Telemental Health Services in Frontier Areas: Provider and Consumer Perspectives

Table of Contents

Introduction | Evaluation of TMHS: Positive Reactions | Evaluation of TMHS: Problems and Concerns | Research | Tell Your Government | Summary

Introduction

Isolated rural or frontier areas, found primarily in the western United States, often struggle to provide mental health services. Systems must offer an array of related social and case management services to persons with acute to severe and sometimes p ersistent disabilities. These consumers are often far from a major population center and the wide array of services it might offer. Providing mental health services is made more difficult by the usually long distances between existing providers and cons umers. However, with advances in technology these remote areas are now beginning to have additional options in dealing with their distance and isolation challenges. One such option is telemedicine or telehealth services. This Letter will discuss te lemental health services (TMHS), which is connotative of all mental health services whose delivery is assisted by telecommunications technologies. The technologies in use range from telephone and fax to live interactive video. The services include, but are not limited to, prevention, diagnosis, consultation, outreach, case management, education and treatment, as well as transfer of mental health data for use in the provision of services to specific clients.

Letter to the Field No. 3 in this series defined and described the current situation in the provision of telemental health services in frontier areas. Since that letter, published work regarding the use and proliferation of TMHS has increased, and the re is now a substantial amount of available information about telemedicine in general. Little of this literature, however, directly reports the experiences of non-medical mental health service providers or the experiences of consumers with TMHS. This Le tter to the Field reports the results of two focus groups conducted by the Frontier Mental Health Services Resource Network in the fall of 1997 — one with TMHS service providers and one with consumers of those services.

Focus Group Site and Composition. The site of the focus groups was a small, remote Community Mental Health Center in a frontier area of the western United States. The Center was a participant in a federal rural health project that connected th em — via ISDN lines supporting interactive video — to other rural health settings, hospitals in urban areas, and the state hospital mental health unit. The service provider focus group consisted of eight staff members. Providers’ backgrounds ranged from a bachelor degree with experience to a licensed psychologist. The experience of the service provider group members with TMHS ranged from a high of two years to a low of one month.

The consumer focus group consisted of nine consumers who had volunteered to participate. They all were a part of the caseload of a psychiatrist located in an urban area over one hundred miles from the Community Mental Health Center. All had experienc e with the use of TMHS and all were in active treatment. The consumer with the least amount of experience with TMHS had participated in six TMHS sessions. Each consumer reported a major psychiatric diagnosis and one was also physically disabled. Two of the consumers reported that they had received only medication reviews in TMHS sessions. Six consumers reported on-going, periodic treatment in TMHS sessions, and one consumer related an intensive, crisis oriented psychotherapeutic TMHS intervention.

The Typical TMHS Service Episode. TMHS services involving consumers were usually instituted after an initial face to face visit with the psychiatrist. The sole exception in the focus group was a consumer who was receiving crisis intervention a nd had not yet met with the psychiatrist face to face. For these sessions, the psychiatrist went to a broadcast booth located in a nearby hospital. Consumers — usually accompanied by their local service provider — went to a multi-purpose room in the men tal health center that was set up like an old style classroom. The room was large enough to hold public meetings. In the room, the consumer sat at a table on which there was an operator’s panel and a microphone. He or she faced a set of two large monit ors that looked like TV sets, one of which had a camera on top of it. When the session was initiated, one monitor would display the remote site and the second monitor would display the picture being captured at the local site. In other words, the consum er would see himself or herself on one of the monitor displays. Functions of the site’s interactive video — such as pan, zoom, and switching off displays — could be controlled using an operator’s panel. The panels are small, the controls easy to use, an d they were located near the participant so that they could control a session without moving from their seat. After a few experiences where consumers had specifically asked to control the environment, the psychiatrist routinely gave each consumer instruc tions that enabled them to use the operator panel during the session. Consumers describe the interactive video setup as "being on TV," and this seemed to be a good, shorthand manner of describing TMHS sessions for everyone. Because they could p lace the event in such a familiar landscape as television, very little about the technology of these sessions seemed remarkable to either the service providers or consumers. Session length was the same as session length face to face. Consumers initiated some of the sessions; however, these were not usually treatment events. Instead, they consisted of consumers visiting with family or relatives, who were, for example, residential patients at the State hospital. TMHS services involving service providers , but with no consumers, consisted of education, case supervision, and case management. Sessions were sometimes conducted ad hoc, or were evoked by consumer needs, but usually they were pre-scheduled.

