• Printer-friendly Telemental Health: Delivering Mental Health Care
  at a Distance (473 KB)

Henry A. Smith, LCSW
Ronald A. Allison, MA
October 2001

Disclaimer
This document was prepared by the authors under an Interagency Agreement between the Substance Abuse and Mental Health Services Administration (SAMSHA) and the Health Resources and Services Administration (HRSA). The views expressed in this report are those of the authors and do not necessarily reflect the views of SAMHSA, HRSA, the Public Health Service or the Department of Health and Human Services.

Foreword
The provision of mental health services in America's rural and frontier areas remains a critical health services challenge. Telemental health - the provision of mental health services from a distance, using telecommunications technologies - is increasingly helping to surmount that challenge.

This report is a joint effort of the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (SAMSHA) and the Office for the Advancement of Telehealth, Health Resources and Services Administration (HRSA). It was produced to inform Federal, State and local mental health administrators about options for utilizing telecommunication and information technologies to improve the delivery of mental health services to rural and frontier populations.

Since the re-emergence of telemedicine programs in the late 1980's, telemental health services have consistently been one of the top three most frequently provided health services using telehealth technologies. In 1998-99, over 61 programs in 35 states were delivering telemental health services. Telemental health services are bridging the health services access gap not only for those who traditionally have had limited access to mental health services, in particular those in rural and frontier areas, but also for those who because of mobility problems, poverty, or incarceration have limited access to health care services.

Telemental health services are being delivered in a range of settings -- rural primary care clinics, hospital emergency rooms, community mental health centers, schools, and nursing homes. They are also being delivered directly into homes as well as on board Navy ships and in jails, and state and federal prisons.

Telemental health technologies are being utilized to provide the full range of mental health services, including pre-admission and discharge planning, assessments and evaluations, case management, medication management, family visits, pyschotherapy, court commitment hearings, and family and consumer support groups. These technologies also provide a means to train mental health providers for rural practice. In some states, the one-year clinical internship of master's level prepared social workers is supervised via telehealth technologies. The use of these technologies for continuing education and in-service sessions is also providing access to educational opportunities that have been limited in rural areas.

Increasingly, state and local agencies responsible for mental health services are exploring the use of telehealth technologies to assist them in delivering services to rural and frontier populations and meeting their mandates. Some have begun to invest in telehealth technologies or provide payment for services delivered via telehealth. We hope that this report will assist policy makers, as well as mental health professionals and consumers, as they explore how to effectively utilize these technologies, integrate the technologies into their practices, or advocate for their use to enhance access to services.

For mental health care providers and consumers in rural and frontier America, the future is now. Interactive telecommunication and information technologies make it possible for mental health providers to literally be in two places at once, extending scarce resources to individuals, and to entire regions, that are medically underserved.

Telecommunication technologies have been used for some 40 years to provide limited mental health interventions, mostly on an experimental basis. Beginning in the 1990s, however, the use of interactive telecommunication technologies flourished. The number of telemedicine programs in the United States grew from nine in 1993 to over 100 in 1997, and most of them provide mental health services. The seven most active telemental health projects in the nation, highlighted in this report, conducted approximately 70% of all the telemental health service contacts reported by the 50 most active projects in 1996.

The range of mental health services provided to rural consumers over a telemental health network is virtually limitless. At the present time, it appears that all traditional mental health services, which do not involve direct physical contact with the client, can be provided by telemental health. Telemental health networks are also used for education and training for mental health staff, and to bring consumers and family members together for information and support.

In some situations, telemental health services may be superior to face-to-face services. For example, telemental health allows a psychiatrist to observe a patient close up, without invading his or her personal space. This makes it easier to examine a patient for side effects of psychotropic medications.

Telemental health applications also enhance continuity of care for consumers in rural areas. With telemental health, a "virtual treatment team" can be formed between the community and the inpatient psychiatric facility staffs. Consumers can be followed in the community by the same physician who treats them in the hospital, and family members can be involved in treatment and discharge planning.

Much of what is known about the impact of telemental health comes from the combined experience of staff and consumers who operate and participate in these networks. Though no rigorous outcome studies have been done to date, informal findings suggest that telemental health improves continuity of care for rural consumers, increases family and consumer involvement in treatment, and reduces lengths of stays and readmission rates to state psychiatric facilities. Participant satisfaction surveys reveal that consumers perceive telemental health services as worthwhile, of high quality, and worth continuing.

The introduction of telemedicine into a rural mental health care program requires leadership, vision, and authority. Typically, there is a consortium of member sites, comprised of decision-making personnel, that meets on a regular basis to oversee the development, management, and growth of the network. This group identifies the consumers to be served, designs the clinical system, determines staffing levels, creates informed consent and confidentiality procedures, and researches technological issues. Front-line staff meet to share practical knowledge and suggestions.

Start-up costs for a telemental health network are becoming more affordable due to decreasing equipment costs, and are therefore now within reach of most rural mental health programs. Indeed, in many cases, providers will find it more cost-effective to join a network than to purchase an automobile to transport mental health consumers to distant service providers. However, the single biggest limitation on the use, expansion, and long term sustainability of telemental health systems is often the ongoing telecommunication costs.

