Telemental Health: Responding to Mandates for Reform in Primary Healthcare

Abstract

Telemental health (TMH) has established a niche as a feasible, acceptable, and effective service model to improve the mental healthcare and outcomes for individuals who cannot access traditional mental health services. The Accountability Care Act has mandated reforms in the structure, functioning, and financing of primary care that provide an opportunity for TMH to move into the mainstream healthcare system. By partnering with the Integrated Behavioral Healthcare Model, TMH offers a spectrum of tools to unite primary care physicians and mental health specialist in a mind–body view of patients' healthcare needs and to activate patients in their own care. TMH tools include video-teleconferencing to telecommute mental health specialists to the primary care setting to collaborate with a team in caring for patients' mental healthcare needs and to provide direct services to patients who are not progressing optimally with this collaborative model. Asynchronous tools include online therapies that offer an efficient first step to treatment for selected disorders such as depression and anxiety. Patients activate themselves in their care through portals that provide access to their healthcare information and Web sites that offer on-demand information and communication with a healthcare team. These synchronous and asynchronous TMH tools may move the site of mental healthcare from the clinic to the home. The evolving role of social media in facilitating communication among patients or with their healthcare team deserves further consideration as a tool to activate patients and provide more personalized care.

Overview

The dichotomy of healthcare into physical and mental health service sectors recapitulates humankind's conceptualization of soma and psyche. However, there are times in human history when new forces synergize to change traditional thinking. Current mandates to reform healthcare are converging with innovations in telecommunications technologies to produce an equitably distributed, patient-centered, effective, and efficient healthcare system—an integrated system that includes mental and behavioral healthcare (aka, mental healthcare). Telemental health (TMH) scaffolds telecommunications technologies onto new models of collaborative healthcare to unite primary care physicians, mental health specialists, and patients in a mind–body conceptualization of illness and treatment.

This discussion considers a broad perspective of TMH that includes (1) the core definition of the use of real-time, interactive video-teleconferencing (VTC) to render mental healthcare that is usually provided in person and (2) the use of other synchronous and asynchronous electronic media in clinical and nontraditional settings to activate patients in their healthcare. By integrating with and expanding collaborative models of care, TMH responds to the mandate for primary healthcare reform and is poised to enter the mainstream of healthcare.¹

The Rationale for a Rapprochement of Physical and Mental Healthcare

The mandate to integrate mental health services into primary care is supported by multiple investigations demonstrating that the majority of primary care visits are related to mental healthcare needs, substance abuse, or lifestyle issues, rather than an identified medical condition,² that often develop in the course of complex and/or chronic medical disorders. Conversely, patients with mental health and substance abuse disorders are at high risk of compromised physical health disorders that further impair their quality of life. It is estimated that 25–50% of Medicaid clients need mental health and/or substance abuse treatment, and much of this need is unmet. The National Comorbidity Survey Replication Study has shown that of patients needing mental healthcare, 59% were untreated, and of the 41% who were treated, the majority (56%) received their care within primary care.³

Although the treatment needs of patients with comorbid medical and mental health disorders have been recognized for decades, relevant services remain poorly coordinated. There is a credibility gap between what is known and what the healthcare industry has addressed. Perhaps the same can be said for the Graduate Medical Education that has the responsibility of preparing resident physicians for practice. The expectation that primary care physicians will manage complex medical, mental health, and behavioral health problems alone has become unrealistic as healthcare needs have evolved from acute to chronic interventions that require specialty care and close monitoring and adjustment of treatment plans to achieve optimal outcomes and as regulatory oversight has increased. In response to these changes, the Chronic Care Model was proposed over a decade ago. This model uses a team approach to bring specialty care to the patient's primary care site, to provide decision support to primary care physicians, and to involve patients in their healthcare.⁴ This model has relevance to evolving healthcare reform, particularly for the provision of mental and behavioral healthcare within primary care.

The Drivers of Healthcare Reform

The Patient Protection and Affordable Care Act

The federal mandate to reform healthcare to better serve Medicare and Medicaid populations is driving change across the public sector and will likely affect the private healthcare sector as well. The Patient Protection and Affordable Care Act (ACA) (PL111-148), or the federal healthcare law, is a U.S. federal statute signed into law by the President on March 23, 2010 and upheld by the U.S. Supreme Court on June 28, 2012. The ACA constitutes the most significant government expansion and regulatory overhaul of the U.S. healthcare system since the passage of Medicare and Medicaid in 1965. The ACA is aimed at decreasing the number of uninsured Americans and improving healthcare and outcomes, while also reducing the overall costs of healthcare. Several core principles of the ACA provide nodal points for TMH-based care.

