Mental health provider perspectives of the COVID19 pandemic impact on service delivery

Bornheimer et al.
BMC Health Services Research
(2022) 22:718
https://doi.org/10.1186/s12913-022-08106-y
RESEARCH ARTICLE
Open Access
Mental health provider perspectives of the COVID?19 pandemic impact on service delivery: a focus on challenges in remote
engagement, suicide risk assessment, and treatment of psychosis
Lindsay A. Bornheimer1,2*, Juliann Li Verdugo1, Joshua Holzworth1, Fonda N. Smith1 and Joseph A. Himle1,2
Abstract
Background: The COVID-19 pandemic has been impacting the need, utilization, and delivery of mental health
services with greater challenges being faced by clients and providers. With many clients facing reduced access to services and social isolation, a focus on suicide risk assessment and prevention is critical. Concern is particularly increased for clients with schizophrenia spectrum disorders given data show suicide rates are disproportionately high for those with psychosis in comparison to the general population. Provider perspectives of challenges in service delivery are needed to inform efforts to improve access, feasibility, and quality of mental health care throughout the evolving pandemic. This study explored mental health provider perspectives of client challenges in service utilization and provider challenges in service delivery, including remote engagement, suicide risk assessment, and treatment of psychosis.
Methods: Data were collected from social work mental health providers (n = 12) in United States community mental health setting. Providers consented to participate and responded to questions about service delivery experiences in late 2020 and in relation to COVID-19. Demographic and practice-related provider data were explored descriptively using SPSS and qualitative data using open coding and grounded theory methods in Dedoose.
Results: Among the 9 providers who engaged in remote service delivery, 7 (77.8%) experienced challenges in remote engagement with clients and 8 (88.9%) experienced challenges in treatment of psychosis. Among the 7 providers who engaged in remote suicide assessment, 4(57%) experienced challenges. Qualitative themes emerged
including logistic (e.g., technology access and use), engagement (e.g., virtual rapport-building and limited remote services), and clinical (e.g., difficulty assessing suicide risk, internal stimuli, abnormal involuntary movement, and affect) challenges in service delivery.
Conclusions: Provider perspectives are essential to inform efforts to build resources and problem-solve challenges and barriers that both providers and clients face throughout various shifts in mental health service delivery. Findings emphasize the need to troubleshoot client access to technology, bolster support for providers to prevent burnout, and greater provider training to improve skills in remote engagement, assessment, and treatment, particularly in
*Correspondence: [email protected]
1
University of Michigan, School of Social Work, Ann Arbor, MI, USA
Full list of author information is available at the end of the article
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Bornheimer et al. BMC Health Services Research
(2022) 22:718
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relation to psychosis and suicide prevention. Study implications are not only critical for the evolving COVID-19 pandemic, but also in preparation for ongoing shifts in service delivery as technology evolves.
Keywords: Mental health, Service delivery, Suicide, Risk assessment, Community mental health, Psychosis
Introduction
The COVID-19 pandemic has led to substantial psychological impact in the United States and worldwide [1–3].
For many individuals, mental health needs have been
rising throughout the pandemic’s progression [4], with
adjustment-related impacts of quarantine, health anxiety, economic and financial stressors, social isolation,
and more [5, 6]. Aligning with preexisting epidemic and
outbreak-related studies [7–9], the COVID-19 pandemic
has prompted greater anxiety and depression [10], social
isolation [11], and risk for suicide [12]. While the pandemic’s impact on mental health has been increasingly
investigated, greater understandings of its impact on
mental health services and delivery are needed from the
perspective of mental health providers. Furthermore, and
importantly, less is known to date about challenges providers community mental health (CMH) face in remote
assessment and treatment of psychosis and suicide risk in
the United States.
Suicide is a critical public health problem and leading cause of preventable death among individuals with
schizophrenia spectrum and other psychotic disorders
[13], Bornheimer, 2020) [14]. Data estimate the risk for
suicide among individuals with schizophrenia spectrum
disorders is over eight times greater than the general
population [15]. It is predicted that short- and long-term
impact of the COVID-19 pandemic may disproportionately affect individuals with psychosis [16] and given
the potential for worsening mental health symptoms
[6], there are rising concerns of suicide risk within this
population [17]. As a result, it is essential that mental
health providers gain skills to effectively conduct comprehensive suicide-risk assessments, formulate levels of
risk, and deliver treatments and services to reduce risk
and prevent death. Furthermore, CMH settings are wellpositioned to engage in suicide prevention efforts as they
are among the largest providers of outpatient behavioral
health in the United States, and particularly so for clients
with serious mental illness and psychosis [18].
