**3. Primary care, mental health and telemedicine**

#### **3.1. Mental health services in primary care**

Primary care medicine is crucial to mental health care delivery in the United States, for over half of those suffering from mental disorders (Regier et al 1978), particularly in rural areas where access to specialists is a greater problem. This lack of mental health services leads to poor outcomes, such as higher rates of homicide and suicide, as well as increased use of emergency services, hospitalizations, and placement in mental health institutions (Lishner et al 1995; Health Data Summaries 2000). Primary Care Providers (PCPs) in rural areas also report having inadequate skills to manage mental health issues, and they would benefit from assistance (Geller and Muus 2002; Geller 1999). However, rural areas inherently have provider shortages, particularly with regard to consultation-liaison psychiatrists.

Health providers use a number of psychiatric, health service and disease management models to reach primary care patients, predominantly in suburban and urban locales (Katon et al 1995; Pincus 1987; Strathdee 1987). The traditional referral or replacement model uses the psychiatrist as the principal provider of mental health services. The consultation care model includes the PCP as the principal provider of mental health services, after a psychiatric consultation. The collaborative care model involves mental health services jointly provided by the PCP and psychiatrist, including frequent communication between providers. Variations on these models also include use of mental health extenders and a stepped care to judiciously use scarce psychiatric resources (Katon et al 1997). Quality improvement programs also improve treatment rates and outcomes for depressed patients with comorbid medical illness in primary care (Koike et al 2002) and are cost-effective, too (Wells et al 2001).

These models have been evaluated both in the United States and Great Britain. In Great Britain, the majority of psychiatrists function in the traditional referral model (Strathdee 1987). The majority of PCPs, though, favored the collaborative care model, as having the psychiatrist located in the primary care clinic setting versus an offsite mental health clinic greatly improved the consultation process (Katon et al 1995; Bailey et al 1994). Such research shows that those PCPs patients are more likely to receive adequate doses of antidepressants and recover from depression (Simon et al 2000). But in rural areas, there is a dearth of specialists (Off Tech Assessment 1990), resulting in travel for patients or providers. In addition, some rural sites have unique needs and issues (e.g., high rates of substance disorders and few treatment options at an Native American reservation; enmeshed small communities, wherein patients want an objective person from the outside).

#### **3.2. Telemedicine history**

Population dispersion of tribal groups in California makes it unlikely that a hospital-based service program will develop or support the members, meaning many rural and even some urban clinics depend on specialists outside the IHS. High costs associated with distance, time, and a shortage of primary care physicians in rural areas put Native Americans at high risk for suicide, trauma, and diabetes. Native Americans often do not obtain treatment due to barriers to care, differences in help-seeking behaviors, and higher dropout rate for mental health

A few studies have been completed regarding substance issues in Native Americans. A previously mentioned study that examined the relationship of substance abuse and psychiatric disorders among family members (Robin et al 1997) also considered their use of mental health services. Of those with a mental disorder, only 32% had received mental health or substance abuse services. The AI-SUPERPFP showed that Native American men were more likely than those in NCS to seek help for substance use problems from specialty providers; Native American women were less likely to talk to nonspecialty providers about emotional problems (Beals et al 2005b). Help-seeking from traditional healers was common in both Native Amer‐

There are many serious manifestations of untreated mental illness in Native Americans, particularly in rural areas. The prevalence rate of suicide for Native Americans is 1.5 times the national rate, particularly higher rates for males aged 15-24 and women aged 25-44 (U.S. HHS 2004; National Women's Health Information Center 2006). More Native Americans live in rural areas compared to Caucasians (42% to 23%) (U.S. HHS 2004). These areas have a shortage of mental health services and inadequate treatment (e.g., 70% of patients have an inadequate antidepressant dose for depression) (Unutzer et al 2002), and rural depressed patients have three times more hospitalizations and higher suicide rates than suburban patients (Rost et al 1999; Rost et al 1998). On the whole, rural communities are experiencing an acute shortage of adult, adolescent, and child psychiatric providers and those skilled in culturally appropriate

Primary care medicine is crucial to mental health care delivery in the United States, for over half of those suffering from mental disorders (Regier et al 1978), particularly in rural areas where access to specialists is a greater problem. This lack of mental health services leads to poor outcomes, such as higher rates of homicide and suicide, as well as increased use of emergency services, hospitalizations, and placement in mental health institutions (Lishner et al 1995; Health Data Summaries 2000). Primary Care Providers (PCPs) in rural areas also report having inadequate skills to manage mental health issues, and they would benefit from

outpatient services than Caucasians (Weinick et al 2000).

ican populations and was especially common in the Southwest.

care (Am Acad Child Adol Psychiatry 2004; Martinez 1993).

