NADD Bulletin Volume IV Number 2 Article 2

Complete listing

Telehealth in Rural America

John Holderegger, M.S., Kim K. Faulkner, R.Ph., Ph.D., Theresa A. Faulkner, Ph.D, Jon Fortune, Ed.D., Barbara Fortune

Introduction

In a general atmosphere of escalating healthcare costs and increasing consumer expectations, additional challenges arise when serving persons with complex needs in very remote settings. For example, in Wyoming, responding to these more general challenges is exacerbated by the long distances between service-delivery agencies involved and the intemperate weather occurring throughout much of the year. Data from the 1990 United States Census Database provide a template for understanding the demographic, social, economic, and cultural landscape of Wyoming. The population for the state having the ninth largest land mass is numbered at 453,588, making it the least populated state, with the overwhelming majority of individuals living in rural and frontier areas. In an arena such as this, physically transporting specialized professionals to remote locations to render on-site treatment or quality training to workers in the field on subjects that are individualized and interactive is practically impossible. Coordinating and funding such efforts on any consistent basis is a logistically difficult, time-consuming, and expensive endeavor.

For these reasons, in Wyoming and elsewhere, there is an increasing interest in the use of telehealth as a means of healthcare delivery. Telehealth can be defined as the use of telecommunications technologies to provide health information and services. Moreover, recent technological advances have made this medium simpler to use and less expensive, both of which occur in a context of transmitting information with greater accuracy and fidelity. Collectively, these factors further support the viability of telecommunications networking as an excellent means of providing services, and doing so at a reasonable cost. Consequently, to meet these challenges in Wyoming, a pioneering telehealth project was begun in August 1995 in which specialists (in this case psychologists) make use of state of the art technology to provide statewide consultations from a single location to professionals and paraprofessionals dispersed throughout the state, who, in turn, live and provide direct treatment services to individuals in sparsely populated settings.

More specifically, this ongoing project functioned to provide effective early interventions for individuals with developmental disabilities plus a major psychiatric disorder. The initial aim of the project was to prevent decompensation among this complex group of individuals severe enough to require acute psychiatric hospitalization. By utilizing the State’s compressed video network in conjunction with highly trained psychologists to orchestrate early interventions, it has become possible for individuals with dual diagnoses to avoid these more costly hospitalizations. This alone has saved millions of dollars and, more importantly, has assured a high quality-integrated life for persons with co-occurring disorders by allowing them to remain in their home communities.

However, since its initial inception, this telehealth project has gone two steps further, the second step having evolved into an additional service provided to the State’s Division of Developmental Disabilities (DDD). First, it has been used to provide monthly statewide training modules for all participating compressed video sites on important topics such as active treatment and psychopathology. Second, it has been used as an expeditious route for timely referrals which allow more specialized assessment and treatment protocols to be implemented such that direct psychiatric hospitalizations can be avoided. Summarily, this technology furnishes a cost-effective way to ‘bridge the gap’ of distance while simultaneously avoiding delays due to inclement weather common in Wyoming during much of the year. In this paper, we will present data supporting how an integration of technology, the use of specialists in the field of dual diagnosis, and a telehealth format has been used to successfully address the more general and specific challenges in delivering health care services to individuals with severe needs.

Characteristics of Wyoming

Several factors make Wyoming the optimum environment for capitalizing on the benefits afforded by telehealth in general and more specifically for serving persons having mental health needs. In rural Wyoming, there is often a scarcity of resources for those seeking services from a mental health professional and large distances between psychological delivery sources (Butz &, Recor, 1994). In most small towns, there are no mental health professionals to deliver services. Long driving distances and inclement weather combine with the mental health stigma in western society to make seeking such services prohibitive. Telehealth allows these services to be delivered to the persons in need in their own community by providing training to local staff who are in a tangible position to meet the needs of the person served. Few providers in rural areas (usually generalists), large distances between providers, insufficient knowledge of persons with developmental disabilities and co-occurring mental illness, treacherous winters, and expensive and difficult air travel precipitated the need to develop creative solutions for service provision in Wyoming.

