Primary care providers in New York City, one of the U.S. epicenters of the COVID-19 crisis, were some of the first to feel the brunt of the disease's effects. With patients afraid to seek care in person and social distancing necessitating as little face-to-face contact as possible, many clinicians pivoted to telehealth – some with more success than
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Telehealth Models for Increasing Access to Behavioral and Mental Health Treatment
Rural communities are using telehealth to provide mental and behavioral health services — referred to as telemental health or telebehavioral health. The Rural Mental Health topic guide describes a significant need for mental health services in rural America and notes that telehealth has been successful in helping to alleviate the lack of mental health services in rural areas. A large body of evidence has demonstrated that telemental health programs help increase access to care in areas with limited mental health resources, provide effective treatment for mental health conditions, and improve medication adherence.
Telemental health interventions typically fall into four domains:
- Hospital care – Rural hospitals connect to behavioral and mental health specialists through telehealth. For example, a psychiatrist can use video telehealth technology to diagnose patients in a rural emergency department.
- Integrated primary care – Patients can receive behavioral and mental health services through telehealth in primary care settings. For example, patients at a rural primary care clinic could use live-video teleconferencing to receive counseling from a remote psychologist.
- Mobile health applications or remote monitoring programs – These can support longer-term interventions or management of behavioral health conditions. For example, rural patients could use a tablet, smartphone application, or computer program to track medication adherence, monitor their symptoms, and receive self-management education.
- Direct to consumer services – These allow rural patients to connect directly to behavioral and mental health providers using on-demand telehealth applications from any setting, including the home.
Rural communities are using telehealth to provide the following behavioral and mental health services:
- Evaluation and diagnosis – Providers can use telehealth technology to observe the patient; administer scales, assessments, and screenings; and diagnose conditions.
- Case consultation – Some telemental programs enable rural providers to consult with psychiatrists and psychologists. Consultations can take place by direct video communication, telephone, or email.
- Treatment – Behavioral and mental telehealth programs typically provide counseling and psychotherapy, which can be delivered to individuals, couples, or groups. Some programs also offer more specialized therapies such as medication-assisted therapy (MAT), cognitive processing therapy, or prolonged exposure therapy for post-traumatic stress disorder (PTSD). Programs may also use telehealth to deliver interventions such as education about mental health conditions and skills coaching.
- Medication management – Telehealth can help rural patients adhere to their medication regimens. Tools that rural communities have used for medication adherence include monitored in-home dispensing devices, mHealth apps, and telephone counseling.
- Continuing care – Some rural programs provide case management services through telehealth to improve patient outcomes. For example, a nurse care manager could coordinate with family members, social services agencies, and healthcare facilities through the phone to meet the identified needs of their patients.
- Provider education – Rural providers can receive training or continuing education about behavioral telehealth through distance learning, telementoring, or webinars.
Examples of Behavioral and Mental Health Telehealth Programs
- Summit Healthcare Regional Medical Center facilitates access to behavioral healthcare in primary care offices across rural Navajo County, Nevada. Patients in the primary care offices meet with behavioral health providers through telehealth-enabled tablets or video carts.
- Greater Oregon Behavioral Health, Inc. uses a telehealth platform that allows patients in rural Oregon to connect to behavioral health services from their personal smartphones, tablets, or computers. Patients use the platform to communicate with behavioral health clinicians via videoconference or text from any location.
- The Madison Outreach and Services through Telehealth (MOST) Network provides counseling services to the growing Latino population of rural Brazos Valley in Texas. Counselors at Texas A&M University offer psychotherapy to patients in rural clinics via telephone and live video. Local community health workers help facilitate telehealth appointments by transporting residents to rural clinics and providing other outreach services.
- The Wyoming Trauma Telehealth Treatment Clinic provides psychotherapy via videoconferencing to rural crisis center clients who have experienced some form of violence. The University of Wyoming Psychology Department and the University of Wyoming Center for Rural Health Research and Education partnered to establish the clinic.
- The South Carolina Department of Mental Health (SCDMH) Emergency Department Telepsychiatry Consultation Program was initially established to connect patients in dozens of emergency departments across the state with psychiatrists in urban practices. As the program has grown, SCDMH has expanded the program to include telehealth sites in community mental health centers and mental health clinics. The program is the largest provider of telepsychiatry in South Carolina.
