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Telemental
Health: Delivering Mental Health Care at
a Distance
A Summary Report |
Henry
A.
Smith,
LCSW
Ronald
A.
Allison,
MA
October
2001
Disclaimer
This document was prepared by the authors under
an Interagency Agreement between the Substance
Abuse and Mental Health Services Administration
(SAMSHA) and the Health Resources and Services
Administration (HRSA). The views expressed in
this report are those of the authors and do
not necessarily reflect the views of SAMHSA,
HRSA, the Public Health Service or the Department
of Health and Human Services.
Foreword
The provision of mental health services in America's
rural and frontier areas remains a critical
health services challenge. Telemental health
- the provision of mental health services from
a distance, using telecommunications technologies
- is increasingly helping to surmount that challenge.
This report is a joint effort of the Center
for Mental Health Services, Substance Abuse
and Mental Health Services Administration (SAMSHA)
and the Office for the Advancement of Telehealth,
Health Resources and Services Administration
(HRSA). It was produced to inform Federal, State
and local mental health administrators about
options for utilizing telecommunication and
information technologies to improve the delivery
of mental health services to rural and frontier
populations.
Since the re-emergence of telemedicine programs
in the late 1980's, telemental health services
have consistently been one of the top three
most frequently provided health services using
telehealth technologies. In 1998-99, over 61
programs in 35 states were delivering telemental
health services. Telemental health services
are bridging the health services access gap
not only for those who traditionally have had
limited access to mental health services, in
particular those in rural and frontier areas,
but also for those who because of mobility problems,
poverty, or incarceration have limited access
to health care services.
Telemental health services are being delivered
in a range of settings -- rural primary care
clinics, hospital emergency rooms, community
mental health centers, schools, and nursing
homes. They are also being delivered directly
into homes as well as on board Navy ships and
in jails, and state and federal prisons.
Telemental health technologies are being utilized
to provide the full range of mental health services,
including pre-admission and discharge planning,
assessments and evaluations, case management,
medication management, family visits, pyschotherapy,
court commitment hearings, and family and consumer
support groups. These technologies also provide
a means to train mental health providers for
rural practice. In some states, the one-year
clinical internship of master's level prepared
social workers is supervised via telehealth
technologies. The use of these technologies
for continuing education and in-service sessions
is also providing access to educational opportunities
that have been limited in rural areas.
Increasingly, state and local agencies responsible
for mental health services are exploring the
use of telehealth technologies to assist them
in delivering services to rural and frontier
populations and meeting their mandates. Some
have begun to invest in telehealth technologies
or provide payment for services delivered via
telehealth. We hope that this report will assist
policy makers, as well as mental health professionals
and consumers, as they explore how to effectively
utilize these technologies, integrate the technologies
into their practices, or advocate for their
use to enhance access to services.
For mental health care providers
and consumers in rural and frontier America,
the future is now. Interactive telecommunication
and information technologies make it possible
for mental health providers to literally be
in two places at once, extending scarce resources
to individuals, and to entire regions, that
are medically underserved.
Recent Growth Telecommunication
technologies have been used for some 40 years
to provide limited mental health interventions,
mostly on an experimental basis. Beginning in
the 1990s, however, the use of interactive telecommunication
technologies flourished. The number of telemedicine
programs in the United States grew from nine
in 1993 to over 100 in 1997, and most of them
provide mental health services. The seven most
active telemental health projects in the nation,
highlighted in this report, conducted approximately
70% of all the telemental health service contacts
reported by the 50 most active projects in 1996.
Substantial Benefits The range
of mental health services provided to rural
consumers over a telemental health network is
virtually limitless. At the present time, it
appears that all traditional mental health services,
which do not involve direct physical contact
with the client, can be provided by telemental
health. Telemental health networks are also
used for education and training for mental health
staff, and to bring consumers and family members
together for information and support.
In some situations, telemental health services
may be superior to face-to-face services. For
example, telemental health allows a psychiatrist
to observe a patient close up, without invading
his or her personal space. This makes it easier
to examine a patient for side effects of psychotropic
medications.
Telemental health applications also enhance
continuity of care for consumers in rural areas.
With telemental health, a "virtual treatment
team" can be formed between the community
and the inpatient psychiatric facility staffs.
Consumers can be followed in the community by
the same physician who treats them in the hospital,
and family members can be involved in treatment
and discharge planning.
Positive Outcomes Much of
what is known about the impact of telemental
health comes from the combined experience of
staff and consumers who operate and participate
in these networks. Though no rigorous outcome
studies have been done to date, informal findings
suggest that telemental health improves continuity
of care for rural consumers, increases family
and consumer involvement in treatment, and reduces
lengths of stays and readmission rates to state
psychiatric facilities. Participant satisfaction
surveys reveal that consumers perceive telemental
health services as worthwhile, of high quality,
and worth continuing.
Organizational Considerations
The introduction of telemedicine into a rural
mental health care program requires leadership,
vision, and authority. Typically, there is a
consortium of member sites, comprised of decision-making
personnel, that meets on a regular basis to
oversee the development, management, and growth
of the network. This group identifies the consumers
to be served, designs the clinical system, determines
staffing levels, creates informed consent and
confidentiality procedures, and researches technological
issues. Front-line staff meet to share practical
knowledge and suggestions.
Technology Needs Start-up
costs for a telemental health network are becoming
more affordable due to decreasing equipment
costs, and are therefore now within reach of
most rural mental health programs. Indeed, in
many cases, providers will find it more cost-effective
to join a network than to purchase an automobile
to transport mental health consumers to distant
service providers. However, the single biggest
limitation on the use, expansion, and long term
sustainability of telemental health systems
is often the ongoing telecommunication costs.
The type of telecommunication service(s) available
from telephone companies will dictate network
design and cost. In many rural areas, advanced
transmission technologies or services, such
as Integrated Services Digital Network (ISDN),
are not yet available. Also, transmission charges
are often more expensive in rural areas because
many transmission rates are distance-based.
The more advanced the transmission technology,
the greater the bandwidth a telecommunications
system will have available. Bandwidth refers
to the information-carrying capacity of the
telecommunications channel (i.e., the size of
the pipeline that carries the video and audio
signals). At higher bandwidths, picture and
sound are transmitted more quickly and with
better quality. Lower bandwidth systems are
more affordable, but they create noticeable
lags in video and audio transmission that may
negatively impact the service applications.
Financing Ongoing expenses
often prove to be a barrier to continued operation
of a telemental health network. In response,
many programs form alliances to gain a broader
base of support, and network members share the
costs for equipment, maintenance, personnel,
and transmission systems. Federal, State, and
private funds, and third-party reimbursement
and service contracts, help sustain these vital
efforts.
Meeting the Challenge Telemedicine,
and in particular, telemental health networks,
have the potential to diminish the disparity
of mental health care based on population density
characteristics. However, additional funding
is needed to support research into the effectiveness
of telemental health programs, and to enable
additional areas of the country to benefit from
this new tool for mental health service provision.
|
Introduction
top |
For mental health care providers and consumers
in rural and frontier America, the future is now.
Telecommunication technologies have been used
for some 40 years in limited mental health interventions,
mostly on an experimental basis. Beginning in
the 1990s, however, the use of interactive telecommunications
technologies moved past the demonstration and
experimental phase into routine mental health
service integration. It's not an exaggeration
to say that one mental health treatment specialist
can now be in two or more places at the same time.
Rural Characteristics
Telemedicine, and in particular, telemental
health networks, have the potential to diminish
the disparity of mental health care based on
population density characteristics. Rural and
frontier communities typically are the last
areas to receive advances in mental health care,
such as newer antipsychotic medications or specialized
treatment programs.
Funding of the public mental health care system
is often based on population size, which limits
the amount of money available to develop an
adequate continuum of care in less populated
areas. Further, psychiatrists are usually located
in urban areas, leading to a scarcity of services
for people with serious mental illnesses in
rural communities.
The use of telecommunication technologies to
provide rural mental health services offers
the following benefits:
Extending scarce resources into geographic
areas of service need, Improving existing services,
and Creating new services and applications that
are unique products of the use of this technology.