When the telehealth project began, there were only nine providers serving 670 individuals; only two of those providers employed full-time psychologists to provide treatment to persons with a developmental disability and co-occurring mental illness. Today, there are over 400 providers of services to approximately 800 adults with a developmental disability. Still, only two of these providers have psychologists on staff, while a few others subcontract for psychological services from psychologists who are typically not specialized in treating persons with co-occurring disorders.

The Genesis of the Project

Under these contingencies, Wyoming’s DDD was faced with the dilemma of devising a means of expanding the resources available at one of the community programs, Mountain Regional Services, Inc. (MRSI), where a cost effective and therapeutically efficacious program was already in place. Consequently, MRSI was asked by the adult program manager of the DDD to explore methods of providing consultation services to other programs where no psychological services were offered. MRSI’s President and CEO, having had previous experience using Wyoming’s Compressed Video Network, suggested the time slots available in the early morning hours, before college classes, could be used to provide consulting services via this networking system. Subsequently, MRSI psychologists began on-line consultation sessions via teleconferencing to the Regional Service Providers of Wyoming. The nature of the services required by participating agencies necessitated the implementation of two approaches to consultative efforts. These included a person-centered case consultation model and a consultee-centered educational consultation model, the latter for the purpose of providing education on selected topics relevant to serving individuals with developmental disabilities.

Services Provided Via Teleconferencing

In the person-centered case consultation model, a consultee encounters problems with a specific person they are serving. The task of the consulting psychologist is to identify and assess specific problematic behaviors, suggest a provisional diagnosis if this can be reasonably determined, then suggest intervention, treatment, and/or referral options. In the consultee-centered educational consultation model, the consultant focuses on the consultee and provides assistance with any difficulty the consultee has in performing his or her work role with the persons served. Examples include difficulties due to lack of knowledge, skills, objectivity, or confidence. In the latter case, it is common to find the staff member has the knowledge, skills, and objectivity required, but lacks confidence in his/her ability to carry out what is known.

Prior to the provision of person-centered consultations, providers are asked to supply the following information about the person served for use by the psychologist in preparation for the consultation meeting: age, level of intellectual functioning, DSM-IV diagnoses previously rendered, developmental history, history of institutionalizations, history/nature of physical and/or sexual abuse, normal daily routine, nature/quality of relationships with staff and peers (including differences if they exist), who is currently involved in the daily routine of the person receiving services, recent changes in the environment, current medication and any recent medication changes, types of behavior problems (antecedents and consequences of those behaviors), what has been attempted to manage the behaviors and what was the outcome of each of the attempts, and any previous psychological evaluations available.

At the time of the actual two-hour consultation, all team members are asked to be present at the site. More specific data about the person receiving services can be elicited from the various team members. Then, a conceptualization of the person receiving services’ problems and intervention recommendations are provided. If necessary, follow-up consultations can occur to address incomplete symptom remission or less than acceptable improvement in behavior. Often, a second consultation is not necessary; rarely is more than a second consultation required to fine-tune recommended interventions.

Alternatively, in consultee-centered sessions, each compressed video site or multiple sites can simultaneously receive training in requested and/or relevant areas necessary for effectively treating persons with developmental disabilities. In addition, this model has another benefit in that issues of confidentiality encountered in the person-centered case consultation format do not have to be addressed, as no specific cases are discussed.

Assessment Outcomes

To assess consumer satisfaction, following each consultation or educational session, individuals attending were asked to complete a one-page evaluation form assessing helpfulness. Helpfulness was measured on a five-point scale ranging from 1 (definitely not helpful) to 5 (definitely helpful). Results indicated a mean rating of 4.6, falling between 4 (probably helpful) and 5. This finding was opined to support the notion that consultation services via teleconferencing were helpful. More specifically, consultees identified the following factors as contributing to their perception of helpfulness: 1) receiving factual information (e.g., what is psychosis?); 2) receiving specific recommendations (e.g., how do I reduce the aggressive behavior in this client?); 3) interacting with the consultant and their own teammates (e.g., group discussion and problem-solving); 4) interpersonal qualities of the consultant (e.g., interesting, keen observer, understanding, open to questions, good listener); 5) receiving an alternative viewpoint (e.g., a different way to look at or understand the reasons for the client’s behavior); 6) getting feedback on their current practices or case conceptualization (e.g., we were giving consequences to an already self-punitive person, and we needed to be giving more praise); 7) the structuring of the consultation services (e.g., thorough, systematic, used examples, provided a focus, simplified the issues); and, 8) the specific benefits provided by the teleconferencing medium (e.g., visual contact, immediate transfer of information, cost effectiveness) (Faulkner & Faulkner, 1998).

