Availability refers to the presence or absence of services and service providers. Accessibility refers to whether or not people can reach the services they need. Acceptability indicates a person’s attitude to mental health issues, willingness to seek services and enter treatment. There is clear evidence that the availability of mental health services and the number of mental health providers in rural areas is severely inadequate. Rural America has been underserved by mental health professionals for the past 40 years.
The perception of need for care is the first step in seeking care, and rural residents enter care later than do their urban peers due to a lower perception of need—a problem that is then compounded by their perceiving less access to care. Empirical studies show that lower access to mental health services is directly related to lower availability or supply of mental health providers (Lambert & Agger, 1995). The barrier to care posed by provider availability in rural areas is discussed further in the next section. The ability to travel to services and to pay for those services if accessed is a significant barrier to rural persons. Physically and psychologically accessible and affordable transportation services may be unavailable, especially to rural children, people with disabilities and the elderly. Public transportation is often not an option to rural consumers of mental health services. As a result, many rural mental health providers operate some form of transportation service to bring consumers to care—an operational cost not often incurred by their urban counterparts. Rural consumers and families must often travel hundreds of miles weekly to access care available only in larger communities that serve as “regional centers of trade.” Employment-based health insurance covers a wide variety of health services for Americans, and is the most common form of health insurance coverage in the United States, covering 64.9 percent of the non-elderly population and 34.4 percent of the elderly population in 1998. Size matters; often small employers do not offer a full range of benefits and employers with 50 or fewer workers were exempt from the Mental Health Parity Act of 1996. Retiree health benefits have steadily declined over the past decade, with only 30 percent of employers offering retiree health benefits in 1998, as compared to 40 percent in 1993 (McDonnell & Fronstin, 1999). A similar dramatic decline occurred for mental health benefits, where per employee expenditures for behavioral health benefits have gone from $151.54 in 1988 to $69.61 in 1997 (The Hay Group, 1998). For rural Americans, the cost of health services (only partially reimbursed by Medicare Part B; or at a discount by Medicaid) may be too expensive—especially prescription drugs. Small group and individual purchasers, who often cannot afford comprehensive policies, dominate the rural health insurance marketplace. As a result, these policies often have large deductibles, and limited or no behavioral health coverage (McDonnell & Fronstin, 1999). Rural residents also have longer periods of time without insurance than do their urban peers and, hence, a greater likelihood of pent-up demand. Also, they are more likely not to seek physician services when they cannot pay, both because of pride and limited opportunities for free or reduced-fee clinical care (Mueller, Kashinath & Ullrich, 1997). Parents who have children with mental health problems but limited or no ability to pay for treatment may have to face a disturbing option: relinquishing custody of the child in order to obtain needed services. Multiple groups have commented on this practice, including the National Alliance for the Mentally Ill (NAMI), the Bazelon Center for Mental Health Law, and the Federation of Families for Children’s Mental Health (FFCMH).2
The recruitment and retention of certified mental health professionals is of major concern in rural communities (Kimmel, 1992). In addition, Medicare reimbursement rates are often lower in rural areas, which affect the earning potential for rural mental health professionals (Meyer, 1990).
Telemedicine Institute ofOklahoma, PLLCOverview of Telemedicine Needs andBenefits, TIO Staff and Philosophy
Telemedicine Institute ofOklahoma, PLLC• The Telemedicine Institute of Oklahoma, PLLC (TIO)was established in 2012.• Mission: Provide high quality mental health servicesto the rural populations of Oklahoma.• TIO equipment inspected and approved byODMHSAS in Oct 2012.• Practice established solely for the purpose ofproviding mental health services via videoteleconference.
What is Telemedicine?• The American Telemedicine Association definestelemedicine as:“the use of medical information exchanged from one site toanother via electronic communications to improve a patientshealth status”• Allows health care professionals toevaluate, diagnose and treat patients in remotelocations using telecommunications technology• Developed by NASA to monitor and treat astronautswhile in space.
Why Telemedicine?• Barriers exist that may prevent rural Oklahomansfrom seeking care.• Problems facing rural health care centers furtherdecrease access to care.• Telemedicine can provide:– Measurable improvement in patient care in terms ofaccessibility and availability.– Documented cost savings to clinics and patients thatparticipate in telehealth encounters.