Today, not only is it possible to access a
mental health care provider located in an urban
center, but within a rural and frontier region,
a telemental health network can unite groups
and organizations that have common goals and
interests. These networks can be used to attract
additional resources from outside the region,
as well as to expand the boundaries of the rural/frontier
mental health care village.
Key Definitions
Many of the key terms used throughout this report
are defined in the Glossary. Several are worth
mentioning at this point. In particular, the
term "telemedicine" refers to the
use of modern telecommunication and information
technologies to deliver health care services
at a distance. "Telepsychiatry" is
the specific application of telemedicine to
psychiatry.
A "telemedicine system or network"
is an integrated health care network that uses
modern telecommunication and information technologies
to provide comprehensive health care services
to a specific group. When the system-wide influence
of these approaches is considered, the term
"telemental health" is used in this
report.
Telemental health has a broader mental health
care systems meaning, and includes non-clinical
applications, such as family and consumer support
meetings, civil commitment hearings, case conferences,
and prevention and education. A telemental health
system uses interactive telecommunication technologies
to integrate, within a region, a comprehensive
array of mental health care services of related
organizations.
National Telemental Health Leaders
The number of telemedicine programs has grown
from only nine in 1993 to over 100 in 1997.
Almost all telemedicine programs provide mental
health services. In 1996, these services accounted
for nearly a quarter of all telemedicine consultations
or sessions conducted.
This report was produced primarily from the
collective experiences of seven of the most
active telemental health projects in the nation.
These projects are:
- The Appal-Link Network of Virginia.
- The Menninger Center for Telepsychiatry
(Kansas).
- The Eastern Montana Telemedicine Network.
- The University of Kansas Medical Center
Telemedicine Services.
- VideoLink of St. Peter's (Montana).
- The Northern Arizona Regional Behavioral
Health Authority.
These seven projects carried out approximately
70% of all of the clinician/patient telemental
health service contacts reported by the 50 most
active telemedicine projects in 1996.
The Summary Report
This summary report explores, in brief, the
applications, accomplishments, and benefits
of telemental health systems, particularly as
they impact service delivery to people with
serious mental illnesses in rural and frontier
areas. The summary addresses:
- The history of telepsychiatry/telemental
health and recent developments.
- Mental health services that are, or could
be, provided with interactive telecommunications.
- Selected client and service system outcomes
of telemental health services.
- Organizational, technological, and financial
considerations involved in establishing a
telemental health system.
Full Text Report
Readers who would like to explore this topic
in more detail are referred to the full report
Telemental Health: Delivering Mental Health
Care at a Distance - A Guide for Rural Communities,
which is available from the Office for the Advancement
of Telehealth, HRSA. (An updated Summary Report
will be available Spring of 2002.)
|
History
and Recent Developments top |
For the past 40 years, telemental health projects
have increased access to needed services for consumers
in rural and remote regions of this country. Though
early telemental health efforts used less advanced
technologies and had limited applications, these
projects paved the way for later advancements
by establishing several important principles.
History
The first documented use of telecommunications
technology to provide health care at a distance
occurred in 1920 at Haukeland Hospital in Norway,
where radio links were established to provide
health care support services to ships at sea.
It wasn't until the 1950s, however, under the
pioneering efforts of Dr. Cecil Wittson and
his staff at the Nebraska Psychiatric Institute
(NPI), that telemedicine was used in the field
of mental health.
The technology used by these early projects
would be considered primitive by today's standards.
The University of Nebraska designed a simple
one-way closed circuit system using small black
and white televisions for lectures and instructional
purposes. More than 1,000 students at the Medical
College of Nebraska received instruction via
this network in the 1954-55 academic year.
The following year, the National Institute
of Mental Health (NIMH) funded an interactive
audio link connecting Nebraska Psychiatric Institute
to seven hospitals in Nebraska, Iowa, and North
and South Dakota. The Institute broadcast its
weekly visiting lecturer series to the rest
of the network and participants could ask questions
to the lecturer in Omaha, allowing audience
interaction with the site of origin for the
first time.
With continued Federal funding, the University
of Nebraska program expanded throughout the
late 1950s and 1960s. Milestones included the
first audio-visual interactive system in 1959,
and the use of microwave technology to open
a link in 1964 with Norfolk State Hospital,
which was 112 miles away. This latter development
meant that picture and sound could originate
from multiple locations at either site. In the
late 1960s, the Nebraska project linked the
Veteran's Administration hospitals in Omaha,
Lincoln, and Grand Island into the existing
network.
In 1968, NIMH funded a project to develop a
closed circuit link using two microwave relay
stations between the Department of Psychiatry
at Dartmouth Medical School and a rural hospital
in Claremont, New Hampshire. The technology
allowed for timely mental health consultation
without moving the patient from his or her home
environment. Also, for the first time highly
trained technicians were not needed. Program
staff, with limited technical training, could
now operate these more "user-friendly"
systems, eliminating the problem of down time
due to technical difficulties.
In 1968, Dr. Thomas Dwyer expanded an existing
telemedicine project at Massachusetts General
Hospital to provide emergency psychiatric consults
to staff at Logan Airport Medical Station in
Boston, some 2.7 miles away. This project used
a bi-directional television transmission system
equipped with remote camera control that allowed
the consulting psychiatrist at the hospital
to pan, zoom, and focus the camera located at
the remote site.
This capability helped psychiatrists observe
physical and emotional nuances without invading
an individiual's personal space (Baer, Cukor
and Coyle, 1997). In particular, doctors reported
that communication with adolescents, children,
and certain patients with schizophrenia was
easier than the conventional face-to-face interview
process. For the first time, the technology
was said to be more effective with these groups
than the established "best practice"
model.
Lessons Learned
Several important lessons emerged from the early
telepsychiatry projects. Most important, consumers
and physicians found the new technology both
useful and comfortable.
Further, these early projects tested some new
applications that were found to be effective,
such as psychiatric evaluations, family member
visitations, and pre-discharge planning.
They also addressed potential roadblocks to
widespread acceptance of telepsychiatry, including:
- Initial hesitancy of staff members to use
the technology;
- Technical problems such as sound pick-up
and camera operations in larger groups;
- The high costs of equipment and transmission
time.
Without continued external funding, however,
these projects could not maintain the high costs
of transmission and network support expenses.
When Federal funding for these projects ended
by the early 1970s, and third-party reimbursement
options were not available, the programs were
forced to close.
Recent Developments
The inauguration of telemedicine's third generation
began in the late 1980s. Renewed Federal funding,
the rapid advancement of telecommunication and
computer technologies, and the introduction
of managed care created opportunities to further
investigate potential applications of this still-emerging
technology. Seven current projects, and their
key components, are outlined below.
Current Projects
Oregon's RODEO NET. The first of these third-generation
projects in the field of mental health was Oregon's
RODEO NET. The Eastern Oregon Human Services
Consortium in La Grande received a three-year
Rural Health Outreach grant in 1991 from the
Federal Office of Rural Health Policy (ORHP),
Health Resources and Services Administration
(HRSA), DHHS. The grant enabled the Consortium
to use a new statewide telecommunications system
(Oregon ED-NET)--which offered the capability
of videoconferencing via satellite and dial-up
access to the Internet--for the delivery of
mental health services, training, and information.
By providing scheduling, protocols, procedures,
evaluation and training, RODEO Net became the
interface for providers to make use of the systems
of the Oregon ED-NET.
Because there are many locations throughout
Oregon with limited telephone transmission technology
and access to the satellite network, RODEO NET
broadened its reach by incorporating a mixture
of satellite, microwave, and POTS (plain old
telephone service)-based technologies. By using
this combination of technologies, RODEO NET
has been able to expand its services, which
include psychiatric consultation, case management,
and medication management, to a larger number
of rural Oregonians.
The
University of Kansas and the Menninger Center
for Telepsychiatry. A
study of rural health care needs at the University
of Kansas Medical Center led to the implementation
in 1992 of a state-wide interactive telemedicine
network providing clinical and educational services
for residents throughout the state of Kansas.
Residents at more than 20 sites throughout Kansas--from
group homes to hospitals and jails--have access
to more than 200 specialists at the Medical
Center.
