Introduction to Rural Telebehavioral Health: Key Clinical and Administrative Issues

Abstract

Relevance/Introduction. Rural health-care settings are challenged to provide timely and evidence-based care, particularly for culturally diverse patients with behavioral health (BH) disorders. Telepsychiatry (TP) and telebehavioral health (TBH) improve access to care and leverage scarce resources. Methods. This chapter focuses on the three areas for rural health care: (1) the intersection of rural health, telebehavioral health, and culture; (2) process improvement, teams, and sustainability; and (3) overview of key clinical and administrative topics. Findings/Results. Telebehavioral health is feasible and empowers rural underserved patients, providers, and systems by helping with everyday practice and teamwork. Both telebehavioral and in-person care require integrated cultural and technology skills. Teamwork, partnerships, and process improvement are instrumental for the rural health mission. Administrative adjustments are needed with technology, in order to optimize workflow and reduce the barriers that detract from providers’ interest and preclude funding/reimbursement. Conclusions. Rural populations need clinical, training, and administrative approaches to integrate telebehavioral health care.

FormalPara Case Study

Theme: The interface of depression, psychosis, culture, and telebehavioral health in a rural emergency department.

HPI: A.B. is a 23-year-old English-speaking Hispanic American male who presented to the emergency department (ED) of a regional, rural (population 3000) hospital due to depression, hopelessness, and auditory hallucinations (AH) with commands to kill himself. He was admitted to the medical floor for unstable diabetes (i.e., glucose 311), but downplayed the AH or thoughts of suicide. His primary care provider (PCP) noted a superficially bright mood that did not fit with the previously described restricted and flat affect.

Telepsychiatric Consultation: The patient chose to speak English when offered this or a Spanish interpreter. The telepsychiatrist started with routine questions, but shifted to social questions after noting disinterest and/or resistance to discuss the symptoms. Using the Diagnostic and Statistical Manual Cultural Formulation Interview (CFI, American Psychiatric Association, 2013) as a guide, questions were asked about the patient’s culture, heritage, experiences, and expectations for help. He was born in Mexico and the family immigrated to the USA at age 4, so he grew up in California and became the first of his family to speak English along with siblings. He had past periods of “depression,” but stated, “We never talked about it much… they thought I was just being lazy.” He was encouraged to push through school, go to church, and keep busy. He recalled a depression in his late teens. He reported trouble getting and staying asleep.

MSE: The patient was anxious and aloof, but warmed up over the first 15 minutes of the interview. English appeared to be very well spoken. Mood was “a little depressed” and affect restricted. Thoughts were linear and the content included worry and disbelief about the AH. His insight/judgment was fair, despite his initial hesitance to talk/share. He reported SI due to the intensity of AH, but not a preference to die; no HI. Cognition was intact.

PE/Lab/Imaging: Glucose lowered to 202; other laboratories were unremarkable except for cholesterol at 229; no head imaging was completed.

A/P: A.B. met the criteria for a recurrent, depression, severe with psychotic features. He was agreeable to start an antidepressant sertraline 50 mg AM or fluoxetine 10 mg AM and an antipsychotic Abilify 5 mg AM or olanzapine 5 mg HS. The consultation built in the PCP attending the last 5 minutes to discuss the findings and select medications (sertraline, fewer drug interactions, olanzapine due to concurrent insomnia despite metabolic risk). It was suggested that the term “worry” be used with family instead of depression, and A.B. was discharged 2 days later. When asked about telehealth, he stated, “I hardly noticed it… it’s fine… we could really talk.” A.B. also stated he had a preference seeing this telehealth provider again rather than seeing a new provider in person, if given the option.

FormalPara Analysis

• 1. Telebehavioral health provided access to a specialist trained in mood and cultural issues.

• 2. Telehealth may offer a wide range of services and be augmented with interpreters and/or cultural consultants, depending on a patient’s needs.

Introduction

The challenge to deliver appropriate rural behavioral health (BH) care has attracted national and global attention from all professions (Hilty et al., 2015b). Rural communities around the world face chronic shortages of medical, nursing, and allied health professionals that contribute to serious inequalities between urban and rural residents. Three concepts have been identified as relevant for health workforce recruitment and retention: sense of place (i.e., emotive bonds or experiences in particular locations and environments), place attachment (i.e., ongoing relationships), and belonging in place (Gillespie et al., 2022). Rural depressed patients have three times more hospitalizations and higher suicide rates (Rost et al., 1995, 1998). Rural PCPs would like to help with consultation and in developing skills to manage BH issues (Geller, 1999; Geller & Muus, 2000). The Hispanic population in rural and frontier America is the most rapidly growing segment of the population in non-metropolitan countries since 2005, according to the US Department of Agriculture studies (US Department of Agriculture, 2015).