TMH and the Principles of the ACA

The Medical Home

The ACA was enacted at a time of considerable rethinking across multiple sectors of how to improve the accessibility of healthcare, the quality of care, and health outcomes. The Medical Home was reborn. The concept of the Medical Home was introduced in 1967 by the American Academy of Pediatrics as a central source for all the medical information about a child, especially those with special needs. In 2008, the National Committee for Quality Assurance (www.ncqa.org) defined the Medical Home as a model of care that strengthens the clinician–patient relationship by replacing episodic care with coordinated care and a long-term healing relationship.^5,6 Each patient has a relationship with a primary care clinician who leads a team that takes collective responsibility for patient care, providing for the patient's healthcare needs and arranging for appropriate care with other qualified clinicians. The primary care physician coordinates team efforts with nurses, pharmacists, receptionists, schedulers, medical assistants, and patients themselves. Patients are part of the team—they own their information. The Medical Home is intended to result in more personalized, coordinated, effective, and efficient care. It achieves these goals through a high level of accessibility, providing excellent communication among patients, clinicians, and staff and taking full advantage of the latest information technology to prescribe, communicate, track test results, obtain clinical support information, and monitor performance. Emerging outcome data indicate that the integrated, patient-centered focus with team-based coordination of care in managing the continuum of patients' care needs results in better care at reduced cost. The Medical Home model builds on the aforementioned Chronic Care Model as a prominent framework for improving healthcare and outcomes for those with a chronic condition^4,7 and, more recently, for the general population.⁸

The Medical Home Model has been adapted to the integration of mental healthcare into primary care.⁷ The Integrated Behavioral Healthcare Model utilizes a care manager as the liaison between the primary care physician and a collaborating psychiatrist. Typically, the psychiatrist is available on site to meet with the care manager, who presents cases to the psychiatrist, documents recommendations for the primary physician to implement, tracks scheduled follow-up appointments, and obtains standardized measures of patients' response to treatment. For individuals who are not responding optimally, the psychiatrist may provide direct patient consultation and/or ongoing care and update the treatment plan.⁹

A role for TMH is obvious and is being implemented for psychiatry collaboration, for example, at federally qualified healthcare centers (R.L. Solomon, pers. commun., February 2013) or community health centers (J. Unutzer, pers. commun., October 2012). VTC telecommutes a psychiatrist into the primary care setting, either across the country or across town. The psychiatrist works with the care manager, who is co-located at the primary care center, to review the primary care physician's caseload of patients with mental and behavioral healthcare needs and to supervise the care manager's tasks, including tracking patients' progress and adjusting treatment plans as needed. Other team members may obtain formal or informal supervision through VTC.¹⁰

Models for Integrated Behavioral Healthcare, including models using TMH to provide expert collaboration, have focused on the provision of psychiatric services in part because of the maldistribution of the psychiatric workforce and in part reflecting the core role of medication that can be provided by primary care physicians, with appropriate collaboration. However, this model is readily applicable to other mental healthcare. The expertise of psychologists at major medical or psychiatric centers can be telecommuted through VTC to distant sites to consult with primary care physicians or to directly evaluate their patients (J. Gonzales, pers. commun., March 2013) and to provide training and supervision to therapists working in distant communities (C. McCarty, pers. commun., March 2013). TMH is one effective and efficient mechanism to disseminate evidence-based psychotherapies from academia to the community.

One unresolved issue is the level of technology best suited to the Integrated Behavioral Healthcare Model, both for collaborating with the care manager and other team members and for the provision of direct service. Current guidelines recommend matching the technology to the service provided and using the highest level of technology that an agency or provider can afford.¹¹ Advances in technology have made inexpensive, desk-top, computer-based systems a feasible option for the provision of TMH-mediated integrated behavioral healthcare. However, these lower technologies may not provide the same quality of clinical encounter for patients and may be more stressful for TMH providers and care managers. There are no investigations addressing the association of the technology with patients' outcomes or with TMH providers' satisfaction and competence with their positions. This should be an area of future investigation. The care managers' duties are substantial and potentially stressful, especially if an agency is not able to use trained clinicians, such as nurses or social workers, in this position but must retrain other staff, such as medical assistants or paraprofessional staff, for care managers' positions.