Evaluation of TMHS: Positive Reactions

Satisfaction. Service providers expressed a high level of satisfaction with the system and mentioned a number of uses and potential uses that the system could accommodate. One person commented that the system broke through much of the i solation that they felt as professionals in a remote community and enabled them to communicate regularly with professionals in other places. Satisfaction of the service providers also seemed to come from the improved continuity of service that they descr ibed. For example, a number of the providers commented that they now could participate in discharge planning and have a good sense of the consumer and other members of the case management team. Others mentioned the opportunity to talk with peers and exp erts at other sites as a source of satisfaction and improved service.

Consumers were quite satisfied with the TMHS services they had received. They expressed the opinion that the services were good and may not have been otherwise available. As one consumer said; "The TV provides access to timely treatment and actu ally gives me what I think is more quality direct contact with my therapist." Consumers felt satisfied with the arrangement of having their local service provider present. They felt this allowed the local service provider to participate in their tre atment and provide insights that they sometimes didn’t have or that they might have been unable to express during the session. Service providers reported that they sometimes left the room if the consumer needed either privacy or confidentiality. One ser vice provider was more forceful in describing their participation, saying that they would "…determine the situation as to whether or not I need to be there."

A Needed Service Capacity. Service providers felt that TMHS availability kept everyone in communication in a manner that was different than the telephone. Perhaps this was due to the fact that interactive video meant that everyone needed to be in place at a scheduled time for the event. This most certainly decreased "telephone tag" and increased timeliness. In that manner, they felt that TMHS saved time and discouraged fragmentation of treatment. They also talked about the persona l contact TMHS afforded them. By personal contact, they meant the increased sense of presence over telephone contact provided by the combined visual and auditory medium.

Through out the focus group session, consumers emphasized that TMHS helped them cope with problems of daily living. They explained that TMHS provided them access to a psychiatrist or provider, or to family and community, particularly when travel condi tion were difficult (including weather, poor roads, availability of transportation and long time consuming distances) and when quick access to services was required — such as during a crisis situation. Stated differently, because of TMHS, a consumer was n ot concerned about problems of access due to geography, particularly when they were acutely ill. Further, they felt they had more direct contact with their provider when TMHS was a part of existing mental health services.

Evaluation of TMHS: Problems and Concerns

Personal contact. Some consumers reported that they did not like TMHS at first, but that after they used them they judged them much more favorably. There was consensus among the consumers that TMHS was much more personal than telephone contact, but not as personal as a face-to-face meeting with their provider. Consumers felt that more attention to "business" and less to socialization characterized TMHS sessions. One consumer pointed out that "some of the fun is gone." They a lso indicated that they would still like to see their psychiatrist in person from time to time, even if they saw them regularly via TMHS.

Service providers pointed out that TMHS need to be viewed as part of a set of services. They expressed the opinion that TMHS allows service providers to augment or supplement services, but they do not replace face to face services. Service providers reported that consumers who did not have face to face contact with the distant provider seemed to do less well than those who had at least one such session.

Confidentiality & Privacy. Both service providers and consumers expressed some reservation about the ability of TMHS to protect confidentiality. No specific examples of non-confidential behavior were cited, but consumers noted that technic ians and other non-professional people were involved in the provision of TMHS services.

Consumers felt that providing TMHS at home may violate privacy rather than support it. They also felt that such services might distress family members, particularly children, who are not ready to accept the fact that a close family member has a mental illness. They noted that having the services at home might preclude the presence of the local therapist, a condition that focus group members felt facilitated effective communication. Further, participants noted that availability of at home services mig ht overload the provider.

Paying for services. Participants of both groups emphasized that because insurance companies are not always willing to pay for TMHS, they have serious concerns about how their TMHS will be funded. A federal grant initially paid for TMHS at this site; unfortunately, the grant has been completed. Medicare and Medicaid generally pay when other insurance pays, and need to be encouraged to pay for TMHS. Medicare/Medicaid do not always pay for TMHS. One consumer reported that they had to obtain a co urt order so that their insurance company would pay for TMHS provided to them.

Computer Access. Most of the consumers had access to personal computers, but not to Internet services. A few mentioned that they used the Internet in the local library. Consumers related the provision of TMHS services to the spread in access to networked computers, but, as a group, they had no opinion about where this might lead in terms of access to support groups, educational information, or other types of computer mediated mental health services.

Scheduling the use of TMHS was the major disadvantage expressed by service providers. Providers also gave diverse reports about the capability of their computing environment. Five of them had computers at home and two of them reported Internet access on those computers. The Center had Internet access, but only two of the service providers had used it. One service provider commented that "…we probably had the network…because everyone had a computer on their desk…but, I mean, I could do virtuall y everything except word processing stuff…faster with a pen."

TV Appearance. One consumer expressed a strong dislike for seeing " myself on TV," and "didn't appreciate seeing how bad I looked". This consumer felt much better when able to use the operator’s panel to turn off the monitor display whenever they were talking.