**3. Primary care, mental health and telemedicine**

**3.1. Mental health services in primary care**

**2.1. Substance, rural health and Native Americans**

78 Telemedicine

Telemedicine, defined as the use of technology to deliver health care (usually through videoconferencing), is one strategy to improve the accessibility of mental health care, partic‐ ularly to areas underserved by physicians (Preston et al 1992; Hilty et al 2004a; Hilty et al 2013a). Telecommunications technology has been used to link specialists at academic health centers with health care professionals in rural areas for the management of patients (Hilty et al 1999). Videoconferencing, telephone and computer-based (e.g., e-mail) connect specialists with PCPs for patient care (Nesbitt et al 2000; Levine and Gorman 1999; Dick et al 1999; Hilty et al 2004b).

Medical home, home health and other mobile technology methods are in development and need to be better studied, although costs are dramatically decreasing. The patient-centered medical home (PCMH) is a concept founded on the presence of inadequate treatment in primary care and/or an inability to access needed services (Rosenthal 2008). PCMH allows telepsychiatric input at home, still under the general purview of the primary care provider, and it has been shown to improve patient care and health (Hollingsworth et al 2011). Deskmounted video systems offer great convenience for therapy to cancer patients to avoid travel, but the cost used to be prohibitive for most consumers (Cluvey et al 2005). Internet-based video technology via personal computers and mobile devices must be HIPAA-adherent. Use of these technologies is increasingly becoming available, and will support the move of telepsychiatry to the home, such as programs that are now being implemented by the Veteran's Health Administration (Shore 2011).

referral. The average duration of consultation was 47 minutes, and the consultation was accompanied with a 4-page summary/case for the referring physician. The top three services requested for consultation were psychiatry (e.g., management of behavioral disturbance), medical genetics (e.g., diagnosis), and gastroenterology. PCPs rated items baseline satisfaction on a 7-point Likert scale: 1) pre-existing local services at 3.37; 2) timeliness of the PACT Net consultation at 5.45; 3) quality of the communication at 6.3; and 4) overall quality and utility of the consultation at 6.2. Specialists rated the quality of the communication at 6.45, and the ease of the service at 6.46. While phone and e-mail consultation was effective, it was not used

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**Model 3:** An integrated program of mental health screening, therapy on site, and telepsychi‐ atric (video, phone, e-mail) consultation to rural primary care. The UCDHS and Northern Sierra Rural Health Network collaborated to develop a program for rural Northeastern California, funded by the California Endowment. Over a three-year period, 10 rural sites learned how to utilize screening instruments for multiple disorders (e.g., depression, alcohol‐ ism, and anxiety disorders), and collect basic outcome measures for depression at regular intervals, in concert with telepsychiatric consultations and on site therapy visits. The number of consultations per year increased by 120%. Continuing medical education (CME) was provided annually for PCPs and other providers. Services included a telepsychiatric consul‐ tant / therapist on site 25% for specific brief therapy and integrated planning meetings between rural primary and mental health care staff. Outcomes were that most children were seen only once, but a statistically significant improvement between initial evaluation and three-month follow-up in the convenience sample was seen in the Affect and Oppositional domains of the Child Behavioral Checklist (CBCL) for girls and boys, respectively; incorporating standardized checklists, may assist in diagnosis and treatment of rural children (Neufeld et al 2007).