The Menninger Center for Telepsychiatry in
Topeka provides specialty consultation services
via this interactive network and manages the
adult and child/adolescent units at Providence
Medical Center in Kansas City, Kansas, some
80 miles from the Menninger campus. The Menninger
Center is also involved in distance learning
and continuing education to other psychiatric
and medical facilities across the nation.
The
Eastern Montana Telemedicine Network.
The Eastern Montana Telemedicine Network (EMTN)
began as a cooperative effort among health care
providers to research the potential of using
two-way, interactive video conferencing technology
to provide medical and mental health services
throughout their region. Begun in 1993, EMTN
has continued to expand its 11-site network
providing a variety of clinical, educational,
administrative, and community development services
to the region.
A grant from the U.S. Department of Agriculture's
Rural Electrification Administration (REA),
now the Rural Utilities Service (RUS), funded
the equipment for the original five sites. A
three-year Rural Telemedicine grant in 1994
from the Federal Office of Rural Health Policy,
HRSA allowed EMTN to expand. Telemental health
services are the leading medical application
from a wide array of other specialty areas that
make EMTN one of the more comprehensive networks
in the nation.
Northern Arizona Regional Behavioral Health
Authority. In 1996, the Northern Arizona Regional
Behavioral Health Authority (NARBHA) received
funding from the Arizona Department of Health
Services to develop a telemedicine system to
enhance the delivery of behavioral health services
throughout northern Arizona. NARBHA contracts
with a network of community-based agencies that
provide behavioral health services to adults,
children, families, and people with serious
mental illnesses in a 62,000-square-mile rural
area with a population of 440,000.
The system, NARBHA NET, uses advanced technology
capable of delivering two-way interactive video
and audio, tape recordings, and numerous computer
applications. Twelve video conferencing sites,
including the Arizona State Hospital in Phoenix,
participate, with at least four additional sites
planned.
Video Link of St. Peter's (Montana). In 1994,
the Federal Office of Rural Health Policy awarded
a three-year Rural Health Outreach grant to
St. Peter's Hospital Foundation in Helena, Montana,
to develop an interactive telecommunications
system within the region. VideoLink of St. Peter's
(formerly Southwest Montana Telepsychiatry Network)
serves a 12-county, 28,509-square-mile area
with a population of 190,000. The service area
has a population to psychiatrist ratio of 30,000
to 1.
VideoLink uses two-way, interactive compressed
video technology within the project's six-site
network, which includes Montana State Hospital
in Warm Springs and Montana Developmental Center
in Boulder. Collaboration with other existing
networks has expanded access to 25 communities
in Montana.
The
Appal-Link Network (Virginia).
The Appal-Link Network was created to improve
access to psychiatric care in rural and remote
areas of southwest Virginia. Funded as a three-year
Rural Health Outreach demonstration project
by the Federal Office of Rural Health Policy,
Appal-Link began operations in 1995. Appal-Link
is the first telepsychiatry network in Virginia
and one of only six telemedicine networks in
the nation dedicated exclusively to testing
telecommunications technology to deliver mental
health services at a distance.
Originally, the program served clients of the
Cumberland Mountain Community Services Board
in Cedar Bluff who were hospitalized at the
Southwest Virginia Mental Health Institute in
Marion. Within two years, all of the community
service boards in the Institute's service area
joined the network. The telemental health system
uses compressed video and audio transmission
over high-speed, enhanced telephone lines.
Increased Access to Mental Health Services
Though each telemental health project was developed
to meet the specific needs of its area, they
all were created to address a lack of mental
health services, in general, and psychiatric
care, in particular, to rural areas. Some, such
as the Kansas University Medical Center and
the Eastern Montana Telemedicine Network, offer
a wide range of medical services, with telemental
health being the primary application. Others,
like Video-Link of St. Peter's and Appal-Link,
are dedicated to mental health services and
were developed to reach underserved populations.
A Full Range of Services.
The range of mental health services provided
to rural consumers over a telemental health
network is virtually limitless and includes
all of the same services that can be provided
in-person. These include the following:
- patient evaluations
- case management
- edication management
- crisis response
- pre-admission and pre-discharge planning
- treatment planning
- individual and group therapy
- family therapy
- mental status evaluations
- court commitment hearings
- case conferences
- family visits
- family and consumer support groups
- staff training
- administrative activities
Substantial Benefits
The benefits of telemental health programs
are substantial. Many patients in remote regions,
who are now being seen via a network, would
otherwise have gone unserved, or they would
have had to leave their home communities to
receive care, often at great cost to themselves
or their families.
In addition, telemental health networks provide
continuity of care for rural clients by allowing
the community treatment team to monitor their
progress in the hospital and to be involved
in discharge planning. Also, the same psychiatrist
who treats the patient while hospitalized can
more effectively monitor his or her medication
in the community.
Telemental health networks have enabled family
members to speak with and see their loved ones
who are receiving treatment in distant locations
and to participate in treatment planning. Families
also provide valuable support to one another
over a telemental health network, creating a
"virtual support group."
A Wide Range of Applications
Telemental health networks have enormous potential
to provide a wide range of mental health services,
provider education, and administrative functions.
The next section outlines services that are,
or can be, provided to rural areas using interactive
telecommunications technology. |
Telemental
Health Services top |
Telecommunication technologies have the potential
not only to extend scarce mental health services
into geographic areas of need, but also to improve
existing service delivery and to create programs
and services that meet unique needs. Telemental
health also has broad application as an education
and training tool and as a way to bring special
interest groups together for information and support.
This section highlights a broad array of services
that are, or could be, delivered to rural areas
using modern telecommunication and information
tools. Traditional Mental Health Services
The types of telemental health services most
frequently provided are those that replicate
traditional mental health care. When scarce
mental health care is delivered into remote
areas of need, telemental health is "the
next best thing to being there." In some
situations, telemental health may be superior
to face-to-face contact.
For example, telemental health allows a psychiatrist
to observe a patient close up, without invading
his or her personal space. This makes it easier
to examine a patient for side effects of psychotropic
medications. Also, in clinical interventions
that focus on confronting an individual's destructive
behaviors, or on revealing past abuse, telemental
health creates a comfort zone for some consumers.
There is no mental health service currently
being offered face-to-face that can't be delivered
via telemental health. Some specific examples
follow. However, like traditional mental health
services, telemental health services may not
be effective for every consumer. For example,
a consumer with serious mental illness such
as paranoid delusions focused on electronic
monitoring, will need to be observed closely
for his/her reaction to the use of this new
tool.
Intake and Assessment
Professional staff at distant service locations
can use a telemental health network to take
social histories, conduct mental status examinations,
and determine an individual's eligibility for
ongoing services. The individual need only travel
to a local site connected to the network.
Psychotherapy and Counseling
Rural service sites that do not have local therapists
available can offer individual, marital, family,
and group psychotherapy and counseling over
a telemental health network. This is especially
useful when individuals need a therapist who
serves special needs, such as those of adult
survivors of childhood sexual abuse or Vietnam
veterans.
Crisis Intervention
Telemental health can bring the psychiatric
emergency room to the consumer. A rural mental
health consumer in crisis can be examined by
a distant psychiatrist over a telemental health
network. The psychiatrist can assess the need
for medication changes and inpatient care. Community
mental health staff and family members can participate,
as well.
Medication Management
Telemental health has enormous potential in
the area of medication management. Most notably,
the same psychiatrist who treats an individual
as an inpatient, or initially on an in-person
outpatient basis, can provide long-term follow-up
in the client's home community. The ongoing
psychiatrist/consumer bond, maintained through
telemental health, can eliminate unnecessary
medication changes, reduce the need for readmission,
and shorten the length of inpatient stays. Also,
the treating psychiatrist can monitor a client's
use of a new atypical antipsychotic medication,
thereby ensuring equal access in rural areas
to the most effective treatments.
Finally, telemental health extends the service
range of nurse practitioners, physician assistants,
and psychiatric clinical nurse specialists who
serve rural areas and practice in consultation
with psychiatrists to provide medication review
clinics and manage difficult cases.
