A multiyear effort to pipe big-city mental health providers to rural communities over video accomplished a trifecta of telehealth victories: It reached people who wouldn’t otherwise have access to mental health care; it tackled difficult diagnoses that don’t have simple answers; and it stretched how many people the most skilled providers can treat.
Now comes the inevitable question that follows any technology breakthrough: Does it scale?
Over a four-year span, a study led by researchers at the University of Washington sought to deliver treatment to rural patients with post-traumatic stress disorder and bipolar disorder, complex diagnoses for which treatment is often located hours away, if it’s accessible at all. Researchers connected psychiatrists and psychologists to primary care clinics within federally qualified health centers in three states that didn’t have any on staff.
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Just over 1,000 people participated in the project — the Study to Promote Innovation in Rural Integrated Telepsychiatry, or SPIRIT — and the results were overwhelmingly positive. In a recently published paper, the researchers reported that patients showed a 32% improvement on a scale of mental health functioning. The findings underscore the potential of technology to address gaps in rural health care.
“It goes to show that if you provide evidence-based treatment to patients in underserved settings that haven’t had access to it before, that you can just make huge gains in those clinical settings,” John Fortney the lead researcher and a professor of psychiatry at the University of Washington told STAT. “And we should be thinking about working harder to provide services in those settings.”
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Even at the beginning of the study, in 2016, a Zoom subscription and a webcam were inexpensive and simple to set up — and providers who’d never delivered care over video before adapted quickly.
The novel design of the trial meant the health care system needed to be rewired — a complex undertaking with many moving pieces. The urban mental health providers needed to be credentialed and privileged to provide care in the health centers. They needed access to medical records, billing and insurance arrangements needed to be hammered out, and providers had to be trained in new workflows.
And in some cases, they needed a crash course in a new spin on a treatment modality called collaborative care, in which the local primary care staff deliver the behavioral health treatment with support from the urban experts.
Patients were randomized to one of two types of treatment: a collaborative care plan, or a referral system. In the referral group, patients were connected from clinics over video to a psychiatrist from a state medical school who started an ordinary course of treatment, perhaps in collaboration with a psychologist, which might be a 12-session course of cognitive processing therapy for PTSD or medication management and cognitive behavioral therapy for bipolar disorder.
In the collaborative care group, a psychiatrist made a diagnosis over video but then faded into the background as a care manager at the local clinic, usually a nurse or a social worker, took over to deliver treatment. Any prescriptions were written by the patient’s primary care physician at the clinic. The care manager regularly communicated with the patient in person or over the phone and periodically spoke with the psychiatrist to discuss any changes needed in treatment strategy.
There are more than two decades of research showing collaborative care can be beneficial in treating anxiety and depression. But applying it to PTSD and bipolar disorder — and connecting it to telehealth — are newer ideas. Fortney said the concept was met with early skepticism among some physicians who didn’t have experience writing prescriptions for mood stabilizers, but “pretty much all of them by the end of the study felt comfortable treating those disorders,” he said.
While patients in both arms showed significant improvement, collaborative care had a clear advantage over the referral model as a method for getting more people treatment.
That’s deeply valuable in a world where the number of professionals with the highest training is in short supply. The collaborative care model “has the capacity to treat two to three times more patients,” Fortney said, while “every person in the referral model in rural areas means there was one less person in the urban area that could be treated.”
While Fortney and his colleagues overcame the hurdles to get the staff, logistics, and funding needed to pull off the approach in a study, pushing the new collaborative care methods to the next level will require just a little more hand-holding.
Long before the pandemic made telehealth necessary, Fortney, a geographer by training who had studied how travel distance was a huge barrier to mental health care, saw its potential emerging in two streams of research over a decade ago. First, a body of evidence built up since the 1990s has shown that video-based mental health diagnoses and treatments were just as good as those done in person.
At the same time, evidence was mounting in support of collaborative care. The trouble is that in rural settings, a consulting psychiatrist needed for the approach might not be available locally. Technology seemed to be the obvious solution.
Fortney, who was working as a professor in Arkansas at the time and doing research for the Department of Veterans Affairs, conducted a study from 2009 to 2012 to deliver collaborative care for PTSD in rural VA clinics with experts connecting over video from parent centers.
John Paul Nolan, a Gulf War veteran, was a patient in that initial study. He experienced problems with trauma and substance misuse almost immediately after leaving the military in 1992, but didn’t receive treatment or even a diagnosis for years. He lives in rural Arkansas, 90 miles from the nearest Veterans Affairs medical center in Shreveport, La. Even when the VA started setting up community-based outpatient clinics, they didn’t have the mental health resources to properly treat Nolan, who wasn’t diagnosed with PTSD until 2007. Three years later, he was referred to Fortney’s study, and began working with a local care manager as well as a psychiatrist from the VA in North Little Rock over video.