The type of telecommunication service(s) available from telephone companies will dictate network design and cost. In many rural areas, advanced transmission technologies or services, such as Integrated Services Digital Network (ISDN), are not yet available. Also, transmission charges are often more expensive in rural areas because many transmission rates are distance-based.

The more advanced the transmission technology, the greater the bandwidth a telecommunications system will have available. Bandwidth refers to the information-carrying capacity of the telecommunications channel (i.e., the size of the pipeline that carries the video and audio signals). At higher bandwidths, picture and sound are transmitted more quickly and with better quality. Lower bandwidth systems are more affordable, but they create noticeable lags in video and audio transmission that may negatively impact the service applications.

Ongoing expenses often prove to be a barrier to continued operation of a telemental health network. In response, many programs form alliances to gain a broader base of support, and network members share the costs for equipment, maintenance, personnel, and transmission systems. Federal, State, and private funds, and third-party reimbursement and service contracts, help sustain these vital efforts.

Telemedicine, and in particular, telemental health networks, have the potential to diminish the disparity of mental health care based on population density characteristics. However, additional funding is needed to support research into the effectiveness of telemental health programs, and to enable additional areas of the country to benefit from this new tool for mental health service provision.

Rural Characteristics
Telemedicine, and in particular, telemental health networks, have the potential to diminish the disparity of mental health care based on population density characteristics. Rural and frontier communities typically are the last areas to receive advances in mental health care, such as newer antipsychotic medications or specialized treatment programs.

Funding of the public mental health care system is often based on population size, which limits the amount of money available to develop an adequate continuum of care in less populated areas. Further, psychiatrists are usually located in urban areas, leading to a scarcity of services for people with serious mental illnesses in rural communities.

The use of telecommunication technologies to provide rural mental health services offers the following benefits:

Extending scarce resources into geographic areas of service need, Improving existing services, and Creating new services and applications that are unique products of the use of this technology.

Today, not only is it possible to access a mental health care provider located in an urban center, but within a rural and frontier region, a telemental health network can unite groups and organizations that have common goals and interests. These networks can be used to attract additional resources from outside the region, as well as to expand the boundaries of the rural/frontier mental health care village.

Key Definitions
Many of the key terms used throughout this report are defined in the Glossary. Several are worth mentioning at this point. In particular, the term "telemedicine" refers to the use of modern telecommunication and information technologies to deliver health care services at a distance. "Telepsychiatry" is the specific application of telemedicine to psychiatry.

A "telemedicine system or network" is an integrated health care network that uses modern telecommunication and information technologies to provide comprehensive health care services to a specific group. When the system-wide influence of these approaches is considered, the term "telemental health" is used in this report.

Telemental health has a broader mental health care systems meaning, and includes non-clinical applications, such as family and consumer support meetings, civil commitment hearings, case conferences, and prevention and education. A telemental health system uses interactive telecommunication technologies to integrate, within a region, a comprehensive array of mental health care services of related organizations.

National Telemental Health Leaders
The number of telemedicine programs has grown from only nine in 1993 to over 100 in 1997. Almost all telemedicine programs provide mental health services. In 1996, these services accounted for nearly a quarter of all telemedicine consultations or sessions conducted.

This report was produced primarily from the collective experiences of seven of the most active telemental health projects in the nation. These projects are:

• The Appal-Link Network of Virginia.
• The Menninger Center for Telepsychiatry (Kansas).
• The Eastern Montana Telemedicine Network.
• The University of Kansas Medical Center Telemedicine Services.
• VideoLink of St. Peter's (Montana).
• The Northern Arizona Regional Behavioral Health Authority.

These seven projects carried out approximately 70% of all of the clinician/patient telemental health service contacts reported by the 50 most active telemedicine projects in 1996.

The Summary Report
This summary report explores, in brief, the applications, accomplishments, and benefits of telemental health systems, particularly as they impact service delivery to people with serious mental illnesses in rural and frontier areas. The summary addresses:

• The history of telepsychiatry/telemental health and recent developments.
• Mental health services that are, or could be, provided with interactive telecommunications.
• Selected client and service system outcomes of telemental health services.
• Organizational, technological, and financial considerations involved in establishing a telemental health system.

Full Text Report
Readers who would like to explore this topic in more detail are referred to the full report Telemental Health: Delivering Mental Health Care at a Distance - A Guide for Rural Communities, which is available from the Office for the Advancement of Telehealth, HRSA. (An updated Summary Report will be available Spring of 2002.)

History
The first documented use of telecommunications technology to provide health care at a distance occurred in 1920 at Haukeland Hospital in Norway, where radio links were established to provide health care support services to ships at sea. It wasn't until the 1950s, however, under the pioneering efforts of Dr. Cecil Wittson and his staff at the Nebraska Psychiatric Institute (NPI), that telemedicine was used in the field of mental health.