Service providers reported that the TV appearance was "intimidating, if they are having paranoid delusions." They felt this was a special group that needed more assistance for TMHS to be used successfully. They also reported that consumers s eem to get confused by the time delay in the voices and expected it to work "just like TV."

Research

When asked about research topics, consumers and service providers indicated that an investigation of the range of mental health services that could be provided though TMHS should be explored. Both groups were interested in 1) identifying the correct m ix of face to face and TMHS; 2) understanding the interaction between control of the TMHS environment and consumer mental illness; 3) investigating the phenomena of having both the therapist and psychiatrist present with the consumer at TMHS sessions; and 4) exploring the effects of having TMHS services available at home.

Tell Your Government

Funding. The consumer group asked a simple question: why would the federal government underwrite such a needed service and then withdraw the funding? Recognizing the importance of finding funds for TMHS, service providers suggested that funds should be transferred from activities that they considered to have low priority areas (such as administration) to activities they considered to have high priority (such as provision of TMHS to isolated rural areas). In particular, they were concerned abo ut rural communities that have limited access to mental health services.

Outreach. Focus group participants recommended that awareness of both the potential availability and effectiveness TMHS services should be encouraged. They felt that many potential users are unaware that TMHS exist and are useful. They felt the government needs to initiate outreach campaigns. They speculated that such campaigns would facilitate community support for TMHS.

Congress. Focus group participants felt that congress should support keeping TMHS in small isolated communities. Their rationale is that TMHS is a reasonable way of providing essential services to isolated rural persons, particularly those who do not have easily geographic access to providers.

Summary

When asked what the major benefit of TMHS was, service providers answered that it saved time and money. They thought that a second major benefit was the role TMHS played in what they termed prevention. By prevention they meant the increased ability t o provide continuity of care and immediate response to problems. Consumers also felt more secure in their home community knowing that TMHS was available.

Service providers and consumers were remarkably similar in their positive attitudes towards and high level of satisfaction with TMHS. Both groups reported that TMHS increased access and decreased isolation. Both reported that the technology afforded them a different level and type of personal contact that was not previously available. Consumers particularly noted that they felt TMHS supported timely intervention, increased attachment to community and family, and feelings of security in regard to the availability of expert help. Service providers felt that TMHS discouraged fragmentation of treatment, kept people in communication, saved time, and supported more personal contact.

The environment in which the services took place was important to both consumers and service providers. Consumers wanted the psychiatrist to appear in the same office that was used for face to face sessions — not a broadcast room. They disliked the r oom used locally and wanted one smaller, more comfortable and congenial. Based on comments from focus group participants, providers should generally expect a period of consumer adjustment to the TMHS. Thus, when first exposed to TMHS, some of the consumer s did not like the service. After exposure to THMS, consumers began to express much more positive opinions.

Consumers noted that they were nervous the first time they experienced TMHS, "not knowing what to expect". Based on the consumer comments it appears that some type of initial training should be considered before a patient is exposed to TMHS. Consumers did not like being passive in sessions — i.e. seated in a large room and subsequently exposed to the provider on the screen. Also, for at least one consumer, lack of control over the situation was distressing. Clearly there is a need to provide orientati on and training to both service providers and consumers.

There is no need to present telemental health services as experimental or innovative. Most consumers like the idea of being on TV, and those who did not expressed comfort when they were able to control the environment. While service provider resistan ce has been a concern nationally, none of these service providers expressed resistance. The use of an initial face to face session seems to be good practice, and certainly intermittent face to face contact appears to increase the consumer’s expression of satisfaction with treatment.

Finally, the major issue underlined by the conversations in the focus groups is the development of an understanding of the personal and supportive uses of the technology. Both groups personalized the uses of the technology; for example, service provid ers felt less isolated and more effective in continuity of care, while consumers felt more attached and comfortable that help could be provided when it was needed. Both groups reported supportive uses. For example, one of the unplanned uses of the techn ology was its use to allow visitation by family members. It is a sign of the strength of the project that this type of use was permitted. It is also a good example of how unanticipated uses of technology are often the most powerful. Still, many unantici pated effects are not as positive and need to be reported, investigated and noted as well. For example, it seems clear that certain types of consumers will not tolerate a TV monitor that pictures them. Fortunately, in this case they were given control o f the monitor and could remove their own video images if they wished. In developing a knowledge base about TMHS, we would do well to consider the positive and negative effects of the use of the technology reported by consumers and service providers here; they stand on the frontier of what we now know and understand about TMHS.

Write us with comments on our site This project is supported by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration Contract No. 280-94-0014

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