Report of FMHSRN/WICHE Training Institute on Telemental Health Services

Sixteen representatives of the state Mental Health Authorities from 11 western states (AZ, ID, CO, HI, OR, ND, NM, SD, WA, WY, UT) assembled in Denver on November 9-10, 1997 to participate in an intensive training-and-implementation "Institute" on delivering telemental health services (TMHS) to rural and frontier areas. The Institute, conducted by 20-plus faculty currently working in the TMHS arena, was sponsored and supported by the Frontier Mental Health Services Resource Network (FMHSRN),a technical-assistance "center" funded by the U.S. Center for Mental Health Services. The Mental Health Program of the Western Interstate Consortium on Higher Education provided the administrative services for the meeting. Primary focus of the Institute was on how states can implement existing TMHS technology to supplement (or, in some areas, even initiate) the delivery of mental health and substance abuse services to residents of isolated, "frontier" rural areas of the West.

Telecommunications services of all types, from telephone to interactive video conferencing, are playing increasingly important roles in mental health services throughout the country. Indeed, a recent Telemedicine Today survey of programs offering interactive televised consultations notes that mental health is now the single most common type of consultation service provided by all non-radiology U.S. telemedicine projects (3,460 of 17,579 total consultations reported for 1996). It is just this strongly escalating development of TMHS services that moved the FMHSRN to convene this Institute to further the delivery of TMHS to remote and isolated "frontier" areas of the U.S.

Institute Faculty And Training Offered

The Institute's faculty included directors and staff of five currently active TMHS projects; federal officials from the Office of Rural Health Policy (HRSA) and the Joint Working Group on Telemedicine; and several TMHS consultants, including FMHSRN's own TMHS expert, Dr. Walter LaMendola from Wheat Ridge, CO.

Intensive consultation and/or training, including live interactive two-way video demonstrations, were provided on these topics:

• the nature of telemental health services using different techniques and equipment;
• the content and volume of such services currently operating;
• current federal and state legislation and policies impacting TMHS;
• funding opportunities for TMHS in western regions, including those under the federal Telecommunications Act of 1996;
• successful examples of funding TMHS through third-party reimbursements and barriers remaining to such funding in specific states;
• how to ensure delivery of high-quality TMHS through clinician training and performance standards;
• conceptualization and implementation of different kinds of collaborative arrangements that would facilitate rapid implementation of TMHS in these states; and
• the future of TMHS as more managed-care organizations adopt, or are required to provide, these techniques to improve coverage of mental health and substance abuse service needs of rural and frontier regions.

Major highlights of the Institute included live demonstrations of TMHS delivery utilizing two- and three-way interactive hook-ups with:

• the Eastern Montana Telemedicine Network headquartered in Billings, MT (Thelma McCloskey Armstrong, Director), demonstrating a role-play of a psychiatric assessment and social casework; and

• the Southwestern Virginia Telepsychiatry Project ("Appal-Link") of Cumberland Mountain Community Services (Henry A. Smith, LCSW, Chair), demonstrating long-distance hospital-to-community psychiatric medication review and case management.

Still another two-way interactive video hook-up between the Denver site and the Office of Rural Health Policy in Rockville, MD featured a review of telemedicine performance and current federal legislation and policy by Dena Puskin, Chair of the Joint Working Group on Telemedicine. This same link-up enabled presentation of multiple federal and state funding opportunities for TMHS by Cathy Wasem, federal Office of Rural Health Policy.

See the Institute Agenda for the specific sessions presented, and also the names and affiliations of the Institute Faculty.

Institute Results And Conclusions

Participants from the 11 state mental health offices had the unusual opportunity to spend two full days in intensive discussion about and demonstrations of TMHS with persons directly engaged in delivering mental health services via interactive TV, several of which are operating in very rural and frontier areas of the West. Some general conclusions of the two-day Institute include the following:

1. Current TMHS Capacity and Volume

While most western states are currently delivering few mental health services via interactive TV, the necessary "infrastructure" (capacity to deliver TMHS) is growing rapidly in most of these states. Several already have installed dedicated networks of high-capacity communications lines reaching from their population centers to their rural regions. Also, some recent TMHS "start-ups" have resulted from capitalizing upon the existence of "unused" bandwidth or communication capacity previously installed by non-MH systems (medical, educational, administrative, etc.). Steadily increasing development of capacity over the next two to three years should improve this situation even further.