Tele-EAP Services
The Eastern Montana Telemedicine Network at
the Deaconess Billings Clinic has contracted
to provide an Employee Assistance Program to
personnel of one of the network's participating
hospitals. Strict policies govern confidentiality
for counseling sessions. Tele-EAP services to
private businesses and industries may be a potential
source of revenue for telemental health networks.
Enhanced Service Delivery
Telemental health applications can also improve
existing service delivery by enhancing continuity
of care for consumers in rural and remote areas.
With telemental health, a "virtual treatment
team" is formed between the community and
inpatient psychiatric facility staffs. Community
and hospital staffs meet more frequently, have
a closer working relationship, and understand
the resources and limitations of each system.
Family members can be involved in every step
of the treatment and discharge planning process.
In addition, such collateral services as vocational
rehabilitation, social services, and health
care can be provided as part of a consumer's
overall case management plan. Community providers
can begin working with consumers even while
they are hospitalized.
Telemental health can also support individuals
living at home and in community residential
programs. Some specific examples follow.
Family Visits
Telemental health removes cost and travel barriers
for rural families. Family members can visit
their loved ones who are hospitalized and make
plans for their return home. These personal
visits take place outside of more formal treatment
and discharge planning conferences.
In-Home Services
The Menninger Center for Telepsychiatry in Kansas
is using low-cost, "plain old telephone
service" (POTS)-based video conferencing
technology to provide medication management
and case management services directly into the
homes of people with serious mental illnesses.
Daily "tele-home visits" help these
individuals remain independent and avoid group
home settings.
Programs of Assertive Community Treatment
(PACT)
The PACT model of intensive, wrap-around community
services for people with serious mental illnesses
is in the forefront of many advanced mental
health service systems. Central State Hospital
in Petersburg, Virginia, and District 19 Community
Services are experimenting with the use of telemental
health to form a PACT team between community
staff and the state psychiatric facility.
Support to Residential Programs/Group
Homes
Individuals leaving state hospitals after many
years may be difficult to place in private residential
facilities. Locating telecommunications technology
in a community home (e.g., a group home) provides
round-the-clock support from staff at the inpatient
facility and training and continuing education
for the community-based staff. Ultimately, this
allows the consumer to remain in the community.
Commitment Hearings
All states have involuntary commitment statutes
that allow them to detain people with serious
mental illnesses believed to be a danger to
themselves or others. In rural areas, this often
means that an individual has to be transported
to a distant psychiatric facility for temporary
detention pending a civil commitment hearing.
The hearing may be held at the facility, or
the patient may be returned to the local community
for the commitment proceedings.
With the use of telemental health, a commitment
hearing can take place over the network. The
judge can either be at the distant facility,
when there is no judge available in the community,
or located in the community when state laws
so require. Community staff, family members,
and other necessary participants are able to
participate in the commitment hearing.
Specialized Services
Specialized services are expensive to provide
in rural areas to small numbers of individuals.
However, using telemental health networks, providers
can more economically offer a wide range of
specialty services, such as forensic status
evaluations, to rural clients. Programs for
special needs include those featured below.
Services for Consumers Who Are Deaf
and Hard-of-Hearing
The Appal-Link Network in Virginia provides
interpreting services and case consultation
to people with serious mental illnesses who
are deaf and hard-of-hearing. Also, community
staff receive training in how to work with these
individuals. Previously, the specialist who
provides these services covered an area of 15,000
square miles in her car.
Psychiatric Services to Rural Nursing
Homes
By some estimates, as many as 70% of nursing
home residents have a psychiatric disorder.
Many of these patients are diagnosed with dementia,
or with dementia concurrent with depression.
By providing specialty psychiatric services
via telemental health systems, the Menninger
Center for Telepsychiatry in Kansas helps nursing
home staff provide early intervention for behavioral
problems, closer medication management, and
continuity of care between inpatient and outpatient
settings.
Services to Individuals with Mental
Retardation
Many states still maintain residential institutions
for long-term care of people with severe and
profound mental retardation. As these facilities
begin to downsize, telemental health systems
can help facility staff, community providers,
and family members plan for an individual's
successful return home.
Substance Abuse Services
A regional substance abuse detoxification and
residential treatment program (The Laurels of
Southwest Virginia) screens potential individuals
for admission over the Appal-Link Network. The
program also uses the network to conduct treatment
and discharge planning conferences, relapse
prevention programs, and civil commitment hearings.
Services to Infants and Children with
Special Needs
In rural and frontier areas, children with developmental
delays and their parents have to travel great
distances to consult with physical and occupational
therapists, neurologists, and pediatricians.
Telemedicine networks enable these services
to be delivered to network sites closer to a
family's home community. Programs in Texas,
Georgia and Missouri are currently providing
services using such networks. Also, when a child
has to be hospitalized away from home, parents
can visit by using a portable, video-conferencing
system in the child's hospital room.
School-Based Telemental Health
Two telemedicine programs -- East Carolina University
and the University of Kentucky -- have established
rural school-based telehealth programs, and
the University of Kansas Medical Center has
established an inner-city school-based telehealth
program. These programs enable children in medically
underserved areas to access health and mental
health services from the school nurse's office.
In Kansas, Kansas Medicaid and Blue Cross/Blue
Shield reimburse for services provided in the
Tele-Kidcare program.
Education, Prevention, and Training
In addition to traditional and specialized mental
health services, telemental health has broad
application in the areas of education, prevention,
and staff training. For example:
Education and prevention programs on such topics
as fetal alcohol syndrome, AIDS awareness, or
parenting can be presented by an educator at
a central location to one or more sites in the
network. Interactive technology allows the audience
to participate in the program.
Graduate and specialized training courses,
and continuing education programs, can be provided
by distant universities or large medical centers.
Often, universities are willing to pay the network
usage expense in order to broaden their student
market. In Montana, VideoLink of St. Peters
provided a psychiatric nursing continuing education
program to over 100 participants at 13 different
sites simultaneously.
Professionals preparing for state certification
or licensure can be supervised by a distant
clinician. The Eastern Montana Telemedicine
Network provides supervision of Ph.D. candidates
over the network. At the University of North
Carolina, social work students living in distant
rural communities receive field placement supervision.
Group Meetings and Support
Finally, in areas of the nation where population
centers are separated by great distances and
travel may be difficult, telemental health networks
allow health and consumer interest groups to
participate in regional and statewide planning
meetings. For example, the Montana State Mental
Health Association and the Montana Chapter of
the National Alliance for the Mentally Ill hold
their meetings via this technology.
Within the Appal-Link Network, 15 support groups
have formed for individuals who have a family
member with a mental illness. Some of the groups
may have only a few members, but telecommunications
technology allows them to form a larger "virtual"
group for mutual education, advocacy, and support.
In the same way, consumer groups can become
part of a larger, common interest community
that eliminates geographic barriers.
Evaluating Outcomes
Consumers, providers, and family members all
stand to benefit from the use of telecommunications
technology to provide needed mental health services
in rural areas. The next section examines some
client and service system outcomes of this new
and promising approach.
|
Selected
System and Client Outcomes top |
This section highlights some of the key literature
on telemental health outcomes, as well as surveys
and reports compiled by the seven projects profiled
in this summary. Most of these reports are from
staff and consumers who are participating in the
telemental health projects. The literature, although
limited, addresses organizational changes, cost/benefit
analyses, and changes in mental health service
use as a result of telecommunications technology.
System Outcomes
Staff Relationships
The integration of interactive telecommunication
technology into a mental health care system
changes established roles and relationship styles
among psychiatric hospital staff, community
providers, consumers, and family members. These
changes are common to most telemental health
projects.
In most public mental health systems, professional
working relationships between community providers
and hospital staff are courteous but superficial,
and in some cases strained. Often, neither sector
is aware of the other's resources, strengths,
and limitations, which leads to duplication
of effort, confusion for the consumer and gaps
in care.
Telemental health brings staffs closer together.
When hospital and community staffs work as colleagues
over the network, they become more supportive
of one another and more familiar with each other's
roles. They are more willing and able to cooperate
not only for the success of the telemental health
network, but ultimately for the success of individual
consumers. Improvements in the mental health
service system, and in consumer outcomes, are
likely to result.
