Rural Mental Health: Implications for Telepsychiatry in Clinical Service,Workforce Development,and Organizational Capacity

Rural Health Disparities in Hawai‘i

The State of Hawai‘i is one of the most geographically remote places on Earth. The geography of an island-state complicates access to healthcare and service delivery. All five inhabited islands outside of the metropolitan center of Honolulu on the island of O‘ahu are considered rural. ¹ Kaua‘i, Maui, Molokai, Lana‘i, and Hawai‘i Island are federally designated as Health Professional Shortage Areas and Medically Underserved Populations/Areas. ¹ About a third of the state's residents live on these rural islands, ² and the populations of these rural communities are increasing faster compared with O‘ahu. ³ Because of health professional shortages, rural residents can expect to wait between 1.5 and 3 months to see a physician. ⁴ Many rural residents take time off from work or school to travel to urban Honolulu where 80% of the state's healthcare resources are concentrated. ^{4 –6} Rural residents report dissatisfaction with healthcare services and delaying seeking care, which leads to higher rates of emergency room use and/or hospitalization, higher costs associated with treatment, and negative health outcomes. ⁷

The Potential of Telepsychiatry

Telepsychiatry provides a link between urban areas, which have a higher concentration of psychiatrists, with rural areas in dire need of specialists. ^8,9 Through telepsychiatry, primary care providers may access specialists for patient care and education, which enables them to continue treating their patients rather than referring them to an outside resource. ¹⁰ Therefore, providers are able to serve patients from their communities, thus reducing costs for transfers, and retaining dollars that otherwise may have been lost to suburban centers upon referral. Other benefits of telepsychiatry include diagnostic accuracy and service satisfaction, which have been found to be comparable between in-person and telepsychiatry assessment. ¹¹ For example, patients speak freely when using telepsychiatry, are willing to use it again, and positively rate their experiences with providers. ¹² Patients also prefer telepsychiatry over waiting a longer period of time to see a specialist or traveling a significant distance for an appointment. ¹³ Moreover, telepsychiatry can reduce absenteeism (work, school), enhance sense of patient choice and control, and spare patients from long, expensive, and life-disrupting journeys. ^12,14

University of Hawai‘i Rural Health Collaboration

The University of Hawai‘i Rural Health Collaboration (UHRHC) was created by the Department of Psychiatry at the University of Hawai‘i to develop collaborative relationships with rural public and private nonprofit health and mental health clinics to provide telepsychiatric services across the State of Hawai‘i. ^15,16 A partnership with the Department of Psychiatry at the Mayo Clinic in Rochester, MN has helped augment the expertise of Hawai‘i-based psychiatrists. Monthly clinical case conferences have provided specialized expertise and training with an emphasis on complex diagnostic evaluation, pharmacogenomics, and cross-cultural psychiatry with relevance to multiethnic communities in Hawai‘i.

Almost two-thirds of Hawai‘i's residents are of Asian and/or Pacific Islander ancestry, and nearly a quarter of the population is of mixed ethnicities, the highest percentage in the country. ¹⁷ Therefore, the potential for assessing and treating ethnocultural differences in metabolizing psychotropic medications during pediatric development has implications for determining the most effective course of treatment. In addition to the Mayo Clinic's partnership with the University of Hawai‘i, the Mayo Clinic has multiple partnerships utilizing their telemedicine capacity to provide psychopharmacogenomic consultation to rural communities. The consultation program with the Mayo Clinic allows real-time and simultaneous participation from child and adolescent mental health providers from multiple islands using interactive video teleconferencing. A treatment team consists of University of Hawai‘i and Mayo Clinic faculty, staff, residents, and community health providers who meet regularly with patients and their families from rural areas to provide consultation and treatment. The composition of each treatment team is diverse, depending on the age, psychopathology, and mental health treatment goals of each patient, and may include primary care physicians, probation officers, educators, school- and community-based mental health care providers, and the foster care program.

To address workforce development needs related to rural mental healthcare, UHRHC has developed a telepsychiatry training curriculum for psychiatry residents and fellows. ¹⁸ The curriculum is built on practice parameters recommended by the American Academy of Child and Adolescent Psychiatry, which include program sustainability, model of health service delivery, program infrastructure development, legal and regulatory issues, administrative strategies, technical applications, quality of service, and clinical outcomes assessment. ^19,20 Each resident or fellow is paired with an attending faculty psychiatrist for the duration of the 6-month to 1-year rotation. Residents/fellows are responsible for a specified caseload, with case continuity provided by the attending faculty as well as the primary care provider. The curriculum focuses on a service-learning approach that guides residents and fellows to reflect on the connection between academic course work and patient and community needs. This service-learning approach allows the learner to apply psychotherapeutic and psychopharmacological principles through direct patient contact, while learning about community concerns and resources through local partners. ²¹ The consultation program with the Mayo Clinic provides psychiatric residents with experience in working with primary care providers who are managing patients with more complex mental health needs. Incorporating telemedicine into the curriculum for resident learners improves rural access to behavioral healthcare while building on the resident clinical skill set. Out of the 11 trainees who completed the telepsychiatry curriculum and residency program, 73% have gone onto serve in rural areas and continue to use telepsychiatry. Standardizing telemedicine as a common practice in the next generation of psychiatrists removes the distance barrier and improves access for rural communities seeking behavioral health services.

To assess the comprehensive effectiveness of telepsychiatry, various quality assurance evaluation and research that are related to clinical services and outcomes, curriculum development, education, and workforce development are currently underway. In a pilot survey conducted during the start-up phase of the new child telepsychiatric services among psychiatric faculty and residents who rated nearly 100 telepsychiatric service encounters, both groups expressed satisfaction with telepsychiatry's effectiveness for diagnosis, treatment, and planning, client communication and comfort, overall satisfaction with quality of services provided, and satisfaction of residents with training and supervision. ²²

Future Directions/Implications

Telepsychiatry is a promising strategy to address distance barriers and improve access to care for patients living outside of urban Honolulu. The service-learning training program addresses mental health professional shortages in rural areas by providing timely consultative services for primary healthcare providers. Although the number of available telepsychiatrists is currently limited to the UHRHC training program, the volume of consultation-liaison services has increased from every 3 months to weekly events.

Because many rural residents may not utilize primary care services, the next step for UHRHC is to develop additional telehealth initiatives. Telehealth may be used to assess patient symptoms remotely and to provide psychoeducation through existing open source technology that may reach a wider community (e.g., smartphones and Web-based applications). ²³ In pursuit of such initiatives, UHRHC is in the initial stages of developing and testing telehealth technology with its community partners to provide virtual access to care for rural residents. ²⁴ The aim of such initiatives includes improving access to primary prevention, increasing patient autonomy when seeking care, and providing a mechanism to tailor specific interventions to address rural health disparities.