Service delivery has increasingly shifted to telehealth
and virtual formats throughout the COVID-19 pandemic with notable impact on individuals seeking care,
mental health providers adjusting to remote service
delivery, and an increased need for mental health services [19, 20]. In the United States in particular, the
demand for mental health services have remarkably
increased [21]. Across the globe and within numerous
individual contexts, there are varying perceptions
about and experiences with virtual healthcare services
among providers and clients. For some clients, virtual
services increase accessibility to care, and for others,
technology barriers have made care more inaccessible when face-to-face services are not an option [22].
Among providers, there is a similar spread of virtual
services being experienced as acceptable and effective
in practice, yet also challenging given technology access
and clinical barriers (e.g., not being able to observe certain nonverbal cues and less privacy) that may arise [1,
23, 24]. One qualitative study exploring healthcare provider experiences during the pandemic yielded themes
of a prevailing sense of helplessness, overwhelming
workloads for providers, and increased mental health
decline among clients [25]. It is evident that providers
have been impacted throughout the onset and progression of the COVID-19 pandemic. While the pandemic’s
overall impact on mental health services is increasingly
investigated, greater understandings are needed from
provider perspectives regarding the impact on service
delivery in United States CMH settings, such as perceived challenges of clients receiving treatment and
provider challenges in workload, engagement, assessment, and treatment. The CMH context in the United
States is particularly important, given many clients
engaging in community-based mental health services
reside in low-income, underserved, or rural areas with
less access to technology [22]. Additionally, there are
gaps in knowledge about the pandemic’s impact on
provider assessment and treatment of both symptoms
of psychosis and suicide risk. In particular, the remote
nature of service delivery likely poses complexities in
client engagement, assessment of mental status and
symptoms, and delivery of behavioral interventions.
Given ongoing changes in mental health service
delivery and increased need for care, emerging research
from the perspective of providers in CMH is particularly vital to inform clinical practice and future research
aiming to disseminate mental health services in mental
health service systems. The current study explored provider perspectives of mental health services and delivery challenges in relation to the COVID-19 pandemic
with specific focus on providing services to individuals
with psychosis symptoms and at risk for suicide.
Bornheimer et al. BMC Health Services Research
(2022) 22:718
Methods
Data were collected as part of a National Institute of
Mental Health (NIMH)-funded study (R34MH123609;
PI: Bornheimer) focused on suicide prevention among
adults with psychosis in a CMH setting. As a first step in
the study, survey data were collected in the fall of 2020 to
explore the impact of the COVID-19 pandemic on providers delivering mental health services. This manuscript
presents our pandemic-related demographic and qualitative data among social work mental health providers in a
CMH setting and aligns with the consolidated criteria for
reporting qualitative studies (COREQ; [26].
Setting, Participants, and Procedures
A total of 12 mental health providers in a midwestern CMH setting of the United States participated in
this study. Using purposive sampling methods, providers were recruited through informational presentations
given in virtual provider staff meetings. This CMH setting provides mental health services to adults with severe
mental illness and developmental disability, offering a
breadth of programs including crisis residential services,
case management, outpatient mental health, medication
management, assertive community treatment (ACT),
and more. Prior to the pandemic, the majority of services in this CMH setting were delivered in-person (e.g.,
individual and group psychotherapy, psychiatric evaluations, medication management, and case management),
with few services being delivered outside of CMH facilities (e.g., ACT for clients with serious and persistent
mental illness involving multidisciplinary care in their
home and community). The range of attendance in the
CMH facility ranged by service type, with some clients
attending multiple times a week for therapeutic services,
many attending once or twice a month for case management and medication management, and a smaller subset
attending every few months. Once the pandemic began
to impact this region of the United States in early 2020,
many services became limited for CMH clients (e.g.,
case management, medication management, and therapy sessions occurred less often than typical) and some
services were temporarily discontinued (e.g., group psychotherapy). Importantly, and uncommon in CMH prior
to the pandemic, teletherapy and virtual service delivery
became a standard approach to care when local lockdowns occurred, and safety protocols were put in place
with less in-person access to the CMH facility to prevent
the spread of COVID-19. ACT continued in the community with home visits being completed less frequently,
while the remaining CMH services were primarily virtual
with clients having limited in-person access to the CMH
facility for more than 1 year. This CMH setting also represents a public mental health system encompassing the
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diversity of the midwestern United States (race, ethnicity,
socioeconomic status, organizational services, insurance/
payment types, etc.). Currently the site is serving over
700 clients with schizophrenia spectrum disorders and
this region of the United States has a rate of 14.3 deaths
per 100,000 total population suicide, which is a 33%
increase since 1999 [27].