Continuity of Care
Telemental health networks have clearly demonstrated
improvements in continuity of care. Consumers
have been followed by the same psychiatrist
for more than three years in some projects.
Hospital and community providers, as well as
family members, are connected in an ongoing,
coordinated treatment approach. Some specific
examples follow.
Follow-Up Care
More than two thirds of nursing home
patients have psychiatric disorders, particularly
dementia, and admission to inpatient facilities
is common. The Menninger Center for Telepsychiatry
in Kansas is exploring the use of telepsychiatry
to provide the follow-up care rural nursing
home residents need following discharge from
Menninger Center. Preliminary results are promising.
The same psychiatrist who cares for the patient
in the hospital provides follow-up care in the
nursing home via telepsychiatry. Follow-up visits,
which may have been few and far between because
of the distance involved, are now conducted
as needed.
Also, the psychiatrist gets a more accurate
picture of the patient's psychiatric condition,
which can be negatively affected by the stress
of travel between the nursing home and the hospital.
Though no formal outcome studies have been done,
nursing home staff and psychiatrists believe
that telemental health has increased their patients'
stability.
Continuity of Service
In rural Virginia, people with serious mental
illnesses see general practitioners in the community
and facility-based psychiatrists in the hospital.
The Appal-Link Network has bridged this fragmented
system of care.
More than 400 people with serious mental illnesses
who were treated at the Southwestern Virginia
Mental Health Institute have maintained contact
with hospital psychiatrists over the network.
Consumers involved in the telepsychiatry clinic
show improved self-esteem, resulting in greater
motivation to participate in treatment. They
are more likely to keep appointments and take
prescribed medication as a result.
Conversely, there are circumstances in which
the locus of care is more effective if it remains
with the community-based psychiatrist. The telemental
health network can work "in reverse"
to allow community practitioners to maintain
involvement with clients who need to be hospitalized.
Increased Family and Consumer Involvement
Many families living in frontier and rural communities
do not have the ability to travel to visit loved
ones hospitalized hundreds of miles away. Telemental
health services increase the likelihood that
individuals will have their family's support
during inpatient stays, and that family members
will be included in commitment hearings, development
of a treatment plan, and discharge planning.
Ongoing Support for Consumers and Families.
Consumer and family groups, including local
chapters of the National Alliance for the Mentally
Ill and the National Mental Health Association,
use telemental health services to support one
another and to reach out to patients. For example,
some consumer groups have used the Appal-Link
Network to provide community outreach to hospitalized
patients detained on forensic status.
In addition, with a grant from the Southwest
Virginia Mental Health Board, the Appal-Link
Network connects 15 family support groups in
rural Appalachian communities. Family groups
from two or more locations hold interactive
support group meetings. Seventy-one percent
of group members surveyed believe the support
they received helped them keep their loved ones
out of the hospital.
Client Outcomes
More research needs to be done in the area of
client outcomes as a result of telemental health
services. However, some earlier studies and
current observations indicate that interactive
telecommunication technologies can be a reliable
assessment tool, have a positive impact on service
use, and are well accepted by both consumers
and providers.
Validity of Assessment Tools
Two efforts to empirically validate the use
of telemental health systems found that these
technologies can be reliably used to administer
certain psychiatric assessment tools. These
studies are reported in the chapter titled "Telepsychiatry:
Application of Telemedicine to Psychiatry"
by Baer, Cukor and Coyle (1997).
In one of these studies, English investigators
administering the Mini-Mental Status Exam to
11 psychiatric patients found a correlation
of .89 between video-based and face-to-face
conditions. This result was identical to the
test-retest reliability for the instrument in
the original normative sample.
In the second study, the chapter's authors
tested the reliability of two raters in both
video-conferencing and live interview sessions
(Baer, Cukor, Jenike, Leahy, O'Laughlen and
Coyle, 1995). Twenty-six patients with obsessive-compulsive
disorder were divided into two groups: 16 participated
in face-to-face interviews and 10 took part
in video-mediated interviews. Investigators
found near perfect reliability in the video
sessions on three scales -- the Yale-Brown Obsessive-Compulsive
Scale, the Hamilton Depression Scale, and the
Hamilton Anxiety Scale.
Reliability as a Function of Bandwidth.
An important study of video assessment reliability
conducted in the mid-1990s by Zarate addressed
two major research questions: whether video
assessments of patients with schizophrenia are
comparable to live assessments, and whether
video quality effects the ability to assess
subtle negative symptoms.
Forty-five individuals with schizophrenia were
divided into three groups. Fifteen were used
to establish reliability for the Brief Psychiatric
Rating Scale (BPRS), the Scale for the Assessment
of Positive Symptoms (SAPS), and the Scale for
the Assessment of Negative Symptoms (SANS).
Fifteen individuals were tested at the two different
transmission bandwidths. [Bandwidth refers to
the size of the pipeline that carries the video
and audio signals and at higher bandwidths,
picture and sound are transmitted more quickly
and with better quality.]
Results of Zarate's study established equal
reliability for global severity of schizophrenia
and a summary score of positive symptoms among
the three assessment methods: in-person, remote
128 kbps video, and remote 384 kbps video. Because
positive symptoms of schizophrenia are more
tied to verbal cues, they can be more reliably
assessed at the slower speeds. However, at the
lower bandwidth, negative symptoms of schizophrenia
were more difficult to assess.
In a similar vein, an unpublished 1997 study
by the Southeastern Rural Mental Health Research
Center and the Appal-Link Network addressed
reliability of psychiatric assessments at different
bandwidths. A high visual dependency measure,
the Abnormal Involuntary Movement Scale (AIMS),
and a low visual dependency measure, the Brief
Symptom Inventory (BSI), were administered to
84 people with serious mental illness, both
in-person and using video conferencing. Videoconferencing
was done using three different transmission
rates (112 kbps, 384 kbps, and 762 kbps).
Results indicate high reliability for the low
visual dependency test (BSI) at all transmission
rates, but greater reliability for the high
visual dependency assessment (AIMS) at higher
transmission rates. In fact, the AIMS assessment
was actually most reliable when conducted at
a distance using the highest bandwidth. That
is, it was more reliable when conducted using
video-conferencing at 762 kbps than when conducted
in-person. This may be explained by the fact
that facial and tongue movements can be examined
more closely over the video system without violating
social space.
Service Use Patterns
Changes in service use by consumers using telemental
health care can be measured by frequency of
services, types of services received, and the
quality or clinical value of these telemental
health services as compared to traditional face-to-face
services. Though little rigorous research has
been done, there are some emerging studies in
this area.
VideoLink of St. Peter's in southwest Montana
attempted to determine whether telemental health
services such as family visits and discharge
planning, provided while the individual was
hospitalized, reduced lengths of stay at the
state psychiatric hospital. Fifteen psychiatric
patients with a history of multiple inpatient
admissions who participated in interactive sessions
were matched with a comparison group of 30 individuals
of similar ages, sex, diagnoses, and number
of admissions.
The mean length of stay for the telemental
health group was shorter than that of the comparison
group (58 days compared to 74 days). Though
the results were not statistically significant,
in part because the experimental group was too
small, investigators feel this question warrants
further research.
In 1996, the Appal-Link Network of southwest
Virginia conducted a retrospective records review
of 54 cases to compare service use six months
prior to participation in telemental health
services to service use during the six months
after participation. Results indicate that telemental
health clients have more frequent and lengthier
contacts with their psychiatrist, which leads
to greater stability and medication compliance.
Reviewers looked for possible service changes
in five areas: psychosocial rehabilitation,
outpatient therapy, case management, medication
management, and medication compliance. Psychosocial
rehabilitation, outpatient therapy, and case
management were all provided face-to-face in
the community, while medication management was
offered via the network.
Reviewers found a significant increase in the
frequency of medication management sessions
and a corresponding decrease in face-to-face
case management contacts. Consumers took part
in fewer than two medication consultations,
on average, in the six months prior to using
the Appal-Link Network. In the six months after
they began using the network, the mean number
of medication consultations rose to 7.5.