- The Arrowhead Telepresence Coalition increases access to behavioral healthcare in seven rural Minnesota counties and three tribes. The coalition contracts with a range of providers, such as chemical dependency specialists and pharmacists, to provide virtual appointments for diagnosis and treatment at county jails, schools, rural hospitals, community health centers, crisis response centers, and tribal health and human services agencies.
- The Lutheran Social Services of North Dakota Abound Counseling program leverages trusted community partners to offer telemental health counseling services to youth and adults across the state. Lutheran Social Services established teleconferencing rooms in local Lutheran churches and other community spaces where community members can receive confidential counseling services. The program also contracts with specially trained therapists to better serve local military members and their families.
Examples of Programs Focused on Children
- The University of Kansas Medical Center's Telehealth ROCKS program offers a range of telebehavioral health services to rural children and their families. Providers from University of Kansas connect with children and their families through live-video telehealth at schools and primary care practices, including community health centers. Telebehavioral services include parenting programs, therapy, medication management, behavior analysis, and assessments, including autism assessments and psychological evaluations. In addition, Telehealth ROCKS is using Project ECHO to build the capacity of rural providers, school personnel, and other child-serving systems to manage behavioral health conditions among children.
Examples of Programs Focused on Veterans
- Alaska Veterans Telehealth and Biofeedback Services uses telehealth and provides veterans with trauma-informed treatment services. Veterans enrolled in the program take an 8-week stress reduction training that uses biofeedback to address trauma. Veterans can also access ongoing counseling services to receive treatment for depression, anxiety, PTSD, and other physical and emotional concerns.
- The Rural Telemental Health (RTMH) Program provides rural veterans in Idaho, Oregon, and Washington with access to mental health services, including evaluation and diagnosis, case consultation, medication management, and continuing care.
- The Indiana Veterans Behavioral Health Network connects rural veterans at community mental health centers to providers at the VA Medical Center for diagnosis and treatment.
Examples of Programs Focused on Older Adults
- The University of Vermont Medical Center's Nursing Home Telepsychiatry Service offers psychiatric care via videoconferencing to rural nursing home residents in New York and Vermont. Telehealth is a particularly important approach to increasing access to care for nursing home residents with complex health needs and conditions that limit mobility.
The American Psychiatric Association (APA) and the American Telemedicine Association (ATA) have developed official guidelines and resources for advising programs that are implementing telemental and telebehavioral care. Together, the organizations released the Best Practices in Videoconferencing-Based Telemental Health. These best practices describe comprehensive administrative, technological, and clinical considerations for providing behavioral and mental health services through videoconferencing technology.
APA also offers an extensive online Telepsychiatry Toolkit with considerations for training, legal issues, and clinical practice, including a discussion of telemental health in rural and remote practice settings. In addition, the Resource Document on Telepsychiatry and Related Technologies in Clinical Psychiatry from APA provides an extensive overview of liability considerations and risk management.
Additional resources from ATA include:
- Practice Guidelines for Telemental Health with Children and Adolescents, which includes considerations for providing behavioral and mental health services to youth through real-time videoconferencing.
- Practice Guidelines for Video-based Online Mental Health Services, which focuses on real-time telemental health services delivered through videoconferencing.
- Evidence-Based Practice for Telemental Health, which describes the evidence for telemental health populations, ongoing mental healthcare, and populations of special focus such as children and older adults.
The Telehealth Resource Centers also provide helpful resources and tools for rural communities seeking to implement or expand telemental and telebehavioral health programs. For example, the Mid-Atlantic Telehealth Resource Center hosts the Telebehavioral Health Center of Excellence, which offers a wealth of information to help programs implement or expand telebehavioral health services. The Northwest Regional and Upper Midwest Telehealth Resource Centers have developed a Telemental Health Toolkit with a 13-part video series that reviews videoconferencing technology and professional and clinical considerations.
Additional considerations by topic area include:
- Safety planning – Providers often work with patients and their families to ensure that patients are supported in the event of a mental health crisis. Safety planning can involve creating a physical document that identifies triggers, warning signs, coping strategies, and potential interventions. Rural communities that offer home-based telebehavioral or telemental care should be aware of special considerations for safety planning. For example, the ATA suggests that providers ask patients to identify a Patient Support Person who can be called upon in an emergency. The American Telemedicine Society also notes that providers should be aware of high rates of firearm ownership and geographic distances to emergency services when developing safety plans.