The delivery of BH services via video and technology requires “good” clinical, cultural, and technology skills for providers, clinical staff, and technology staff (Yellowlees et al., 2008; Hilty et al., 2020a). Culture itself and its components include race, ethnicity, spirituality, religion, sexual preference, gender identity, geography (urban, rural, global), special populations (e.g., incarcerated), and language (Lim & Lu, 2008); others add socioeconomics, education, and other parameters to this list. Cultural and language differences were initially believed to be more challenging for telebehavioral health (TBH) compared to in-person consultations (Shore et al., 2006), but descriptive studies have shown effectiveness in many culturally diverse populations including Hispanics/Latinos, Asians, Native American, and other populations (e.g., sign language) (Hilty et al., 2013). In this case, TBH specialist care to a rural setting allowed A.B. the opportunity to express his symptoms once culture concerns were addressed.

This chapter focuses on the three areas: (1) the intersection of rural health, telebehavioral health, and culture; (2) process improvement, teams, and sustainability; and (3) overview of key clinical and administrative topics based on book sections and chapters.

Rural Clinical Landscape: The Impact of Telebehavioral Health and Culture

The Role of TBH in Rural Health Care

PCPs in rural areas also report having inadequate skills to manage these mental health issues, and they would benefit from assistance (Geller, 1999). Video is a high-intensity model and it is the best-studied option, with collaborative and consultative care showing effectiveness. Low- and mid-intensity technology options, like telephone, e-mail, mobile health (e.g., text), and e-consults, may provide better access for patients and more timely provider communication and education. They are also probably more cost-effective and versatile for health system workflow (Hilty et al., 2018).

New models of psychiatric and behavioral intervention have improved the accessibility and quality of mental health care in the primary care setting, particularly in rural areas. This includes telehealth innovations like videoconferencing, telephone, e-mail, and other technologies, often with consultation-liaison service to primary care rather than direct clinical care (Hilty et al., 2018). Synchronous telepsychiatry or TBH – a term inclusive of other disciplines and used rather than telemental health to be inclusive of addiction care – leverages care for diagnosis/assessment, consultation, and a range of treatments. It has been used in many populations (e.g., adult, child, geriatric), cultures, and settings (e.g., primary care).

TBH providers need familiarity and dexterity with a range of technologies (Table 1.1). The goal with technology is to simulate real-time experiences related to feelings, perception, images, and interaction. Even low-cost systems facilitate engagement and a “social presence” for participants to share a virtual space, get to know one another, and to discuss complex issues (Hilty et al., 2020c). For example, with asynchronous consultation, the specialist develops a treatment plan for the PCP to implement a brief psychotherapy (e.g., problem-solving therapy) and/or to prescribe a psychotropic medication. The PCP has the option of asynchronous or phone follow-up as needed.

Table 1.1 E-health continuum for behavioral health interventions for primary care

Culturally Competent Care: Foundations, Approaches, and Challenges

Cultural issues include, but are not limited to, symptoms, presentation, meaning, causation, family factors, coping styles, treatment seeking, mistrust, stigma, immigration, and overall health status; likewise, the culture of the clinician affects the interaction, particularly the inability to speak the patient’s language (Office of the Surgeon General, 2001). BH disorders in minority populations are often difficult to recognize and diagnose due to complex beliefs, differences in help seeking, and stigmatization. All of these factors affect access and/or treatment initiation/completion. A study of illness beliefs among Chinese Americans also showed that many patients with depression were reluctant to refer to their illness as psychiatric in nature for fear of being stigmatized (Yeung et al., 2004). A foundation in cultural humility, safety, and competency appears essential for patient assessment, triage, and treatment (Hilty et al., 2021).

Patients gain a sense from providers and clinics if culturally sensitive treatment is available (Shore et al., 2006). Patients may shy away if staff and providers do not “look like” them. In addition, some prefer alternative approaches (e.g., shaman, natural remedies, traditions). The patient-centered medical home (PCMH) (Rosenthal 2008) focuses on access, patient, and family engagement (Cené et al., 2016) – the gap there is the PCP clinic may not be the destination for help seeking. Socioeconomic factors that affect technological access include poverty, educational level, and geographic location. Poverty has been shown to be a significant barrier to receiving culturally appropriate psychiatric care, both in person and by telecommunication. Furthermore, rural ethnic minority groups have about twice the poverty rate of the white rural populations (Yellowlees et al., 2013).

