Telehealth: Bridging the care gap in mental health treatment

As technology advances, nursing curricula need to address ethics and privacy.

Telehealth is helping these educators address three important mental healthcare issues—lack of access, need for interprofessional collaboration, and patient stigma.

The burden of mental health disorders continues to grow across the world. Since 2005, the global rates for depression have increased by more than 18 percent. Although genetics play a role in the development of mental health disorders, social determinants also play a significant role. Access issues related to stigma and lack of services in indigent and underserved populations confound the mental health problem.

Background
Mental health problems have been around for millennia. As an advanced practice registered nurse who has worked with the medically underserved in the United States for 20-plus years, I [Rene Love] can personally attest to these struggles.

In the United States, insufficient access to mental health treatment via traditional insurance plans has fostered lack of parity between mental health disorders and other health issues. Insurance companies providing mental health coverage were “treatment limited” and often did not adequately cover necessary treatment for ongoing care. Pre-existing conditions added to the disparity. Burdened with either paying out of pocket or being unable to access services for present mental health needs, patients and their families were also concerned they would be denied health insurance in the future.

Mental health concerns are one of society’s best-kept secrets. Historically, to provide patient anonymity, mental health providers have been sequestered outside the main healthcare arena. People with physical health conditions are typically open to discussing those issues with relatives and friends, but the same is not true for those with mental health conditions. Thus, it has been difficult for individuals with mental health diagnoses to elicit support or comfort from others.

When someone did seek treatment, mental health information—including medications and diagnoses—was segregated behind a firewall within the electronic health record. Prior to electronic records, mental health documentation was kept in a separate chart in a secured environment away from physical health documentation. Communication between the physical and mental health worlds did take place but, for the most part, the two rarely intersected or collaborated.

The issue of parity for mental health treatment was addressed in the United States during the 1990s, but there is still ample work to do. Across the world, continued commitment is needed to address ongoing issues, which include lack of access, need for more interprofessional collaboration, and stigma.

Three problems, three solutions
Lack of access to adequate mental healthcare is a worldwide problem. People living in rural locations often find it difficult to obtain services. Because technology now supports secure and private patient-provider interaction, one way to address the access issue is telehealth, which has been evolving over the last several years. Even though providers may not be geographically available, they can now offer therapeutic services via telehealth technology.

Telehealth’s convenience has greatly increased the number of people using it. And, based on growth in mental health diagnoses and ongoing lack of access to treatment, we expect telehealth usage to continue increasing in the future. It is imperative, therefore, that graduating nursing students recognize nuances related to these innovative technologies as they relate to mental health treatment and care coordination.

For example, topics such as ethics, privacy, confidentiality, and equipment need to be included in the curriculum. Moreover, to obtain a level of comfort with telehealth, students should be given the opportunity to have simulated interviews with patients. Interviewing a virtual patient is a great way for a student to understand the process, gain experience in remote assessment of a patient, and become more comfortable with the technology itself.

Allowing students to experience this type of practice in a clinical setting is important. For example, after assessing a “patient,” students can use telehealth’s capability to call a faculty nurse practitioner to give a report. This simulates consultation about patient care with a collaborating provider and allows the student an opportunity to experience interprofessional collaboration with colleagues in a structured learning environment.

The second need is interprofessional collaboration that benefits the patient and supports the provider. Over the past three years, I [Rene Love] have achieved improved patient care in this environment while building support across disciplines and specialties both formally and informally. 

Collaboration that occurs within one physical space is ideal. Bringing together physical and mental health within a single facility not only increases care collaboration but also decreases patient stigma. When all patients sit together in one waiting area, no one knows which provider the patient is seeing. Additionally, all physical and mental health information is combined in one electronic health record for providers to review before each patient encounter. Although it is ideal to be in one geographic location, providers are not always located in close proximity, especially in rural areas. In that situation, technology allows them to communicate seamlessly and confidentially with each other on behalf of the patient.

Finally, because people who need mental healthcare often experience stigma, many are embarrassed to seek treatment. Healthcare providers should begin talking about brain health just as we do heart health. Prevention and treatment of disorders and diseases affecting all body parts are necessary for overall health. For that reason, we need to take care of our brain in conjunction with our other organs and our body as a whole. Both interpersonal collaborative care and telehealth promote access and help improve brain health.

Action plan
These three issues—lack of access, need for more interprofessional collaboration, and stigma—drove us, faculty members of the University of Arizona College of Nursing, to develop and implement a telehealth module in our Doctor of Nursing Practice program. The module consists of six areas: rationale, ethics, privacy and confidentiality, technology and equipment, the patient, and the provider. After viewing a video that shows a telehealth-based provider-patient session, students take a quiz to demonstrate learning. Based on their feedback, we address issues students find most challenging. In this way, we are learning how to assist students most effectively in acquiring assessment information needed for effective intervention. Because they understand the importance of telehealth for patient assessments, students generally support learning how to use it.

In summary, technology advancements in healthcare continue to be made, facilitating care for underserved patients who, without telehealth, would become even more vulnerable. Telehealth is a means to bridge the care gap. Using secure communication pathways, providers can engage with patients and facilitate mental healthcare delivery. Technology has also improved provider collaboration on behalf of patients by providing a means for long-distance collaboration that includes the patient.

Addressing mental health issues is a priority. Using technology to bridge distance can assist in reducing perceived stigma. While much work is yet to be done, these improvements decrease stigma and improve brain health overall. RNL

Rene Allen Love, PhD, DNP, PMHNP-BC, FNAP, FAANP, is clinical associate professor of nursing and director of the Doctor of Nursing Practice program at the University of Arizona (U of A) in Tucson. Jane M. Carrington, PhD, RN, FAAN, is associate professor of nursing at U of A and assistant professor in the university’s cognitive science graduate interdisciplinary program.

Editor’s note:
Rene Love will present “Using 21st Century Technology for DNP Student-Patient Interview and Interprofessional Care Collaboration” on Sunday, 22 July 2018, at Sigma’s 29th International Nursing Research Congress in Melbourne, Australia. Register here for congress.