Closing the Distance: The Integration of Technology and Collaborative Care to Improve Outcomes of Patients with Mental Illness in Rural Areas

by Christina J. Ansted, MPH, CCMEP

What is rural? Depending on whom you ask, the definition of rural differs. Most people think of a sparsely populated area with few conveniences, like shopping centers and large supermarkets, which many of us consider essential. There are more than 15 definitions of rural used by the federal government (see Table 1). However, the notion of rural extends beyond just population density. Other factors such as socio-demographics, access to care, social networks, and culture can impact the definition of a “rural” area. It is also important to note that not everyone living in a particular county or zip code is to be considered rural; some people living in urban areas may be very rural, and some people living in rural areas may be very urban.

The demographic differences between urban and rural patients can be seen in socio-economic presentations such as lower incomes, lower education levels, and higher age ranges typically associated with a rural population.(1,2,3) Level of education in a rural area is an important point to consider when providing explanations to patients regarding medication side effects, treatment plans, and/or patient education materials. Level of written and verbal ability, inclusive of language barriers, can also hinder patient understanding, thereby compromising adherence to treatment regimens. While some rural patients may be very well educated, there must be sensitivity on the part of rural healthcare providers to recognize those patients who may not understand directives regarding maintenance of therapy, and who may require additional time with the physician or case manager to assure comprehension of the treatment plan.

Role of Social Networks
An important factor in how patients seek and react to healthcare in rural areas is the concept of the social network. In rural areas, social networks tend to be smaller, denser (i.e., most everyone in the network knows each other) and exist for a longer duration (i.e., extended families and individuals who live in an area for a long period of time). In rural areas, social networks can have a profound effect on how patients perceive their illness (for better or worse), can influence patients to seek care or to avoid it, and can sometimes also serve as a network for substitute services (e.g., home remedies or home-spun theories on how to “fix” depression). The “extended” or long-term network arrangement also leads to a lack of anonymity in rural communities and increases the probability that someone who seeks mental health care will be labeled "crazy.”(4) The rural culture supports self-reliance, and a propensity to seek “alternative” or informal methods of care like faith-supported interventions, or non-traditional healers.

Barriers to Optimal Care
A main barrier to care in the rural environment is the presence of stigma. Stigmatization can come from three main areas: public, provider, and self-stigma. Public stigma is the public’s perception of a particular illness or the reaction to individuals based on beliefs formed from a collective of peers or from the media, and can perpetuate beliefs of prejudice and discrimination. Provider stigma is when providers may have a preconceived idea about a particular patient population and treat that population differently as a result, which is indicative of healthcare disparities in clinical practice. Provider stigma can also be associated with disease; for example, the reluctance of some healthcare provides to treat mental disorders, and the resulting poor quality of care those patients occasionally receive. Self-stigma is the idea of internalized, self-imposed beliefs that one is “different” or “has problems” and encourages the inclination to avoid seeking help (i.e., avoidance of social settings or not telling someone about a mental illness for fear of being branded “crazy” or being ostracized). This type of stigma is perhaps the most dangerous as it’s the first barrier to prevent a patient from seeking care. Persons living in most rural environments are more likely to hold stigmatized attitudes toward mental healthcare and these views are strongly predictive of willingness to seek care.(5)

Healthcare providers most often on the front lines of rural medicine are primary care providers (PCP). Patients in rural areas are more likely visit their local PCP before seeing a specialist, especially for mental health concerns. In a webcast presented by CME Outfitters, LLC, on the improvement of healthcare in rural populations, program faculty John Fortney, PhD, commented that "The most promising approach to improving mental health (MH) outcomes is to support rural primary care providers in their delivery of evidence-based treatments." This means that in terms of mental health services, primary care providers need to be able to effectively prescribe psychotropic drugs in accordance with evidence-based recommendations and available clinical guidelines. "Psychotropic medications prescribed by primary care providers are just as effective as medications prescribed by psychiatrists," said Dr. Fortney.

Collaborative Care and Telehealth Strategies
The underlying theme for the improvement of mental health in rural areas is collaborative care—a method for providing healthcare to patients that involves the interdisciplinary approach between medical teams, patients, and families. In the care of patients with mental illness in rural areas, collaboration must exist principally between primary care providers and psychiatrists. But how do you collaborate with a colleague who is 600 miles, or even 3,000 miles away, when you are in an isolated area? The answer is in the integration of technology, more specifically, telehealth, where telemedicine-based collaborative care involves off-site mental health specialists collaborating with rural primary care providers via telephone, Internet, electronic medical records, and interactive video.(6)

The Institute of Medicine defines telemedicine as "the use of electronic information and communications technologies to provide and support health care when distance separates the participants." Current technologies include the use of phone and cell phone interactions and the use of the Internet for providing patient education. However, one of the most successful modalities is the use of video conferencing. Many treatments such as psychotherapy and pharmacotherapy via interactive video are equivalent in terms of success rates when compared to face-to-face interactions.(7,8) In addition, there is diagnostic reliability when using interactive video, and patients have felt similar satisfaction between interactive video and face-to-face interactions.(9-12) An interesting point regarding interactive video is the idea of increased privacy. There is no danger of running into anyone who might know you as you’re leaving a psychiatric office, and the only people in the room are you and your doctor. For many rural patients, this type of confidentiality can mean the difference between receiving regularly scheduled care, especially appointments for recurring therapy, and falling through the cracks.

It is also important to consider the value of telehealth for urban locations. Privacy and confidentiality concerns are just as important in urban areas as in rural ones. And telehealth could be a method of reaching those patients who avoid in-person office visits. Telehealth can also provide a solution for those patients who have limited mobility, or for whom transportation is an issue. Living in a city or densely populated area does not necessarily imply that you aren’t isolated or aren’t at a substantial distance from your healthcare provider. Patients who are at a considerable distance from healthcare facilities may be hindered from getting care (e.g., by problems with child care or elder care or lack of transportation) and from accessing medication, special equipment, and other healthcare services associated with healthcare, such as occupational therapy, rehabilitation care, or home care.(13) It therefore stands to reason that the further a patient has to travel to receive care, the less likely he or she will do so.

The benefits of telehealth far outweigh the modest costs. Upfront costs include the purchase of interactive video equipment and monthly Internet fees, but the expected return on this investment is high. Telemedicine-based collaborative care for depression is superior to usual care, and telemedicine-based collaborative care for depression is superior to practice-based collaborative care in environments without mental health specialists (e.g., rural-based primary care (PC) practices).(14) In addition, the expanded opportunities for telehealth include such innovations as virtual Assertive Community Treatment (ACT) teams, training and workforce support, interactive peer support, and around-the-clock distance monitoring of critically-ill patients.

Integration of Telehealth into Clinical Practice: Key Points

1. Telemedicine can change the dynamics of rural healthcare.
2. There are advantages of telemedicine-based collaborative care in both rural and urban settings.
3. Unique challenges associated with caring for people in rural locations can be overcome with technology.
4. Telehealth counseling can be as effective as face-to-face counseling.
5. Even 5 minutes of time from primary care providers via electronic media can help people with mental illness.

• Agency for Healthcare Research and Quality (AHRQ) - Improving health care for rural populations. Available at http://www.ahrq.gov/research/rural.htm
• Rural Assistance Center (RAC). Available at http://www.raconline.org/info_guides/mental_health
• Health Resources and Services Administration (HRSA) - Telemental Health: Delivering Mental Health Care at a Distance, A Summary Report. Available at http://www.hrsa.gov/telehealth/pubs/mental.htm

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