Public Health Strategies for Rural Child Mental Health: Policy Brief

Telemedicine is the general use of technology to provide health services, and telemental health refers to mental health services provided at a distance.7

Telemental health could increase access for all rural Americans by allowing the existing mental health workforce to reach people who don't have access to in-person services.

While telemental health has been used more with adults than children, pediatric use is increasing.6Although telemental health is a promising option for expanding access to care, there are some barriers to widespread adoption and use (including pediatric use).

Insurance coverage for telemedicine

Telemedicine services are governed by federal and state laws, and regulation varies considerably because each state defines telemedicine services differently. These definitions determine the services that qualify for reimbursement under Medicaid and private insurance.8

The Centers for Medicare and Medicaid Services (CMS) encourages states to "use the flexibility built into Medicaid to create innovative payment methodologies for services that incorporate telemedicine technology."9 Here are examples of how some states handle payment:

• 48 states and the District of Columbia provide some level of Medicaid reimbursement for telemedicine. 10
• 39 states have some form of Medicaid coverage and reimbursement for telemental health services. 1112
• On the private payer side, 32 states and the District of Columbia have private payer policies in place for telehealth. However. these policies differ considerably in which services are covered and how much providers are reimbursed.813
• 23 states and the District of Columbia require that payments for telemental health services be equivalent to those received for in-office treatment.14

Some evidence shows that when telemedicine is not reimbursed or is reimbursed at a lower level than in-person services, providers may not have sufficient financial incentives to provide telemedicine services. 15To increase adoption of telemedicine, states could consider adopting private payer parity laws.16 More research is needed to determine the effect that parity laws may have on the adoption and use of telemental health.

Licensure requirements

Each state establishes licensure requirements for healthcare professionals who practice within their borders. The unique nature of telemedicine services could allow doctors and mental health providers to easily provide services across state lines. However, many states' licensure requirements limit this possibility.

These licensure laws cover physicians as well as psychologists, social workers, nurses, and pharmacists. 17Some evidence suggests that adding licensing requirements for professionals who practice across state lines may slow or limit the expansion of telemedicine technologies by some healthcare facilities.16

To deal with this emerging issue, states have established several options for licensing telemedicine practitioners:

• Eight states accept conditional or telemedicine licenses from out-of-state physicians.
• Three states have established registries that permit qualifying out-of-state physicians to practice in the states.
• 18 states have adopted the Federation of State Medical Boards' compact. This "enforces an expedited license for out-of-state practice" for doctors, including psychiatrists. 18
• Similar multistate agreements that would include other mental health professionals, such as psychologists, are in the early stages of development.14

Evidence of effectiveness

Evidence suggests that telemental health services can be effective for underserved populations, such as rural Americans.19 Telemental health can also:

• Effectively treat underserved children with specific conditions, such as ADHD.20
• Meet the broader behavioral health needs of children and adolescents.
• Successfully meet the psychiatric needs of rural children.21

Although these studies demonstrate effectiveness for these specific populations, more evidence is needed to support the use of telemental health for the broader population of rural children with MBDDs. In rural areas, adoption of new interventions and methods often outpaces research into the potential effectiveness of expanding those programs.22

More rigorous research into these innovative approaches can expand the evidence base and may increase adoption of telemedicine services and interventions for treating rural children with MBDDs.

Challenges

Privacy. Providers must ensure that patient privacy and confidentiality are maintained at the same level as with an in-person visit. 23

The Health Insurance Portability and Accountability Act (HIPAA) created "national standards to protect individuals' medical records and other personal health information (PHI)."24 Telemental health providers handling PHI must follow the same HIPAA requirements as for in-person meetings. 25

Cost. The cost of telemedicine technology may limit adoption. These costs include:26

• Equipment and installation of telecommunications lines.
• Rental cost of telecommunications lines.
• Salary, wages, and administrative expenses.
• Data transmission costs, service fees, and maintaining and upgrading equipment.

Research shows that integrating mental health and primary care services can improve health outcomes. Integrated care may be an effective approach to caring for patients with multiple, complex healthcare concerns.27

Research has shown that practices that implement a collaborative, fully integrated model for primary care and behavioral health:

• Improve children's behavioral health outcomes. 28
• Improves measures of accessibility and acceptability.28
• Improve symptoms, increase retention rates, and improve access for children with serious emotional disturbance.29
• Increase access to mental health services in rural areas.30

SAMHSA framework

Integration can take many forms, but there are common features. The Substance Abuse and Mental Health Services Administration (SAMHSA) proposed a standard framework for integration.

