent-child conflict due to increased time in shared spaces at home • Difficulties navigating virtual school Created and distributed COVID-19 resources document for clinic families Provided brief interventions during consult as appropriate Liaison work became more challenging with limited referral options due to COVID-19

Psychology team provided brief interventions during consult Identified outside providers offering services via telehealth Some patients and their families faced barriers to engaging with providers via telehealth • Lack of access to smart devices, unreliable internet, no private space at home • Difficulty sustaining attention during appointments (i.e., "Zoom fatigue") • Financial and social stressors related to COVID-19 pandemic Patients were able to come to the clinic and use an iPad to connect with their providers, who were offsite (a limited number of nursing staff were available onsite to coordinate) Psychology team used creative, interactive methods to engage patients during visits (e.g., playing an online game, using the Zoom Whiteboard feature, sharing screen to review materials) Psychology team routinely asked about COVID-19 stressors during patient visits and tailored recommendations based on family needs Legal and ethical considerations Telehealth encounters introduced concerns regarding patient location (e.g., participation from car or work) and/or surroundings (e.g., to ensure patient privacy)

Problem-solving with patients to ensure safety and confidentiality (e.g., use of headphones, identifying a separate space, rescheduling)

Due to increased flexibility of telehealth, patients able to attend visit from out of state • Patients might attend visit while traveling to another state within US (i.e., on vacation) or from residence outside of the US (i.e., whereas they would normally travel to the clinic, travel and/or financial restrictions may interfere) • Consulting psychologist not licensed in other countries, states • Creates ethical problems if there is a need to follow up on suicide risk or concerns about child abuse

Request that patient and family inform clinicians of their location Patients outside of the US were not able to receive services Described these limitations to the interdisciplinary team Distributing generic time-unlimited screener links led to removing items related to suicide, given inability to ensure availability of psychology team to provide immediate support

Systematically assessed for suicidal ideation during consultation Youth elevated on depression, anxiety, or eating disorders automatically receive consult; same for youth who score in at-risk range for four or more domains Addressing reports of suicidal ideation via telehealth Assessing risk in the same manner as would be done in person Creating coping card using free apps (e.g., Safety Plan), identifying resources (e.g., suicide hotline) If child appears to be at risk, initiating process for voluntary or involuntary hospitalization as would be done in person Some patients are age 18 or older, so consent was necessary in order to speak with parents, but often only had parental contact information on file

Contacted caregiver to ask for child's contact information (cell, email) Psychology subsequently communicated and coordinated directly with patient rather than caregiver Connected with patient after their medical visit to complete consult and to gain permission to speak with caregivers as needed team sent a personalized, electronic version of the mental health screener to caregivers' email addresses the morning of their child's appointment. The personalized links could only be opened once and were associated with the caregiver's email address. Additionally, the links could only be used between 8 am and 5 pm on the day of the child's appointment to ensure that the psychology team could follow up immediately if the child indicated any suicide risk. Endocrinologists and diabetes educators referred patients to the psychology team for consultations, and the psychology team contacted caregivers by phone to schedule a virtual consultation via Zoom, a HIPAA-compliant video conferencing platform. Caregivers were required to complete and return a separate telehealth consent form before the consultation could occur.

During Cycle 2, which was initiated in early April to address insufficient screening responses (see Fig. 1 ), the psychology team began calling caregivers on the morning of their child's visit to remind them to complete the mental health screener. The team also provided the endocrinologists with a list of patients to be screened each day so that they could provide additional reminders to youth who did not complete the screener before their visit. To address consultations during Cycle 2, the psychology team sent an email with mental health resources and psychology team contact information to the clinic's caregiver listserv to remind caregivers that the psychology team was available as needed for consultations. All Cycle 2 procedures were in addition to Cycle 1 procedures, which remained in place.

In early May 2020, a university-wide EHR update allowed medical teams to conduct virtual visits with Zoom integrated in Epic, which removed the need for a separate consent form as caregivers were able to consent to telehealth services while accessing the virtual visit through their patient access portal. At this point, Cycle 3 was initiated for consultations. This involved creating a virtual warm handoff procedure, in which endocrinologists emailed the psychology team to join the medical visit, provided a brief summary of the medical visit and introduction to psychology, and then left the visit so that the psychology team member could meet with the family privately. Cycle 3 for screening was initiated in early June 2020 and involved a shift to using generic (rather than personalized) links to the screener that were sent several days in advance of the youth's medical appointment. Use of generic links allowed more time for the youth to complete the screener, as the links did not expire and could be completed at any time. Additionally, personalized links were only able to be opened once, whereas the generic links could be opened multiple times (e.g., if child opened link and began survey, but did not complete it, they could return and re-open it later without the team sending a new link). The screener asked patients to input their name and date of birth, allowing responses to be connected to patients even when using the generic link. Because the psychology team is only available during the diabetes clinic times (i.e., 8am to 2 pm on Tuesdays and Thursdays), suicide items were removed from the survey. Questions about suicide were instead asked during virtual visits with youth who screened positive for other concerns (i.e., depression) or who received consultation for other concerns (e.g., difficulties with diabetes management).