Additional support for the positive outcome of the services provided came from administrative personnel directing Wyoming’s Division of Developmental Disabilities (DDD). Data available to them indicated that none of the persons with a developmental disability served over the last four years by the DDD had returned to the state hospital. Moreover, only 1% had returned to the State Training School, with this being attributable more to overall medical than mental health concerns. In most other states, recidivism rates are typically much higher, falling in the range of between 5 to 15% or more. This decline and its maintenance has been attributed to the added combination of teleconferencing services and the comprehensive evaluation services provided by MRSI.

How teleconferencing services have proven to be cost effective is further manifested by the progressively decreased number of consultations since the inception of the service in August 1995. The range of consumers helped, as well as a second demonstration of cost effectiveness, is attributable to MRSI’s comprehensive evaluation services. This service is provided when consumers manifest intransigent behaviors or present as diagnostic enigmas that cannot be resolved because of the limitations inherent in teleconferencing. These consumers are referred to MRSI and receive a comprehensive evaluation on-site that ends when an in-person consultation is provided to representatives of the referring agency. In this way, more difficult cases receive specialized treatment allowing them to forego more costly psychiatric hospitalizations. Viewed collectively, outcome data collected from service providers and DDD officials support the notion that consultation and referral procedures utilizing a teleconferencing format has had a beneficial and cost-effective impact in the state of Wyoming.

Thus, telehealth has met our goal of providing effective early interventions to individuals with developmental disabilities and co-occurring psychiatric/behavioral distress before they decompensate to a level necessitating acute hospitalization. Utilization of the Wyoming State Compressed Video Network and services provided by highly trained psychologists has resulted in interventions capable of preventing hospitalization for all persons receiving services in Wyoming. Because of the effectiveness of this project, millions of dollars have been saved and persons with severe disabilities have been permitted to remain in their home communities. In fact, in the last five years of using statewide DDD telehealth conferencing, 90 individual consultations and 55 all-sites training sessions have occurred, with no consumer benefiting by the services later being admitted into the Wyoming State Hospital.

Impact of the Olmstead Decision

Such findings have a direct bearing on the compliance plans mandated by the Health Care Financing Administration (HCFA) in lieu of the landmark Olmstead decision and its far-reaching interpretation of the requirements of Title II of the Americans With Disabilities Act. As each state examines its institutionalized populations, the need for viable treatment options for individuals with mental retardation and co-occurring mental illness will become increasingly apparent. Defining the appropriate “least restrictive environment” for these individuals will present frustrating challenges unless service providers are capable of surveying existing programs and building comprehensive databases on current clinical and financial outcomes.

At the core of any systems analysis will be the issue of diagnostic capabilities available to a state upon which it can build a defensible system of referral, placement, and treatment. In this regard, Wyoming has created a unique center at MRSI, which provides both in-house comprehensive evaluations as well as individual diagnostic consultative services via the state’s community college compressed video network. Using a team of clinicians specialized in the diagnosis and treatment of persons with developmental disabilities and psychiatric/behavioral disorders, the Division of Developmental Disabilities uses both H.C.B.S. Waiver assessment funds and state monies to both identify potential consumers seeking services and improve habilitation services provided to current waiver recipients. As a result, the DDD had to create little in the way of new policies to develop its part of the Olmstead compliance plan, and has yet to be involved with any legal action with regard to its placement decisions in this arena. Rather, Wyoming is directing its efforts at maintaining its most challenging consumers in community settings and expanding the capabilities of other provider agencies to increase their expertise in serving this most challenging population.