Since the ability to communicate with less English proficient patients is essential in clinical care, it is a common practice to use “interpreters” on site; however, sometimes family members or untrained interpreters may miscommunicate medical complaints, de-emphasize information, and miss cultural metaphors (Hilty et al., 2020a). This is potentially very significant in psychiatric care and led to a call for credentialing of interpreters (Carlson, 2010; Hilty et al., 2015b). In one TBH study, PCPs and staff rated the importance of valuing cultural differences and being able to speak (or use an interpreter) in the patient’s primary language at 5.4 on a Likert scale from 1 to 7 (not important to very important); this overshadowed ratings of quality of care at 4.9 and availability of a competent trained interpreter at 4.4 (Hilty et al., 2015b). Subanalysis of PCP versus staff ratings did not differ.

Telebehavioral Health Programs and Sustainability

The overall goal with technology is to create value for patients, providers, staff, and leaders – for TBH care, that should include simple steps for users, ease of scheduling, good communication, and assistance (e.g., clerical, administrative, technical) when needed. Process improvement (e.g., lean) considers the users’ experiences, needs, and expectations and includes all members of the organization in working together to improve (Table 1.2). While patients are the center of the system’s approach, providers and staff are equally important as part of the Quadruple Aim, which includes: patient satisfaction; implementation research to further population-centered health; increase service delivery effectiveness; and reduce clinician workload burden, fatigue and burnout (Bodenheimer & Sinsky, 2014).

Table 1.2 Reasons for telehealth program failures and dos to ensure success

Hallmarks of “Good” Programs: Evaluation and Effectiveness

The premises for the good evaluation of outcomes begin with program fitness: organization, function, leadership, the “right” members/workforce, experience, and many other parameters. Thinking more broadly, the approach to evaluation may start with how to set up a “good” team, program, organization, or other body – or in assessing its overall fitness in general and its ability to change. Ultimately, responsible, conservative implementation is safer than doing too much at once. A basic plan with an option or two for expansion works well. Timelines are crucial for the sake of urgency, to keep focus and be productive. It is prudent to expect the unexpected.

There will be layers of complexity, problems, complications, and other untoward events that are not foreseen. Resolution of the specific problem is key, but the “dos” of evaluation almost always include monitoring, gaining input, and ongoing improvement. Using existing, well-developed methods or procedures (e.g., standardized measures that have undergone multiple iterations, levels of review, and psychometric testing) is helpful. In addition, specific measures and generalized measures, accounting for confounding events, and accurate and time-efficient self-report/user completion are helpful. When possible, prospective data collection and someone with training (e.g., academic, statistics, process improvement) involved earlier rather than later are helpful. This requires planning and funding for evaluation.

Clinical and Administrative Outcomes

Strategic planning necessitates evaluation of external and internal factors that affect the organization, and ethnic attitudes and behavior influence program utilization and steer communications, hiring and training, and program structure. The current rapidly evolving health-care environment adds urgency to assessment and its effectiveness, in order to better define the value of TBH interventions to patients, communities, leaders, funding organizations, and other decision-makers in health care. TBH research has moved beyond general satisfaction to implementation, cost/economics, and other outcomes (Hilty et al., 2020c, 2022). For underserved populations, though, important information is gleaned when evaluation is properly designed, administered, and analyzed (Nelson, 1985).

For specifics of evaluating outcomes, the American Telemedicine Association TBH expert consensus produced a lexicon for outcomes in the following areas: patient satisfaction (i.e., access, distance to service, use of), provider satisfaction, process of care (e.g., no shows, coordination, completion of treatment), communication (e.g., rapport), reliability/validity (e.g., assessment, treatment vs. in person), specific disorder measures (e.g., symptoms), cost (i.e., length of service, travel, hardware and software), and other administrative factors (e.g., facility management, team staffing) (Shore et al., 2013).

Culture of Teamwork and Improvement

Team-based care with technology ideally offers a variety of options: learning by patients and clinicians (e.g., curricula), levels for low- to high-experienced members, attitudes and skills in addition to knowledge outcomes, explicit activities for teams to communicate (e.g., huddles), teaching methods with case/practice in addition to lecture/didactic, and perhaps, most-importantly, supervision for feedback, reflection, and developing good habits (e.g., text to supervisor in time for help). For example, care coordinators/managers can manage secure mail, nurse practitioner/physician assistant can initiate e-consults, and BH professionals may evaluate less complex cases – each of these options preserves physician time for analysis of data, complex cases, and supervision. Teamwork is facilitated by a shared mental model of expectation, roles, and outcomes (Ross & Allen, 2012). Physical (e.g., schedules, huddles), virtual (i.e., on-site and distant member), and other training interventions may substantially improve team-based care – coordination, communication, and teamwork (Hilty et al., 2020b).