**Model 4:** Cultural consultation to rural primary care using telemedicine. Early in the telepsy‐ chiatry service of UC Davis Department of Psychiatry and Behavioral Sciences in 1996, culturally informed consultation became incorporated into the telemedicine rural primary care collaboration. Some rural patients faced language and cultural barriers to seeking and receiving care from their local primary care physician. For example, a 56 year-old Mexican American female who became depressed following the sudden death of her husband of thirty years, was diagnosed with major depression, and started on an antidepressant but did not improve despite 4 months of treatment (Cerda et al 1999). She did not take medication as recommended and did not communicate concerns to the PCP because of the stigma and cultural reasons. A 60-minute telepsychiatric evaluation was conducted by a Mexican Amer‐ ican psychiatrist, who met with the PCP and patient. At follow-up the patient reported daily compliance with medication thereafter, the depression had remitted and the frequency of medical visits decreased from one-to-two times per month over a one-year period to only a

**Model 5:** Collaborative care via telepsychiatry. This model is co-provision of medication for primary care patients by the telepsychiatrist and primary care provider in rural communities, based on the earlier models of in-person care to achieve national standards of antidepressant prescriptions (Fortney et al 2013; Katon et al 1997).This model is often integrated with stepped

single visit in the six months since the consultation.

as much as expected.

Telemedicine was first used for medical purposes for psychiatric consultation (i.e. telepsy‐ chiatry) in the 1950's and 1960's to help the Nebraska Psychiatric Institute provide education, patient care, and consultation to a variety of sites (Wittson et al 1961). In the 1960s, telemedicine was also used to connect academic centers with urban populations (Straker et al 1976). Over the past several decades, academic health systems consisting solely of the medical center, are reaching out with telemedicine to rural clinics by using a consultation model of care. The University of California Davis Health System (UCDHS) connects the Medical Center with approximately 50 suburban and rural primary care clinics, up to 300 miles away, with telepsychiatric care (Nesbitt et al 2013; Hilty et al 2004a).

Telepsychiatry, in the form of consultation to primary care, and psychiatric management, has been well-received, enables valid and reliable evaluations, has good (preliminary) outcomes, and empowers parties using it (Hilty et al 2004a). PCPs in rural areas also have reported inadequate skills to manage mental health issues, and benefit from assistance (Geller 1999; Geller and Muus 2002). Telemedicine has been shown to improve medication adherence, depression severity, mental health status, health-related quality of life, and satisfaction for patients being treated for mental illnesses in primary care practices lacking on-site psychiatrists (Hilty et al 2006a; Hilty et al 2007a). The American Telemedicine Association has published telemental health practice guidelines (Yellowlees et al 2010) as has the American Association of Child and Adolescent Psychiatry (AACAP 2007).

#### **3.3. Models of care for rural populations (Hilty et al 2006b)**

**Model 1:** Randomized controlled trial (RCT) for depression in adults. A RCT recruited depression patients through self-report and structured psychiatric interviews (Hilty et al 2007b). Subjects were randomized to: 1) usual care with a disease management module (DMM) using telephone and self-report questionnaires; or 2) a DMM using telephone, questionnaires, and repeated televideo psychiatric consultation coupled with training of the PCP. Subjects' depressive symptoms, health status, and satisfaction with care were tabulated at 3, 6, and 12 months after study entry. There was significant clinical improvement for depression in both groups, with a trend toward significance in the more intensive module. Satisfaction and retention were statistically superior in the intensive group; there was no change in overall health functioning.

**Model 2:** Formal, multi-specialty phone and email physician-to-physician consultation. The UCDHS and California Department of Developmental Services (CDDS) developed the Physician Assistance, Consultation and Training Network (PACT Net) to assist PCPs in the treatment of patients with developmental disabilities in rural California (Hilty et al 2004b). PACT Net was a 24-hour warm-line in design and was funded from CDDS at approximately \$450,000 over three years. Thirty consultations were completed: 28 by telephone and 2 by email; 24 of those consultations were able to be responded to within one business day of the referral. The average duration of consultation was 47 minutes, and the consultation was accompanied with a 4-page summary/case for the referring physician. The top three services requested for consultation were psychiatry (e.g., management of behavioral disturbance), medical genetics (e.g., diagnosis), and gastroenterology. PCPs rated items baseline satisfaction on a 7-point Likert scale: 1) pre-existing local services at 3.37; 2) timeliness of the PACT Net consultation at 5.45; 3) quality of the communication at 6.3; and 4) overall quality and utility of the consultation at 6.2. Specialists rated the quality of the communication at 6.45, and the ease of the service at 6.46. While phone and e-mail consultation was effective, it was not used as much as expected.