A separate analysis revealed that the average
length of the tele-medication review session
is 24 minutes, with a range of 12 to 45 minutes.
This compares to 15-to-20-minute sessions conducted
face-to-face. Investigators speculate that the
hospital-based psychiatrists, who have worked
with consumers as in-patients, develop a closer
therapeutic relationship that carries over into
the telemental health setting. In addition,
a hospital-based psychiatrist using video-conferencing
may have a smaller number of patients to see
than does a traveling community psychiatrist,
and is therefore able to participate in lengthier
sessions.
Consumer and Provider Satisfaction
There are many reports in the literature of
surveys assessing consumer and provider satisfaction
with interactive telecommunications approaches.
Though such surveys are often seen as questionable
research instruments, it is worthwhile to note
that every telemental health participant satisfaction
survey available reports that consumers perceive
these services as beneficial, of high quality,
and worth continuing. There appears to be a
universally high level of acceptance by both
providers and consumers.
For example, VideoLink of St. Peter's asked
878 consumers to rate the project on a scale
of 1 to 5, with 5 indicating complete satisfaction.
Survey participants gave the system a 4.5 rating
for successfully meeting their individual service
needs. They rated overall satisfaction of the
technology at 4.3.
A sample of 81 consumer satisfaction surveys
completed by individuals who use the Appal-Link
Network for medication review sessions reveals
that all consumers report being "very satisfied"
with the service.
The Northern Arizona Regional Behavioral Health
Authority (NARBHA) also has conducted client,
staff, and family satisfaction surveys, as well
as a cost/benefit analysis of the technology.
Some of the results are shown below in Table
1:
Table 1: Satisfaction with the NARBHA
Net Program Percent of clients who: (n=284)
Percent
of clients who: (n=284) |
92% |
Believed
the treatment they received via the network
was as good or better than face-to-face
contact |
70% |
88% |
Believed
they would not have received services
without the system |
76% |
Were comfortable
with the technology |
91% |
49% |
Believed
the equipment saved time |
83% |
Compared
to projected staff time and travel costs
for the second quarter of 1997 |
$14,324 |
Future Research Needs
A growing number of studies and reports validate
the usefulness of interactive telecommunication
technologies as an important mental health service
tool. However, funding is needed to support
rigorous research studies.
Some of the questions worth examining include
the effect of telemental health services on
the average length of inpatient stays, recidivism
rates, and length of time in the community between
hospitalizations. Though it is clear that consumers
are satisfied with this service, research needs
to examine what difference telemental health
makes in their lives.
Fitting the Pieces Together
Establishing an effective telemental health
system requires an understanding of clinical
and organizational factors, the technology and
costs involved, and how staff are likely to
respond. These issues are explored in the final
section. |
Establishing
a Telemental Health System top |
The usefulness of telecommunications technology
to enhance a mental health care system is in direct
relationship to the extent that it is integrated
as another tool within the array of service approaches.
Ideally, the goal of an effective telemental health
network is to have a transparent vehicle--the
technology--to carry out the established mental
health services mission. This section explores
personnel considerations, organizational and clinical
characteristics, technology needs, and financing
strategies for establishing a successful telemental
health care program. Personnel Considerations
The introduction of telemedicine into a rural
mental health care program requires leadership,
vision, and authority. Though most mental health
professionals already know everything necessary
to use telemental health effectively--including
the use of television, computer, and telephone
technologies--there may be some initial resistance
on the part of staff.
In particular, some staff may be anxious about
being "on television." Also, because
broadcast television is a passive medium, the
interactive nature of telecommunications technology
may be unfamiliar and uncomfortable at the outset.
Allowing staff, consumers, and family members
time to experiment with the new technology increases
their level of comfort with seeing their image
on the screen and participating in a two-way
dialogue.
Other staff may fear either increased workloads
or staff reductions as a result of the new technology.
Their fears can be allayed with the knowledge
that this is a new tool to provide established
services, not a new field of practice. The equipment
enhances staff effectiveness, but it does not
replace the need for their involvement.
Fear of outsiders may cause some rural providers
to resist, initially, formation of a telemental
health network. In particular, they may be apprehensive
that the consulting specialists at a large hospital
or medical center may be critical of their work,
training, and lack of resources. Preliminary
face-to-face meetings between local providers
and the distant consultants can be used to establish
protocols and develop working relationships.
In general, rural providers respond to the fact
that telecommunication technologies can help
them support people with serious mental illnesses
in their home communities.
Programs that initiate a telemental health
network need telehealth proponents in key positions,
including technical, service, and administrative
staff. Support from the highest levels in the
organization is critical. The level of success
of remote sites is a direct reflection of the
degree of leadership and enthusiasm of the person
responsible for that site's inclusion in the
network.
Organizational and Clinical Characteristics
The Start-Up Phase
Successful telemental health networks have strong
organizational characteristics. In many ways
the development of the network is like starting
a small business, with the same types of issues
involved.
Leadership Consortium. To
be successful at this venture, there must be
some ongoing, collective group process that
oversees the development, management, and growth
of the network. For example, many projects establish
a consortium, comprised of decision-making personnel
from member sites, which meets on a regular
basis.
The consortium addresses network management
issues, funding, public relations and marketing,
service applications, time usage, scheduling
conflicts, staff assignments, and troubleshooting
of technical or human resource problems. In
addition, it monitors the progress of new sites
that join the network.
Staff Work Group. A second
type of ongoing work group consists of front-line
service staff who meet to share practical knowledge
and suggestions. In some telemental health networks,
this group stimulates development of service
applications.
For example, at the Appal-Link Network in southwest
Virginia, staff involved in discharge planning
meet to discuss scheduling, telepsychiatry clinic
referrals, and network usage. This group also
trains staff at new sites as they join the network.
Joint Meetings. The consortium
and the service groups can hold their meetings
over the network. However, for large networks
with numerous sites, a so-called "bridged
meeting" over the network may be very expensive
if every site is included in the teleconference.
It may be more economical in some networks,
where distances are not too great, for staff
to travel to two or three sites that rotate
holding the teleconferences.
Schedule Coordinator. A successful
telemental health network needs one person responsible
for scheduling all activities across the network.
Many telemental health programs are part of
a larger telemedicine project where medical
applications compete with each other, and with
remote telemental health sites, for network
access. Even within a dedicated mental health
network, multiple sites pose scheduling difficulties.
Scheduling software programs are now available,
some which allow the coordinator to manage a
single calendar to which each site has access.
Identifying Consumers
Before the telepsychiatry clinic begins services,
the network consortium should identify the specific
target population(s). Typically, telemental
health services are focused on groups that have
no access, or restricted access, to traditional
mental health services or for whom travel to
such services is difficult, including children,
adults with serious mental illnesses, and elderly
individuals.
Some programs restrict services to individuals
who are known to them. For example, only consumers
who have been treated at the Southwest Virginia
Mental Health Institute are followed in the
Appal-Link Network's telepsychiatry clinic,
and crisis intervention services are restricted
to established telepsychiatry consumers. Other
networks, such as the Northern Arizona Regional
Behavioral Health Authority, work with consumers
who may never be seen in person.
The consortium should also develop referral
criteria and train staff at all sites to make
appropriate admissions to the clinic. These
guidelines should be consolidated within the
network's telepsychiatry clinic protocol.
System Design
In most telemental health projects, the system
design resembles a hub-and-spoke model, often
with a regional medical center or state psychiatric
hospital serving as the hub and community-based
programs as the system's spokes. Much of the
information is transmitted from the central
site or hub to the community providers. In some
projects, spoke sites are also able to directly
connect to each other. There is a developing
trend toward free-standing sites, capable of
connecting to any site within a network or alliance
of networks.
Staffing Issues
In addition to the psychiatrist at the hub site,
telepsychiatry clinic sessions typically include,
at the spoke site, a community mental health
staff member who provides case management, information,
and support. For example, at the Appal-Link
Network, a registered nurse is always present
with the consumer to arrange medication orders
and to provide vital signs, if warranted. In
addition to the nurse, a case manager or mental
health therapist may attend the session as needed.
This is the same arrangement as traditional
face-to-face care.
