The Continued Growth of Telemental Health
By Sue Coyle, MSW
Social Work Today
Vol. 18 No. 2 P. 18

Professionals across fields are developing and incorporating telemental health services as the need grows.

It is no surprise that telecommuting is prevalent throughout the social work field, in a variety of mediums and methods. Not least among them is telemental health (TMH)—the act of providing mental health services from afar. This, too, isn't new, says Allan Barsky, JD, MSW, PhD, a professor at the Phyllis and Harvey Sandler School of Social Work at Florida Atlantic University. "Consider the use of crisis hotlines, allowing people with homicidal or suicidal ideation to use telephones to access help from social workers or other mental health professionals," he describes. "Consider also the use of fax machines—in days gone by—to transmit clinical records to clients, treatment providers, and insurance companies."

Though not a new concept, TMH is a method of service provision that is continually evolving as need and technology/programs advance and the less direct aspects of service from insurance to law to research attempt to keep pace.

Need
The need for TMH services derives first and foremost out of accessibility. While clients in need of mental health treatment exist in every corner of the country and the world, providers do not. This is particularly true in rural areas, where even when clinicians are in the area, they are not easily accessed if individuals lack the necessary resources.

"Telemedicine could be a great benefit to people living in rural areas," says Jamey Lister, PhD, MSW, an assistant professor at Wayne State University School of Social Work. "In particular, it could help reduce travel burdens for patients needing to routinely visit providers. It also has the potential to allow physicians in urban/suburban areas to better connect with rural communities where access to physicians with training in addiction medicine is sparse," he says, referring specifically to the behavioral health needs that have stemmed from the opioid crisis increasingly prevalent in rural communities.

That's not to say that urban communities cannot benefit from TMH services as well. Even with public transportation systems and other benefits of city accessibility, clients cannot always reach necessary practitioners. Time constraints, work schedules, time off limitations, and funding for transportation are among the many barriers common to rural and urban clientele.

Similarly, individuals with disabilities often have difficulty reaching practitioners, in terms of getting to them and communicating with them. Again, TMH services can help overcome these obstacles. "A client who is convalescing in a hospital can connect with a mental health professional through videoconferencing. Text-based technology may be used to facilitate communication with clients who are deaf or hearing impaired. A client with agoraphobia may find going to a professional's office very stressful but may connect more easily through the use of avatar-based communication," Barsky explains.

But accessibility isn't just about location or client-specific barriers. It's also about providers or the lack thereof. Take, for example, child and adolescent mental health needs. As understanding and awareness of when and how mental health issues can arise in children/adolescents continue to expand, the need for practitioners trained to serve the population grows. Just as with physical health, there is a difference in how one treats a child vs. an adult. However, the supply in response to the demand is not keeping up.

"There is a low number of child psychiatrists in the nation," says Evelyn Orozco, PhD, program director of Rutgers University Behavioral Health Care. "There are 8,000 [child psychiatrists] that provide services in the nation. In the urban and rural area, that number is even lower.

"The expectation," she continues, "is that there will be a need for more than 12,000 child psychiatrists when approximately 8,300 will be expected to be functioning and working in society."

Programs
In response to the growing demand, social workers and other practitioners have continued to develop TMH programs and delivery systems. As with many aspects of mental health services, there are a great variety.

"One approach to telemental health would be to replicate what we have currently," says Ateev Mehrotra, MD, MPH, an associate professor of health care policy and medicine at Harvard Medical School and a hospitalist at Beth Israel Deaconess Medical Center. "You go and you see a social worker in person every week or every two weeks," he describes, referencing a current, prominent mode of treatment. Telemedicine services could mimic this setup. "[However] maybe the greatest advances may not come from replicating that but through other innovations," he says.

One of the innovations Mehrotra describes is the ability of a primary care provider to reach out to a specialist for an e-consult. In this situation, the patient does not have to see the specialist unless absolutely warranted. "For about a quarter of the specialty consultations, the patient never has to see the specialist. It's faster. You can often make sure the patient gets to the right place," he says.

This method is one aspect of Essex HUB—a program created by Rutgers University Behavioral Health Care in conjunction with New Jersey Medical School and Essex County pediatricians.

The goal of the program is to connect youths to necessary mental health services by starting in the pediatrician's office. "We know that pediatricians are uniquely positioned to address mental health and substance use issues because the families are coming in for regular appointments. The primary care physicians are in a position to observe and request a consultation to get services immediately," says Debra Waksberg, MSW, project coordinator.

When pediatricians decide that a child or adolescent may be in need of assessment, they call a hotline to access a psychiatrist. The consultation can be between the pediatrician and psychiatrist alone or the child may be involved as well. "They can come up with a plan for moving forward," Orozco says. "If there's a concern, they can ask one of our staff members to reach out to the parent. If the pediatrician is asking for a full battery of assessments, our staff will reach out to the family. Our staff will do a full evaluation and send that report to the pediatrician.

"We want the pediatrician to continue serving and caring for that child," she adds.

Another innovation Mehrotra has observed is the use of TMH to provide more frequent, shorter practitioner-client interactions. "Instead of trying to replicate face to face, why not just have very short consults via text messages? A social worker has a panel of 300 patients, and he or she checks in with them once every or every other day."

Barsky notes that TMH is also branching out into aspects of technology beyond videoconferencing and texting. "Some of the more recent examples of TMH include the use of mobile apps, avatars, social robots, and various forms of biofeedback.