technology via personal computers and mobile devices must be HIPAA-adherent. Use of these technologies is increasingly becoming available, and will support the move of telepsychiatry to the home, such as programs that are now being implemented by the Veteran's Health

Telemedicine was first used for medical purposes for psychiatric consultation (i.e. telepsy‐ chiatry) in the 1950's and 1960's to help the Nebraska Psychiatric Institute provide education, patient care, and consultation to a variety of sites (Wittson et al 1961). In the 1960s, telemedicine was also used to connect academic centers with urban populations (Straker et al 1976). Over the past several decades, academic health systems consisting solely of the medical center, are reaching out with telemedicine to rural clinics by using a consultation model of care. The University of California Davis Health System (UCDHS) connects the Medical Center with approximately 50 suburban and rural primary care clinics, up to 300 miles away, with

Telepsychiatry, in the form of consultation to primary care, and psychiatric management, has been well-received, enables valid and reliable evaluations, has good (preliminary) outcomes, and empowers parties using it (Hilty et al 2004a). PCPs in rural areas also have reported inadequate skills to manage mental health issues, and benefit from assistance (Geller 1999; Geller and Muus 2002). Telemedicine has been shown to improve medication adherence, depression severity, mental health status, health-related quality of life, and satisfaction for patients being treated for mental illnesses in primary care practices lacking on-site psychiatrists (Hilty et al 2006a; Hilty et al 2007a). The American Telemedicine Association has published telemental health practice guidelines (Yellowlees et al 2010) as has the American Association

**Model 1:** Randomized controlled trial (RCT) for depression in adults. A RCT recruited depression patients through self-report and structured psychiatric interviews (Hilty et al 2007b). Subjects were randomized to: 1) usual care with a disease management module (DMM) using telephone and self-report questionnaires; or 2) a DMM using telephone, questionnaires, and repeated televideo psychiatric consultation coupled with training of the PCP. Subjects' depressive symptoms, health status, and satisfaction with care were tabulated at 3, 6, and 12 months after study entry. There was significant clinical improvement for depression in both groups, with a trend toward significance in the more intensive module. Satisfaction and retention were statistically superior in the intensive group; there was no change in overall

**Model 2:** Formal, multi-specialty phone and email physician-to-physician consultation. The UCDHS and California Department of Developmental Services (CDDS) developed the Physician Assistance, Consultation and Training Network (PACT Net) to assist PCPs in the treatment of patients with developmental disabilities in rural California (Hilty et al 2004b). PACT Net was a 24-hour warm-line in design and was funded from CDDS at approximately \$450,000 over three years. Thirty consultations were completed: 28 by telephone and 2 by email; 24 of those consultations were able to be responded to within one business day of the

Administration (Shore 2011).

80 Telemedicine

telepsychiatric care (Nesbitt et al 2013; Hilty et al 2004a).

of Child and Adolescent Psychiatry (AACAP 2007).

health functioning.

**3.3. Models of care for rural populations (Hilty et al 2006b)**

**Model 3:** An integrated program of mental health screening, therapy on site, and telepsychi‐ atric (video, phone, e-mail) consultation to rural primary care. The UCDHS and Northern Sierra Rural Health Network collaborated to develop a program for rural Northeastern California, funded by the California Endowment. Over a three-year period, 10 rural sites learned how to utilize screening instruments for multiple disorders (e.g., depression, alcohol‐ ism, and anxiety disorders), and collect basic outcome measures for depression at regular intervals, in concert with telepsychiatric consultations and on site therapy visits. The number of consultations per year increased by 120%. Continuing medical education (CME) was provided annually for PCPs and other providers. Services included a telepsychiatric consul‐ tant / therapist on site 25% for specific brief therapy and integrated planning meetings between rural primary and mental health care staff. Outcomes were that most children were seen only once, but a statistically significant improvement between initial evaluation and three-month follow-up in the convenience sample was seen in the Affect and Oppositional domains of the Child Behavioral Checklist (CBCL) for girls and boys, respectively; incorporating standardized checklists, may assist in diagnosis and treatment of rural children (Neufeld et al 2007).