Patient-Centered Care (Aka Person-Centered Care)

Patient-centered care refers to the principle that all care should be based on the individual's preferences, needs, and values.¹² This marks a paradigm shift from the traditional medical model in which the provider is defined as the expert who determines what and how healthcare is provided and the consumer is the passive recipient who “complies,” or not, with treatment. Patient-centered care requires that the consumer is an informed and active participant in decisions and collaborates in care through the development of self-management skills.¹³

By definition, the use of TMH with the Integrated Behavioral Healthcare Model responds to the mandate for patient-centered care by increasing patients' access to care in their home communities and by uniting the mental health specialist and primary care physician in the patient's healthcare needs. The increasing availability of desk-top, computer-based TMH systems further responds to this mandate by offering direct patient care services in individuals' homes. Virtual home-based TMH has been safely implemented¹⁴ and is a core mental health service offered in the Veterans' Administration (VA) with Veterans diagnosed with serious mental health conditions (P. Shore, pers. commun., October 2012), and several private vendors now offer this opportunity either to contracting agencies or to individuals (P. Hirsch, pers. commun., March 2013). Virtual home-based TMH is also being examined for the implementation of parent management training interventions for children with disruptive behaviors (J. Comer, pers. commun., October 2012). To date there are limited published data documenting the feasibility, acceptability, and effectiveness of providing home-based TMH outside of a major medical organization with dedicated staff such as available at the VA. Work in this area is likely to expand as it is patient-centered, ecologically valid, and financially advantageous for families and healthcare organizations. It will be interesting to follow developments in virtual home-based interventions as Integrated Behavioral Healthcare Models are implemented. The care manager will have the additional task of reaching out to patients at home to assess their progress and to encourage them to complete assessment measures through online portals for later presentation to the collaborating mental health specialist.

Another promising approach to patient-centered mental healthcare is the availablity of an intervention through various platforms so that patients can access the intervention on demand, on their chosen platform, according to their need, convenience, and discretion. Mobile applications for specific disorders, such as depression, anxiety, and posttraumatic stress disorder, allow patients to access the intervention recurrently to “boost” the effect of initial intervention and to practice skills in the moment or at their convenience.

Evidence-Based Care

Evidence-based care refers to the use of the best available evidence to guide treatment decisions and delivery of care, including preventive and health promotions services, screening, assessment, treatment, and relapse prevention. Care is explicitly informed by and grounded in relevant clinical research demonstrating treatment effectiveness. Because there is never sufficient evidence to guide all treatment decisions, external clinical evidence from systematic research must be combined with individual clinical expertise.¹²

A solid evidence base is developing to support a range of mental healthcare activities provided through TMH. Multiple studies have documented the feasibility and acceptability^15
–17 of providing psychiatric care through VTC. Effectiveness has been supported in investigations using pre-/post-intervention designs and comparability study designs with inpatient and outpatient samples.^18
–20 Several well-designed studies have shown that manualized psychotherapies can be faithfully and reliability implemented through TMH^21
–23 and are of comparable effectiveness to the same therapies provided in person.^24

–27 One investigation has examined a TMH-based Collaborative Care Model adapted for dispersed small clinics without on-site psychiatrists. Fortney et al.²⁷ randomized Veterans with comorbid physical illness and depression to TMH-collaborative care or to usual care. The model was well accepted, and patients randomized to TMH-collaborative care showed better adherence to care. They also experienced greater gains in their mental health status. However, a downside to the model was the failure of the depression care team to recommend a follow-up TMH appointment for patients who failed a second antidepressant trial. Many of these patients were referred to in-person care. This may reflect some skepticism by local clinical staff regarding the relevance of TMH or the Collaborative Care Model for more severe illness. Other resources supporting the effective utilization of TMH in patient care that are available to guide agencies and clinicians in proving evidence-based care through VTC include a summary of evidence-based practice for TMH²⁸ and practice guidelines for TMH.¹¹