Providers were given a link to view and sign a written consent form via Research Electronic Data Capture
(REDCap) software and subsequently responded to
qualitative questions related to the COVID-19 pandemic
(described in the measurement section below). Recruitment and data collection continued until saturation was
reached [28]. All data were collected between November
and December of 2020 and Institutional Review Board
approval was obtained.
Measurement
Qualitative COVID-19-related questions were preceded
by introductory questions about demographic characteristics (e.g., provider age and gender) and practice-related
characteristics (e.g., provider license type and duration
of practice experience) to increase understandings of the
sample. Data collection involved approximately 30 min
of time for providers. Prior to question design, it was
apparent in conversations with staff and leadership in
the CMH setting that many challenges were being faced
by clients and providers, thus, questions were focused
on challenges with the goal of gaining understandings of
potential barriers to service delivery to develop potential solutions and strategies for challenge mitigation. A
total of 5 qualitative questions were established by the
investigative team, with prior experience in developing
qualitative questions, and sought to explore the following within the COVID-19 pandemic-context: 1) provider
observations of challenges related to telehealth and virtual services, 2) provider workload changes, 3) challenges experienced in remote engagements with clients,
4) challenges related to engagement with clients who
experience symptoms of psychosis, and 5) challenges
related to remote suicide assessment. As shown in Fig. 1,
qualitative questions were preceded by introductory yes/
no questions related to challenges being present, and an
additional qualitative question was asked at the end of
the survey to gather any additional information, experiences, or observations.
Data Analysis
Demographic and practice-related data were viewed
using SPSS27 (e.g., number and percentage for categorical information, means and standard deviations for
continuous information) and qualitative question data
analyzed using Dedoose. We first viewed demographic
Bornheimer et al. BMC Health Services Research
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Fig. 1 Questions given to providers
and practice-related data to better understand the sample, followed by qualitative question data analysis with
an aim of expanding on descriptive details of the sample (Creswell et al., 2017) [29]. For open-ended qualitative questions, responses were independently coded by
two Master’s-level research assistants (JLV and JH) in
preparation for codebook development. An open coding technique was used to generate themes across the 6
qualitative questions (Saldana, 2016) [30] and grounded
theory methods were utilized for analysis [31]. After an
initial round of coding, the lead author (LAB) met with
both research assistants to discuss emerging themes
from the qualitative data, reviewed field notes from
the coding process, and agreed upon a codebook. The
research assistants conducted a second round of coding with use of the established codebook and the lead
author resolved any disagreements to achieve intercoder consistency. Themes were ultimately organized into a final framework and findings are presented
in the results section below. Strategies for qualitative
rigor [32] in the current study include: 1) analytic triangulation (i.e., more than one qualitative coder was
involved), 2) audit trail, and 3) member checking.
Results
Demographic and practice-related provider data are
presented in Table 1. Providers (n = 12) were on average 35.67 years of age (SD = 6.387), most often identified as female (n = 8, 66.7%), and all (n = 12) identified
as White and non-Hispanic/Latinx. As is common
in CMH settings in the US, all providers identified
as social workers with 11 having a master’s degree in
social work and 1 reporting being currently enrolled in
a social work master’s degree program. Providers either
had a social work license (LMSW or LCSW; n = 9, 75%),
limited social work license (LLMSW; n = 2, 16.67%), or
were a Master of Social Work Student in training (MSW
student; n = 1. 8.33%). All providers (n = 12) endorsed
having direct contact with clients with the majority in a
mental health therapist, clinician, or case manager role
(n = 10, 83.3%). The average duration of work experience providing services in the mental health field was
5 years and 10 months (SD = 4 years and 1 month) with
a range from 6 months to 14 years. The average duration of work experience in their current CMH setting
was 4 years and 6 months (SD = 3 years and 1 month).