**Model 4:** Cultural consultation to rural primary care using telemedicine. Early in the telepsy‐ chiatry service of UC Davis Department of Psychiatry and Behavioral Sciences in 1996, culturally informed consultation became incorporated into the telemedicine rural primary care collaboration. Some rural patients faced language and cultural barriers to seeking and receiving care from their local primary care physician. For example, a 56 year-old Mexican American female who became depressed following the sudden death of her husband of thirty years, was diagnosed with major depression, and started on an antidepressant but did not improve despite 4 months of treatment (Cerda et al 1999). She did not take medication as recommended and did not communicate concerns to the PCP because of the stigma and cultural reasons. A 60-minute telepsychiatric evaluation was conducted by a Mexican Amer‐ ican psychiatrist, who met with the PCP and patient. At follow-up the patient reported daily compliance with medication thereafter, the depression had remitted and the frequency of medical visits decreased from one-to-two times per month over a one-year period to only a single visit in the six months since the consultation.

**Model 5:** Collaborative care via telepsychiatry. This model is co-provision of medication for primary care patients by the telepsychiatrist and primary care provider in rural communities, based on the earlier models of in-person care to achieve national standards of antidepressant prescriptions (Fortney et al 2013; Katon et al 1997).This model is often integrated with stepped models of care, which similar to above use 'less intensive or expensive interventions' first then if patients fail to improve, 'step it up' to more intensive services, and

2012a). These services have occurred in a number of Western States (Alaska, Colorado, Montana, New Mexico, South Dakota, Wyoming), involved both consultative and direct service models in a range of settings (community clinics, hospitals) and spanned age ranges from children and adolescents to geriatric population. These services have helped to demon‐ strate the feasibility of telepsychiatry with native populations, various models of clinical

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83

A recent review (Shore et al 2012a) summarizes 10 years of CAIANH work with rural Native Veterans, of rural American Indian Veterans who serve at the highest rate per capita in the military, and who have the highest rates of posttraumatic stress disorder and substance abuse related to their military service. These clinics represent a unique multi-organizational collab‐ oration between the Department of Veterans Affairs, the Indian Health Service, the University of Colorado and Tribal partners. Outcomes provide strong evidence of the positive impact of improved access and quality of care to rural Native veterans. For example a recent published report described the increase in service utilization and appropriate medications for patient in these clinics (Shore et al 2012b). The clinics utilize a model that includes culturally knowl‐ edgeable providers, onsite clinic tribal outreach workers and collaboration with local services including as appropriate traditional medicine. This work strongly suggests the importance of the development and use of an appropriate telepsychiatry clinic model for Native patients that accommodates cultural issues, maintains overall fidelity of approach but can be adapted to

This article is a description of the patients seen from three California Native American IHS sites using a telepsychiatric consultation program from the academic medical center. Its objectives were to: a) describe the population's demographics and illnesses, b) identify needs of patients and physicians, c) report the services delivered to this patient population, and d) examine the quality of psychopharmacologic services. Patient, clinic, and system factors related to telepsychiatric consultation, which have important implications for federal health

The University of California Davis Health System (UCDHS) is based in Sacramento, California, and serves a 33-county area to the Oregon state border. Since 1995, UCDHS has provided telemedical consultations since 1995 in 28 specialties to 42 clinics (26 rural, 16 prisons) between 100 and 350 miles away (Nesbitt et al 2013). The telepsychiatry service has provided over 4,000

structure and integration and the importance of cultural adaptation.

**4. UC Davis telepsychiatric Native American study**

policy toward Native Americans, will be noted (Dixon 2001).

consultations, using a variety of models (Hilty et al 2006b).

best fit local services and culture.