The technology used by these early projects would be considered primitive by today's standards. The University of Nebraska designed a simple one-way closed circuit system using small black and white televisions for lectures and instructional purposes. More than 1,000 students at the Medical College of Nebraska received instruction via this network in the 1954-55 academic year.

The following year, the National Institute of Mental Health (NIMH) funded an interactive audio link connecting Nebraska Psychiatric Institute to seven hospitals in Nebraska, Iowa, and North and South Dakota. The Institute broadcast its weekly visiting lecturer series to the rest of the network and participants could ask questions to the lecturer in Omaha, allowing audience interaction with the site of origin for the first time.

With continued Federal funding, the University of Nebraska program expanded throughout the late 1950s and 1960s. Milestones included the first audio-visual interactive system in 1959, and the use of microwave technology to open a link in 1964 with Norfolk State Hospital, which was 112 miles away. This latter development meant that picture and sound could originate from multiple locations at either site. In the late 1960s, the Nebraska project linked the Veteran's Administration hospitals in Omaha, Lincoln, and Grand Island into the existing network.

In 1968, NIMH funded a project to develop a closed circuit link using two microwave relay stations between the Department of Psychiatry at Dartmouth Medical School and a rural hospital in Claremont, New Hampshire. The technology allowed for timely mental health consultation without moving the patient from his or her home environment. Also, for the first time highly trained technicians were not needed. Program staff, with limited technical training, could now operate these more "user-friendly" systems, eliminating the problem of down time due to technical difficulties.

In 1968, Dr. Thomas Dwyer expanded an existing telemedicine project at Massachusetts General Hospital to provide emergency psychiatric consults to staff at Logan Airport Medical Station in Boston, some 2.7 miles away. This project used a bi-directional television transmission system equipped with remote camera control that allowed the consulting psychiatrist at the hospital to pan, zoom, and focus the camera located at the remote site.

This capability helped psychiatrists observe physical and emotional nuances without invading an individiual's personal space (Baer, Cukor and Coyle, 1997). In particular, doctors reported that communication with adolescents, children, and certain patients with schizophrenia was easier than the conventional face-to-face interview process. For the first time, the technology was said to be more effective with these groups than the established "best practice" model.

Lessons Learned
Several important lessons emerged from the early telepsychiatry projects. Most important, consumers and physicians found the new technology both useful and comfortable.

Further, these early projects tested some new applications that were found to be effective, such as psychiatric evaluations, family member visitations, and pre-discharge planning.

They also addressed potential roadblocks to widespread acceptance of telepsychiatry, including:

• Initial hesitancy of staff members to use the technology;
• Technical problems such as sound pick-up and camera operations in larger groups;
• The high costs of equipment and transmission time.

Without continued external funding, however, these projects could not maintain the high costs of transmission and network support expenses. When Federal funding for these projects ended by the early 1970s, and third-party reimbursement options were not available, the programs were forced to close.

Recent Developments
The inauguration of telemedicine's third generation began in the late 1980s. Renewed Federal funding, the rapid advancement of telecommunication and computer technologies, and the introduction of managed care created opportunities to further investigate potential applications of this still-emerging technology. Seven current projects, and their key components, are outlined below.

Current Projects
Oregon's RODEO NET. The first of these third-generation projects in the field of mental health was Oregon's RODEO NET. The Eastern Oregon Human Services Consortium in La Grande received a three-year Rural Health Outreach grant in 1991 from the Federal Office of Rural Health Policy (ORHP), Health Resources and Services Administration (HRSA), DHHS. The grant enabled the Consortium to use a new statewide telecommunications system (Oregon ED-NET)--which offered the capability of videoconferencing via satellite and dial-up access to the Internet--for the delivery of mental health services, training, and information. By providing scheduling, protocols, procedures, evaluation and training, RODEO Net became the interface for providers to make use of the systems of the Oregon ED-NET.

Because there are many locations throughout Oregon with limited telephone transmission technology and access to the satellite network, RODEO NET broadened its reach by incorporating a mixture of satellite, microwave, and POTS (plain old telephone service)-based technologies. By using this combination of technologies, RODEO NET has been able to expand its services, which include psychiatric consultation, case management, and medication management, to a larger number of rural Oregonians.

The University of Kansas and the Menninger Center for Telepsychiatry. A study of rural health care needs at the University of Kansas Medical Center led to the implementation in 1992 of a state-wide interactive telemedicine network providing clinical and educational services for residents throughout the state of Kansas. Residents at more than 20 sites throughout Kansas--from group homes to hospitals and jails--have access to more than 200 specialists at the Medical Center.

The Menninger Center for Telepsychiatry in Topeka provides specialty consultation services via this interactive network and manages the adult and child/adolescent units at Providence Medical Center in Kansas City, Kansas, some 80 miles from the Menninger campus. The Menninger Center is also involved in distance learning and continuing education to other psychiatric and medical facilities across the nation.