There are a variety of reasons that TBH programs fail to succeed (Table 1.3). This may be divided into assessment of need/planning, key contributions by participants, and other steps for improving quality. A developmental approach to rural telepsychiatry emphasizes stages of needs identification, infrastructure survey, partnership organization, structural configuration, and pilot implementation (Shore & Manson, 2005). Alignment of the missions of partners, collection of data for needs, and prioritization of steps are essential. Key contributors are the team champions, providers, and those doing program evaluation. Interprofessional teams – and particularly mid-level practitioners – will play a role, as high-level trained clinicians are not best used for doing it all. BH practitioners may need to gain experience working alongside PCPs, getting “warm” handoffs, or dealing with emergencies. Providers with combined psychiatry/family medicine or psychiatry/internal medicine training can facilitate integration naturally. Physicians are a crucial leverage point in these systems, complemented by interdisciplinary teams and stepped care models (Hilty et al., 2018). This shift also requires faculty development for teaching, supervision, and evaluation (Hilty et al., 2015a).

Table 1.3 Creating value for patients, providers, staff, and leaders via process improvement

Overview of Key Clinical and Administrative Issues

The book is informally organized into three sections: (1) foundations for TBH in rural health; (2) approaches to technology-based care, teamwork, and special populations; and (3) implementation, regulatory, and leadership issues. This book focuses on outcomes for readers – in the form of behaviors, skills, and processes – more than ideas or knowledge. The authors use short chapters, learning objectives, cases, and summaries for the “what to do and how to do it.” Direct living, clinical, research, and organizational (i.e., health system, policy, military) experience with rural, remote, and otherwise isolated populations is the foundation of this approach.

The first section which serves as a foundation starts with “Rural Telebehavioral Health Competencies, Models of Care, and Sustainable Administrative Approaches” as a reminder for participants – both on site with the patient and at a distance – that clinical and administrative or institutional competencies are needed to ensure therapeutic engagement, quality of care, and sustainable practices. Purposeful selection of learning activities, models of care, and outcome monitoring guide the effort. The chapter “Person- and Patient-Centered Care Turns ‘30’: Being Informed by Person and Patient Experience in Virtual Care” helps us to apply the patient-centered clinical method to the virtual care environment, while appreciating the potential challenges to the therapeutic relationship in doing so. “Digital Compassion, Health Equity, and Cultural Safety – from the Therapeutic Relationship to the Organization of Virtual Care” helps explain digital compassion and consider its manifestations at individual and organizational levels. It also defines digital health equity, cultural safety, and cultural humility as an approach for patients or people to best get help when they are suffering or in need. Likewise, “Self-Care and Well-Being for Providers, Teams, and Systems” provides principles for reflection and practice, which are important for in-person and virtual care, particularly for the latter as daily life presents challenges and workflows shift with a variety of technologies in health care.

The section on approaches to technology-based care, teams, and special populations provides approaches for nontraditional interventions, special populations, innovative treatment (e.g., computer-assisted cognitive behavior therapy and mobile applications), and service integration with in-person, synchronous, and asynchronous care. “Telemental Health Delivered to Nontraditional Locations and for Special Populations” provides tips for implementing nontraditional services, how to capitalize on the flexibility of TBH, adapting it to children/adolescents and geriatric patients, and processes to ensure quality and safety. The chapter “Approaches to Virtual Care in Underserved Communities and Settings: Bridging the Behavioral Healthcare Gap” emphasizes setting quality outcomes, efficient processes for evaluation, and alignment of provider, system, and institutional goals. Low- and middle-income countries have challenges, though in order to scale up community mental health programs, the processes above are essentially the same. Though video is most widely known in primary care and rural settings, “Practical Considerations for Emerging Types of Telebehavioral Health Care: Computer-Assisted Cognitive Behavior Therapy and Mobile Applications” offers other technological options for patients to seek help, which is particularly helpful for younger generations and technophiles. “Integrating In-Person, Video, and Asynchronous Technologies” emphasizes integration of in-person, video, and asynchronous options like mobile health into workflow. This requires patient, primary care team, and BH provider skill sets and team-based care for service delivery.