We monitored screening and consultation rates on a monthly basis, as well as biweekly during the first month of the pandemic. The psychosocial screening rate was calculated by dividing the number of screeners completed by the number of screeners distributed per week. The psychology consultation rate was calculated by dividing the number of consultations completed by the total number of patients with diabetes seen in the clinic per week.

As shown in Fig. 1 , screener completion rates began to decline for 1 month prior to the shift to telehealth (67% in January to 51% in February). This decrease was unrelated to telehealth and corresponded to an adjustment in clerical responsibilities within our clinic that occurred in January. This trend continued in early March (48%) and coincided with a psychology trainee transition (i.e., the start of a new rotation cycle). We initiated Cycle 1 in response to the suspension of in-person services on March 17th, 2020 (see Table 1 for details). We initiated Cycle 2 in response to the continued decline in screening rates during the first 2 weeks of April (36%). Although interventions employed in Cycle 2 (i.e., phone call reminders to caregivers from psychology team morning of visit, reminders from endocrinologists during visit), seemed to initially improve rates (50% in late April), they were not maintained (43% by May). As such, we initiated Cycle 3 (i.e., shift to generic links to screener sent several days in advance of appointment) in June, which led to a steady increase in screener completion rates (reaching 56% by August).

Also displayed in Fig. 1 , psychology consultation rates consistently corresponded to psychosocial screener completion rates, which is unsurprising given that many consultations are scheduled in response to elevated scores on the screener (Brodar et al., 2021) . Thus, consultation rates also began to decline prior to the shift to telehealth (30% in December to 20% in February). As was the case for screening, we initiated Cycle 1 (i.e., psychology team contacted caregivers to schedule virtual consultation outside of medical visit, separate consent form required) in response to the suspension of in-person services (see Table 1 for details). We initiated Cycle 2 (i.e., mental health resource email sent to caregiver listserv with information about how to schedule a consult) in response to the continued decline in consultation rates between late March (13%) and early April (9%). Although Cycle 2 did not produce immediate effects (7% in late April), it was also interrupted by our institution integrating our HIPAA-compliant videoconferencing platform (Zoom) into the EHR. This change made it possible to develop a virtual warm handoff procedure, as the psychological portion of the visit no longer had to be scheduled for a separate time and did not require a separate consent process. As such, we initiated Cycle 3 (i.e., virtual warm handoff procedure) in early May following this change. Subsequently, we observed substantial increases in our consultation rates (31% in May), which remained close to our target rate of 25% until another psychology trainee transition and a surge in COVID-19 infections in South Florida in late July 2020 (The New York Times, 2021) was followed by another decrease (15% in August).

This quality improvement initiative leveraged an iterative approach (i.e., three PDSA cycles) to increase psychosocial screening and psychology consultation rates within an outpatient pediatric diabetes clinic during the COVID-19 pandemic. Interventions employed during Cycles 1 and 2 did not produce desired outcomes for either target. However, increases in screening and consultation rates followed Cycle 3 interventions. Despite coming close to our target (60%), our team was inspired to continue implementing changes to ultimately obtain a completion rate that approached 100%. Thus, efforts to incorporate the screener into the EHR, which will require eligible patients to complete the screening questions as part of the telehealth and/or in-person visit check-in process are underway. Results of this intervention are not yet available due to delays with implementing new procedures during the pandemic. Our findings are limited in that we cannot draw causal inferences about the interventions we employed. It is likely that the changes we observed resulted from the combination of our specific intervention efforts, institutional changes, and the amount of time provided to acclimate to challenges presented by the COVID-19 pandemic and telehealth service delivery formats. As one example, the mental health resource email our team distributed was sent to families only 2 weeks prior to our institution integrating our HIPAA-compliant videoconferencing platform into the EHR, so it is difficult to determine the extent to which the two interventions differentially affected our outcomes. Likewise, our findings are likely specific to academic medical centers with access to psychology trainees and may not generalize to other clinic settings. Despite these limitations, our experience highlights several considerations for future practice relevant to a broad spectrum of integrated health settings. Furthermore, given room for improvement in pre-pandemic screening and consultation rates, procedures outlined in this paper reflect QI efforts addressing challenges that predated the shift to telehealth and may be relevant for application following the COVID-19 pandemic.