"Many professionals," he continues, "are using combinations of in-person services and services that are mediated through the use of technology. Consider a patient who completes an intake form online, meets in person with a social worker for a psychosocial assessment, and uses a mobile app to facilitate cognitive structuring and online text messaging to facilitate narrative therapy; the social worker then uses teleconferencing to facilitate supervision."

Challenges
While programs exist and continue to be developed, there are challenges to delivering services from a distance.

One of those challenges is licensure. Licensed social workers typically gain licensure in a specific state.

"States want to have control over how and when and why they issue licenses to different types of health care professionals," explains Amy Lerman, JD, MPH, member of the firm Epstein, Becker & Green. A health regulatory attorney, Lerman and her team focus on helping varying practitioners prepare for and deliver health care services via telehealth. "With increased utilization of telehealth technologies, you've got this notion of multistate practice, and people went crazy [thinking about how the technology could completely changed the way they practiced]."

"I can totally make a Skype call!" she remembers hearing from some of her clients, noting that the technology was well ahead of states' preparation from a regulatory standpoint.

"Typically, state licensure boards are very concerned about where the patient is located. They've been extremely progressive with telemedicine, but if you're going to talk to [their residents], you need a license," she says. Lerman notes that most states have been working to address the related regulatory concerns and that significant changes already have occurred between 2015 and 2017.

This is most apparent in states with the greatest need for TMH, such as Alaska, where many residents live in remote, inaccessible areas. In 2016, Alaska passed SB 74, which among other things permitted a variety of practitioners to provide telemedicine services to Alaskans without being in the state. Providers still have to be licensed by Alaska but can live remotely. This law vastly expands the services/practitioners available to state residents.

Another challenge is insurance. Most plans have restrictions around who can be seen and how often. "Many people with opioid use problems in rural communities may be on public insurance that requires them to attend specialty clinics," Lister says. "Many others lack the financial means to pay out of pocket for services. The lack of insurance coverage or personal finances is a significant barrier to overcome until more people can reliably use telemedicine to promote recovery from opioid use disorder."

Mehrotra adds that even when insurance companies cover telemedicine, they often do so on a limited basis. "With Medicare, the rules are that you can only get telemedicine if you live in a rural community."

Again, states are taking steps to alleviate these barriers. "Many states have enacted parity laws in which states have communicated to commercial insurances companies, if they are going to cover certain services if they are provided in person, they should be covering those services in a comparable manner if they are provided via telemedicine," Lerman says. Again, Alaska provides an example. In 2016, the governor signed HB 234 into law, which requires insurance companies to treat TMH services like in-person mental health services. The law does not address other areas of telemedicine.

Ethics and Practice
As states attempt to keep pace with development in TMH, the profession must, as well. There is a danger in apps and other avenues of technology offering mental health services.

"One of the primary challenges in TMH is that many practitioners are using technology without sufficient training, competence, and research evidence," Barsky says. "Here, I use the term practitioners rather than professionals," he emphasizes. "In some cases, people without mental health education or credentials are developing and providing mental health services. Consider a person with a computer science background who develops an addictions app that is sold to thousands of people—despite having no training in substance use disorders and no understanding of potential risks from using the app."

For this reason and others, NASW has updated its Code of Ethics and practice standards on the use of technology. Barsky chaired NASW's Code of Ethics Review Task Force from 2015 to 2017 and was a member of the National Task Force on Standards for Technology in Social Work Practice.

"Ethical concerns regarding mental health and technology include the big three Cs—confidentiality, competence, and cross-border practice," he says. "In terms of confidentiality, risks include the possibilities of unauthorized users gaining access to client information (including live communication and digitally stored data), as well as theft of computers or other devices."

He adds that when practitioners provide services in regions with which they are not familiar, they may not be as culturally competent as desired. They may also be unaware of various environmental and legal factors.

Moving Forward
These risks, however, don't negate the benefits of TMH services. There are risks and challenges, after all, in providing in-person mental health services. To best mitigate obstacles, further development and research must be completed.

For Lister, that means universities must be involved. "Universities have the means to earn grant funding to design large-scale clinical trials that help build the evidence base for telemedicine treatment of opioid use disorder," he says. "A few universities, most notably the Universities of Kentucky and Washington, both have dedicated and excellent rural health research centers. As a result, they have led the field of rural health research and helped identify important knowledge developments that stakeholders are actively using to improve the lives of rural citizens."

He adds, "It is pivotal that future research examines the efficacy of telemedicine, barriers to implementation, and other aspects of telemedicine."

Barsky agrees, noting that the greatest developments in TMH in recent years have been research. "Research has shown that there are many forms of technology-mediated interventions that are just as effective, and sometimes more effective, as interventions without technology. Research is now showing us under what circumstances that particular uses of technology are helpful in facilitating positive change for a range of mental health conditions."

With enough research, training, and practice, many hope that TMH services will be a seamless part of mental health treatment.

"One day," Barsky says, "we may wonder why we questioned whether social workers could effectively provide mental health services at a distance."

To access the NASW Code of Ethics and practice standards, visit:

• www.socialworkers.org/About/Ethics/Code-of-Ethics

• www.socialworkers.org/Practice/Practice-Standards-Guidelines

— Sue Coyle, MSW, is an award-winning freelance writer, a social worker in the Philadelphia suburbs, and a frequent contributor to Social Work Today.