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Author: Shelby Robbins
Date: July 6, 2022

A guide to behavioral telehealth in rural communities

Contents

Behavioral telehealth is transforming the way rural communities navigate mental healthcare challenges. There are many immediate benefits of telehealth that result in expanding access and improving the quality of care.

How telehealth improves access to care in rural communities

Telehealth allows small rural hospitals and clinics to provide quality healthcare services locally and at lower costs, which benefits rural patients since they are no longer required to travel long distances to access specialty care. Avoiding patient transfers is critical for both small hospitals and provider viability in rural areas. It also helps tertiary care centers keep beds open for patients in need of critical care.

Using telehealth to provide specialty services is more feasible for rural healthcare facilities than staffing those facilities with specialty providers. Telehealth makes a wider range of healthcare services available to rural communities via telemedicine, including:

  • Psychiatry and behavioral health services
  • Medication for Opioid Use Disorder
  • Ophthalmology
  • Dermatology
  • Dentistry
  • Audiology
  • Cardiology

Effective healthcare services and programs administered through telehealth technology in rural communities include:

  • Chronic care management interventions provides patients with access to integrated care during their primary care visits.
  • Provider-to-Provider models allow rural primary care providers and specialist providers to work as a team to share knowledge and manage patient care. E-Consults are an asynchronous provider-to-provider model.
  • Access to emergency care providers in real-time for evaluations and consults with local providers.
  • Home monitoring can engage patients in their homes between medical visits by helping them effectively manage their conditions. Bridges to Care Transitions-Remote Home Monitoring and Chronic Disease Self-Management is an example of a telehealth remote monitoring program that assists patients with behavioral health conditions in their homes.
  • Intensive care units (ICUs) provide round-the-clock critical care patient monitoring by a team of subspecialists and critical care nurses.
  • Long-term care services offered through telehealth can bring specialized care to elderly populations who reside in long-term care facilities in rural areas.
  • Online therapy and remote counseling link rural residents with urban behavioral health and mental health counseling services.
  • Telepharmacy extends access to pharmacy services, including medications and medication counseling, at rural healthcare facilities and community pharmacies.
  • Interpreter services can be transmitted on-demand through audio and/or visual technology for patients who speak limited or no English.

Programs supported by telehealth offer new methods for improving healthcare access and quality by extending the reach of healthcare services, improving the ability of rural providers to address a broader range of medical conditions, and facilitating collaboration between professionals with limited access to their colleagues. Provider Bridge, a program funded by HRSA and HHS, and managed by the Federation of State Medical Boards, is a platform that connects healthcare providers with state agencies and healthcare organizations to increase patient access to telehealth. The National Emergency Tele-Critical Care Network (NETCCN) is another collaborative resource project that has emerged as a result of the COVID-19 pandemic, providing surge support by virtually connecting providers to a clinical-technical team trained in critical care assistance.


Challenges of telehealth in rural communities

Despite the promise telehealth holds for improving access to healthcare services in rural areas, there are policy barriers and infrastructure inadequacies that must be overcome.

Insurance Reimbursement

The issue of Medicare reimbursement is commonly cited as a major challenge for telehealth programs, including concerns related to geographic and originating site restrictions, provider restrictions, and service restrictions.

Individual state Medicaid programs vary in their guidelines regarding reimbursement for telehealth services. The 2019 National Rural Health Association (NRHA) policy brief Telehealth in Rural America elaborates on barriers to telehealth and provides policy recommendations to increase access to telehealth. Reimbursement by private payers for telehealth services can also vary. Some health insurance companies reimburse for telehealth services, while others do not.

In response to the COVID-19 pandemic, the U.S. Department of Health and Human Services implemented temporary policy changes to increase flexibility in offering telehealth services, including reimbursement. These changes address many of the barriers described above, but those barriers may return if changes in telehealth policy are rescinded after the public health emergency ends.