- Workforce challenges – Some rural programs have experienced challenges with engaging and retaining behavioral and mental healthcare providers to offer telehealth services. Several rural programs addressed this challenge by partnering with psychiatry and psychology programs at medical and graduate institutions in their states. These telehealth partnerships allow future mental health providers to gain experience practicing in rural healthcare settings while completing clinical practice requirements. Researchers at the University of Washington developed a comprehensive set of considerations and recommendations for developing telemental health partnerships between state medical schools and Federally Qualified Health Centers.
- Stigma around behavioral and mental health conditions – Rural programs offering telemental health services may experience challenges with stigma. For example, rural residents might feel discouraged from seeking help for behavioral health due to stigma associated with mental illness and perceived lack of privacy or confidentiality. Additional issues related to stigma are described in the Primary Care Behavioral Health Model of the Rural Services Integration Toolkit. Rural organizations that offer telemental care may choose to emphasize the integrated nature of their services and ensure that patients have private and confidential spaces to meet with remote providers. The SAMHSA-HRSA Center for Integrated Health Solutions offers a Telebehavioral Health Training and Technical Assistance Series that is designed for safety net providers and rural health clinics.
- Confidentiality – Some rural programs report that patients prefer receiving telemental health services over the telephone instead of through video because they can stay anonymous. Rural programs may also consider the possibility of making counseling and other services available through text messaging, which can also address connectivity issues that arise from limited broadband availability.
Program Clearinghouse Examples
- Alaska Veterans Telehealth and Biofeedback Services
- Greater Oregon Behavioral Health, Inc.
- University of Kansas Medical Center
- Summit Healthcare Regional Medical Center
Resources to Learn More
A Treatment Improvement Protocol: Using Technology-based Therapeutic Tools in Behavioral Health Services
Describes the use of technology in providing behavioral health services. Covers case studies of telebehavioral health programs, including a rural telephone- and videoconference-based intervention for substance use disorders.
Organization(s): Substance Abuse and Mental Health Services Administration
Center for Technology and Behavioral Health
Reviews the evidence base for behavioral health interventions involving technology. Describes innovative uses of technology to address behavioral health conditions.
Organization(s): Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College
Guidelines for the Practice of Telepsychology
Describes ethical guidelines for providing psychological services through telehealth, including standards of care, informed consent, and confidentiality, among other considerations.
Organization(s): American Psychological Association
Improving Behavioral Health Access & Integration Using Telehealth & Teleconsultation: A Health Care System for the 21st Century
Provides recommendations for overcoming policy and legal challenges that pose barriers to the implementation of telehealth.
Author(s): Townley, C. & Yalowich, R.
Organization(s): National Academy for State Health Policy
In Brief: Rural Behavioral Health: Telehealth Challenges and Opportunities
Describes the ways that rural communities are using telehealth to address the behavioral health continuum of care. Discusses challenges and opportunities to implementing rural behavioral health services via telehealth. Addresses differences in state policies for telemedicine coverage through private insurance.
Organization(s): Substance Abuse and Mental Health Services Administration
Statewide Partnership Provides Mental Health Assessments via Telemedicine to Patients in Rural Emergency Departments, Reducing Wait Times, Hospitalizations, and Costs
Describes the successes and lessons learned of the South Carolina Department of Mental Health's Emergency Department Telepsychiatry Consultation Program that provided access to psychiatrists via telehealth to assess patients and provide treatment options at rural hospital emergency departments.
Organization(s): Agency for Healthcare Research and Quality
Telebehavioral Health Strategies for Rural Hospitals & Clinics
Describes billing considerations and reviews the regulatory environment for telebehavioral health services. Provides examples of rural telehealth programs and addresses challenges to implementing telebehavioral health programs.
Organization(s): National Consortium of Telehealth Resource Centers
Telemental Health in Today's Rural Health System
Describes common staffing structures and services provided by rural health programs. Includes challenges and opportunities of providing rural telemental care.
Author(s): Lambert, D., Gale, J.A., Hansen, A.Y., Croll, Z.T., & Hartley, D.
Organization(s): Maine Rural Health Research Center
The Use of Telehealth Within Behavioral Health Settings: Utilization, Opportunities, and Challenges
Analyzes data collected from behavioral health providers across the U.S. to describe challenges specific to providing telehealth in rural communities.
Author(s): Mace, S., Boccanelli, A., & Dormond, M.
Organization(s): School of Public Health Behavioral Health Workforce Research Center, University of Michigan