February 2022

Dial S for service: healthcare that’s only a call away

As COVID-19 made its way to Australia in the early months of 2020, major cities were plunged into living with restrictions and a perpetual seesawing between lockdowns and liberty began nationwide.

Consequently, so did the constant shifting between the modes of providing harm minimisation services. Sometimes, this was regardless of a city’s current lockdown laws, as the ubiquitous risk of COVID transmission was, and remains, particularly pertinent for the vulnerable communities that harm minimisation services work with.

In such service provision, where the therapeutic relationship and trust between clinician and consumer is imperative to successful intervention, the provider jury’s still out as to whether telehealth will remain a fixture of these services as we enter a post-pandemic world.

The Australian Institute of Health and Welfare’s 2019–20 annual report Alcohol and Other Drug Treatment Services in Australia reflects these efforts of harm minimisation providers to maintain the provision of AOD treatment to consumers while ensuring their safety from infection with COVID.

National trends outline a steep drop-off of residential and outreach treatment in the middle months of 2020 as COVID restrictions took effect almost nationwide, and show at the same time an increase in home-based treatment, largely comprised of online and telehealth services. Rehabilitation and education as treatment also declined in the second half of 2020, replaced by an increase in counselling as treatment.

A workable alternative

Not all in-person harm minimisation treatments were ceased.

The transfer to online services was made if the benefit to removing in-person consultations and care, and thus mitigating the risk of COVID transmission, outweighed the possible negatives of consulting and providing care via the internet.

Australia’s only two safe injecting facilities, located in Sydney and Melbourne, remained open throughout the entire first year of the pandemic as the risk of closing their doors on consumers who needed to access safe needle programs was deemed to outweigh the risk of COVID transmission within these facilities.

Dr Adam Searby

For clinicians who had less luck with being able to continue to provide in-person services, Dr Adam Searby, an AOD nursing researcher and lecturer at Deakin University, says the transition to online services was difficult. In the early days of COVID restrictions in the beginning of 2020, Adam says the transition for AOD nurses was made with haste, leaving them simultaneously working “on the frontline” and managing their clients’ transitions to virtual care.

“They were doing the stuff that couldn’t be done over the phone,” he says. “They were doing all the physical health stuff; a lot of problem-solving, particularly around phones and technology; and getting consumers onto telehealth.”

Adam is referring to his research with colleague Dianna Burr in 2020 in which they interviewed AOD nurses across Australia and New Zealand and found common concerns surrounding the rapid transition to telehealth for consumers: a diminished therapeutic rapport and consumers missing out on services due to technological barriers.

Increased access

Tegan Nuckey, Harm Reduction Co-ordinator at QuIHN Gold Coast in Queensland, says an increase in the number of clients accessing the organisation’s counselling services was due to the reduced barriers of access that telehealth offers, such as to people who live in rural and regional areas. Tegan says QuIHN intends to keep virtual consultations a part of its service offering, as some clients tend to engage better in an online capacity.

However, she explains that engaging consumers who were new to QuIHN’s hepatitis C treatment and management program had been trickier as enabling their access to consistent care was difficult in the midst of COVID restrictions in Queensland. “Because of telehealth, there wasn’t that face-to-face rapport there. Trying to follow up [with clients] has been a little bit difficult. The counselling team have been okay over the phone, but with the hepatitis C treatment, trying to get people to call up and let them know when to start treatment has been hard, because there’s been no rapport [built] face-to-face.”

Adam Searby echoes this sentiment, saying new consumers were near-impossible to engage compared to their existing counterparts. “Therapeutic engagement over the phone worked well for people who were already in the service, who already had that relationship with their nurse.”

Conversely, Alex, who works in AOD assessment for clients who are at particularly high risk of overdose or of harming themselves or others, says there are huge benefits for consumers in engaging virtually. “It’s so much easier [for clients] to just pick up the phone… The number of people that actually show up for their assessments is a lot higher since it’s been over the phone. It’s been a surprising benefit to us working from home.

It’s so much easier [for clients[ to just pick up the phone… The number of people that actually show up for their assessments is a lot higher since it’s been over the phone. It’s been a surprising benefit to us working from home.

Alex, AOD assessment worker

“Some clients find it difficult to travel in to the office, either it’s because they don’t have any money for public transport or it’s because their drug use makes their schedule incompatible [with ours], they might have anxiety about getting public transport, and how am I supposed to expect them to get to an office to do an assessment when I can just give them a call instead?”