Oklahoma’s Mental Health Needs• Oklahoma in 2008-2009:– 21.6% of Oklahomans experienced a diagnosablemental, behavioral, or emotional disorder– 7.4% of adults experienced at least one major depressiveepisode– 8.09% of youth aged 12-17 experienced at least one majordepressive episode– Data derived from State Estimates of Substance Use and MentalDisorders from the 2008-2009 National Surveys on Drug Use andHealth• Over 1.27 million of Oklahoma’s population livesin counties defined as rural (less than 50K)
The Problems• Three factors may prevent rural persons with mentalillnesses face from receiving the mental health carethey need: accessibility, availability, and acceptability.• These variables lead rural residents with mentalhealth needs to:– Enter care later in the course of their disease than do theirurban peers;– Enter care with more serious, persistent and disablingsymptoms; and– Require more expensive and intensive treatment response(Wagenfeld et al., 1994).Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services
Accessibility• Three significant components of access to mentalhealth services that put rural residents at asignificant disadvantage: knowledge, transportationand financing.– Patients need to know when one needs care and whereand what care options are available to address needs.– The ability to travel to services and to pay for thoseservices if accessed is a significant barrier to rural persons.– For rural Americans, the cost of health services (onlypartially reimbursed by Medicare Part B; or at a discountby Medicaid) may be too expensive—especiallyprescription drugs.Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services
Availability• Lower access to mental health services is directly relatedto lower availability or supply of mental health providers(Lambert & Agger, 1995).• The availability of rural mental health services andproviders is seriously limited in rural communities.– Over 85 percent of the 1,669 Federally designated mentalhealth professional shortage areas (MHPSAs) are rural(Bird, Dempsey & Hartley, 2001).– According to the National Advisory Committee on Rural Health(1993), of the 3,075 rural counties in the United States, 55percent had no practicing psychologists, psychiatrists, or socialworkers, and all of these counties identified were rural.Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services
Acceptability• Many Americans attach stigma to having or seekinghelp for mental health or substance abuse problems.• This is more of an issue in rural communities, asthere is less anonymity in seeking help.• Ethnic minority individuals may be more hesitant toenter treatment based on fear that the provider maynot understand their culture and traditions.Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services
Rural Populations at Risk• Rural populations often experience stress because ofthe high poverty rates, high unemployment rates andlow educational opportunities.• Demographics particularly at risk include:– Women– Children– Elderly– VeteransDerived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services
These factors result in a loss of health services torural communities.Problems Facing Rural HealthcareCenters• Limited availability of mental health providers• Limited availability of outpatient services• Decreased operating budgets• Inadequate access to continuing education andtraining
Availability of Providers• It is estimated that approximately two-thirds ofindividuals with symptoms of mental illness receive nocare at all.• Of those who do receive treatment in ruralareas, approximately 40 percent receive care from amental health specialist and 45 percent from a generalmedical practitioner (Regier et al., 1993).• The availability of mental health services and the numberof mental health providers in rural areas is severelyinadequate .• The availability of specialty mental health services(e.g., neuropsychology, geriatric) is even lower than thatof general mental health services.Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services
Availability of Providers (cont.)• Primary care physicians and other general medicalpractitioners are often the first-line mental healthproviders for rural residents.• Primary care physicians may not be adequately trained toidentify and treat mental illness and behavioral disorders(Ivey, Scheffler & Zazzali, 1998; Little et al., 1998;Susman, Crabtree & Essink, 1995).• Law enforcement is often responsible for responding tomental health emergencies in rural jurisdictions(Larson, Beeson & Mohatt, 1993); they generally do nothave the training or experience recognizing mental illnessand/or providing triage or stabilization assistance toindividuals in immediate crisis.Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services
Decreased Operating Expenses• Fiscal realities have resulted in declining operatingbudgets for many rural hospitals, health clinics, andmedical practices.• Priorities for care are focused on acute needs andoutpatient services are often eliminated completelyor in part.
Access to Training• It is difficult for many rural providers to stay abreastof emerging mental health treatment and medicationprotocols, especially in those areas served solely byprimary care physicians.
A Solution• Treatment using telemedicine can address gaps incare for rural populations.• Treatment using telemedicine can provide:– Improvement in Patient Care– Cost Savings– Improved Patient Satsifaction
Improvement in Patient Care• Telemedicine can provide:– Improved access to care;– Provision of a higher level of care locally or in a moretimely fashion;– Timely medication management;– Improved continuity of care;– Increased family involvement;– Improved treatment compliance; and– Better coordination of care.
