In Brief: Rural Behavioral Health: Telehealth Challenges .
In BriefFall 2016 Volume 9 Issue 2Rural Behavioral Health:Telehealth Challenges and OpportunitiesThis In Brief looks at common acceptability, availability,and accessibility barriers to mental and substance usedisorder (behavioral health) treatment and services inrural* communities and presents ways telehealth canhelp surmount some of these barriers. Challenges toimplementing effective telehealth services in sparselypopulated areas are also discussed. This information isdesigned to be useful to behavioral health practitioners andmany other professionals—such as attorneys, behavioralhealth training program faculty, clergy, pharmacists,and primary care practitioners—who are concernedwith behavioral health in their communities. Theseprofessionals may be local centers of influence to whomothers turn for behavioral health information and help. Formore information on the use of telehealth for behavioralhealth services, see Treatment Improvement Protocol(TIP) 60, Using Technology-Based Therapeutic Tools inBehavioral Health Services.1The term telehealth† refers to using internet andcommunications technologies (ICTs), such asvideoconferencing, chat, and text messaging, to providehealth information and treatments in real time. Telehealthalso includes exchanging information and deliveringservices asynchronously, such as through secure email,webinars, or “store-and-forward” practices, which includevideotaping a client encounter and forwarding the videoto a professional who is offsite, for analysis at a latertime. As access to at least some types of ICTs increasesacross the United States, the potential for telehealth alsoincreases. Increasing levels of access create opportunitiesfor providers to address rural–urban disparities across thebehavioral health continuum of care (see Exhibit 1).2,3Exhibit 1. Telehealth Across theBehavioral Health Continuum of anagement/monitoringContinuing careEducationCollaborationTelehealth ExampleOnline substance usequestionnaireCognitive–behavioral therapythrough videoconferencingText message reminders to takemedications as directedGroup chats for relapsepreventionWebinars for clients andprovidersInteractive video for consultationNearly one in five U.S. residents lives in a rural area.7According to most estimates, individuals living in rurallocations experience mental and substance use disordersat rates that are similar to (and sometimes higher than)those of their urban counterparts.8,9,10,11,12,13 In a survey ofrural health stakeholders, when participants were askedto identify the top 10 rural health priorities from a largerlist of focus areas, they ranked mental health and mentaldisorders fourth and substance abuse fifth.14Despite having a similar need for services, people in ruralareas have less access to the behavioral health continuumof care than do people in urban areas.15,16 Although fundingcuts, workforce shortages, and other systemic issues* There are many definitions of rural, even within the federal government.17 This In Brief uses the word rural in a general sense to refer to areas ofthe United States that are sparsely populated.“Telehealth is different from telemedicine because it refers to a broader scope of remote healthcare services than telemedicine. While telemedicinerefers specifically to remote clinical services, telehealth can refer to remote non-clinical services, such as provider training, administrative meetings,and continuing medical education, in addition to clinical services.”18†Behavioral Health Is Essential To Health Prevention Works Treatment Is Effective People Recover
In Briefhinder access to timely and appropriate behavioral healthtreatment and services in urban and rural areas alike,people in rural areas face additional barriers, such as alack of adequate internet infrastructure,19,20 a need to travellong distances to see specialty providers, and a lack ofanonymity about receiving treatment.21The idea of using telehealth to expand access to carefirst surfaced in the 1960s.22 Technology can facilitatethe delivery of behavioral health services to people inrural areas in two main ways: (1) by linking clients tobehavioral health practitioners located at a different site,and (2) by connecting nonspecialists in rural areas—commonly primary care practitioners—to networks ofbehavioral health specialists throughout the country forcase consultation.23Acceptability BarriersTreatment acceptability refers to whether patients considertreatment to be relevant, beneficial, and worthwhile.There is evidence that some rural communities normalizesubstance use and certain types of mental illness, such asdepression, making it difficult for residents to judge whentheir condition warrants treatment.21,24,25,26 Numerous otherfactors influence whether individuals believe treatment isan acceptable response to their condition. For instance,a history of the U.S. agricultural population’s behavioralhealth care cites a culture of self-reliance as one reasonthis population tends to “avoid seeking behavioralhealthcare even when needed.”27 Two major acceptabilitybarriers facing individuals living in rural locations are alack of privacy about receiving treatment for behavioralhealth conditions and a lack