References

Butz, M. R. & Recor, R. D. (1994). Rural psychology: Differences in culture, differences in therapy. Paper presented at the annual meeting of the Montana Psychological Association, Great Falls, MT.

Faulkner, T. & Faulkner, K. (1998). Consultation via teleconferencing in rural Wyoming for providers of psychological services to the mentally retarded and mentally ill client. 15th Annual Conference Proceedings: Excellence from the Heart (pp. 80-84). Kingston, NY: NADD Press.

Additional Recommended Information Sources

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Baigent, M. F., Loyd, C., Kavanagh, S. J., Ben-Tovim, D. I., Yellowlees, P. M., & Kalucy, R. S. et al. (1997). Telepsychiatry: ‘tele’ yes, but what about the ‘psychiatry’? Journal of Telemedicine and Telecare, 3(Supp. 1), 3-5.

Ball, C. J., McLaren, P. M., Summerfield, A. B., Lipsedge, M. S., & Watson, J. P. (1995). A comparison of communication modes in adult psychiatry. Journal of Telemedicine and Telecare, 1, 22-26.

Blackmon, L. A., Kaak, H. O., & Ranseen, J. (1997). Consumer satisfaction with telemedicine child psychiatry consultation in rural Kentucky. Psychiatric Services, 48, 1464-1466.

Callahan E. J., Hitty, D. M., & Nesbitt, T. S. (1998). Patient satisfaction with telemedicine consultation in primary care: Comparison of ratings of medical and mental health applications. Telemedicine Journal, 4, 363-369.

Clark, P. H. J. (1997). A referrer and patient evaluation of telepsychiatry consultation-liaison service in South Australia. Journal of Telemedicine and Telecare, 3(Supp. 1), 12-14.

Dongier, M., Tempier, R., Latinec-Michaud, M., & Meunier, D. (1986). Telepsychiatry: psychiatric consultation through two-way television. A controlled study. Canadian Journal of Psychiatry, 31, 32-34.

Duffy, J. R., Werven, G. W., & Aronson, A. F. (1997). Telemedicine and the diagnosis of speech and language disorders. Mayo Clinical Proceedings, 72, 1116-1122.

Graham, M. (1996). Telepsychiatry in Appalachia. American Behavioral Scientist, 39, 602-615.

Harrison, R., Clayton, W., & Wallace, P. (1997). Can telemedicine be used to improve communication between primary and secondary care? British Medical Journal, 313, 1377-1381.

Huston, J. L., & Burton, D. C. (1997). Patient satisfaction with multispecialty interactive teleconsultations. Journal of Telemedicine and Telecare, 3, 205-208.

Ioane, M. A., Bloomer, S. F., Corbett, R., Fedy, D. J., Gore, H. F., Mathews, C. et al. (1998). Patient satisfaction with realtime teledermatology in Northern Ireland. Journal of Telemedicine and Telecare, 4, 36-40.

Mahmud, K., & Lenz, J. (1995). The personal telemedicine system. A new tool for the delivery of health care. Journal of Telemedicine and Telecare, 1, 173-177.

McLaren P. M., Blunden, J., Lipsedge, M. L., & Summerfield, A. B. (1996). Telepsychiatry in an inner-city community psychiatric service. Journal of Telemedicine and Telecare, 2, 57-59.

Perednia, D. A., & Allen, A. (1995). Telemedicine technology and clinical applications. Journal of the American Medical Association, 273, 483-488.

For more information:

John Holderegger
Mountain Regional Services, Inc.
P. O. Box 6005
Evanston, Wyoming 82931-6005
johnh@mrsi.org

Kim K. Faulkner, R.Ph., Ph.D.
Theresa A. Faulkner, Ph.D
Mountain Regional Services, Inc.
Evanston, Wyoming

Jon Fortune, Ed.D.
WyomingDevelopmental
Disabilities Division
Cheyenne, Wyoming

Barbara Fortune
University of Wyoming,
Wyoming Practice Residency