The problem: Too few mental health providers, spread too thin — geographically and in terms of patient load. Michigan’s mental health service struggles
even before a pandemic threw all health care services across the country into a state of upset.
Now mental health providers are looking at the potential of telehealth
— allowing patients to meet with providers via videoconference or other remote technology methods— to increase access to mental health services, especially in rural areas where those services are stretched to the limit.
Michigan law defines telemedicine as “…the use of an electronic media to link patients with health care professionals in different locations” that follows protocols compliant with patient privacy laws.
Because mental health services generally don’t require physical examinations, they are especially suitable for telehealth appointments.
They’re also a potential godsend in rural areas where weather and transportation issues can often be a challenge, and where there may not be a mental health professional for miles.
By computer or smart phone, patients are able to confer with therapists
in offices anywhere in the state from patients’ remote rural homes. With a statewide pool of potential providers, telehealth options also let patients try different therapists to find a good fit instead of hoping for the best with the only therapist in town.
And with no need to actually visit the office, privacy, especially in smaller communities, may be enhanced by virtual appointments where neighbors won’t run into each other in the waiting room or spot a familiar car in the parking lot.
Telehealth is already a popular option at Pine Rest Christian Mental Health Services, says Jean Holthaus, Telehealth Clinic Manager and Southwest Regional Director. Pine Rest gets referrals from every county in the state and the Telehealth Clinic has almost 50 clinicians who provide solely telehealth services, she says.
“We are able to provide follow-up for those patients virtually, regardless of where they live,” Holthaus says.
Holthaus says the telehealth option is especially helpful for families with children.
“Obtaining psychiatric services for children and adolescents often requires parents to take time away from work, take their child out of school, and drive several hours each way for an appointment multiple times per month,” she says. “This is not always feasible for parents and is financially costly.
“Additionally, taking a child out of school frequently intensifies some of the child’s mental health struggles,” she says. “Having the option to obtain services via telehealth minimizes the time away from work for parents, keeps children in school, allows the family to maintain a consistent schedule, and allows children to remain involved in extracurricular activities — which can be important for their mental health.”
In the Upper Peninsula, the Michigan Department of Health and Human Services contracts with the NorthCare Network
as the prepaid health plan for all Upper Peninsula Medicaid recipients needing mental health services. There, the use of telehealth for mental health benefits grew during the pandemic and continues.
Andy Kulie, chief information officer for NorthCare Network, says that in the Upper Peninsula, telehealth options have continued to expand, though not at the pace seen during the earlier days of the pandemic.
For instance, during the first two fiscal years of the pandemic telemedicine services at NorthCare Network made up more than five percent of services provided throughout the region, up from just over one third of a percent of all service units provided.
“That proportion of telemedicine services does appear to be dropping back down again in the most recent fiscal year,” Kulie says. “We're currently estimating just under two percent of services were provided via telehealth in our most recent fiscal year, which is still a significant increase from pre-pandemic levels.”
“In-person provision of services continues to rebound,” Kulie says, and much of the current wave of technology focus is being placed on improving workflows for the remote scenarios that are ongoing, whether they be hybrid work-from-home arrangements or direct service provision via telemedicine.
“Several initiatives have begun to take a hard look at workflows and system interoperability improvements designed to better adapt the work we do to a more virtual world,” he says.
The numbers support the practice
Research into the efficacy of remote services seems to support continued expansion of telehealth services in rural MIchigan.
The Ann Arbor-based nonprofit Altarum
Institute was awarded a grant in 2019 to help improve adolescent depression in rural areas of Michigan through the use of telehealth; the findings of that study
will be presented at the American Public Health Association annual conference in November.
According to the institute’s website, anxiety, depression, and stress related disorders in adolescents have been rising steadily for decades and Michigan adolescents are experiencing the behavioral health epidemic that is seen nationwide. Rural youth are especially vulnerable — poverty, isolation, stigma, and a lack of treatment anonymity all contribute to higher rates of mental illness and gaps in access.
A two-year pilot program, Responding to Adolescent Depression through Integration and Telemedicine was designed to address these problems. From September 2019- December 2021, Altarum delivered training, technical assistance, and evidence-based resources to rural primary care clinicians. The program reached more than 2,000 adolescents, improved adolescent depression screening and follow-up, and decreased the severity of adolescent depression among those who screened as at-risk.