The SAMHSA framework has three categories of collaboration (coordinated, co-located, and integrated care) and two levels of development within each category. 31The framework focuses on elements of communication, physical proximity, and practice changes.31 However, some or all of these elements may not be feasible in rural areas where specialists can be scarce.

This framework assumes that there are enough mental health providers and support staff to successfully execute these categories of collaboration. Larger metropolitan areas may be better able to provide mental health professionals and support staff. Rural healthcare providers and practices may find it more difficult to integrate in these traditional ways.

In addition, traditional models can rely on separate professionals providing discrete services. While this may be possible under some conditions, in some rural areas, shortages and poor distribution of behavioral health professionals could make it difficult for primary care physicians to get a consultation or make a referral.32 In rural and urban areas, primary care physicians will continue to be frontline providers of mental health services.

Roughly 65% of rural residents get treatment from a primary care physician for their mental health issues.32 There are successful models for integrating behavioral health services into primary care practice where primary care physicians are trained to use evidence-based practices to screen for and treat conditions such as depression.33

While this model may be a more feasible way for rural physicians and practices to combine services, there are still challenges for this type of integration, including physician time constraints and ensuring that the quality of care that patients receive is comparable to care received from a mental health professional.

Another challenge is providing primary care physicians with the training and support they need to feel more comfortable diagnosing and treating pediatric patients who present with MBDDs.34

School-Based Health Centers (SBHC) provide a model that may address the issue of children's mental health access in rural areas. With SBHCs, an interdisciplinary team of health professionals deliver health care to children on-site at school. These teams can include primary care and mental health clinicians.35

From 2013 to 2014, there were an estimated 2,315 SBHCs located across the United States, with 34.6% of these facilities located in rural areas.36 Since schools are the center of services and activities in some rural areas, SBHCs can leverage their influence and work with communities to improve children's mental health.37

SBHCs typically have the following characteristics:38

• SBHCs provide primary health care and may also provide mental health care, social services, dentistry, and health education.
• Services may be available only during some school days or hours, and they may also be available in nonschool hours.
• Student participation requires parental consent, and services for individual students are sometimes limited for specific types of care, such as reproductive or mental health.
• SBHCs may provide services to school staff, student family members, and others within the surrounding community.
• Services are often provided by a medical center or provider independent of the school system (such as a federally qualified health center or academic institution).

Scope of mental health services

SBHCs can provide services for children with MBDDs. According to an SBHC census conducted by the School-Based Health Alliance, SBHCs screen for the following:

• Depression
• Anxiety
• Social skills
• ADHD37

SBHCs can monitor medication, review medical records, and assist in Individualized Education Plans (IEPs) that children may need.

Additionally, SBHCs can assist in providing care for children with special health care needs. These children are at a higher risk for chronic, physical, and emotional conditions, and they typically require more services. Common issues for these children include ADHD, anxiety, and autism spectrum disorder.

Accessibility

Although there are more urban students enrolled in SBHCs, one study found that rural students utilize all SBHC services, including mental health services, at a higher rate.39 SBHCs also utilize telemedicine to increase their accessibility and improve health care utilization.3915.8% of rural SBHCs use telemedicine services.40 Parents of students can participate in services such as health education classes or receive information about community events.41

A study conducted in Oregon estimated the cost of operating an SBHC. The study found that the cost of starting an SBHC ranges from $49,750 to $128,250. The average operating cost ranges from $90,750-$152,750 for a SBHC operating during the nine-month school year. The main source of revenue for SBHCs sponsored by Federally Qualified Health Centers (FQHC) was billing. SBHCs with this particular sponsorship were able to cover an average of 26% of their operating costs.4243

SBHCs have also shown financial benefits. Studies have found that SBHCs produce annual benefits "between $15,028 and $912,878 per SBHC in averted costs related to treatment, productivity losses, and transportation, combined with other relevant benefits."38

Additionally, studies have also shown net savings to Medicaid ranging from $30 to $969 per visit or $46 to $1,166 per user. The range in the savings are due to the different services that a SBHC can offer.38

To operate SBHCs, it's important to consider the funding and financing sources. Some federal government funding sources may include the following:

• School-Based Health Center Capital Program (HRSA)
• Section 330 Public Health Services Act (PHSA): FQHC Funding
• Title X PHSA: Family Planning.