Licensure

The 2013 NRHA policy brief, Streamlining Telemedicine Licensure to Improve Rural America, describes how the current physician and therapist licensure system places burdens on physicians wanting to expand their practice to rural areas. Physicians who wish to practice across state lines must be licensed by the professional licensing board in each state where they are delivering care to patients.  Actions states have taken to ease licensure barriers and the associated burden are:

  • Offering specific licenses for telehealth
  • Reciprocity and endorsement with other states
  • Creating interstate compacts

In 2021, the Federation of State Medical Boards, with the support of HRSA and HHS, launched Provider Bridge, a platform that facilitates license portability to allow providers to submit credentials and treat patients in high-demand areas via telehealth. Supporting licensure compacts helps to expedite the process for qualified service providers to be licensed to practice in multiple states.

Broadband

Affordable broadband is required to support telehealth programs, health information technology, and health information exchanges, all of which increase access to and the quality of healthcare. Traditionally, healthcare facilities needed broadband to provide telehealth services, but with modern applications of telehealth such as remote patient monitoring and e-visits, broadband is also necessary in patients' homes. Many rural communities do not currently have access to internet connection speeds that support efficient transmission of data to provide telehealth services. The broadband gap has the potential to lead to a new set of health inequities due to disparate access to telehealth. The 2021 report Broadband Today: Rural America's Critical Connection discusses the importance of broadband access to rural business, telehealth, and remote work opportunities.

Stigma

Nearly 1 in 5 adults in the U.S. experiences a mental disorder within any given year according to the National Alliance on Mental Illness. Yet, the misconceptions, myths, and cultural stigma associated with mental illness are significant barriers that keep people with mental health disorders from seeking and receiving treatment in rural areas. Factors that may influence rural residents to avoid seeking care include such issues as:

  • Lack of understanding and knowledge of mental illness, including among healthcare staff
  • Prejudice or stigma towards mental illness treatment
  • Secrecy about mental illness in the community and general hesitancy to seek care
  • Perception of a lack of confidentiality and privacy in small towns with closely-tied social networks

While there are drawbacks to small communities when it comes to mental health, there are positives as well. The close-knit nature of rural communities can also mean that residents are more likely to rally around each other and provide community support in times of need. A strong external support group can help facilitate a person's success in treatment and also help support the family's efforts in attending to the care seeker.

Suicide: a rising rural mental health concern

Suicide continues to be higher in rural counties and the gap between rural and urban suicides has widened over time. A 2017 CDC report, Trends in Suicide by Level of Urbanization — United States, 1999–2015, discusses possible causes for the geographic disparity:

  • Limited access to mental healthcare
  • Social isolation
  • The opioid overdose epidemic
  • Economic recession
Graph of Suicide Rates
Source: Trends in Suicide by Level of Urbanization — United States, 1999–2015, MMWR (Morbidity and Mortality Weekly Report), 66(10), 270-273, 2017.

According to a 2020 report from the CDC, from 2000 to 2018, the rural suicide rate increased by 48% while urban rates increased by 34%. In 2018, the suicide rate in rural counties was 19.4 deaths per 100,000 compared with urban counties at 13.4 deaths per 100,000.

Additional information regarding the impact of suicide in rural communities can be found in Understanding the Impact of Suicide in Rural America.


A positive impact on rural healthcare providers

Telehealth use in rural areas can reduce a provider's feelings of isolation and burn-out, and subsequently improve provider retention. Telemedicine: Changing the Landscape of Rural Physician Practice highlights testimonials from healthcare providers practicing in rural areas throughout the U.S.

Healthcare systems with the infrastructure and staffing to support telehealth services impact how rural providers are able to provide patient care by giving them access to:

  • Team-based care
  • Other specialists and subspecialists for consults in real-time
  • Virtual networks with peers
  • Outsourced diagnostic analyses
  • In-home monitoring of patients for follow-up care
  • Continuing education and training, reducing travel and out-of-practice time

A positive financial impact on rural facilities and communities

The financial impact of implementing telehealth services in a community can vary, depending on the type of healthcare service or services to be offered using telehealth and the patient population. Anticipating Economic Returns of Rural Telehealth, a 2017 NTCA—The Rural Broadband Association report, describes telehealth potential benefits including the following quantifiable benefits:

  • Decreased transportation costs
  • Minimizing lost wages
  • Reduced hospital staffing costs
  • Increased local lab and pharmacy profits

The report also lists nonquantifiable benefits:

  • Increased access to specialists
  • Providing timely care
  • Ensuring patient comfort
  • Reducing the need for transportation
  • Benefits to the provider
  • Improved patient outcomes

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