The last section focuses on implementation, regulatory, and leadership issues for providers, systems, and administrators. “An Implementation Roadmap for Virtual Care in Rural and Underserved Settings” outlines steps and approaches to facilitate acceptability, adoption, feasibility, implementation, cost, and sustainability factors that govern design, evaluate, and change in health-care services with technology. “Technology, Business, and System Implementation: Getting the Right Care to the Right People in the Right Place” adds to that approach with more rural emphasis, a useable and targeted reference guide, and illustrative case examples. While most providers and administrators have learned by building and refining systems, “Implications of Legal and Regulatory Issues in Telebehavioral Health” covers a landscape systematically and with new changes to enhance outcomes. Likewise, “Resources on Funding, Economic/Cost Assessment, and Reimbursement” provides a real-life, nuts-and-bolts, lessons-learned approach to find and use resources to create a business approach based on economics of health care, compare estimated versus real costs, and maximize reimbursement. Finally, “Health Systems Perspectives on Integration, Planning, and Leadership” looks at infrastructure requirements for audio/video therapy in primary care or in a home environment, walks through challenges and solutions in building or improving care, and applies a case example to apply the material.

Conclusions

Rural health-care settings are challenged to provide timely and evidence-based care, particularly for culturally diverse patients with behavioral health disorders. Telepsychiatry and telebehavioral health improve access to care and leverage scarce resources. National organizations are beginning a shift to attitudes and skills in addition to knowledge – consistent with the competency-based medical education movement – and advocate for cultural skill development. A key issue is identifying the degree of alignment of providers and patients, at least in terms of linguistic, cultural, and racial concordance, which facilitates patient and provider satisfaction, as well as patient adherence to treatment (Hilty et al., 2020a).

Culturally competent care has shifted from knowledge to skills, from individual to team approaches, and from a specialization in a single culture (e.g., matching his/her own culture or training) to an approach that provides flexibility/versatility to help many diverse populations. More recently, there is a shift from cultural competence to cultural humility and/or cultural safety (Fisher-Borne et al., 2015; Curtis et al., 2019). A positive care and work environment, training, and “good” administration can address this to a large degree – particularly by importing expertise via telehealth.

There are a variety of TBH service delivery options available, but the key ingredients of a “good” model are fairly consistent: easy access, low cost, in-time help to the user (e.g., person, patient, consultee), and meaningful outcomes. While high-intensity models have substantially better outcomes, mid- and low-intensity models also have many benefits like building relationships and complementing in-person services. They may also be more sustainable (e.g., provider-to-specialist consultations by telephone, e-mail, and other modes). Regardless of the model, health-care organization and administration systems try to promote clinical responsibility and decision-making, co-location of services, integrated funding, integrated program evaluation, and integrated outcome measurement. When it comes to TBH, an e-platform for technologies and adjustments in reimbursement approaches are also necessary.

The overall administrative approach should attend to process, procedures, policy, and evaluation of telehealth – there are many dos and don’ts related to planning, implementing, and managing a program. Flexible basic and advanced approaches may require a fundamental shift in philosophy – from seeing what happens with planned services – to advanced planning of outcome targets and then subsequent design of the services. This book’s “what to do and how to do it” – based on direct living, clinical, research, and organizational experience – shapes the approach. The three sections of TBH in rural health, approaches to technology-based care and teamwork, and implementation and leadership issues will help readers focus on outcomes – in the form of behaviors, skills, and processes – more than ideas or knowledge.

CE/CME Questions

• 1. Health workforce recruitment and retention for rural settings takes into account provider

  • (a) Sense of be

  • (b) Attachment to the setting or people

  • (c) Belonging in place

  • (d) Workflow steps and barriers

  • (e) All of the above

• 2. Which of the following technologies are being applied to rural health care with the help of specialists?

  • (a) Video

  • (b) Telephone

  • (c) E-mail and e-consults

  • (d) Mobile health (e.g., text)

  • (e) All of the above

• 3. Rural depressed patients have approximately what proportion (i.e., _ times) higher hospitalizations and higher suicide rates than urban counterparts?

  • (a) 2

  • (b) 3

  • (c) 5

  • (d) 10

  • (e) 20

• 4. Teamwork and team-based care (i.e., coordination, communication, and teamwork) among professions – between on-site and virtual team members – is best facilitated by

  • (a) Regular work hours

  • (b) Division of tasks

  • (c) A shared mental model of expectation, roles, and outcomes

  • (d) Regular pay increases

  • (e) Extra meetings

• 5. Which of the following best predict patient satisfaction and adherence to treatment, in terms of the relationship to the provider?

  • (a) Belief concordance

  • (b) Cultural concordance

  • (c) Linguistic concordance

  • (d) Racial concordance

  • (e) Cultural, linguistic, and racial concordance

Answers

• 1. (e)

• 2. (e)

• 3. (b)

• 4. (c)

• 5. (e)