Bornheimer et al. BMC Health Services Research
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Table 1 Demographic and practice-related provider data (n = 12)
Characteristics and Questions
Age (M ± SD)
  25–29
Page 5 of 12
N
12
4
%
35.67 ± 6.387
33.33
  30–34
4
33.33
  35–39
2
16.67
2
16.67
  40–45
Gender
12
  Female
8
66.67
  Male
4
33.33
Race
  American Indian or Alaska Native
0
0
  Asian
0
0
  Black or African American
0
0
  Native Hawaiian/Pacific Islander
0
0
  White
12
100
  Other
0
0
Ethnicity
  Non-Hispanic/Latinx
12
100
  Hispanic/Latinx
0
0
Licensing Status
  Social Work License (LMSW/LCSW)
9
75
  Limited Social Work License (LLMSW)
2
16.67
  Social Work (MSW) Student
1
8.33
Role in Community Mental Health (CMH)
  Clinician (Therapist/Clinician/Case Manager)
10
83.3
  Clinical Supervisor
1
8.33
  Administrator
1
8.33
Years in Mental Health Field (M ± SD)
5.83 ± 4.07
  0–4.99
6
50
  5–9.99
3
25
  10–14
3
25
4
33.33
Years at CMH (M ± SD)
  0–2.99
4.49 ± 3.04
  3–5.99
4
33.33
  6 +
4
33.33
Have you observed an increase in the need for suicide prevention given the COVID-19 context in your CMH setting?
  Yes
8
66.7
  No
4
33.3
Have you observed clients having challenges related to telehealth/virtual services since COVID-19 began?
  Yes
8
66.7
  No
4
33.3
Have you experienced a change in your own workload due to remote work or engagement with clients?
  Yes, increase in workload
7
58.3
  Yes, decrease in workload
1
8.3
  No change
4
33.3
Have you experienced challenges related to remote engagement with clients?
  ­Yes a
7
58.3
  No
2
16.7
  N/A not a clinician or not doing remote engagement with clients
3
25.0
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Table 1 (continued)
Characteristics and Questions
N
%
Have you experienced challenges related to remote treatment with clients who experience symptoms of psychosis?
  ­Yesa
8
66.7
  No
1
8.3
  N/A not a clinician or not doing remote treatment with clients who experience symptoms of psychosis
3
25.0
Have you experienced challenges in remote suicide assessment with clients?
  ­Yesb
4
33.3
  No
3
25.0
  N/A not a clinician or not doing remote suicide assessment with clients
5
41.7
a
Among the 9 providers who delivered remote services with clients, 77.8% experienced challenges in remote engagement and 88.9% in remote treatment of
psychosis
b
Among the 7 providers wo engaged in remote suicide assessment with clients, 57% experienced challenges in remote assessment of suicide
Table 2 Themes of provider responses to qualitative question topics
Qualitative Topic
Theme
Description
Provider observations of client challenges
1. Logistic challenges
Limited availability of a device capable for video and internet,
government-supported phones don’t always accept restricted
calls from providers who use a blocked number
2. Engagement challenges
Less ability to engage in individual and group therapy, less comfort engaging with providers remotely, less therapeutic rapport
3. Clinical challenges
More client agitation, physical altercations, social isolation, anxiety
1. Logistic challenges
Assisting clients with technology and troubleshooting challenges, capturing signatures from clients on remote documentation, separating services previously grouped together
2. Service need
Greater caseload due to increased need for services
3. Staffing challenges
Providers not passing COVID-19 screening questionnaire, needing to quarantine, becoming ill, and taking sick days to manage
mental health and stress
Provider workload changes
Provider challenges in remote client engagement
4. New tasks
Assessing for physical health symptoms
1. Logistic challenges
Clients have limited access to technology and devices for
telehealth, clients may not respond to phone or phone is not
on, clients are less likely to reach out because it is more difficult
remotely
2. Health concerns
Clients concerned about COVID-19 and don’t want to go in for in
person services
3. Service delivery challenges Harder to engage/build rapport with clients remotely, some
services are not possible to deliver remotely, difficult to assess
mental status, less accurate information provided by clients
Provider challenges in remote treatment of psychosis 1. Assessment challenges
2. Engagement challenges
Abnormal Involuntary Movement Scale (AIMS) via telehealth is
very challenging, responses to internal stimuli are hard to assess
for remotely, mental status exam is hard to administer remotely,
Activities of Daily Living (ADL) are hard to assess for remotely
Psychosis makes it difficult to engage in telehealth, paranoia
may limit desire to engage, social isolation is common among
individuals with psychosis and is the pandemic has worsened
3. Service delivery challenges Some services are not possible to deliver remotely
Provider challenges in remote suicide assessment
1. Assessment challenges
Difficult to conduct mental status exam, hard to assess without
seeing facial expressions and/or body movements, not as possible to gauge affect, easier for clients to evade questions
2. Rapport challenges
Hard to build report well and find relatable environmental factors
Bornheimer et al. BMC Health Services Research
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Provider Observations of Client Challenges
All qualitative data findings are presented in Table 2. The
majority of providers (66.7%, n = 8) observed clients having challenges related to diminished access to telehealth
and virtual mental health services during the COVID-19
pandemic. Challenges observed by providers resulted in 3
themes: 1) logistic challenges (qualitative responses: limited availability of a device capable for video and internet, government-supported phones do not always accept
restricted calls from providers who use a blocked number), 2) engagement challenges (less ability to engage in
individual and group therapy, less comfort engaging with
providers remotely, lower therapeutic rapport), and 3)
clinical challenges (more agitation, more physical altercations, heightened anxiety, and increased social isolation).