However, Alex is concerned about conducting adequate risk assessments for consumers during a telehealth consultation, “When you are assessing someone in person, you can assess if they’re using drugs. You can witness their mannerisms, posture, assess their eye contact – are they shifting their focus? It’s a lot harder to assess that over the phone… When we’re doing family violence assessments, we ask people to be in a private area of their own home… but we have no idea if a perpetrator is sitting right next to them.”

Not a universal solution

Adam Searby says it’s a “shame” that telehealth is being considered the “new normal” in a post-COVID world. While he agrees the choice is invaluable for those facing geographical access barriers, he says the therapeutic relationship simply can’t be replaced, including being able to utilise techniques such as silence and eye contact.

“You can have eye contact and so on with telehealth but it doesn’t replace the in-person connection… If I stopped talking on the phone to try to engage silence [as a tool for communication], you’d be saying, ‘Hi? Hello?’, wondering where I’d gone.” He says that despite years of online service offerings, it hasn’t become clients’ default way to access help. “They’re not going to be picking up the phone to access support; they’re going to drop in to a service in times of crisis or when they’re in need of some serious care.

“Nothing beats that human interaction, that human connection.”

Nothing beats that human interaction, that human connection.

Dr Adam Searby

However, Dr Naomi Crafti, Course Coordinator of the Graduate Certificate of Telehealth at Turning Point, is inspired by the recent years’ innovations in telehealth and says it can be an invaluable asset for providers and clients, even as the era of lockdowns grows smaller in the rear-view mirror. Naomi says she wants telehealth to be seen as an addition to harm reduction services instead of a circumstance-based replacement. “We don’t want to see telehealth as being something that we just do during COVID or these crisis emergency situations. We need to see it a great option in and of itself.”

Naomi says telehealth can be innovatively utilised in ways other than transferring an existing consultation online. “If we think of telehealth as being all those things that we currently do to deliver health information, it could be an online module, a discussion forum online.” She says this could be especially applicable in the AOD sector. “People could learn the basics of harm reduction by completing a series of online modules.”

Naomi acknowledges COVID was the necessary catalyst that prompted providers to embrace online delivery of their care. “COVID has really pushed people into making these changes and embracing these innovative techniques; improvements in technology have made it even easier… We’ve all realised this is a great thing.”

The same can be said for clients, too. “Calling a telephone helpline was seen as a second-class option rather than walking into a clinic or seeing somebody face to face. What’s changed over COVID is people are now seeing that as an acceptable form of communication in and of itself. You can think of telephone helplines as being an adjunct to face-to-face therapy, rather than a step down.”

‘Just as good, if not better’

While many providers have experience of traditional telehealth consultations yielding a less desirable therapeutic relationship than those held face-to-face, Naomi says that with the right training and setting, telehealth can be just as good as, if not better than, in-person services.

“Studies have shown that not only is the therapeutic alliance as good as face-to-face but it can also be better. It doesn’t mean it’s for everybody, but if you think about the fact there’s a normal distribution of people who engage well face-to-face, there’s another distribution of people who engage really well with online therapies.”

Alex agrees. He says while they don’t have a pre-existing relationship with the clients they assess each day, he thinks the virtual set-up yields even greater information from clients who are often from groups that face judgement and discrimination in public spaces. By participating in assessments over the phone, they aren’t afraid of facing prejudice or subconscious bias from their providers and thus are more comfortable being assessed. “It feels less formal for the client so it’s easier to be a little bit more personable. One thing I’ve heard from clients is that whenever they enter a grocery store, whenever they’re walking down the street, they just get stared at. I think [telehealth] subconsciously helps them receive better treatment because they’re not afraid of being looked at in that way.”

Dr Naomi Crafti

Telehealth is not just sitting at a computer having a video consultation with another health professional. Telehealth literally means healing at a distance, and so it’s any form of health-related communication that is done where you don’t have the health practitioner and the client in the same space.

Dr Naomi Crafti

Such is the breadth of opportunity for practitioners and consumers that Naomi is now co-ordinating a Graduate Certificate of Telehealth in partnership with Monash University. “One of the things we’re going to be teaching in the grad cert is that telehealth is not just sitting at a computer having a video consultation with another health professional. Telehealth literally means healing at a distance, and so it’s any form of health-related communication that is done where you don’t have the health practitioner and the client in the same space.”

 

– Julia Banks