Funding may also happen with support at the state and local level through county and city governments as well as school districts. Corporations and private foundations are also possible funding sources.36

Additionally, Medicaid and the State Children's Health Insurance Program (SCHIP) have been common sources of financing for SBHCs.36 In December 2014, the Centers for Medicaid and Medicare Services (CMS) drafted a letter that allows for schools to be able to bill Medicaid for services they provide. This policy is known as the Free Care Rule Reversal.44 In order for schools to be able to bill for Medicaid, it must be included in their Medicaid State Plan.

Though SBHCs are promising, these facilities may face challenges related to the following issues:

Capacity for primary care. A common issue is that these facilities may not be able to serve as primary care facilities.35 Since SBHCs typically operate during school hours, they may not be able to provide care before or after the school day. Holidays or breaks when schools are not in session may also affect care.35

Funding. One study notes that despite the variety of funding sources to run a SBHC, they struggle to provide care for all students regardless of if they have Medicaid or another insurance provider. The "volume of currently nonreimbursable educational and preventive services SBHCs provide" may affect the SBHCs' sustainability.35

Privacy. As with telemedicine, privacy regulations may affect SBHCs. SBHCs require parental consent in order to obtain services. There are laws such as Family Educational Rights and Privacy Act (FERPA), which protects "the privacy of student education records" and HIPAA, which protects "individuals' medical records and other personal health information."45

Evaluation. SBHCs may be difficult to evaluate based on limited resources. Additionally, studies have noted that the evaluation method is complicated by "difficulty in establishing randomized control designs, confidentiality and consent concerns, diverse school environments, small sample sizes, and attrition within school populations."35

Project ECHO (Extension for Community Healthcare Outcomes)

Project ECHO is an innovative program to train primary care physicians to perform enhanced services.46 Project ECHO connects specialists and primary care physicians via videoconferencing in order to build knowledge and support for providers who see patients with complex conditions, including behavioral health issues. Project ECHO has 75 hubs in the United States.47

In Oregon, Project ECHO is training primary care physicians to better care for children with mental health issues. The Oregon Health and Science University is training providers to diagnose and manage these patients. The program, which includes 18 sites around the state, establishes weekly live video sessions that provide lectures and case reviews with child psychiatry specialists. The session topics include ADHD diagnosis and management, depression diagnosis and management, and prescription of psychotropic medications.48

Overall, Project ECHO has shown promise for expanding and improving care in rural areas, but more research is needed to evaluate outcomes. In 2016, Congress passed the Expanding Capacity for Health Outcomes (ECHO) Act. This legislation is intended to integrate "technology enabled collaborative learning and capacity building models" such as Project ECHO into more health systems. The law requires a study by the Department of Health and Human Services on the models' effect on workforce development and patient care, specifically the "impact on addressing mental and substance use disorders, chronic diseases and conditions, prenatal and maternal health, pediatric care, pain management, and palliative care" and "the delivery of health care services in rural areas, frontier areas, health professional shortage areas, and medically underserved areas."49

Westside Park Elementary School Health Center

In 1995, Westside Park Elementary School in Adelanto, California, was able to open an SBHC with funding they received from HRSA. Through the 15 years of operation, the SBHC has been able to work with the Adelanto Unified School District to obtain support for the facilities and services. This school also has a partnership with the state school-based health agency, California School Based Health Alliance.

The SBHC serves about 1,300 patients a year "providing basic medical care, immunizations, dental screenings, and counseling services." A bilingual counselor is also present. As transportation is an issue for the residents of this community, the SBHC has a van to transport children to health services such as dental appointments. This school has worked with partners ranging from San Bernardino County Public Health to local agencies such as the food bank. Since opening, the leadership of the SBHC has learned that partnerships are needed to sustain the SBHC.50

Southwest Open School (SWOS) School-based Health Center

Bordering Ute Mountain Ute Reservation and the Navajo Reservation, the Southwest Open School has had a SBHC for 12 years. According to a report from the Colorado Association of School-Based Health Care, SWOS is "the only health care safety net for underinsured/uninsured adolescents in the Montezuma-Cortez school district." A lesson learned from this SBHC is the need for multitasking. Staff in the SBHC often fill multiple roles such as providing patient care, writing grants, and operating the center. Additionally, it was noted that staff such as nurses filled multiple roles.51