Evidence-based TMH approaches also include psychotherapies that are self-administered asynchronously either online or through CD-ROM, particularly for depression²⁹ and anxiety,³⁰ including therapies for adolescents.^31
–33 Although many individuals who log on to such sites do not engage in the interventions, those who do engage show good outcomes (effect size range from 0.2 to 0.6). The advantage of online versus CD-ROM-based therapies is the ability to monitor individuals' use of the modules and their progress in symptom reduction. Some online interventions include therapist support in the form of prompts to complete and utilize the therapy modules. Such therapist support appears to improve outcomes, as do booster sessions to prevent relapse. These e-interventions have not been addressed in Integrated Behavioral Healthcare Models, but their strong evidence base and cost-efficiency suggest a role, and oversight by the team may improve engagement for more individuals. Future models may consider inclusion of e-interventions in a spectrum of services. For example, individuals with mild to moderate levels of depression or anxiety might be required to complete a trial of an asynchronous online intervention, either in place of a traditional therapy provided by a therapist over VTC or in preparation for such treatment.

Other TMH approaches are most visible as tools to aid clinicians in providing evidence-based care. Psychiatrists and primary care physicians access Web sites on demand to update their knowledge or to check the evidence base on a treatment, such as to check algorithms for the “next steps” in pharmacological management of depression. The smartphone is becoming a third presence during the clinical encounter as physicians try to match patients' descriptions of their prior medications with photographs provided online and check for possible medication interactions. Therapists use text messaging to communicate with patients regarding the “homework” assigned during cognitive behavior-based therapies or may log onto games or music sites to engage their young clients in office.¹⁰ The TMH toolkit to support the Integrated Behavioral Healthcare Model is growing.

TMH and ACA Fiscal Reforms

Perhaps the greatest change to primary care practice for physicians caring for Medicare and Medicaid patients is the fiscal model. The ACA requires insurance companies to cover all applicants and to offer the same rates regardless of preexisting conditions or sex. The ACA has outlined a system of care in which providers would be paid for performance as a defined group rather than individually receiving a fee for service.

Accountable Care Organizations

The ACA provides several mechanisms to reform the structure and fiscal foundations of a new healthcare system—including mandates, subsidies, and tax credits—to employers and individuals in order to increase the coverage rate. The mechanism to accomplish this restructuring is the accountable care organization (ACO). The Centers for Medicare and Medicaid (CMS) refers to an ACO “as a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care ) that will work together to coordinate care for the Medicare Fee-For-Service patients they serve. The goal of an ACO is to deliver seamless, high-quality care for Medicare beneficiaries, instead of the fragmented care that often results from a Fee-For-Service payment system in which different providers receive different, disconnected payments. The ACO will be a patient-centered organization where the patient and providers are true partners in care decisions. The ACO will be responsible for maintaining a patient-centered focus and developing processes to promote evidence-based medicine, promote patient engagement, internally report on quality and cost, and coordinate care.” (http://www.cms.gov/medicare/medicare-fee-for-service-payment/sharedsavingsprogram/downloads/aco_qualitymeasures.pdf). CMS's plan is to provide incentives to ACOs for the comprehensive management of their patients across a system of care that includes all healthcare services. Incentives are based on providing value rather than underutilization (capitations) or overutilization (fee-for-services). ACOs allow variable approaches to provide needed services from the physical co-location of providers, to collaborative care models, to physically dispersed networks of providers.

TMH in the ACO

TMH-mediated integrated behavioral healthcare seems especially well suited to an ACO that serves the mental healthcare needs of a defined group of patients living outside of major metropolitan areas or for other groups that lack access to services because of geographic or other barriers. TMH vendors or providers considering participation in an ACO should carefully review the conditions of participation including time allotted for clinical sessions, relationships with other providers in the ACO, and collaboration with the primary care team. Participation in an ACO may be limited to contracted vendors such as a medical center or private companies. Potential TMH providers should carefully review the financial implications for their participation. Also to be addressed is the range of TMH services that might be allowed in an ACO. For example, although the use of TMH in the Integrated Behavioral Healthcare Model and for the provision of direct service to patients in clinic will be included in an ACO, it is not clear whether home-based TMH or asynchronous e-interventions will be possible.

TMH and Activating Patients in Their Care

TMH approaches to improving mental healthcare and outcomes include individuals' perspectives and their use of e-health resources. Before federal mandates to transform the structure, functioning, and financing of the healthcare system, informal mandates for personalized healthcare were developing and evidenced in sharing by physicians of health knowledge that had traditionally been hidden from public view.