**4.1. Overview**

**4.2. Methods**

**Model 6:** Asynchronous telepsychiatry. Traditionally, there have been two main types of telemedicine: *synchronous*, which typically relies on live, two-way interactive video to a remote area, and *asynchronous* (store-and-forward), which transmits clinical information via email or web applications for later review by a specialist. Broadly speaking, synchronous communica‐ tion by phone or with video allows synthesis of information and easy exchange of information, with in -the-moment questions by PCPs. *Asynchronous* telemedicine has been commonly used and well-received for pathology, cardiology, radiology, dermatology and other fields. A study of synchronous telepsychiatry, including Native American patients, revealed that PCPs are highly satisfied with the service, with 100% of the respondents noting the consultation as fast as from a regular face-to-face visit, was able to meet their patient's needs and lead to an improvement in the management of their patient; 64% thought the ATP consultant was able to completely meet their patient's needs and the feedback they received over ATP was as good as from a regular face-to-face visit (Yellowlees et al 2010; Butler and Yellowlees 2012).

#### **3.4. Telepsychiatry and cultural populations**

Ethnicity, culture and language issues affect health (Office of Surgeon General, 2001) and there is often inadequate access to specialists (Moreno et al 2012) —inroads to patient needs and preferences that can be met by telemental health are progressing. A recent study of nearly 40 rural health clinics compared impressions of 25 primary care providers and 32 staff impres‐ sions of factors important to care: using providers who value differences (5.4/7.0), quality of the provider's care (4.9/7.0), access to care in general (4.5/7.0) and availability of trained interpreters for use with patients (4.4/7.0) (Hilty et al 2013). Others are studying the specific needs of Hispanics/Latinos (Moreno et al 2012; Nieves et al 2007, Chong et al 2012), Asians (Ye et al 2011), Native Americans (Weiner et al 2005, Shore et al 2007, Shore et al 2008), Eastern Europeans (Mucic, 2004), and those using sign language (Lopez et al 2004) —all using telepsychiatry for service provision. With patients of different cultural backgrounds, using the patients' primary language allows for a more comfortable atmosphere where they may express their genuine feelings and emotions.

#### **3.5. Telepsychiatry to Native Americans**

Northern Plains Native Americans were very satisfied and comfortable with telepsychiatric treatment for post traumatic stress disorder (Shore and Manson 2004a; Shore and Manson 2004b; Shore et al 2006). In fact, location, communication, trust, and confidentiality were equally satisfactory for treatment in-person versus videoconferencing. Even Native American children and families are receptive to telepsychiatric consultation (Savin et al 2006).

#### **U. Colorado.**

Over the past decade the University of Colorado's Center for American Indian and Alaska Native Health (CAIANH) has collaborated on multiple telepsychiatry services targeted at American Indian and Alaska Native populations (Shore et al 2006; Savin et al 2006; Shore et al 2012a). These services have occurred in a number of Western States (Alaska, Colorado, Montana, New Mexico, South Dakota, Wyoming), involved both consultative and direct service models in a range of settings (community clinics, hospitals) and spanned age ranges from children and adolescents to geriatric population. These services have helped to demon‐ strate the feasibility of telepsychiatry with native populations, various models of clinical structure and integration and the importance of cultural adaptation.

A recent review (Shore et al 2012a) summarizes 10 years of CAIANH work with rural Native Veterans, of rural American Indian Veterans who serve at the highest rate per capita in the military, and who have the highest rates of posttraumatic stress disorder and substance abuse related to their military service. These clinics represent a unique multi-organizational collab‐ oration between the Department of Veterans Affairs, the Indian Health Service, the University of Colorado and Tribal partners. Outcomes provide strong evidence of the positive impact of improved access and quality of care to rural Native veterans. For example a recent published report described the increase in service utilization and appropriate medications for patient in these clinics (Shore et al 2012b). The clinics utilize a model that includes culturally knowl‐ edgeable providers, onsite clinic tribal outreach workers and collaboration with local services including as appropriate traditional medicine. This work strongly suggests the importance of the development and use of an appropriate telepsychiatry clinic model for Native patients that accommodates cultural issues, maintains overall fidelity of approach but can be adapted to best fit local services and culture.