Although it is technically possible for the
psychiatrist to conduct the session with no
staff support at the community site, this is
not desirable for several reasons. Unpredictable
consumer reactions place the equipment at risk.
Unknown stresses, which may be revealed during
the session, place the consumer at risk. Equipment
or transmission failures, though infrequent,
can leave the consumer literally cut off from
support and in a high state of anxiety. The
presence of the community staff provides emotional
support to the consumer and essential treatment
information.
Informed Consent and Confidentiality
An informed consent process provides information
to the potential consumer, and explains the
limitations and alternatives to the telepsychiatry
service. If the consumer is opposed to the telepsychiatry
service, he or she should be offered optional
services, even though these may be less accessible.
A consumer satisfaction survey form, to be completed
after each session, should also be reviewed
with the consumer.
Consumers who are inpatients can be introduced
to the technology before they are discharged.
This allows them to gain a level of comfort
with the technology and to meet community staff
who will be part of their treatment team after
discharge.
Resolving Confidentiality Concerns.
Depending upon the type of video-conferencing
transmission technology used, a video-conference
may be more private and secure than a telephone
call. For example, the coding and compression
of analog signals by a codec for transmission
as digital data adds a measure of security,
as does the use of transmission technologies
such as ISDN. Encrypting the signals provides
the highest level of security.
To protect confidentiality within a telepsychiatry
clinic, rooms should be soundproofed and doors
kept closed. Windows, which can expose service
participants, should be covered. The audio on
the monitor should be adjusted so that speakers
at the distant site cannot be heard outside
the room. These needs are no different than
a face-to-face session.
One area of possible concern is at the "bridge
service," which connects multiple meeting
sites, typically for administration and training
sessions. Some networks may purchase this service
from a national telephone company or a contracted
systems integrator. The company providing the
bridge service can see and record all activity
on the network. Providers can require the company
that provides the bridge service to sign a written
agreement demonstrating their efforts to protect
confidentiality.
Network Structure and Alliances
Initially, most telemedicine and telemental
health networks have been stand-alone networks,
and configured in a hub-and-spoke design. Other
networks have been designed to enable connections
to a variety of sites within the network, with
no one particular site serving as the primary
service provider or hub. At some point however,
most telemedicine and telemental health networks
encounter situations in which they want to connect
to specialized providers not in their respective
network. When compatibility of equipment and
transmission systems permit, these needs can
be met by entering into agreements with other
established networks or telemedicine sites.
An example of progressive networking, whereby
various independent networks collaborate to
enhance access to services in a broad region,
is the Montana Healthcare Telecommunications
Alliance. Members include VideoLink of St. Peter's,
the Eastern Montana Telemedicine Network, and
METNET, the state's educational network. Currently,
28 communities in Montana are able to connect
with one another to support the delivery of
mental health care statewide.
Given the high costs of sustaining networks,
projects generally seek innovative ways to remain
viable, such as forming agreements or alliances
to share scarce resources, extend service boundaries,
and reduce costs. Some telemental health projects
have found that sharing their telecommunications
network with the general medical, educational,
human services, and business communities helps
sustain the network by creating a broad base
of support. This concept has been referred to
as creating a "televillage."
Technology Needs
There are as many possible variations of video-conferencing
equipment and transmission systems as there
are telemental health applications. Telemental
health technologies vary based on available
resources and technical expertise, as well as
on the services to be provided. Some general
considerations for all telemental health projects
are highlighted below.
The Concept of Presence
The concept of "presence"--the illusion
that a mediated experience is real--is at the
heart of an interactive telecommunications exchange.
Unlike earlier one-way, closed-circuit systems,
two-way interaction enhances the concept of
presence, making participants feel they are
experiencing an in-person encounter. The degree
of presence required for a particular service
or interaction will help determine the type
of equipment and transmission service a program
needs.
For example, lower bandwidth systems create
noticeable lags in video and audio transmission,
causing jerky or blurred video and poor audio
which may make participants feel disconnected
from one another. However, lower bandwidth systems
may still produce an acceptable level of presence
for simple conversations between two individuals,
particularly when the participants limit their
movements.
Higher bandwidth systems, which create a greater
degree of presence by responding in "real
time" to participants' input, are better
suited to applications that include motion or
that require close and accurate observation
of neurological indicators or subtle changes
in affect. Assessing an involuntary movement
disorder, for example, requires a higher bandwidth
system.
Telecommunications Equipment
Equipment used by telemental health projects
varies from inexpensive, low bandwidth desktop
systems to large boardroom setups that feature
dual monitors. Boardroom systems allow a group
of participants to comfortably see and be seen
in an interactive meeting.
The cost of these systems also varies from
less than $2,000 at the low end to nearly $50,000
at the high end. However, equipment prices have
been declining, making it possible to purchase
a large monitor desktop system, capable of transmitting
at 384 kbps, for about $8000-$10,000.
Indeed, in many cases, a mental health service
provider may find it more cost-effective to
join a telemental health network than to purchase
an automobile to transport mental health consumers
to distant service providers. However, like
an automobile, telemental health costs go beyond
the initial purchase price. By far, the single
biggest limitation on the use and expansion
of telemental health is the transmission costs
(see below).
Transmission: Being in Two Places at
Once
Telecommunications signals are transmitted using
a variety of tranmission technologies, including
telephone lines (both POTS and fiber optic),
microwave, cable and wireless. The type of transmission
service available from telephone, cable and
cellular phone companies will dictate the network
design and cost. The advances in transmission
technologies have made the current growth in
telemental health networks possible.
More advanced transmission technologies typically
have greater bandwidth available and are able
to transmit digital signals. For example, an
Integrated Services Digital Network (ISDN) is
an advanced telephone line-based transmission
system that, because it is digital, allows voice,
data, and video to be sent over the same line
simultaneously. An ISDN circuit is 128 kbps
(referred to as a Basic Rate Interface). The
greater the number of ISDN circuits available,
the higher the bandwidth. ISDN service at 1.544
Mbps is referred to as a Primary Rate Interface
(PRI).
A T-1 telephone line circuit carries 24 64-kbps
channels [23 for audio, video and data; 1 for
signaling and 8kbps for framing] for a total
of 1,544 kbps (1.544 Mbps). Generally, high-end
boardroom systems are capable of transmitting
at a full T-1 bandwidth. A T-1 circuit can either
be dedicated, i.e., fixed between two points
for full-time operation, or provided as a dial-up
service. Although many of the current telemedicine
systems in the United States are capable of
transmitting at T-1 rates, many transmit at
less than a full T-1 (e.g., at 384kbps) for
telemedicine sessions.
In many rural areas, advanced transmission
technologies such as ISDN services are not yet
available. Also, long-distance telephone rates
and network transmission charges vary greatly
across the country and are frequently more expensive
in rural, less populated areas.
Transmission Costs. There
are three types of ongoing costs associated
with network transmission: the monthly cost
of long-distance service access, the varying
cost of long-distance service usage, and the
cost of bridging service.
For ISDN, monthly access costs can range from
$30 per ISDN circuit to as much as $100 per
circuit. With ISDN, networks must also pay usage
charges, which are typically based on distance
and the type of connection. For example, at
384 kbps, rates can vary from $35 to $60 per
hour.
For a dedicated long-distance T-1 line, costs
can range from $400 to $8,000 a month. However,
with this type of service, there is often no
usage charge.
Bridging service is necessary to connect three
or more sites in a multi-site meeting. Bridging
services can be obtained from long-distance
telephone companies and private providers, with
costs ranging from $45 to $60 per hour per site
connected.
Some networks with frequent needs for multi-site
conferences choose to purchase their own bridge.
However, equipment costs range from $50,000
to $100,000, and staff are required to operate
the bridge service during meetings. Networks
with only a few monthly multi-site meetings
are better off purchasing bridging services.
Bandwidth: More or Less
In telemental health debates, the question frequently
arises as to whether it is better to provide
services at a lower bandwidth, which some may
consider "poorer quality" telemental
health care, or to offer no care at all. The
advantage of low bandwidth systems is that they
can be installed in areas of low technology
at affordable cost, thereby providing much needed
care to people who had no previous access to
services.
