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Rural Health Information Hub
Rural Health Information Hub

Telehealth Models for Increasing Access to Behavioral and Mental Health Treatment

Rural communities are using telehealth to provide mental and behavioral health services — referred to as telemental health or telebehavioral health. The Rural Mental Health topic guide describes a significant need for mental health services in rural America and notes that telehealth has been successful in helping to alleviate the lack of mental health services in rural areas. A large body of evidence has demonstrated that telemental health programs help increase access to care in areas with limited mental health resources, provide effective treatment for mental health conditions, and improve medication adherence.

Changes in regulation due to the COVID-19 pandemic have expanded opportunities for access to behavioral and mental health services via telehealth. For example, Medicare expanded coverage for mental health telehealth visits originating in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), including audio-only telehealth services. Research shows that telehealth has helped meet the needs of rural communities during the COVID-19 pandemic.

Telemental health interventions typically fall into four domains:

  • Hospital care – Rural hospitals connect to behavioral and mental health specialists through telehealth. For example, a psychiatrist can use video telehealth technology to diagnose patients in a rural emergency department.
  • Integrated primary care – Patients can receive behavioral and mental health services Relocated through telehealth in primary care settings. For example, patients at a rural primary care clinic could use live-video teleconferencing to receive counseling from a remote psychologist.
  • Mobile health applications or remote monitoring programs – These can support longer-term interventions or management of behavioral health conditions. For example, rural patients could use a tablet, smartphone application, or computer program to track medication adherence, monitor their symptoms, and receive self-management education.
  • Direct to consumer services – These allow rural patients to connect directly to behavioral and mental health providers using on-demand telehealth applications from any setting, including the home.

Rural communities are using telehealth to provide the following behavioral and mental health services:

  • Evaluation and diagnosis – Providers can use telehealth technology to observe the patient; administer scales, assessments, and screenings; and diagnose conditions.
  • Case consultation – Some telemental health programs enable rural providers to consult with psychiatrists and psychologists. Consultations can take place by direct video communication, telephone, or email.
  • Treatment – Behavioral and mental telehealth programs typically provide counseling and psychotherapy, which can be delivered to individuals, couples, or groups. Some programs also offer more specialized therapies such as medication-assisted therapy (MAT), cognitive processing therapy, or prolonged exposure therapy for post-traumatic stress disorder (PTSD). Programs may also use telehealth to deliver interventions such as education about mental health conditions and skills coaching.
  • Medication management – Telehealth can help rural patients adhere to their medication regimens. Tools that rural communities have used for medication adherence include monitored in-home dispensing devices, mHealth apps, and telephone counseling.
  • Continuing care – Some rural programs provide case management services through telehealth to improve patient outcomes. For example, a nurse care manager could coordinate with family members, social services agencies, and healthcare facilities through the phone to meet the identified needs of their patients.
  • Provider education – Rural providers can receive training or continuing education about behavioral telehealth through distance learning, telementoring, or webinars.

Examples of Behavioral and Mental Health Telehealth Programs

  • Summit Healthcare Regional Medical Center facilitates access to behavioral healthcare in primary care offices across rural Navajo County, Nevada. Patients in the primary care offices meet with behavioral health providers through telehealth-enabled tablets or video carts.
  • Greater Oregon Behavioral Health, Inc. uses a telehealth platform that allows patients in rural Oregon to connect to behavioral health services from their personal smartphones, tablets, or computers. Patients use the platform to communicate with behavioral health clinicians via videoconference or text from any location.
  • The Wyoming Trauma Telehealth Treatment Clinic provides psychotherapy via videoconferencing to rural crisis center clients who have experienced some form of violence. The University of Wyoming Psychology Department and the University of Wyoming Center for Rural Health Research and Education partnered to establish the clinic.
  • The South Carolina Department of Mental Health (SCDMH) Emergency Department Telepsychiatry Consultation Program was initially established to connect patients in dozens of emergency departments across the state with psychiatrists in urban practices. As the program has grown, SCDMH has expanded the program to include telehealth sites in community mental health centers and mental health clinics. The program is the largest provider of telepsychiatry in South Carolina.