The Eastern Montana Telemedicine Network. The Eastern Montana Telemedicine Network (EMTN) began as a cooperative effort among health care providers to research the potential of using two-way, interactive video conferencing technology to provide medical and mental health services throughout their region. Begun in 1993, EMTN has continued to expand its 11-site network providing a variety of clinical, educational, administrative, and community development services to the region.

A grant from the U.S. Department of Agriculture's Rural Electrification Administration (REA), now the Rural Utilities Service (RUS), funded the equipment for the original five sites. A three-year Rural Telemedicine grant in 1994 from the Federal Office of Rural Health Policy, HRSA allowed EMTN to expand. Telemental health services are the leading medical application from a wide array of other specialty areas that make EMTN one of the more comprehensive networks in the nation.

Northern Arizona Regional Behavioral Health Authority. In 1996, the Northern Arizona Regional Behavioral Health Authority (NARBHA) received funding from the Arizona Department of Health Services to develop a telemedicine system to enhance the delivery of behavioral health services throughout northern Arizona. NARBHA contracts with a network of community-based agencies that provide behavioral health services to adults, children, families, and people with serious mental illnesses in a 62,000-square-mile rural area with a population of 440,000.

The system, NARBHA NET, uses advanced technology capable of delivering two-way interactive video and audio, tape recordings, and numerous computer applications. Twelve video conferencing sites, including the Arizona State Hospital in Phoenix, participate, with at least four additional sites planned.

Video Link of St. Peter's (Montana). In 1994, the Federal Office of Rural Health Policy awarded a three-year Rural Health Outreach grant to St. Peter's Hospital Foundation in Helena, Montana, to develop an interactive telecommunications system within the region. VideoLink of St. Peter's (formerly Southwest Montana Telepsychiatry Network) serves a 12-county, 28,509-square-mile area with a population of 190,000. The service area has a population to psychiatrist ratio of 30,000 to 1.

VideoLink uses two-way, interactive compressed video technology within the project's six-site network, which includes Montana State Hospital in Warm Springs and Montana Developmental Center in Boulder. Collaboration with other existing networks has expanded access to 25 communities in Montana.

The Appal-Link Network (Virginia). The Appal-Link Network was created to improve access to psychiatric care in rural and remote areas of southwest Virginia. Funded as a three-year Rural Health Outreach demonstration project by the Federal Office of Rural Health Policy, Appal-Link began operations in 1995. Appal-Link is the first telepsychiatry network in Virginia and one of only six telemedicine networks in the nation dedicated exclusively to testing telecommunications technology to deliver mental health services at a distance.

Originally, the program served clients of the Cumberland Mountain Community Services Board in Cedar Bluff who were hospitalized at the Southwest Virginia Mental Health Institute in Marion. Within two years, all of the community service boards in the Institute's service area joined the network. The telemental health system uses compressed video and audio transmission over high-speed, enhanced telephone lines.

Increased Access to Mental Health Services
Though each telemental health project was developed to meet the specific needs of its area, they all were created to address a lack of mental health services, in general, and psychiatric care, in particular, to rural areas. Some, such as the Kansas University Medical Center and the Eastern Montana Telemedicine Network, offer a wide range of medical services, with telemental health being the primary application. Others, like Video-Link of St. Peter's and Appal-Link, are dedicated to mental health services and were developed to reach underserved populations.

A Full Range of Services. The range of mental health services provided to rural consumers over a telemental health network is virtually limitless and includes all of the same services that can be provided in-person. These include the following:

• patient evaluations
• case management
• edication management
• crisis response
• pre-admission and pre-discharge planning
• treatment planning
• individual and group therapy
• family therapy
• mental status evaluations
• court commitment hearings
• case conferences
• family visits
• family and consumer support groups
• staff training
• administrative activities

Substantial Benefits

The benefits of telemental health programs are substantial. Many patients in remote regions, who are now being seen via a network, would otherwise have gone unserved, or they would have had to leave their home communities to receive care, often at great cost to themselves or their families.

In addition, telemental health networks provide continuity of care for rural clients by allowing the community treatment team to monitor their progress in the hospital and to be involved in discharge planning. Also, the same psychiatrist who treats the patient while hospitalized can more effectively monitor his or her medication in the community.

Telemental health networks have enabled family members to speak with and see their loved ones who are receiving treatment in distant locations and to participate in treatment planning. Families also provide valuable support to one another over a telemental health network, creating a "virtual support group."

A Wide Range of Applications
Telemental health networks have enormous potential to provide a wide range of mental health services, provider education, and administrative functions. The next section outlines services that are, or can be, provided to rural areas using interactive telecommunications technology.

Traditional Mental Health Services
The types of telemental health services most frequently provided are those that replicate traditional mental health care. When scarce mental health care is delivered into remote areas of need, telemental health is "the next best thing to being there." In some situations, telemental health may be superior to face-to-face contact.

For example, telemental health allows a psychiatrist to observe a patient close up, without invading his or her personal space. This makes it easier to examine a patient for side effects of psychotropic medications. Also, in clinical interventions that focus on confronting an individual's destructive behaviors, or on revealing past abuse, telemental health creates a comfort zone for some consumers.