Providers shared the following:
“Clients have limited access to devices capable of all
telehealth modalities. Also, doc [doctor] phone numbers come through restricted numbers and some government-supported phones do not accept restricted
phone numbers, so when docs are working remotely,
certain clients cannot be contacted for even a phone
visit by a prescriber.” -provider 1
“I’ve seen more agitation in general with clients, specifically during the actual ‘stay home’ period of the
pandemic. I had incidents of physical altercations?
between residents in homes where there had been little or no signs of aggression in several years.” -provider 3
“Prior to the pandemic, our clients were socially
isolated due to the nature of severe mental illness.
Now they are even more so now as they are not able
to attend psychosocial activities or group therapy
which has led to worsening of symptoms.” -provider 7
Provider Workload Changes
Slightly more than half of the 12 providers (58.3%, n = 7)
noted their workload increased within the context of
the pandemic. Of those who noted an increase, the following 4 themes emerged pertaining to tasks or aspects
of service delivery were negatively impacting workload:
1) logistic challenges (assisting clients with telehealth,
capturing signatures from clients on documentation,
separating services previously grouped together), 2) service need (greater caseload due to increased need for
services), 3) staffing challenges (providers not passing
COVID-19 screening questionnaire, needing to quarantine, becoming ill, and taking sick days to manage
Page 7 of 12
mental health and stress), and 4) new tasks (assessing
more for physical health symptoms). Providers shared
the following:
“Many people have been off due to quarantining or
taking sick days off for mental health to deal with
the stress of COVID-19’s repercussions. This understaffing leads to a cycle of workers having to see more
clients daily, spending less time with each client,
having less time available for paperwork and more
paperwork, and causes more stress to the workers/
interns. Since this makes it so less time is spent with
each client, it increases the risk for crisis situations
which also creates more stress/work for the team.”
-provider 2
“We are having to assess for additional health concerns because of COVID-19 and have had to separate services that are typically grouped together.
Such as, medication reviews and injections, and
shopping groups with multiple consumers.” -provider
9
“In most circumstances, clients are needing telehealth and virtual services to facilitate medication reviews, and many clients don’t have phones
or devices for telehealth, which means I assist with
facilitation of telehealth services by seeing them with
a tablet so they can attend the virtual medication
review.” -provider 12
Provider Challenges in Remote Client Engagement
Of all participants, 7 (58.3%) endorsed challenges
related to telehealth/remote engagement with clients.