of culturally appropriatecare.21,27Lack of privacyIndividuals living in rural locations commonly identify alack of privacy as a barrier to receiving treatment.15,28,29,30Associated with the lack of privacy is the desire to avoidbeing the subject of gossip or being marginalized.21,30 Insmall communities, residents may recognize whose car isin a therapist’s parking lot, for instance. Focus groups haverevealed that certain cultural attitudes and beliefs may alsocontribute to a lack of privacy, exemplified by one studyinvolving a faith community of rural African Americanindividuals (see textbox at right).21Lack of culturally appropriate treatmentSome rural communities harbor negative perceptions abouttreatment for mental disorders or about treatment andservice professionals.21,31,32 At the same time, skepticismmay be warranted if treatment and service providers do notdeliver culturally sensitive diagnoses or care, cannot offera full complement of services, or cannot provide servicesfor the length of time required to see positive outcomes.American Indians and Alaska Natives, for instance,have criticized mental health services as being culturallyunsuitable.31Culturally appropriate treatment accommodates clients’beliefs and practices, preferred languages, individual andfamily histories, differences in symptoms, and preferredapproaches to treatment. A significant challenge toproviding culturally appropriate treatment in rural areasis their racial, ethnic, and cultural diversity. Althoughbetween 79 and 82 percent of the residents of rural areasand small towns are non-Hispanic Whites,9 rural areashave become more racially and ethnically diverse in thepast decade. In fact, racial and ethnic minorities accountedfor 83 percent of the population growth in rural areas fromDepression in a Rural African AmericanCommunity21Focus groups with rural African Americans in a faithcommunity revealed individual and cultural barriers toseeking treatment for depression. Participants said thatprivate information spreads easily through rumors in theirsmall community, increasing the likelihood that individualsexperiencing depression would be judged by others they seeregularly. Fear of being labeled “crazy” prevented peoplewith depression from seeking care. In addition, participantswanted to keep their “personal business” to themselves,and also did not want to pry into anyone else’s business.These attitudes sometimes kept them from knowing thatfriends needed help, as one participant discovered whenhe happened to visit a friend who had just taken pills in anattempt to take his own life.Another barrier was the belief that depression is a normalpart of everyone’s life. In a depressed environment, oneparticipant said, individuals may not even recognize thatthey are depressed; the condition is viewed as a norm, notas an illness that requires treatment.2Behavioral Health Is Essential To Health Prevention Works Treatment Is Effective People Recover
Rural Behavioral Health: Telehealth Challenges and OpportunitiesFall 2016, Volume 9, Issue 22000 to 2010.33 However, as in urban areas, factors besidesrace and ethnicity contribute to the formation of distinctcultures. In a rural area, these factors include the economicbase (e.g., farming, forestry, manufacturing, tourism);proximity to urban centers; and any major subpopulations,such as seniors or veterans. Medical and behavioral healthresearchers and practitioners working in rural areas havenoted the dire need for behavioral health treatment andservice practitioners who understand the needs of farmersand ranchers, veterans, and tribal communities and otherethnic and racial minorities.27,31,34,35,36capacity for involuntary patients; a 16-bed residential unitfor voluntary patients; and a mobile crisis outreach team.The center is staffed by registered nurses, mental healthtechnicians, licensed counselors, licensed vocationalnurses, and a caseworker. Within 1 hour of arrival (nomatter the time or day), patients are assessed and engagedvia videoconference with a psychiatrist. (A psychiatristis also available by phone within 5 minutes.) The centercontracts with psychiatrists at a private behavioral healthtelemedicine practice in Houston. Burke is also equippedto offer detoxification services.43,44Addressing Acceptability BarriersAvailability BarriersOne of the most promising contributions of telehealth isits potential to provide confidential therapies, enablingindividuals living in rural locations to access treatmentand services without inadvertent disclosure to theircommunities. For instance, one prevention interventionused email to treat subthreshold depression before itbecame clinical. Participants who had been screenedonline were sent automated emails containing advice andself-help strategies.37 However, commonly used programsand services such as Skype may not meet Health InsurancePortability and Accountability Act (HIPAA) requirementsfor the protection of private health information.38,39Treatment relying on sophisticated telehealth equipmentsystems could be accessed from hospitals, clinics,educational institutions, professional offices, and othersettings that offer privacy. For example, an individual maygo to a primary care provider’s office or a communityclinic and