There is no mental health service currently being offered face-to-face that can't be delivered via telemental health. Some specific examples follow. However, like traditional mental health services, telemental health services may not be effective for every consumer. For example, a consumer with serious mental illness such as paranoid delusions focused on electronic monitoring, will need to be observed closely for his/her reaction to the use of this new tool.

Intake and Assessment
Professional staff at distant service locations can use a telemental health network to take social histories, conduct mental status examinations, and determine an individual's eligibility for ongoing services. The individual need only travel to a local site connected to the network.

Psychotherapy and Counseling
Rural service sites that do not have local therapists available can offer individual, marital, family, and group psychotherapy and counseling over a telemental health network. This is especially useful when individuals need a therapist who serves special needs, such as those of adult survivors of childhood sexual abuse or Vietnam veterans.

Crisis Intervention
Telemental health can bring the psychiatric emergency room to the consumer. A rural mental health consumer in crisis can be examined by a distant psychiatrist over a telemental health network. The psychiatrist can assess the need for medication changes and inpatient care. Community mental health staff and family members can participate, as well.

Medication Management
Telemental health has enormous potential in the area of medication management. Most notably, the same psychiatrist who treats an individual as an inpatient, or initially on an in-person outpatient basis, can provide long-term follow-up in the client's home community. The ongoing psychiatrist/consumer bond, maintained through telemental health, can eliminate unnecessary medication changes, reduce the need for readmission, and shorten the length of inpatient stays. Also, the treating psychiatrist can monitor a client's use of a new atypical antipsychotic medication, thereby ensuring equal access in rural areas to the most effective treatments.

Finally, telemental health extends the service range of nurse practitioners, physician assistants, and psychiatric clinical nurse specialists who serve rural areas and practice in consultation with psychiatrists to provide medication review clinics and manage difficult cases.

Tele-EAP Services
The Eastern Montana Telemedicine Network at the Deaconess Billings Clinic has contracted to provide an Employee Assistance Program to personnel of one of the network's participating hospitals. Strict policies govern confidentiality for counseling sessions. Tele-EAP services to private businesses and industries may be a potential source of revenue for telemental health networks.

Enhanced Service Delivery
Telemental health applications can also improve existing service delivery by enhancing continuity of care for consumers in rural and remote areas. With telemental health, a "virtual treatment team" is formed between the community and inpatient psychiatric facility staffs. Community and hospital staffs meet more frequently, have a closer working relationship, and understand the resources and limitations of each system. Family members can be involved in every step of the treatment and discharge planning process.

In addition, such collateral services as vocational rehabilitation, social services, and health care can be provided as part of a consumer's overall case management plan. Community providers can begin working with consumers even while they are hospitalized.

Telemental health can also support individuals living at home and in community residential programs. Some specific examples follow.

Family Visits
Telemental health removes cost and travel barriers for rural families. Family members can visit their loved ones who are hospitalized and make plans for their return home. These personal visits take place outside of more formal treatment and discharge planning conferences.

In-Home Services
The Menninger Center for Telepsychiatry in Kansas is using low-cost, "plain old telephone service" (POTS)-based video conferencing technology to provide medication management and case management services directly into the homes of people with serious mental illnesses. Daily "tele-home visits" help these individuals remain independent and avoid group home settings.

Programs of Assertive Community Treatment (PACT)
The PACT model of intensive, wrap-around community services for people with serious mental illnesses is in the forefront of many advanced mental health service systems. Central State Hospital in Petersburg, Virginia, and District 19 Community Services are experimenting with the use of telemental health to form a PACT team between community staff and the state psychiatric facility.

Support to Residential Programs/Group Homes
Individuals leaving state hospitals after many years may be difficult to place in private residential facilities. Locating telecommunications technology in a community home (e.g., a group home) provides round-the-clock support from staff at the inpatient facility and training and continuing education for the community-based staff. Ultimately, this allows the consumer to remain in the community.

Commitment Hearings
All states have involuntary commitment statutes that allow them to detain people with serious mental illnesses believed to be a danger to themselves or others. In rural areas, this often means that an individual has to be transported to a distant psychiatric facility for temporary detention pending a civil commitment hearing. The hearing may be held at the facility, or the patient may be returned to the local community for the commitment proceedings.

With the use of telemental health, a commitment hearing can take place over the network. The judge can either be at the distant facility, when there is no judge available in the community, or located in the community when state laws so require. Community staff, family members, and other necessary participants are able to participate in the commitment hearing.

Specialized Services
Specialized services are expensive to provide in rural areas to small numbers of individuals. However, using telemental health networks, providers can more economically offer a wide range of specialty services, such as forensic status evaluations, to rural clients. Programs for special needs include those featured below.

Services for Consumers Who Are Deaf and Hard-of-Hearing
The Appal-Link Network in Virginia provides interpreting services and case consultation to people with serious mental illnesses who are deaf and hard-of-hearing. Also, community staff receive training in how to work with these individuals. Previously, the specialist who provides these services covered an area of 15,000 square miles in her car.