The COVID-19 pandemic highlighted the need to prioritize cohesion and communication among interdisciplinary team members. Without careful attention to communication and shared decision-making among different providers, moving to a telehealth format could reinforce a multi-disciplinary model with siloed care as providers no longer share physical space. Interdisciplinary collaboration benefits patient care (Powell et al., 2015) , allowing providers to learn from one another and approach patient care from a more holistic standpoint. We recommend that other clinics implement interdisciplinary communication via staff meetings or other formats at regular intervals and allot time during meetings to discuss continuous improvement efforts.

After our first two PDSA cycles proved largely ineffective, Cycle 3 began with a needs assessment to obtain interdisciplinary perspectives on how to improve our procedures. Team members provided helpful insight and suggestions, which guided our approach. Additionally, medical providers became more aware of the low screening and consultation rates, which stimulated collaboration on procedural changes. This is consistent with past research suggesting that including stakeholder perspectives facilitates engagement and uptake of new procedures (Manchester et al., 2014) .

Prior to the pandemic, psychology documented patient encounters and screening results outside of the EHR used by medical providers, primarily because psychology notes were designated as "sensitive" and could not be viewed by other team members. The shift to telehealth revealed that challenges arising from these disconnected systems were transcended by team members sharing a physical space that facilitated interdisciplinary collaboration and coordination of care. However, without consistent verbal communication, it became apparent that accessing separate systems was an impractical and burdensome barrier to effective and efficient interdisciplinary collaboration. Efforts to ensure psychology team members can document patient encounters and results in the EHR and other team members can view such documentation served to resolve this issue. Other work documents how the EHR facilitates communication between providers and improves care coordination (O'Malley et al., 2010) .

When patients are physically present in the clinic, they have often taken time off from work or school to attend the visit and are more amenable to a brief wait period between meeting with the endocrinologist and psychology team. With telehealth, families might be squeezing medical visits between virtual school or work meetings and therefore be less interested in extending the visit. As such, clinics must have a virtual "warm handoff" system in place in which medical providers communicate to families the importance and relevance of psychological well-being within diabetes care. Warm handoffs demonstrate continuity between providers and reinforce the psychology consult as a routine part of care (Taylor & Minkovitz, 2021; Young et al., 2020) .

We recommend reviewing and updating assessment and intervention procedures related to suicidality and abuse reporting (American Psychological Association, 2013; Campbell et al., 2018;  see Table 2 , "ethical considerations"). Clinics must consider the implications of youth being physically distant during consultations and have clear policies for how team members should address safety concerns.

Although telehealth is an acceptable substitute for in-person encounters for many patients and families, it creates additional challenges for some families. For example, families may not have access to a smart device that could join the virtual visit, may feel uncomfortable using technology, may lack a stable internet connection, may not have a private location in which they could meet with their providers from home, or may not have adequate insurance coverage for telehealth visits (Frye et al., 2021) . To connect with these individuals, clinics can offer a "hybrid" option where the patient and family can come to a clinic in person and use a clinic iPad to connect with their providers. This allows for a more limited number of staff to be present on site, which decreases infection risk while also ensuring that patients continue accessing services. Even for families who can access telehealth services, other factors may reduce patient engagement. For example, "Zoom fatigue," or difficulty sustaining attention due to spending significant amounts of time viewing a computer screen, can affect patients and providers alike (Romanchych et al., 2021) . Clinics should ensure that staff are able to take short breaks between patient visits and that staff receive training on how to engage patients via telehealth (e.g., Maheu & Wright, 2020) . It is also important for clinics to ask families about financial and social stressors related to the COVID-19 pandemic, which may also affect their engagement with healthcare providers during visits.

The COVID-19 pandemic has served as a positive impetus for healthcare systems to review and update their procedures, particularly as providers have shifted to primarily seeing patients via telehealth. Telehealth has been described as "the new normal" and will likely continue even after the pandemic ends (Kumar et al., 2020; Perrin et al., 2020) . Mental health providers in consultation-liaison roles must adapt to this shifting landscape, leveraging technology to maintain and/or expand their services. Telehealth offers several exciting possibilities to improve flexibility and convenience of services for patients and thus increase patients' access to psychological care (Stancin, 2020) .

In a post-pandemic world, mental health providers might consider a "hybrid" telehealth/in-person model of service delivery, where providers conduct consultations in person during medical appointments when possible, but can also offer services via telehealth at a time convenient for the patient's family. In addition to increasing options for consultation services provided during medical visits, telehealth enables youth and their families to access psychological support more easily between visits by reducing barriers related to scheduling and transportation (Wade et al., 2020) . Youth who receive mental health referrals from their medical clinic seldom follow up and receive services (Vassilopoulos et al., 2019) . Therefore, future research should examine the impact of telehealth on youths' access to psychological care when delivered through integrated health settings.

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