Extending Mental Health Services to Rural Areas

Outside of major metropolitan cities like New York, Boston, and Los Angeles, child and adolescent psychiatrists are at a premium, and the demand is higher than ever for behavioral health services, particularly in rural areas; the solution, according to a presentation given Friday, Oct. 29, at the AACAP 57th Annual Meeting in New York, NY, is telepsychiatry.

Two child behavioral health providers offered perspectives from their experiences in establishing and maintaining successful telepsychiatry initiatives in two very different areas: Kansas and New Mexico.

First, Eve-Lynn Nelson, PhD, associate professor of pediatrics at the KU Center for Telemedicine and Telehealth, Kansas City, KS, spoke about the need for establishing a program in a state in which 99 of 105 counties have reported shortages in mental health services.

Along with a dearth in child psychiatrists, Nelson identified factors such as disparities in care, insurance barriers, and travel costs and logistics as key drivers in the establishment of the KU Center, which has done more than 25,000 consultations since 1991, with the most targeted specialty being behavioral health. Of those patients, most present with conditions such as ADHD, depression, and adjustment reactions.

According to Nelson, a range of different service models are utilized, with the majority of patients undergoing an onsite assessment followed by treatment delivered through telemedicine consultations. The program includes both psychiatrists and psychologists, who meet with the parent and child (either in person or electronically) to ensure that the care team is on the same page in terms of treatment.

“The goal,” she said, “is to approximate face-to-face care, and we’ve been able to do that.”

Although further research is needed, Nelson said that the model has been very beneficial, particularly in helping psychiatrists and other health care providers communicate better and more frequently with the parents of patients. Another advantage she has seen is that telemedicine can more effectively incorporate recommendations for more care providers, and promotes “a better community approach in being able to consult with more people and get a better picture of the patient.”

From her experience, she suggested that providers looking to set up telepsychiatry programs develop training videos for ancillary care providers on mental health issues; establish a back-up plan in the event of technology issues; have protocols in place for back-up support for children with suicidal ideation.

Finally, it is important to make telemedicine “part of the normal workflow,” she said.

In his presentation, James M. Heneghan, MD, a child psychiatrist and part-owner of an EMR company based in Sante Fe, NM, spoke about the importance of having strong IT support when implementing telehealth programs in a community mental health setting.

Telemedicine, he said, “is the only way to reach rural communities with low population that are geographically isolated.” Heneghan founded a program that provides behavioral health services by teaming psychiatrists with community mental health centers to offer added services for patients. “It’s a difficult population, and you need a team to deal with these issues,” he noted.

Heneghan’s organization, Zia Behavioral Health, received a grant from the state to establish a telepsychiatry program. Once the funds were in place, the next step was to bring on board dedicated IT professionals with a solid understanding of teleconferencing; this he said, was a critical component to ensuring the program’s success.

Being a rural setting (where practices are separated by hundreds of miles), Heneghan believed it was also essential to implement an electronic behavioral health record and management tool for the community-based mental health centers and psychiatrists. Going electronic, he said, led to significant improvements in scheduling appointments, charting, and facilitating more accurate diagnoses through the use of protocols and decision support tools.

Because community health centers face unique challenges dealing with strict Medicaid guidelines, supervision requirements and extensive billing functions, implementing an EMR was a critical step.

“Creating the ability to link a symptom with a diagnosis made a big difference in the community setting,” he said.