Importantly, only 9 of the 12 participants provided
remote services to clients, therefore among the 9 who
engaged remotely, a total of 7 experienced challenges
(77.8%). Challenges experienced by providers resulted
in 3 themes: 1) logistic challenges (clients have limited
to technology and devices for telehealth, clients don’t
respond to phone or phone is not on, clients are less
likely to reach out because it is more difficult remotely),
2) health concerns (clients concerned about COVID19 and do not want to go in for in person services), and
3) service delivery challenges (harder for providers to
engage/build rapport with clients remotely, some services
are not possible to deliver remotely, accuracy of information provided by client in assessment). Providers shared
the following:
“Clients often do not have phones, do not reliably
answer their phones, or their phone service is shut
off. Also, clients rarely have access to video capable
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devices for telehealth.” -provider 4
expressions.” -provider 2
“Many of our clients who state virtually that they’re
doing well were not actually doing well so the lack
of eyes through engagement is impactful.” -provider 8
“Clients may be more likely not to share their
thoughts or feelings when there isn’t face-to-face contact.” -provider 5
Provider Challenges in Remote Treatment of Psychosis
Of the 9 providers who remotely provided services to
clients during the pandemic, 88.9% (n = 8) endorsed
challenges with remote treatment among clients who
experience symptoms of psychosis. Challenges experienced by providers resulted in 3 themes: 1) assessment
challenges (administering the Abnormal Involuntary
Movement Scale [AIMS] via telehealth is very challenging, responses to internal stimuli are hard to assess for
remotely, the mental status exam [MSE] is hard to
administer remotely, Activities of Daily Living (ADLs)
are hard to assess for remotely), 2) symptomatology (psychosis symptoms make it difficult to engage in telehealth,
paranoia may limit desire to engage), and 3) service delivery challenges (some services are not possible to deliver
remotely). Providers shared the following:
“If they are not in person, it is hard to assess all the
aspects of a mental status exam…or to assess for
ADLs when using a phone or tablet.” -provider 5
“It’s more challenging for clients experiencing internal stimuli to maintain engagement generally. Being
remote limits the ability to redirect or re-engage
when clients are experiencing symptoms.” -provider
10
“It is difficult for providers to get a sense of symptomatology through telehealth services. Paranoia
may limit desire to engage.” -provider 12
Provider Challenges in Remote Suicide Assessment
Of the 9 providers who remotely provided services to
clients during the pandemic, 7 endorsed engaging in
remote suicide assessments with clients, and of whom,
4 (57%) experienced challenges in conducting remote
suicide assessments with clients during the pandemic.
Challenges resulted in 2 themes: 1) assessment challenges (difficult to conduct mental status exam, hard to
assess without seeing facial expressions and/or body
movements, easier for clients to evade questions) and
2) rapport challenges (hard to build report well and find
relatable environmental factors). Providers shared the
following:
“Over the phone it has been harder to assess clients’ symptomology without seeing body and facial
“It is easier for people to dodge your questions on the
phone, you can’t build rapport as well, find relatable
environmental factors, and it is hard to get to linking
and information sharing.” -provider 11
Discussion
Literature of the evolving COVID-19 pandemic highlight
an impact on mental health service need, utilization, and
delivery (Ardebili et. al, 2020; [25, 10, 19], Vizeh et al.,
2020). Given the prediction that COVID-19 may disproportionately impact individuals with psychosis [16], a
population that is at greater risk for suicide in comparison to the general population (Adyin et al., 2019,Bornheimer, 2020) [14], it is critical that mental health providers
can effectively engage, conduct suicide-risk assessments,
and deliver services to individuals with psychosis. As a
result, greater understandings of the COVID-19 impact
on services and delivery are needed from the perspective
of providers in CMH with specific attention to challenges
in assessing and treating psychosis and suicide risk. Data
of the current study indicate CMH providers observed a
greater need for suicide prevention, clients facing challenges with telehealth and virtual services, an increase
in workload, and challenges with remote engagement,
treatment of psychosis, and suicide assessment since the
COVID-19 pandemic began. Provider responses to qualitative questions further underscore and expand upon the
logistic, engagement, and clinical challenges emerging
within the pandemic context.
Logistic challenges emerged as a theme including
provider observations of clients facing technology barriers in remote service use, clients reaching out less to
providers, some services not being offered remotely due
to the need for technology, and provider challenges in
engaging with clients due to limited technology. These
technology challenges further reinforce the disparaging
impact of COVID-19 with technology access for remote
engagement with mental health services presenting an
inequality gap [33]. While many may have access to smart
phones, computers, and reliable internet connections,
clients engaging in community-based mental health
services often reside in low-income, underserved, or
rural areas with limited access to technology that is now
needed for virtual services [22]. Some providers shared
that they tried to increase access by allowing clients to
use their device to meet virtually with psychiatrists and
Bornheimer et al. BMC Health Services Research
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primary care providers. Though providing a device for
clients as a method of problem-solving aligns with social
work values of compassion, justice, and beneficence, this
is also unlikely a standard practice due to resources (e.g.,
availability of technology and cost) and provider time
(e.g., increased caseloads due to greater service needs
and staffing challenges). Beaunoyer and colleagues (2020)
propose a mu