Examples of Telemental Health Programs Focused on Racial and Ethnic Populations that Experience Health Inequities

  • The Madison Outreach and Services through Telehealth (MOST) Network provides counseling services to the growing Latino population of rural Brazos Valley in Texas. Counselors at Texas A&M University offer psychotherapy to patients in rural clinics via telephone and live video. Local community health workers help facilitate telehealth appointments by transporting residents to rural clinics and providing other outreach services.
  • The Arrowhead Telepresence Coalition increases access to behavioral healthcare in seven rural Minnesota counties and three tribes. The coalition contracts with a range of providers, such as chemical dependency specialists and pharmacists, to provide virtual appointments for diagnosis and treatment at county jails, schools, rural hospitals, community health centers, crisis response centers, and tribal health and human services agencies.

Examples of Programs Focused on Children

  • The University of Kansas Medical Center's Telehealth ROCKS program offers a range of telebehavioral health services to rural children and their families. Providers from the University of Kansas connect with children and their families through live-video telehealth at schools and primary care practices, including community health centers. Telebehavioral services include parenting programs, therapy, medication management, behavior analysis, and assessments, including autism assessments and psychological evaluations. In addition, Telehealth ROCKS is using Project ECHO to build the capacity of rural providers, school personnel, and other child-serving systems to manage behavioral health conditions among children.

Examples of Programs Focused on Veterans

  • Alaska Veterans Telehealth and Biofeedback Services uses telehealth and provides veterans with trauma-informed treatment services. Veterans enrolled in the program take an 8-week stress reduction training that uses biofeedback to address trauma. Veterans can also access ongoing counseling services to receive treatment for depression, anxiety, PTSD, and other physical and emotional concerns.
  • The Indiana Veterans Behavioral Health Network connects rural veterans at community mental health centers to providers at the VA Medical Center for diagnosis and treatment.
  • Another rural pilot project assessed the Telepsychology-Service Delivery for Depressed Elderly Veterans intervention, which used in-home videoconferencing technology to provide psychotherapy to participants. The pilot found no significant differences between the outcomes of the control group, which received in-person care, and the telehealth group. The in-home telehealth intervention was successful in reducing the symptoms of depression among the participants, who lacked access to in-person care due to transportation and mobility issues.

Examples of Programs Focused on Older Adults

Implementation Considerations

The American Psychiatric Association (APA) and the American Telemedicine Association (ATA) have developed official guidelines and resources for advising programs that are implementing telemental and telebehavioral care. Together, the organizations released the Best Practices in Videoconferencing-Based Telemental Health. These best practices describe comprehensive administrative, technological, and clinical considerations for providing behavioral and mental health services through videoconferencing technology.

APA also offers an extensive online Telepsychiatry Toolkit with considerations for training, legal issues, and clinical practice, including a discussion of telemental health in rural and remote practice settings. In 2021, the Substance Abuse and Mental Health Administration (SAMHSA) also released Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders, which provides a comprehensive overview of the evidence base and provides examples of rural telemental health programs.

The Telehealth Resource Centers also provide helpful resources and tools for rural communities seeking to implement or expand telemental and telebehavioral health programs. For example, the Mid-Atlantic Telehealth Resource Center hosts the Telebehavioral Health Center of Excellence, which offers a wealth of information to help programs implement or expand telebehavioral health services.

Additional considerations by topic area include:

  • Safety planning – Providers often work with patients and their families to ensure that patients are supported in the event of a mental health crisis. Safety planning can involve creating a physical document that identifies triggers, warning signs, coping strategies, and potential interventions. Rural communities that offer home-based telebehavioral or telemental care should be aware of the importance of safety planning in case of an emergency.
  • Workforce challenges – Some rural programs have experienced challenges with engaging and retaining behavioral and mental healthcare providers to offer telehealth services. Several rural programs addressed this challenge by partnering with psychiatry and psychology programs at medical and graduate institutions in their states. These telehealth partnerships allow future mental health providers to gain experience practicing in rural healthcare settings while completing clinical practice requirements. Researchers at the University of Washington developed a comprehensive set of considerations and recommendations for developing telemental health partnerships between state medical schools and Federally Qualified Health Centers.
  • Stigma around behavioral and mental health conditions – Rural programs offering telemental health services may experience challenges with stigma. For example, rural residents might feel discouraged from seeking help for behavioral health due to stigma associated with mental illness and perceived lack of privacy or confidentiality. Additional issues related to stigma are described in the Primary Care Behavioral Health Model of the Rural Services Integration Toolkit. Rural organizations that offer telemental care may choose to emphasize the integrated nature of their services and ensure that patients have private and confidential spaces to meet with remote providers.
  • Confidentiality – Some rural programs report that patients prefer receiving telemental health services over the telephone instead of through video. Rural programs may also consider the possibility of making counseling and other services available through text messaging, which can also address connectivity issues that arise from limited broadband availability.

Additional implementation considerations including licensing and reimbursement are discussed in Module 4: Implementation and Module 6: Funding & Sustainability.

Program Clearinghouse Examples

Resources to Learn More

Center for Technology and Behavioral Health
Website
Reviews the evidence base for treating substance use disorders and co-occurring disorders using technology, and describes innovative uses of technology to address these disorders and other behavioral health conditions.
Organization(s): Center for Technology and Behavioral Health (CTBH)

FQHC Webinar Series Part 3 – Telehealth And Mental/Behavioral Health
Video/Multimedia
Provides Federally Qualified Health Centers (FQHCs) with resources and suggestions for delivering mental and behavioral healthcare through telehealth.
Author(s): Neufeld, J., Steffensen, A., & Weatherill, S.
Organization(s): National Consortium of Telehealth Resource Centers (TRC), HORIZON Health Care
Date: 8/2019

Practice Guidelines for Telemental Health with Children and Adolescents
Document
Includes considerations for providing behavioral and mental health services to youth through real-time videoconferencing.
Author(s): Myers, K., Nelson, E.L., Rabinowitz, T., et al.
Location: Telemedicine and e-Health, 23(10), 779-804
Date: 10/2017

Rural Behavioral Health: Telehealth Challenges and Opportunities
Document
Discusses ways that rural communities are using telehealth to address behavioral health continuum of care. Identifies challenges and opportunities to implementing rural behavioral health services via telehealth. Addresses differences in state policies for telemedicine coverage through private insurance.
Organization(s): Substance Abuse and Mental Health Services Administration (SAMHSA)
Date: 2016

Telebehavioral Health Strategies for Rural Hospitals & Clinics
Video/Multimedia
Presents information on the provision of behavioral health services through live interactive video. Reviews billing considerations and the regulatory environment for these services. Identifies sustainable telebehavioral models for integrating into rural primary care and hospital settings, and addresses challenges to implementing telebehavioral health programs.
Author(s): Neufeld, J.
Organization(s): National Consortium of Telehealth Resource Centers (TRC)
Date: 5/2018

Telehealth Tips: Managing Suicidal Clients During the COVID-19 Pandemic
Document
Provides basic guidelines and other considerations when treating patients with suicidal ideation or intent using telehealth interventions. Discusses assessing suicide risk, clinical management, safety planning, follow-up and monitoring, and documentation.
Organization(s): Center for Practice Innovations
Date: 2020

The Use of Telehealth Within Behavioral Health Settings: Utilization, Opportunities, and Challenges
Document
Analyzes data collected from behavioral health providers across the U.S. to describe challenges specific to providing telehealth in rural and underserved communities.
Author(s): Mace, S., Boccanelli, A., & Dormond, M.
Organization(s): School of Public Health Behavioral Health Workforce Research Center, University of Michigan
Date: 3/2018

Using Technology-based Therapeutic Tools in Behavioral Health Services
Document
Describes the use of technology in providing behavioral health services. Covers case studies of telebehavioral health programs, including a rural telephone- and videoconference-based intervention for substance use disorders.
Organization(s): Substance Abuse and Mental Health Services Administration (SAMHSA)
Date: 2015