2. Importance of Management Issues

Given the availability of communication lines in many states, perhaps the major key to development of active TMHS delivery is the recruitment or assignment of TMHS system managers who can pull together the necessary funding, equipment (currently undergoing steady decreases in costs), software, linkages, and collaboration among state offices and publicly funded service facilities to start up TMHS operations within a state. There are innumerable variations on the patterns of organized systems that can begin delivering TMHS services. Each state must adapt its own communications capacity, resources, and available expertise to this goal, as there exists no single, "standard" way to initiate rural-oriented projects and start-ups.

3. Clinical Applications and Training

It is apparent that certain interactive TV-based direct services are now quite commonplace in many regions of the U.S., including psychiatric assessment, clinician-client consultation, case management and discharge planning, social casework, and clinical review of medication status and client follow-up. Less common are indiviudal and group psychotherapy applications, but these are currently being explored in a number of experimental and research settings, as well as by some clinicians in service settings.

"Indirect" and administrative services also usually accompany direct TMHS delivery, including utilization and peer review operations, clinical supervision, case conferences, continuing education/ training, and other administrative activities such as interactive TV meetings and work sessions. These indirect service applications help to reduce the cost of direct TMHS by sharing, and thus increasing efficiency in use of, available communications capacity and equipment.

A great deal has been learned about the "do's and don'ts" of these applications, ranging from room set-up to image size and personal appearance. Faculty discussed a number of these with Institute participants, and can provide information to assist a state in obtaining appropriate training for interested clinicians when it is ready to commence TMHS operations.

4. Consumer/Client-Based Applications

Another current thrust is the rapid development of consumer/client "self-help", "chat", or "meeting" groups interconnected via computer using E-mail and Internet capabilities. Although most such projects have been developed elsewhere than in the western U.S., at least one (RODEONET in Oregon) has initiated this type of service application. These have not yet involved interactive TV, but at least exploratory use of this medium may be expected in the fairly near future as high-capacity communication lines multiply.

5. Some Apparent Advantages (and Problems) of TMHS Delivery

Faculty generally felt that TMHS can considerably improve access to care (in particular, providing early intervention and/or more timely care). It can also involve lower costs, particularly when the provider no longer has to travel long distances. There can also be savings for consumers if their (unreimbursed) travel requirements are reduced. Additionally, some experts feel that higher-quality care can result, including improvement in continuity of care for patients and family members. Another aspect of improved quality of care may be reduction in isolation of professionals who formerly had to live in isolated areas in order to deliver services in rural regions.

Some problems remain in delivery of TMHS. A major one is the inability of some projects to obtain reimbursement for TMHS from third-party payors such as insurance companies or their state's Medicaid program. For some projects, however, managed-care contracts may eliminate this problem via capitation with no exclusion of TMHS services from those "eligible" for reporting and accountabililty. In addition, there is still a widespread lack of clinical standards of care for TMHS; each project seems to have its own internal clinical guidelines that it follows, and oversight authorities find this difficult to monitor satisfactorily. Finally, the cost of high-capacity communication lines still presents a major problem for some states' TMHS planning, and federal assistance (such as that provided under the new FCC "universal service" funding legislation) may be needed for some states to overcome this initial hurdle.

Evaluation And Future Monitoring Of State Accomplishments

Within 60 days of the conclusion of this Institute, an evaluation questionnaire will be sent to all participants regarding any steps their state may have since taken to further develop and implement TMHS in their rural and frontier areas. Another such effort will be made to determine states' progress along these lines before the FMHSRN project terminates (9/30/98).

All Institute participants have also been invited to join a special E-mail list ("TMHS-Net") that directly interconnects all of the participants and the Institute faculty. Using this shared-communications system, people can spell out any problems encountered or successes experienced in implementing TMHS delivery, and others (including faculty) can respond with suggestions and answers.

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