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Telemental Health: Equity, Inclusion, and Access

In the spirit of the Psychiatric-Mental Health Nursing Scope and Standards of Practice, here are information and resources to bolster equity in treatment by reducing mental health disparities related to telemental health care.

Rural Telemental Health

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The Need

Learn More about rural subpopulations that may benefit from telehealth.

  • 17.1% of rural people have a disability: May have complex health needs or physical limitations; this can make it very difficult to travel to specialized health care providers in particular.
  • Higher suicide rates exist in less densely populated areas
  • Higher rates of tobacco, methamphetamine, and opioid use in rural areas
  • Rural mental health is less accessible, and stigma further complicates the matter
  • Prison facilities are frequently located in rural areas: 40% of prisoners and inmates have a chronic health condition and 1 in 7 have a mental health condition of major depression or psychosis
  • 1/4 of older adults live in rural areas and many wish to age in place
  • Children in rural areas face physical, economic, and social barriers to access to care
    • Children in rural areas have a higher risk for disability and death and are more likely to be overweight or obese
  • Deep poverty rates are higher in rural areas:
  • 25% of veterans live in rural areas
    • Veterans health administration facilities are often located in urban areas
    • Veterans may struggle with homelessness and substance use disorders
  • 1/2 of American Indian/Alaska Natives live in rural areas with significant health disparities compared to other racial and ethnic groups, including risk for suicide
  • Island populations may have limited access to on island care, including specialty care
  • Residents of rural areas tend to be older with less education and income

Learn more about Rural Health

Considerations

Legal, ethical and best practice guidelines:

  • Assure HIPAA compliance
  • Access to health information availability with informed consent and conflict of interest
  • Legal and regulatory considerations include licensing, informed consent, clinical privileging/credentialing, internet prescribing, conflicts of interest, malpractice insurance and protected health information

Barriers to telemental health in rural areas:

  • Limited access to high-speed internet
  • Limited access to smartphones
  • Credentialing and licensing
  • Reimbursement issues
  • Reduced provider participation in asynchronous telehealth
  • Malpractice policies may not cover telehealth
  • Lack of reliable transportation
  • Interoperability with exchange of electronic health information, especially in regard to the sharing of information
  • Mistrust of technology and healthcare
  • Organizational willingness to provide telehealth access to patients
  • Availability of infrastructure
  • Implementation of models of reimbursement
  • Availability of required training, knowledge, and education for providers
  • Implementation of QI models for continuous and feedback processes

Resources

Rural Health Information Hub Rural Telehealth Toolkit

Telemental Health for Older Adults

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Barriers

Some barriers for older adults and techology are listed. Learn more about these barriers here.

  • Lack of experience with technology
  • Lack of access to technology
  • Hearing, vision and/or communication impairments
  • Cognitive issues
  • Socioeconomic factors
  • Connectivity issues
  • Lighting

 

Strategies

  • Use the 4Ms – what matters, medication, mentation, and mobility
    • Montreal Cognitive Assessment has been validated for remote administration leaving out visual items)
  • Encourage use of video
  • Suggest use of headset or headphones, and make sure hearing aids are in for those who use them
  • Speak clearly and concisely without raising your voice or yelling
  • Watch for signs that the patient is not following the conversation or not understanding you
    • Encourage increasing the speaker volume or putting on glasses
    • Repeat or rephrase if the patient seems confused
  • Consider recommending an interpreter to help patient with seeing, hearing, or understanding
  • Use a comprehension technique like teach-back

Resources

Telemental Health for Children & Adolescents

Children’s mental health is in crisis. Roughly 15% of youth (12-17) report suffering from at least one major depressive episode in the past year (www.mhanational.org; Abramson, 2022)

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Considerations

  • Access to technology is often limited and/or dependent upon the presence of a parent/caregiver who owns a device with audio/visual capabilities
  • Access to technology is also limited by age, familiarity with technology, and devices available for telemental health services
  • Ensuring safety and privacy are especially challenging, given the need for parental/caregiver involvement to some extent, without invading/hindering privacy and/or willingness to communicate with the provider
  • “Treating children in the very settings in which symptoms are most problematic may be critical to improving the generalization of treatment gains, but providers, in turn, have less control over children’s treatment environments and, accordingly, it can be more difficult to ensure safety” (Comer & Myers, 2016).

Telemental Health in School Settings

  • “The American Rescue Plan Act, passed in March 2021, included $170 billion for school funding, and many schools used the funding to hire mental health workers” (Abramson, 2022).
  • Important to maintain emergency contact information (Comer & Myers, 2016).
  • School-based telemental health interventions are a growing area of mental health care
    • Reaching children and adolescents in a setting where they spend most of their time and preclude the necessity of missing extended time away from the academic setting, while ensuring access to technology and a support person/system to facilitate the appointment
    • Providing telemental health in schools requires understanding and respect for school personnel and the structures, policies and cultures of the school setting
    • Providers should work with school personnel to optimize the treatment setting, including taking into account the unique privacy and staffing issues in schools.

Learn More

Resources

Telemental Health for People with Disabilities and/or Limited English Proficiency

(Persons who are blind, deaf, have an intellectual disability, or are non-English speakers.)