“They were such a great team together,” he said. “They knew how to talk to us, they knew how to talk to each other. They were so efficient at seeing people.”
It’s through this program that Nolan finally was able to access cognitive processing therapy, which helped him better understand the root of his trauma.
Patients like Nolan who received CPT virtually showed “significantly larger decreases in Posttraumatic Diagnostic Scale scores” compared to those who received usual care in the study, a success that was mirrored in the new research examining the approach in a broader population of people with PTSD or bipolar disorder.
Nolan has since become an active proponent of mental health services for veterans, and Fortney recruited him to serve on the consumer advisory board for his new project, the SPIRIT study, which would try to reach a broader subset of rural patients.
Following the success with veterans, SPIRIT appears to have shown that collaborative care could be hugely impactful for rural mental health, but there are significant hurdles to rolling such an approach out — and paying for it.
It can take months and a hefty financial investment to integrate urban providers into a rural clinic. A policy paper based on the SPIRIT experience describes several steps federally qualified health centers must undertake to bring in external telemental health providers into the fold, including ensuring remote electronic health record access, contracting with state medical schools, securing the right credentials for the new providers with Medicaid and insurance companies, and purchasing additional malpractice insurance.
On top of this, collaborative care introduces a complex new workflow, including an additional administrative layer, called the registry, that helps care managers and consulting psychiatrists track how patients are doing.
As part of this tracking, collaborative care requires rigorous measurement of patient conditions. While PTSD has an established rating scale to capture symptoms, bipolar disorder does not. So as part of the study, researchers developed and published a mania scale that could be used for patients with bipolar disorder in conjunction with the PHQ-9 for depression. The novel rating scale is valuable for keeping tabs on progress, but also adds another new element to learn.
The researchers sought to make the process as painless as possible, but the implementation was still tricky, said Rachael Sewell, a licensed marriage and family therapist. Sewell, a care manager at Moses Lake Community Health Center in the agricultural region over 150 miles east of Seattle, had had no experience with collaborative care when she was hired to work on the study. Despite receiving what she calls some of the best training and support of her career from the study, “the learning curve was steep,” she said.
As the clinic got up to speed, she was working out of three different electronic health record systems at one point and it took the clinic time to find a steady psychiatrist to work with her. Sewell also had to learn the ropes of providing behavioral activation therapy, an approach used in collaborative care that encourages patients to do things that jump-start a cycle of positive activity. Still, for the health center, which had just started to work in behavioral health, the study showed “how powerful it could be and how well it could serve our patients,” Sewell said.
The business case for collaborative care is also murky. The health centers in the study volunteered to participate, and the psychiatrists and psychologists, who were all affiliated with academic medical centers, were motivated to participate. But at a broader scale, it might be hard to find such buy-in among specialists needed to work behind the scenes in a virtual collaborative care model.
“There’s not a lot of incentive to overcome all that red tape to do the telehealth when all you’ve got to do is hang the shingle out and there’s patients walking through your door all day long paying out of pocket.”
John Fortney, researcher and a professor of psychiatry at the University of Washington
“There’s not a lot of incentive to overcome all that red tape to do the telehealth when all you’ve got to do is hang the shingle out and there’s patients walking through your door all day long paying out of pocket,” said Fortney.
Ultimately, he said, better payment systems for more kinds of mental health treatment will be necessary for this type of approach to make a dent in access to care.
“I think it all comes down to reimbursement, which shouldn’t be surprising in our society. There are billing codes for collaborative care but they’re not very generous,” he said.
Some of the groundwork has been laid — Medicare covers collaborative care nationally, and Medicaid now covers it in many states. Startups and large insurers have taken an interest in the model, though coverage for the complex diagnoses may lag behind
Following the success of SPIRIT, the AIMS Center at the University of Washington is working on a follow-up application to the Patient-Centered Outcomes Research Institute, which funded the SPIRIT study, for a grant to help as many practices as possible implement the models from the study.
Virna Little, the chief operating officer of Concert Health, which helps primary practices set up collaborative care and has signed on to be part of the follow-up, told STAT the ongoing work from UW has been instrumental in creating replicable infrastructure for organizations who want to use the modality for anxiety and depression.
What’s needed now, she said, is similar guidance for other diagnoses.
“The rural providers are the only game in town,” she said. “and so they actually oftentimes are way more receptive to trying to figure out how to manage people. So if they have a system — if you had something that they could plug and play — they would probably be way more likely to do it.”