Psychiatric Services to Rural Nursing Homes
By some estimates, as many as 70% of nursing home residents have a psychiatric disorder. Many of these patients are diagnosed with dementia, or with dementia concurrent with depression. By providing specialty psychiatric services via telemental health systems, the Menninger Center for Telepsychiatry in Kansas helps nursing home staff provide early intervention for behavioral problems, closer medication management, and continuity of care between inpatient and outpatient settings.

Services to Individuals with Mental Retardation
Many states still maintain residential institutions for long-term care of people with severe and profound mental retardation. As these facilities begin to downsize, telemental health systems can help facility staff, community providers, and family members plan for an individual's successful return home.

Substance Abuse Services
A regional substance abuse detoxification and residential treatment program (The Laurels of Southwest Virginia) screens potential individuals for admission over the Appal-Link Network. The program also uses the network to conduct treatment and discharge planning conferences, relapse prevention programs, and civil commitment hearings.

Services to Infants and Children with Special Needs
In rural and frontier areas, children with developmental delays and their parents have to travel great distances to consult with physical and occupational therapists, neurologists, and pediatricians. Telemedicine networks enable these services to be delivered to network sites closer to a family's home community. Programs in Texas, Georgia and Missouri are currently providing services using such networks. Also, when a child has to be hospitalized away from home, parents can visit by using a portable, video-conferencing system in the child's hospital room.

School-Based Telemental Health
Two telemedicine programs -- East Carolina University and the University of Kentucky -- have established rural school-based telehealth programs, and the University of Kansas Medical Center has established an inner-city school-based telehealth program. These programs enable children in medically underserved areas to access health and mental health services from the school nurse's office. In Kansas, Kansas Medicaid and Blue Cross/Blue Shield reimburse for services provided in the Tele-Kidcare program.

Education, Prevention, and Training
In addition to traditional and specialized mental health services, telemental health has broad application in the areas of education, prevention, and staff training. For example:

Education and prevention programs on such topics as fetal alcohol syndrome, AIDS awareness, or parenting can be presented by an educator at a central location to one or more sites in the network. Interactive technology allows the audience to participate in the program.

Graduate and specialized training courses, and continuing education programs, can be provided by distant universities or large medical centers. Often, universities are willing to pay the network usage expense in order to broaden their student market. In Montana, VideoLink of St. Peters provided a psychiatric nursing continuing education program to over 100 participants at 13 different sites simultaneously.

Professionals preparing for state certification or licensure can be supervised by a distant clinician. The Eastern Montana Telemedicine Network provides supervision of Ph.D. candidates over the network. At the University of North Carolina, social work students living in distant rural communities receive field placement supervision.

Group Meetings and Support
Finally, in areas of the nation where population centers are separated by great distances and travel may be difficult, telemental health networks allow health and consumer interest groups to participate in regional and statewide planning meetings. For example, the Montana State Mental Health Association and the Montana Chapter of the National Alliance for the Mentally Ill hold their meetings via this technology.

Within the Appal-Link Network, 15 support groups have formed for individuals who have a family member with a mental illness. Some of the groups may have only a few members, but telecommunications technology allows them to form a larger "virtual" group for mutual education, advocacy, and support. In the same way, consumer groups can become part of a larger, common interest community that eliminates geographic barriers.

Evaluating Outcomes
Consumers, providers, and family members all stand to benefit from the use of telecommunications technology to provide needed mental health services in rural areas. The next section examines some client and service system outcomes of this new and promising approach.

System Outcomes
Staff Relationships
The integration of interactive telecommunication technology into a mental health care system changes established roles and relationship styles among psychiatric hospital staff, community providers, consumers, and family members. These changes are common to most telemental health projects.

In most public mental health systems, professional working relationships between community providers and hospital staff are courteous but superficial, and in some cases strained. Often, neither sector is aware of the other's resources, strengths, and limitations, which leads to duplication of effort, confusion for the consumer and gaps in care.

Telemental health brings staffs closer together. When hospital and community staffs work as colleagues over the network, they become more supportive of one another and more familiar with each other's roles. They are more willing and able to cooperate not only for the success of the telemental health network, but ultimately for the success of individual consumers. Improvements in the mental health service system, and in consumer outcomes, are likely to result.

Continuity of Care
Telemental health networks have clearly demonstrated improvements in continuity of care. Consumers have been followed by the same psychiatrist for more than three years in some projects. Hospital and community providers, as well as family members, are connected in an ongoing, coordinated treatment approach. Some specific examples follow.

Follow-Up Care
More than two thirds of nursing home patients have psychiatric disorders, particularly dementia, and admission to inpatient facilities is common. The Menninger Center for Telepsychiatry in Kansas is exploring the use of telepsychiatry to provide the follow-up care rural nursing home residents need following discharge from Menninger Center. Preliminary results are promising. The same psychiatrist who cares for the patient in the hospital provides follow-up care in the nursing home via telepsychiatry. Follow-up visits, which may have been few and far between because of the distance involved, are now conducted as needed.