obtain an assessment or treatment for a mentalor substance use disorder via telehealth without otherpatients knowing the purpose of the visit.Telehealth models can be used to educate healthcareprofessionals about behavioral health issues.40,41 Inaddition, telehealth can be used to train behavioral healthpractitioners on the technical, ethical, cultural, andprofessional competencies they need to work effectivelywith rural clients.4,42Burke, a community mental health services provider inrural eastern Texas, offers comprehensive emergencypsychiatric services entirely by telepsychiatry, covering400,000 people dispersed over 11,000 square miles. Thecenter operates an 8-bed, 48-hour observation unit withEven when individuals living in rural locations wanttreatment, they may have few services and providers intheir areas, and they may have less access than urbanresidents to evidence-based practices (EBPs).Lack of servicesOne report estimated that outpatient substance usetreatment services are almost four times less likely to beavailable in rural hospitals than in urban hospitals (12.1percent and 43.7 percent, respectively, with treatmentservices offered either directly or by arrangement).45Hospitals in large rural areas are about twice as likelyto offer substance use treatment services (17.9 percent)compared with hospitals in small or isolated rural areas(8.2 percent and 8.5 percent, respectively). Rural facilitiesalso provide fewer services along the continuum ofcare. Rural areas are particularly short on detoxificationservices.46 Moreover, although individuals living in rurallocations report higher rates of prescription opioid misusethan do urban residents,12 only about 3 percent of all opioidtreatment programs are situated in rural areas.46Telemedicine Funding for OpioidAddiction Treatment in AppalachiaIn June 2016, Secretary of Agriculture Tom Vilsackannounced the awarding of Distance Learning andTelemedicine grants totaling almost 1.4 million forprojects in rural central Appalachia (Kentucky, Tennessee,and Virginia) to address the growing opioid addiction crisisin this region of the United States.473Behavioral Health Is Essential To Health Prevention Works Treatment Is Effective People Recover
In BriefLack of practitionersRural areas have few behavioral health practitioners,particularly ones who are qualified to provide specialtytreatment4,48,49,50 or EBPs.48 More than 75 percent of allU.S. counties are mental health shortage areas,51 and halfof all U.S. counties have no mental health professionals atall.52No national count of behavioral health workers exists,making it difficult to accurately assess shortages ofsubstance use treatment and service practitioners.However, the Substance Abuse and Mental HealthServices Administration has documented difficulties inrecruiting and retaining staff to replace the country’s agingbehavioral health workforce.50 The Health Resources andServices Administration estimates that more than 7,700professionals are needed to fill existing behavioral healthworkforce gaps.50Challenges to recruiting and retaining substance usetreatment staff in rural areas include:53 Low pay compared with peers in other settings.Professional isolation.Difficulty for spouses to find work.Few social outlets and educational opportunities.Difficulties adjusting to rural life.Lower use of EBPsSome research shows that behavioral health facilities inrural areas are more likely than their urban counterpartsto be independently operated and less likely to collaboratewith a university to train providers on EBPs.48 At the sametime, most studies that support EBPs are not conducted inrural areas or on rural populations.48Addressing Availability BarriersTelehealth has the potential to help bridge the rural–urbantreatment gap by linking rural clients to high-qualitybehavioral health services and providers located in morepopulated areas. Among the various technologies currentlyin use, video telehealth seems to provide the interventionmost similar to office-based treatment, and research showsthat video telehealth users have satisfaction levels andoutcomes similar to those of clients receiving in-persontherapy.35,54The single area where improvedpatient care could be realized isin the significant expansion andactive use of telehealth.32Telehealth can also mitigate rural practitioner isolation andincrease collaboration.4,55,56 New Mexico’s Project ECHO(Extension for Community Healthcare Outcomes) beganwhen the University of New Mexico Health SciencesCenter adopted teleconferencing to train rural primary carepractitioners to effectively treat patients with hepatitis C.The ECHO model links specialist teams at an academic“hub” using multipoint videoconferencing to conductvirtual clinics with community providers. Primary carepractitioners, the “spokes,” become part of a learningcommunity, where they receive mentoring and feedbackfrom specialists. The model, now used in both urban andrural areas, has since expanded to include training ontreating mental and substance use disorders, along withother illnesses and chronic conditions.57When clinicians join Project ECHO, they receive 2 daysof in-person orientation. Then they join disease-specificlearning networks that engage in weekly videoconferences.Training