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The Need

  • “More than 7 million Americans have vision impairment, including 1 million who are blind. These numbers are expected to increase because of the aging population and increase in chronic diseases. Loss of vision has been linked to loneliness, social isolation, and feelings of worry, anxiety, and fear. Depression is common in people with vision loss” (CDC).
  • “1 in 4 adults with vision loss reported anxiety or depression” (CDC).
  • “Younger adults with vision loss had almost 5 times the risk of serious anxiety or depression compared to adults 65 and older” (CDC).
  • “About 11.5 million Americans have some sort of hearing impairment, approximately 3.5 percent of the population” (census.gov).
  • “Poorer mental health is more common among people with hearing loss than those without” (Jiang et al., 2020).
  • “According to the US Census Bureau, 67.3 million U.S. residents spoke a language other than English at home in 2018” (cis.org, 2019)
  • “Miscommunication was reported as a cause of 59% of serious adverse events” (onlinepublichealth.gwu.edu, 2021)

Considerations

  • Although telehealth has many advantages, accessing care via telehealth may present challenges for certain populations. Sometimes these challenges, if not addressed, may result in these populations facing barriers and issues accessing care: Guidance on Nondiscrimination in Telehealth: Federal Protections to Ensure Accessibility to People with Disabilities and Limited English Proficient Persons (ada.gov)
  • Reasonable Modifications for People with Disabilities: Health care providers must make reasonable changes to their policies, practices, or procedures, which may include providing additional support to patients when needed before, during, and after a virtual visit, to avoid discriminating on the basis of disability: Guidance on Nondiscrimination in Telehealth: Federal Protections to Ensure Accessibility to People with Disabilities and Limited English Proficient Persons (ada.gov)
  • To get the full benefit from a telehealth visit, patients should be able to easily understand and communicate with their health care provider. Here are some things to keep in mind when communicating with patients, family members, and patient companions who are deaf or hard of hearing:
    • You must provide interpreter services and communication aids to patients with disabilities and their companions free of charge. (Patients with disabilities are not required to provide their own interpreter.)
    • You may only rely on a companion interpreter (for example, a friend or family member of the patient with a disability) if:
      • There’s an emergency involving an imminent threat and a qualified interpreter is not available.
      • A patient with a disability requests to use an adult friend or family member as an interpreter. However, you may not rely on an adult friend or family member to interpret when there is reason to believe they may be biased, unfair, or otherwise ineffective.
    • This also applies to communicating with patients who do not speak the same language as the provider

Improving access to telehealth | Telehealth.HHS.gov

Resources

Telemental Health for LGBTQIA+ Populations

The LGBTQIA+ community experiences’ significant health care disparities. There are significantly higher rates of suicide, particularly in LGBTQ+ youth. Inclusivity and sensitivity of telemental health providers can save lives, particularly since there may be a lack of appropriate and accepting providers in less populated areas.

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Considerations

  • Several groups like the IOM have recommended that the sexual orientation and gender identity be part of the electronic health record. This can be accomplished by modifying intake forms to be inclusive.  Words matter and demonstrate that the provider is interested in the whole person.
    • Using gender neutral language like ‘spouse’ rather than ‘husband’ or ‘wife’ – ‘parent’ rather than ‘mother’ or ‘father’
    • Gender identity language can include: male, female, non-binary, transgender (can further designate transman or transwoman), and gender queer. Consider a write in section if their identity does not meet the list you choose to include in the intake.
    • Sexual orientation can straight, gay/lesbian, bisexual, pansexual or something else.
    • Identify preferred pronouns
  • At the start of the telehealth visit confirm the preferred pronouns and name.
  • Ask the patient if they feel safe and that they are comfortable with the privacy they have on their end of the visit.
  • Assist them in finding LGBTQIA+ friendly providers for in person health services in their area if possible.
  • HIV/AIDs counseling and therapy may be needed. Identify providers in the patient’s area that provide medical services including PrEP and PEP.

Learn More

Resources

Telemental Health for Substance Use

Drug overdose deaths are on the rise, and it is essential to find ways to deliver care to the substance use population and encourage recovery. Telehealth adds another delivery option and potentially helps in the reduction of stigma related to substance use. There is an opportunity with video telehealth to assess the patient in their home environment, adding additional avenues to intervene and engage with the patient.

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Considerations

  • It is suggested that the provider have training in addiction care techniques and the understanding that multiple treatment methods may be required.
  • Encourage the use of SBIRT and assist the patient in finding face to face resources that will complement the telehealth visits when possible.
  • Be familiar with medication for addictions treatment options and the rules and regulations regarding teleMAT prescribing.
  • This patient population requires integrated care and efforts should be made to partner with the providers of treatment options outside of telehealth visits
  • Be aware of educational, language and cultural issues and provide care in an appropriate format for the individual patient
  • Prioritize patient monitoring and suicide prevention
  • Focus on long term treatment goals and options
  • Identify local resources for patient drug testing

Resources

APNA Telemental Health Toolkit Menu

National Policy Considerations

  • State Licensure & Collaborative Agreements
  • Reimbursement
  • Prescribing
  • Case Management
  • Therapy

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Equity, Inclusion, & Access

  • Rural Populations
  • Older Adults
  • Children & Adolescents
  • People with Disabilities and/or LEP
  • LGBTQIA+
  • Substance Use

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Outcome Measures

  • Theoretical Frameworks & Existing Models
  • Psychometrically Validated Telehealth Survey Instruments
  • Checklists

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Logistical Concerns

  • Planning
  • Platform
  • Building a Program
  • Safety/Crisis Information
  • Technology Issues
  • Taking Care of Yourself

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Education

  • Precepting/Tele-precepting
  • Simulation
  • Frameworks/Competencies

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