Also, the psychiatrist gets a more accurate picture of the patient's psychiatric condition, which can be negatively affected by the stress of travel between the nursing home and the hospital. Though no formal outcome studies have been done, nursing home staff and psychiatrists believe that telemental health has increased their patients' stability.

Continuity of Service
In rural Virginia, people with serious mental illnesses see general practitioners in the community and facility-based psychiatrists in the hospital. The Appal-Link Network has bridged this fragmented system of care.

More than 400 people with serious mental illnesses who were treated at the Southwestern Virginia Mental Health Institute have maintained contact with hospital psychiatrists over the network. Consumers involved in the telepsychiatry clinic show improved self-esteem, resulting in greater motivation to participate in treatment. They are more likely to keep appointments and take prescribed medication as a result.

Conversely, there are circumstances in which the locus of care is more effective if it remains with the community-based psychiatrist. The telemental health network can work "in reverse" to allow community practitioners to maintain involvement with clients who need to be hospitalized.

Increased Family and Consumer Involvement
Many families living in frontier and rural communities do not have the ability to travel to visit loved ones hospitalized hundreds of miles away. Telemental health services increase the likelihood that individuals will have their family's support during inpatient stays, and that family members will be included in commitment hearings, development of a treatment plan, and discharge planning.

Ongoing Support for Consumers and Families. Consumer and family groups, including local chapters of the National Alliance for the Mentally Ill and the National Mental Health Association, use telemental health services to support one another and to reach out to patients. For example, some consumer groups have used the Appal-Link Network to provide community outreach to hospitalized patients detained on forensic status.

In addition, with a grant from the Southwest Virginia Mental Health Board, the Appal-Link Network connects 15 family support groups in rural Appalachian communities. Family groups from two or more locations hold interactive support group meetings. Seventy-one percent of group members surveyed believe the support they received helped them keep their loved ones out of the hospital.

Client Outcomes
More research needs to be done in the area of client outcomes as a result of telemental health services. However, some earlier studies and current observations indicate that interactive telecommunication technologies can be a reliable assessment tool, have a positive impact on service use, and are well accepted by both consumers and providers.

Validity of Assessment Tools
Two efforts to empirically validate the use of telemental health systems found that these technologies can be reliably used to administer certain psychiatric assessment tools. These studies are reported in the chapter titled "Telepsychiatry: Application of Telemedicine to Psychiatry" by Baer, Cukor and Coyle (1997).

In one of these studies, English investigators administering the Mini-Mental Status Exam to 11 psychiatric patients found a correlation of .89 between video-based and face-to-face conditions. This result was identical to the test-retest reliability for the instrument in the original normative sample.

In the second study, the chapter's authors tested the reliability of two raters in both video-conferencing and live interview sessions (Baer, Cukor, Jenike, Leahy, O'Laughlen and Coyle, 1995). Twenty-six patients with obsessive-compulsive disorder were divided into two groups: 16 participated in face-to-face interviews and 10 took part in video-mediated interviews. Investigators found near perfect reliability in the video sessions on three scales -- the Yale-Brown Obsessive-Compulsive Scale, the Hamilton Depression Scale, and the Hamilton Anxiety Scale.

Reliability as a Function of Bandwidth. An important study of video assessment reliability conducted in the mid-1990s by Zarate addressed two major research questions: whether video assessments of patients with schizophrenia are comparable to live assessments, and whether video quality effects the ability to assess subtle negative symptoms.

Forty-five individuals with schizophrenia were divided into three groups. Fifteen were used to establish reliability for the Brief Psychiatric Rating Scale (BPRS), the Scale for the Assessment of Positive Symptoms (SAPS), and the Scale for the Assessment of Negative Symptoms (SANS). Fifteen individuals were tested at the two different transmission bandwidths. [Bandwidth refers to the size of the pipeline that carries the video and audio signals and at higher bandwidths, picture and sound are transmitted more quickly and with better quality.]

Results of Zarate's study established equal reliability for global severity of schizophrenia and a summary score of positive symptoms among the three assessment methods: in-person, remote 128 kbps video, and remote 384 kbps video. Because positive symptoms of schizophrenia are more tied to verbal cues, they can be more reliably assessed at the slower speeds. However, at the lower bandwidth, negative symptoms of schizophrenia were more difficult to assess.

In a similar vein, an unpublished 1997 study by the Southeastern Rural Mental Health Research Center and the Appal-Link Network addressed reliability of psychiatric assessments at different bandwidths. A high visual dependency measure, the Abnormal Involuntary Movement Scale (AIMS), and a low visual dependency measure, the Brief Symptom Inventory (BSI), were administered to 84 people with serious mental illness, both in-person and using video conferencing. Videoconferencing was done using three different transmission rates (112 kbps, 384 kbps, and 762 kbps).

Results indicate high reliability for the low visual dependency test (BSI) at all transmission rates, but greater reliability for the high visual dependency assessment (AIMS) at higher transmission rates. In fact, the AIMS assessment was actually most reliable when conducted at a distance using the highest bandwidth. That is, it was more reliable when conducted using video-conferencing at 762 kbps than when conducted in-person. This may be explained by the fact that facial and tongue movements can be examined more closely over the video system without violating social space.