Cost Savings• Cost savings in out-of-pocket expenses for patientshave been well documented.– As an example, the 866 mental health encountersconducted over the Eastern Montana TelemedicineNetwork from July 2002 – June 2003 represents over$260,000.00 in out of pocket savings for patients. Thesesavings were based on travel cost and lost wages.
Patient Satisfaction• Studies have consistently shown that the quality ofhealthcare services delivered via telemedicine are asgood those given in traditional in-person consultations.• In some specialties, particularly in mental health andICU care, telemedicine delivers a superior product, withgreater outcomes and patient satisfaction.• Patients report high satisfaction with services providedvia telemedicine.– On a patient satisfaction scale of 1-8, 1 being not satisfied and 8being very satisfied patient receiving telemental health servicethrough the Eastern Montana Telemedicine Network reportedan average of a 7.0 satisfaction rating for 5 consecutive years.
Key Terms• Distant Site: Location where the certified medicalprofessional is• Originating Site: Location where the patient is.• Telemedicine: The use of two-way, real time interactiveaudio and video to facilitate the delivery of health careservices, including specialist referral, patientconsultation, remote patient monitoring, andeducation/prevention.• Telehealth presenter: Healthcare provider at theoriginating site at time of interactive consultationresponsible for presenting the patient to the physician orpractitioner.
TIO Medical Staff• Dr. Sarah Land– ABPN Board Certified Psychiatrist• Dr. Tracy Loper• Dr. Peteryn Miller
Authorized Originating Sites• The office of a physician or practitioner• A hospital• A school• An outpatient behavioral health clinic• A critical access hospital• A rural health clinic (RHC)• A federally qualified health center (FQHC)• An Indian/Tribal/Urban Indian (I/T/U) clinic or healthcenter
Originating Site Requirements1. Providing a space for the patient during the consultation, includingInternet and other necessary telecommunications access.2. Providing an appropriate certified or licensed health careprofessional to present the patient to the physician or practitionerat the distant site and remain available as clinically appropriate.3. Providing client file to the physician or practitioner at the distantsite prior to the encounter, to include chief complaint, social-family-medical history, medications, allergies, current diagnosesand treatment plans.4. Providing, operating, and maintaining all equipment and suppliesowned by the originating site to TIO standards.5. Submitting facility site billing data to state agencies and insuranceproviders.
TIO Responsibilities:1. Providing for the scheduling of telemedicineservices.2. Providing intake procedures to include, but notlimited to client orientation and consent forms.3. Distributing prescriptions for Schedule II ControlledSubstances to clients as appropriate and withproviders signature as required by law.4. Providing, operating, and maintaining all equipmentand supplies owned by TIO.
TIO Responsibilities (cont.):5. Ensuring that all physicians and providers hold a currentmedical license and/or certification to provide mental healthservices, is Medicaid and Medicare registered, possesses aNational Provider Identification (NPI) number, and holds andmaintains medical malpractice liability insurance for theprovision of telemedicine services.6. Complying with all requirements for provider credentialingand privileging as required by the originating facility and incompliance with CMS and the Joint Commission.7. Submitting consultation billing data to state agencies andinsurance providers.
Partnership Advantages• Behavioral healthcare that is accessible andaffordable to a large number of patients• Increased scope of services that can be offered torural populations• Reduces the number of mental health crisis visits tothe ER• Better discharge options• Routine monitoring and medication checks of at riskpatients
Process• Signed contract between Rural Healthcare Provider andthe Telemedicine Institute of Oklahoma.• Originating site provides requisite hardware, softwareand network equipment, as necessary.• Originating site equipment is inspected and approved byODMHSAS, as necessary.• TIO provides a licensed health care professional forpatient consultation.• Rural Healthcenter provides presenter to escort patients,perform initial review of patient status, and concludepatient visit.• Originating site and distant site submit for costs.
Guidelines• Requirements derived from Oklahoma Health CareAuthority Policies and Rules• https://www.okhca.org/xPolicy
APA• The American Psychiatric Association supports theuse of telemedicine as an appropriate component ofa mental health delivery system to the extent that itis in the best interest of the patient and is incompliance with the APA policies on medical ethicsand confidentiality. (American PsychiatricAssociation, www.psych.org, August 14, 2003)