Minnesota deploys telehealth to expand mental health access to rural areas
Minnesota’s Arrowhead Region, situated in the northeastern part of the state, encompasses 20,000 square miles of mostly rural communities. The region covers 23% of the state but contains only 6% of its population. Providing regular healthcare services across the vast area is difficult at best; offering adequate mental health services is even more challenging.
Like in many parts of the U.S., Minnesota has a shortage of mental health professionals. The state ranks No. 44 in terms of meeting mental health needs, with just 29% of the need met, well below the national average of 44%, according to the Kaiser Family Foundation.
Recently, the Arrowhead Health Alliance—a collaboration of five county public health and human services departments—assessed how to expand access to behavioral health services across such a wide area with too few providers. With good broadband coverage throughout the region, the answer became obvious.
“The only feasible way for us to extend the scarce resource of mental healthcare is through tele-mental health and engaging the primary-care side to partner in that,” said Dave Lee, director of public health and human services for Carlton County, a partner within the alliance.
The goal of the program, which kicked off in January 2016, has been to link community mental health resources to expand services to schools, jails and Native American Tribal Health and Human Services providers to cover the entire region.
“A lot of what we’ve been doing is focusing on what we call the nontraditional integration of mental health in locations where people are in need of behavioral health services but haven’t been able to receive them— whether it was because of geographic distance, or lack of a provider in that community, or just difficulty in getting (a provider) into that jail as needed,” said Ric Schaefer, director of the Arrowhead Health Alliance.
The alliance partnered with the Minnesota Department of Human Services to use a video system that the agency already had in place to provide telehealth within its hospitals and clinics. The collaboration marks the first time the state agency has linked with a community partner to expand telehealth for behavioral health services. For providers such as Stacy Englund, the use of telehealth has greatly increased her ability to provide mental health counseling to a service area where her clients typically drove nearly two hours for an appointment. Since much of her work is with schoolchildren, getting to an appointment became a logistical challenge.
“A lot of parents would not bring their children to therapy if this were not an option,” said Englund, an outpatient therapist with the Range Mental Health Center in Hibbing. “Students are getting care that they normally would not receive.”
With nearly 1 in 5 U.S. residents living in a rural area, many proponents see telehealth as an effective solution to meet the demand for services within those underserved communities.
“From a sustainability and short-term opportunity perspective, it certainly seems that telehealth offers some effective solutions,” said Katherine Steinberg, vice president in healthcare consulting firm Avalere Health’s Center for Payment and Delivery Innovation, adding that it also allows for providers to conduct therapy during nontraditional hours.
Englund said being able to hold therapy sessions through her laptop has allowed her to almost double her caseload in an average week.
Nonetheless, telehealth continues to face major barriers, not the least of which is reimbursement. Steinberg believes more businesses will adopt the technology as they learn more about its value and ability to actually drive down costs.
“I’m hopeful that because telehealth also offers a lower cost mechanism for providing mental health services that we might see greater expansion of reimbursement,” Steinberg said.
Drew, York was able to trace the source of his anxiety back to a childhood trauma that he had repressed.
“At the conclusion of that conversation I truly felt like this overwhelming weight had been lifted off my body that I didn’t know had existed,” Drew said. After two weeks, which included a follow-up session with York, Drew’s physical symptoms had subsided.
Had it not been for his meeting with the psychologist during his primary-care visit, Drew is convinced he would have never called to make an appointment.
“If I had left that office and didn’t see Dr. York, I am 150,000% convinced that right now I would be taking whatever was prescribed to me to deal with the symptoms of the anxiety,” Drew said. “Having him be right there and having the trust of my primary-care physician was ultimately for me the most powerful thing.”
Crossing the cultural divide
Successfully integrating behavioral and physical health services requires some cultural shifts; it’s not just a matter of embedding a psychologist or mental health professional within a medical unit.
“When a behavioral health provider comes to a primary-care practice, they are often not practicing in the way in which they were trained,” Laderman said. “It can be difficult for a traditionally trained behavioral health provider to practice in primary care, and on the medical side, a lot of physicians and nurses haven’t necessarily been exposed to a lot of information about behavioral health.”
For integrated programs such as Christiana Care’s, it required some adjustments by embedded behavioral-care specialists to provide shorter-term interventions than the more traditional 45-minute psychotherapy sessions, for which a course a treatment can last months or years.
One size does not fit all
Although a number of health systems have taken steps toward integration, there isn’t a single model that works for every environment. Some approaches call for behavioral healthcare services to be on the same premises as medical care, but mostly separate in terms of practice except when a patient is referred. A second calls for coordination between behavioral and physical health providers that includes a constant exchange of information between the two despite them being in different settings. A third fully integrates mental health as part of a care team that works with a primary-care physician at every point of the patient’s care.
Advocate Health Care targets patients with a medical diagnosis who may also have a behavioral health co-morbidity. Advocate, based in the Chicago suburbs, has embedded a behavioral health specialist at two of its outpatient primary-care practices and plans to expand access through a telemedicine platform.
In 2012, the system found that 26% of its medical inpatients had a behavioral health issue, which amounted to approximately $26 million a year in excess healthcare costs and added to their length of stay by an average of 1.07 days.
Advocate has been conducting mental health screening within its primary-care physician practices as well as screening all emergency department and hospital inpatients over the age of 65. “We did not want to miss the opportunity to screen patients and begin treatment if needed while they were in our EDs and inpatient units,” said Jeannine Herbst, executive director for Advocate’s behavioral health service line.
A role for primary care?
The role of primary care in addressing behavioral health continues to be debated. Some feel the workload of the average primary-care physician is heavy enough without adding the responsibility of being a mental health provider. There’s also the question of whether a patient can be effectively treated for a behavioral health disorder by a physician who has little time to spend on issues that may go beyond their expertise. “If a patient is not eager to say I’ve been depressed, I’ve been anxious and I have a backache, it’s not common that the primary-care physician is going to pull that information out of him,” said Catherine Sreckovich, managing director of the healthcare practice for consulting firm Navigant.
But the demands on primary care are constantly evolving to address the public’s health needs. The record number of overdose deaths from prescription opioid painkillers and heroin abuse seen over the past decade has fueled demand for substance abuse treatment. Such care is not as effective without a behavioral healthcare component, which is only going to add to the demand for such services now and in the foreseeable future.
How the nation’s health system ultimately defines mental health’s role as part of the larger healthcare framework will determine the future of not only behavioral health in the U.S., but overall health itself.
Successfully integrating behavioral and physical health services requires some cultural shifts; it’s not just a matter of embedding a psychologist or mental health professional within a medical unit.