The RAD-IT program demonstrated how telemedicine can be used to improve adolescent depression screening, treatment, and follow-up in rural primary care practices and helped uncover what program investments are likely to be most and least useful.
Some of the RAD-IT program findings include:
Challenges to overcome
- Increased screening rates for adolescent depression, from 28 percent to 81 percent post-training
- Improved scores on assessment of the severity of symptoms of depressive disorders and episodes in 64 percent of adolescents who received follow up appointments
- Increases in clinician confidence in screening for and treating depression
- Improved clinician knowledge of and comfort in prescribing antidepressants for adolescents
The successes are promising but it’s not as simple as allowing therapy patients to dial up their doctor on FaceTime. There are potential barriers, experts say, that have slowed access to mental health tele-services.
Some clients may not have access to a computer or smart phone capable of handling virtual counseling sessions. Some patients may feel they have less privacy in their homes, where others may be listening in, than in a provider’s office.
And some parts of rural Michigan still have connectivity issues
that may make virtual visits difficult to impossible.
“The biggest barrier to obtaining services for many families is having an internet connection strong enough to maintain an adequate connection,” Pine Rest’s Holthaus says.
It’s a situation not unique to Pine Rest.
According to the North Care Network’s annual performance report for Fiscal Year 2020 “ a general increase in the use of information technology to stay in touch has placed unprecedented stress on Internet infrastructure. Across the U.P., IT technicians work with staff and their Internet service providers to help keep everything connected, the report says, to ensure that consumers stay connected with the care they need.
“Access to technology -- particularly reliable internet access in rural areas -- is often an obstacle to providing services directly through telemedicine platforms,” Kulie says. “Consumers may not have devices or data plans capable of supporting virtual sessions, and rural internet access, whether through wireless or traditional broadband, can be temperamental or nonexistent, sometimes even near the more populated areas of the region.
Kulie says service providers have come up with creative solutions to help mitigate these issues where they can. “We have also seen efforts by technology partners, including broadband providers, to strengthen their networks to help with the growing need for constant connectivity.”
Obstacles notwithstanding, wherever there is a strong enough internet signal services can be provided via a smartphone or any other device capable of connecting to the internet. “Pine Rest has been and continues to diligently work to improve access to care,” Holthaus says, and currently, most of Pine Rest’s 250+ therapists provide both virtual and in-person services.
That trend is likely to continue to benefit all rural residents.
Pine Rest is partnering with Michigan State University Extension to provide telehealth therapy services to farmers and their families who might not otherwise have insurance for those services.
“Research has shown that mental health services provided via telehealth can be as effective as services provided in-person,” Holthaus says. “Additionally, more than half of the people calling for appointments indicate they prefer to have their services provided via telehealth. This makes expanding our ability to provide mental health services via telehealth extremely important.”
That preference will be noted when Pine Rest opens a pediatric behavioral health center in late 2024
which will include additions to its adolescent outpatient services— including telepsychiatry for providers, families and patients in rural areas.
“Children and adolescents have brains that are rapidly developing and not fully formed. This means that when they are struggling with mental health issues, they need to receive treatment from someone who specializes in treating children’s mental health issues,” Holthaus says.
“Finding this treatment can be extremely challenging for parents who often turn to their primary care providers for assistance. Pine Rest is investing in leveraging the expertise of our child and adolescent psychiatric providers by partnering with primary care providers to provide consultative services to areas where these services either do not currently exist or are scarce," she says.
Additionally, Pine Rest will be able to expand telepsychiatry services to be able to provide more services directly to children and adolescents across the state who are struggling with mental health concerns.
“Ultimately,” Kulie says, “I would say (telemedicine) is working well. We often hear reports of increased engagement from some consumers who may have otherwise had difficulty getting to the office for routine appointments.
"The option to provide emergency screenings to consumers who are in crisis by remote means is one thing offered by telemedicine that has allowed our region to leverage highly qualified professional staff in more efficient ways to provide a key service in a very timely manner, which has especially been helpful in an area that is sometimes defined both by its snowy weather and the long drives between its population centers.”
Reaching out is the first step
Holthaus encourages residents to reach out for help as needed, no matter where they live.
“If you or your child is struggling with mental health concerns, the most important thing to know is that treatment is available. Choosing to reach out for assistance either in person or via telehealth can feel scary, but it is important not to put off seeking services,” she says.