Most current telemental health projects have
resolved the dilemma of low cost/lower quality
versus high cost/higher quality by compromising
at a bandwideth mid-point of 384 kbps. In a
1997 survey conducted by the Association of
Telemedicine Service Providers, 384 kbps or
higher was the bandwidth used for mental health
specialties at 11 of 15 projects surveyed.
Interestingly, participants tend to notice
a difference in quality between 128 kbps and
384 kbps, but there is a less noticeable difference
in quality between 384 kbps and 762 kbps. The
cost difference between these three transmission
rates is significant, however.
Also, because participants first exposed to
video-conferences are used to the full motion
transmission of broadcast television, they tend
to complain about the poor image quality, even
if the transmission is at a moderately high
bandwidth of 384 kbps or more. However, continued
exposure to video-conferences at any consistent
bandwidth tends to train the "mind's eye"
to be less aware of distractions.
Technical Support
Most mental health service organizations have
little technical experience with the equipment
and transmission systems needed to maintain
an interactive telecommunications network. Larger
medical centers and university-based projects
may have staff support to integrate the technology,
but smaller rural organizations will need to
go outside their agency for equipment and system
integration support.
Often, the equipment manufacturer can provide
ongoing support; this may be part of the first
year's warranty on the equipment. For example,
the Appal-Link Network contracts with a "Help
Desk" service, provided by a telecommunications
systems integrator. The service permits staff
from any site to receive immediate technical
support. Most importantly, the system integrator
can troubleshoot network transmission difficulties.
Most often, failure of the network is a telephone
company transmission problem rather than an
equipment failure.
Beyond the first year, extended warranties
can be expensive. To help reduce these costs,
the Eastern Montana Telemedicine Network paid
a one-time fee to the equipment manufacturer
to train a staff member as a "certified
technician." This individual provides technical
support for all network sites.
Also, rather than a full-service extended warranty,
some networks choose a lower cost "parts
replacement, fix it yourself" option. The
system integrator for the Appal-Link Network
helps network technical staff repair hardware
and fix software problems. The Help Desk can
dial into the malfunctioning system to troubleshoot
problems at a distance.
Financing Strategies
As with the early telemental health efforts
described in Section I, ongoing costs continue
to be a problem for the current projects profiled
in this report. In response to their concerns,
a number of projects have developed some innovative
funding strategies.
Sharing Resources
The greater the number of users a telemental
health system has, the more financially viable
it will be. However, less populated areas have
fewer potential providers and consumers. In
these areas, telemental health networks can
increase usage and realize economies of scale
by creating alliances that broaden the base
of participating organizations and applications.
Sharing network expenses is another common
way to sustain a telemental health network.
Network members have greater purchasing power
when they share costs for equipment, maintenance,
personnel, and network transmission. Transmission
expenses for monthly recurring access, usage,
and bridging service can be prorated based on
each site's monthly activity. Even smaller agencies
with infrequent needs may be willing to share
in the network's operating expenses to obtain
needed services.
Federal and State Support
Federal and State funds have been critical in
initiating telemental health networks and State
funds have been critical in sustaining them.
Almost all telemental health networks were developed
with Federal grant funding. Between 1994 and
1997, a total of 191 telemedicine projects received
$110.5 million from seven agencies. Three of
these--the Office of Rural Health Policy, HRSA,
DHHS, the National Library of Medicine, NIH,
DHHS, and the Rural Utilities Service, USDA--provided
$70 million to 163 projects, many of which included
mental health services as a primary application.
A new telecommunications subsidy program, the
Universal Service Program for Rural Health Providers,
will be critical to sustaining telemental health
networks. Under the Telecommunications Act of
1996, Universal Service telecommunication provisions
were extended to include advanced telecommunication
services, and special provisions were made for
public and non-profit rural health providers.
Under these latter provisions, public and non-profit
rural health providers are eligible for subsidized
telecommunication services up to 1.544 Mbps.
The subsidy or discount a rural provider receives
is the difference between what it must pay for
a telecommunication service and the cost of
the service in the nearest urban areas.
Once a network has been established and demonstrates
successful outcomes and benefits, state departments
of mental health may be willing to help support
and expand the telemental health network. In
addition, special taxes or awards from state
lotteries or other programs may be available.
For example, the Northern Arizona Regional Behavioral
Health Authority's (NARBHA) telepsychiatry project
is funded in large part through an allocation
of state tobacco tax revenues. Other telemedicine
projects, such as in Georgia, were funded by
a return of telephone company overcharges.
Third-Party Payments
In some states, such as Montana, Virginia, and
Kansas, Medicaid reimburses for telepsychiatry
services. This may be a significant source of
revenue depending on the number of Medicaid
consumers served and the specific types of services
covered.
Managed care systems also provide opportunities
for coverage of services or third-party payments.
For example, in the mid-1990s, RODEO NET of
Oregon entered into contracts with Greater Oregon
Behavioral Health, Inc. (GOBHI), a private,
nonprofit managed behavioral health care organization,
and with the Eastern Oregon Human Services Consortium.
Under these arrangements, mental health providers
may pay for services rendered to GOBHI or consortium
clients via the network from the previously
established capitation rate. Both GOBHI and
the consortium pay for the transmission costs
associated with the delivery of these services.
Network costs associated with service provision
are also part of the negotiated capitation rate
for NARBHA NET providers.
Combined Funding Sources
Telemental health projects often must rely on
multiple funding streams. For example, multi-source
funding has allowed the Eastern Montana Telemedicine
Network (EMTN) to plan for organized growth.
In addition to two Federal grants, a private
foundation funded the site that serves as the
project hub. By working collaboratively with
third-party payers in Montana, EMTN was one
of the first telemedicine networks in the nation
to receive reimbursement from both public and
private payers.
Meeting the Challenges
The challenges, and the rewards, of establishing
a telemental health system are great. When rural
health care providers come together--sharing
ideas, resources, and needs--consumers reap
significant benefits. Some of the key points
discussed throughout this report are highlighted
in the conclusion. |
Conclusion
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The future of mental health care is now in rural
and frontier America. Interactive telecommunication
technologies make it possible for mental health
providers to literally be in two places at once,
extending scarce resources to individuals, and
to entire regions, that are medically underserved.
Without these technologies, mental health consumers
in rural communities would have to leave home
to receive care, or they might not receive services
at all.
The range of mental health services provided
to rural consumers over a telemental health
network is virtually limitless and includes
all of the same services that can be provided
in person. Telemental health also has broad
application as an education and training tool
for mental health staff, and as a way to bring
special interest groups, including consumers
and family members, together for information
and support.
Though no rigorous outcome studies have been
done to date, practitioner experience and findings
from program evaluations suggest that telemental
health improves continuity of care for rural
consumers, increases family and consumer involvement
in treatment, and reduces lengths of stays and
re-admission rates to state psychiatric facilities.
Participant satisfaction surveys reveal that
consumers perceive telemental health services
as worthwhile, of high quality, and worth continuing.
Initial start-up costs of a telemental health
network are becoming within reach of more programs,
but ongoing expenses, such as telecommunication
costs, often prove to be a barrier to long-term
network sustainability. To enhance sustainability,
programs form alliances to gain a broader base
of support, and network members share the costs
for equipment, maintenance, personnel, and transmission
systems. Federal, State, and private funds,
and third-party reimbursement and mental health
service contracts, help sustain these vital
efforts.
Telemedicine, and in particular, telemental
health networks, have the potential to diminish
the disparity of mental health care based on
population density characteristics. Sound telehealth
policies are needed at the Federal, State, and
local level to foster the deployment of these
technologies and ensure the quality of care
provided using them. In addition, more funding
is needed to support research into the effectiveness
of telemental health programs and to enable
underserved areas of the country to benefit
from this new tool for mental health service
provision.
FULL REPORT: The full text of the report from
which this summary is drawn - Telemental Health:
Delivering Mental Health Care at a Distance
- A Guide for Rural Communities, includes additional
details and examples from the seven participating
telemental health projects. It is available
from the Center for Mental Health Services,
SAMHSA and the Office for the Advancement of
Telehealth, HRSA. |
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