Clinician-Initiated TMH Resources

Many healthcare agencies and private providers, including those in the mental health sector, now provide asynchronous portals that give patients access to their own healthcare data anytime, anywhere, as well as provide general health information. Patients may conveniently pose questions about their care without having to schedule in-person appointments. Parents may find helpful information on their children's health and development. Immigrant families may find such Web sites more helpful than negotiating the healthcare system for routine issues.

Social media is increasingly being integrated into clinical practice. Mental health providers may communicate with their patients through a blog or “friended” site. There is limited information on the liabilities of such communications. For example, adolescents may post suicidal thoughts or intentions on their social media “page.” If a mental health provider is “friended” on the patient's site, there are no guidelines regarding the appropriate intervention or response to such posts. On the other hand, such a site may greatly benefit elderly patients, for whom travel outside of the home is difficult, in communicating with their mental health clinician. These Web sites and social media are consistent with the patient-centered principles of ACA as they include patients in their care and provide a spectrum of healthcare resources. They can be a mechanism to disseminate evidence-based care to patients in a most user-friendly manner. The use of such resources in integrated behavioral healthcare remains an unexplored, but interesting, area.

Current Patient-Initiated TMH

Individuals are transforming their personal healthcare by accessing information through the Internet and social media. Online platforms do not just resource data; they may also add an evaluation layer (e.g., www.patientslikeme.com). Such evaluation may be provided by triaging feedback from individuals who have personal experience of a topic or by providing input from an expert, perhaps at a cost. Patients may unite online to review treatment options, to challenge pharmaceutical companies or dubious outcomes research, or to share their experiences. Open access publishing means that anyone can review and evaluate research. Social media allows individuals to rapidly query multiple “friends” about their knowledge and experience regarding an issue—a host of instant, real-time, usable information at a “click.” Individuals bring the information they have gleaned online to their primary care providers or may even seek to treat themselves. These individual initiatives are already impacting healthcare and may provide new challenges to providers. The risk that such unfiltered information will lead to misinformation, unrealistic expectations, or harm by delaying appropriate care remains unexplored.

Such disruption in medicine seeks to put patients at the center of healthcare and to produce an informed and activated patient with projected better outcomes—goals that are shared with the Integrated Behavioral Healthcare Model. How well such patient initiatives can truly partner with formal healthcare reform initiatives remains to be addressed. The behavioral healthcare team must work with patients to interpret information accessed online and through social media, and patients must work with their team to individualize their care according to best practices. Despite the unknowns, social media provides potential tools for the team in the Integrated Healthcare Model.

Future Patient-Initiated TMH

As telecommunications technologies advance and the mental health system increasingly puts patients at the center of their care, TMH approaches will become more personalized. Over the past three decades, home monitoring of physiologic functions through digital devices, such as cardiac monitoring, has contributed to greater safety and effectiveness of medical care. Home monitoring of mental health functions, such as mood or activity level, is on the horizon. One intriguing development is “smart clothing” with embedded biosensors that are connected through mobile devices to a database that assesses emotional state. Reportedly, “smart clothing” can monitor vital signs and other physiological indicators (respirations, cardiac rhythm, galvanic skin responses) that can be converted to provide feedback on an individual's emotional states.³⁴ Physiological functioning has been shown to vary with mood and anxiety.³⁵ If further work shows that such monitoring detects early stages of relapse of an impairing mood, anxiety, or psychotic disorder, the Integrated Behavioral Healthcare Model team might be consulted early to prevent relapse, and primary care physicians might be willing to initiate psychiatric medication rather than awaiting clear symptom development. There could then be considerable clinical, financial, and societal benefits of such a pro-active approach. Currently, costs for such technology as “smart clothes” are prohibitive for most patients, and research is needed to better examine the sensitivity, specificity, and prognostic capability of such sensors.

Conclusions

TMH is a well-recognized model of service delivery to improve access, treatment, and outcomes for patients with mental health conditions who face geographic or other barriers to care. Healthcare reform mandated by the ACA provides the opportunity to develop a more comprehensive role for TMH. A TMH-mediated Integrated Behavioral Healthcare Model provides a multifaceted tool to bring together a team of healthcare providers to partner with patients in their mental healthcare. The potential benefits of this model are evidenced in its increasing use in the academic, private, and business communities.

Footnotes

Acknowledgments

Our gratitude to Jen Gelbaugh, President and CEO, Access Psychiatry Solutions (www.accesspsych.com), LLC, for providing helpful information regarding the implementation of telemental health services in community settings.

Disclosure Statement

No competing financial interests exist.

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