is through case-based learning, includingconsultations with specialists. Project ECHO now operatesmore than 90 hubs—in the United States and in 16 othercountries—that deal with more than 45 diseases andconditions.58 The Project ECHO model has also been usedwithin the healthcare systems of the U.S. Department ofDefense.Accessibility BarriersHaving to travel long distances to receive treatment is acommon accessibility barrier for individuals living in rurallocations who may not have a driver’s license, a reliablecar, or public transportation options. The percentage of ruralfamilies with access to a car between 2011 and 2013 washigher than the percentage of their urban counterparts withsuch access during this same period (96 and 90 percent,respectively).59 However, in 2005, the U.S. Department of4Behavioral Health Is Essential To Health Prevention Works Treatment Is Effective People Recover
Rural Behavioral Health: Telehealth Challenges and OpportunitiesFall 2016, Volume 9, Issue 2Agriculture’s Economic Research Service reported thatmore than 1.6 million families living in rural locations didnot have cars.60 Individuals living in rural locations whodo have access to a car may not want to be away from theirfamilies or leave children with others for the many hoursthat a trip to a provider can take, and seniors may not feelsafe driving after dark.Poverty is another significant barrier to accessingbehavioral health treatment and services.36,61 Poorindividuals living in rural locations may not be ableto afford the cost of care and transportation to care.62Minorities in rural areas are more likely to be poor than areminorities in urban areas; for example, in 2014 the povertyrate for nonmetro Blacks was 36.9 percent, compared with26.0 percent for metro Blacks.63Despite the need for publicly funded treatment, onlyabout 60 percent of U.S. counties have an outpatientsubstance use treatment facility that accepts Medicaid (thepercentage is lower in certain Southern and Midwesternstates).64 Counties with a higher percentage of rural, Black,and/or uninsured residents are even less likely to have aMedicaid-funded treatment facility.64Addressing Accessibility BarriersTelehealth can offer clients and providers more convenientways to access services, which may result in reducedtravel time and expense, less time away from families,and fewer missed appointments.35,65,66 Telehealth alsosaves institutions the expenses associated with theirpractitioners’ travel to distant sites. It can facilitateapproaches that otherwise would not be feasible.The U.S. Department of Veterans Affairs piloted asubstance use treatment program using an in-homemessaging device (IHMD), a hand-held device thatconnected to a telephone outlet but did not interruptphone service and did not require an internet connection.Clients used the IHMD every day to access a combinedbehavioral intervention (CBI) for substance use disorders.CBI is a blend of cognitive–behavioral therapy, 12-Stepapproaches, and motivational interviewing. The aim of theprogram was to reduce delays in connecting clients to care,thereby preventing emergencies.67Every day for the length of the 27-day program, clientsreceived text messages on the device to assess theircondition on these measures: substance use in the past24 hours, level of craving, withdrawal symptoms, levelof commitment to remain abstinent, and thoughts of selfharm. Clients pushed buttons on the device to indicatetheir answers, and follow-up questions proceeded logicallyfrom the responses. Client responses were transmitted viasecure server to computers monitored by care coordinators.The program triaged clients’ responses, alerting carecoordinators to any situation that required an immediateintervention. The care coordinator could then contact theaffected client directly or refer the client to a primary carepractitioner. The system also instructed the client to call911 or take other action, as needed. A second componentof the program conveyed steps clients might take daily tobuild coping and other skills to achieve abstinence.A larger IHMD study (62 veterans) found that
Fall 2016 Volume 9 Issue 2 . Rural Behavioral Health: Telehealth Challenges and Opportunities . This . In Brief . looks at common acceptability, availability, and accessibility barriers to mental and substance use disorder (behavioral health) treatment and services in rural * *There are many deinitions of . rural,
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Prior reviews suggested that health professional edu-cation delivered in rural areas is positively associated with rural retention, although participating in rural training may reflect pre-existing intention and moti-vation for rural practice rather than the intervention itself increasing rural retention [11]. Many of the 10,
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Thomas Talarico, Nicole Inan . Pennsylvania Policy Forum, from Solicitor, Richard Perhacs, in which he stated "Empower Erie" and the "Western Pennsylvania Policy Forum" are private entities separate and distinct from the County of Erie." Mr. Davis's question to Council regarding this is that, if Empower Erie is separate from the County, why did Tim McNair current Chair of Empower Erie send a .
