Addressing the rural mental health crisis via telehealth

The Medical University of South Carolina has been awarded $1.75 million from the Health Resources and Services Administration to develop and test the effectiveness and sustainability of the SC Rural Telehealth-enabled Collaborative Care Network (SC-RTECC). The SC-RTECC will deliver psychiatric collaborative care management to 1500 primary care patients over a five-year period in seven diverse, rural, underserved South Carolina counties.

The goal of the project is to test whether telehealth can be used to deliver psychiatric collaborative care management efficiently and sustainably at rural primary care clinics in South Carolina.

The project will be led by Ryan Kruis, Ph.D., director of grants and research at the MUSC Center for Telehealth, one of two HRSA-designated Telehealth Centers of Excellence. The Center will partner with 9 primary care sites in Bamberg, Calhoun, Orangeburg and Williamsburg Counties that are part of MUSC Health’s Regional Health Network, and 10 primary care clinics affiliated with Beaufort Jasper Hampton Comprehensive Health Services, a federally qualified health center (FQHC).

“The MUSC Center for Telehealth is very committed to supporting primary care at large in this state — not just among our own sites, but also at FQHCs and rural health clinics,” said Kruis. “I’m really excited about this opportunity to have the funded ability to really get the model right so that everyone benefits.”

Also excited about the study is Vanessa Diaz, M.D., chief of the Integrated Center  of Clinical Excellence  for Primary Care at MUSC Health.

“We need to find better ways to address the behavioral health needs of our primary care patients if we want to improve health outcomes significantly,” she said. “The collaborative care model funded by this grant is an innovative way to address behavioral health needs in a way that is convenient to patients and easy to implement in primary care practices.”

Jamie Hunter, M.D., chief medical officer/chief clinical officer at Beaufort Jasper Hampton Comprehensive Health Services, looks forward to leveraging telehealth resources to begin to move the needle on mental health care access.

“We at BJHCHS are excited to work with MUSC to provide telehealth access to mental health care for our patients,” said Hunter. “We have counselors on staff but no psychiatrists, so this will be a great resource as our patients will have access to psychiatric care without having to travel a far distance.”

The mental health crisis in rural America

The U.S. is experiencing a mental health crisis, with rural communities hit hardest.

“There has been a heightened focus on behavioral health since COVID,” said Kruis.

“We’ve seen upticks in substance use, depression and anxiety among youth and adults.”

According to Mental Health America, almost 1 in 4 U.S. adults, or 60 million Americans, have experienced a mental illness in the past year. During that time, 1 in 5 youth had at least one major depressive disorder, and more than half of those did not receive treatment. More than three-quarters of U.S. adults with substance use disorders also did not receive treatment.

It is estimated that there are 340 people for every mental health provider, with lack of access to mental health care most acute in rural communities. More than 122 million Americans live in mental health professional shortage areas, including South Carolinians in 43 of the state’s 46 counties. In these areas, only about a quarter of mental health care needs are being met.

In the two primary care networks participating in the SC-RTECC, patients requiring mental health services often wait 3 to 6 months for a psychiatric appointment, leaving the busy primary care physician to try to fill the gap.

A care model that works

The psychiatric collaborative care model is intended to improve behavioral health outcomes while taking some of the pressure off primary care physicians. In this model, physicians rely on behavioral health care managers, each with a case load of 60 to 80 patients. Care managers work closely with primary care physicians, who prescribe any medications, and consult with psychiatrists regularly to discuss cases and decide when to refer for a higher level of care.

This care model has been shown to improve mental health outcomes in more than 90 clinical trials. However, it is resource-intensive, making it difficult to implement, especially in rural clinics far from the urban centers where psychiatric expertise is usually concentrated.

Streamlining the model via telehealth

The HRSA-funded SC-RTECC will leverage telehealth to use behavioral health resources more efficiently and to support the long-range sustainability of this model of care. It will also support a better understanding of how this model can be delivered effectively among racially diverse rural communities.

SC-RTECC will hire two behavioral health care managers, one for each of the partnering primary care networks, as well as rely on behavioral care managers already in place at the MUSC Center of Telehealth. One new care manager will be stationed at the largest participating primary care clinic in each of the two primary care networks. There, each will provide virtual  behavioral health care to patients at all participating clinics in the respective network and offer in-person visits as necessary. Care managers will meet weekly with MUSC Health psychiatrists to discuss cases and decide when referral to a higher level of care is required.

The goal of the project is to find out if a telehealth-adapted collaborative care model can improve behavioral outcomes in rural communities and do so in a sustainable way even after grant funding ends. New South Carolina Medicaid billing codes have been released recently, and the care model is being developed to comply with Medicare and Medicaid reimbursement requirements for behavioral care.

“It’s really exciting that SC Medicaid has opened up the billing and that we will be able to optimize the model and then grow the program because we have revenue sources that can support it long term,” said Kruis.

MUSC is one of 27 sites awarded HRSA funding to explore leveraging telehealth to improve behavioral care. All sites will report their data to the Rural Health Research Center at the University of Iowa for evaluation, with a view to implementation nationwide.