Service Use Patterns
Changes in service use by consumers using telemental health care can be measured by frequency of services, types of services received, and the quality or clinical value of these telemental health services as compared to traditional face-to-face services. Though little rigorous research has been done, there are some emerging studies in this area.

VideoLink of St. Peter's in southwest Montana attempted to determine whether telemental health services such as family visits and discharge planning, provided while the individual was hospitalized, reduced lengths of stay at the state psychiatric hospital. Fifteen psychiatric patients with a history of multiple inpatient admissions who participated in interactive sessions were matched with a comparison group of 30 individuals of similar ages, sex, diagnoses, and number of admissions.

The mean length of stay for the telemental health group was shorter than that of the comparison group (58 days compared to 74 days). Though the results were not statistically significant, in part because the experimental group was too small, investigators feel this question warrants further research.

In 1996, the Appal-Link Network of southwest Virginia conducted a retrospective records review of 54 cases to compare service use six months prior to participation in telemental health services to service use during the six months after participation. Results indicate that telemental health clients have more frequent and lengthier contacts with their psychiatrist, which leads to greater stability and medication compliance.

Reviewers looked for possible service changes in five areas: psychosocial rehabilitation, outpatient therapy, case management, medication management, and medication compliance. Psychosocial rehabilitation, outpatient therapy, and case management were all provided face-to-face in the community, while medication management was offered via the network.

Reviewers found a significant increase in the frequency of medication management sessions and a corresponding decrease in face-to-face case management contacts. Consumers took part in fewer than two medication consultations, on average, in the six months prior to using the Appal-Link Network. In the six months after they began using the network, the mean number of medication consultations rose to 7.5.

A separate analysis revealed that the average length of the tele-medication review session is 24 minutes, with a range of 12 to 45 minutes. This compares to 15-to-20-minute sessions conducted face-to-face. Investigators speculate that the hospital-based psychiatrists, who have worked with consumers as in-patients, develop a closer therapeutic relationship that carries over into the telemental health setting. In addition, a hospital-based psychiatrist using video-conferencing may have a smaller number of patients to see than does a traveling community psychiatrist, and is therefore able to participate in lengthier sessions.

Consumer and Provider Satisfaction
There are many reports in the literature of surveys assessing consumer and provider satisfaction with interactive telecommunications approaches. Though such surveys are often seen as questionable research instruments, it is worthwhile to note that every telemental health participant satisfaction survey available reports that consumers perceive these services as beneficial, of high quality, and worth continuing. There appears to be a universally high level of acceptance by both providers and consumers.

For example, VideoLink of St. Peter's asked 878 consumers to rate the project on a scale of 1 to 5, with 5 indicating complete satisfaction. Survey participants gave the system a 4.5 rating for successfully meeting their individual service needs. They rated overall satisfaction of the technology at 4.3.

A sample of 81 consumer satisfaction surveys completed by individuals who use the Appal-Link Network for medication review sessions reveals that all consumers report being "very satisfied" with the service.

The Northern Arizona Regional Behavioral Health Authority (NARBHA) also has conducted client, staff, and family satisfaction surveys, as well as a cost/benefit analysis of the technology. Some of the results are shown below in Table 1:

Table 1: Satisfaction with the NARBHA Net Program Percent of clients who: (n=284)

Future Research Needs
A growing number of studies and reports validate the usefulness of interactive telecommunication technologies as an important mental health service tool. However, funding is needed to support rigorous research studies.

Some of the questions worth examining include the effect of telemental health services on the average length of inpatient stays, recidivism rates, and length of time in the community between hospitalizations. Though it is clear that consumers are satisfied with this service, research needs to examine what difference telemental health makes in their lives.

Fitting the Pieces Together
Establishing an effective telemental health system requires an understanding of clinical and organizational factors, the technology and costs involved, and how staff are likely to respond. These issues are explored in the final section.

Personnel Considerations
The introduction of telemedicine into a rural mental health care program requires leadership, vision, and authority. Though most mental health professionals already know everything necessary to use telemental health effectively--including the use of television, computer, and telephone technologies--there may be some initial resistance on the part of staff.

In particular, some staff may be anxious about being "on television." Also, because broadcast television is a passive medium, the interactive nature of telecommunications technology may be unfamiliar and uncomfortable at the outset. Allowing staff, consumers, and family members time to experiment with the new technology increases their level of comfort with seeing their image on the screen and participating in a two-way dialogue.

Other staff may fear either increased workloads or staff reductions as a result of the new technology. Their fears can be allayed with the knowledge that this is a new tool to provide established services, not a new field of practice. The equipment enhances staff effectiveness, but it does not replace the need for their involvement.

Fear of outsiders may cause some rural providers to resist, initially, formation of a telemental health network. In particular, they may be apprehensive that the consulting specialists at a large hospital or medical center may be critical of their work, training