Min­nesota de­ploys tele­health to ex­pand men­tal health ac­cess to ru­ral ar­eas

Modern Healthcare - - NEWS - By Steven Ross John­son

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.

Psy­chother­a­pist Amanda Radtke con­ducts a coun­sel­ing ses­sion as part of the Ar­row­head Health Al­liance’s tele­health ini­tia­tive in Min­nesota.

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