Telemental health has been promoted to address long-standing access barriers to rural mental health care, including low supply and long travel distances. Examples of rural telemental health programs are common; there is a less clear picture of how widely implemented these programs are, their organization, staffing, and services. There is also a need to understand the business case for these programs and assess whether and how they might realize their promise. To address these gaps, a national study was conducted of rural telemental health programs including an online survey of 53 programs and follow-up interviews with 23 programs. This article describes the current landscape and characteristics of these programs and then examines their business case. Can rural telemental health programs be sustained within current delivery systems and reimbursement structures? This question is explored in four areas: need and demand, infrastructure and workforce, funding and reimbursement, and organizational fit and alignment.
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This definition of telemental health is consistent with services currently reimbursable through Medicare as well as some Medicaid and commercial payers which require a “one-on-one” encounter between the patient and provider. Collateral contact with family members or others without the patient present are typically not reimbursable. While some mental health stakeholders advocate for a broader use of technology (e.g., e-mail and telephone) to deliver behavioral health services, few third-party payers currently reimburse providers for delivering services using these broader technologies.
A response rate of 40% was also obtained in a similar exploratory study of rural mental health outreach programs conducted by one of the authors for the Substance Abuse and Mental Health Services Administration a decade earlier.23 Rural mental health outreach programs and rural telemental health programs are similar in that they are both relatively popular, usually started with grant funding, and face significant sustainability challenges when grant funding ends. There is not a definitive list or roster of either type of program, creating the need for exploratory study.
Although state Medicaid policies may use similar language, states vary in how telehealth is defined and reimbursed.
Lambert D, Gale JA. Integrated Care in Rural Areas. In: Smalley KB, Warren JC, Rainer JP, eds. Rural Mental Health: Issues, Policies and Best Practices. New York: Springer Publishing Company; 2012:131–148.
New Freedom Commission on Mental Health. Subcommittee on Rural Issues: Background Paper. Rockville, MD: U.S. Department of Health and Human Services; June, 2004. DHHS Publication No. SMA-04-3890.
Smalley KB, Warren JC. The Current State of Rural Mental Health. In: Smalley KB, Warren JC, Rainer JP, eds. Rural Mental Health: Issues, Policies and Best Practices. New York: Springer Publishing Company; 2012:3–16.
Smith HA, Allison RA. Telemental Health: Delivering Mental Health Care at a Distance. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration and Health Resources and Services Administration 1998.
Lambert D, Gale J, Hansen AY, et al. Telemental Health in Today's Rural Health System. Portland, ME: University of Southern Maine, Muskie School of Public Service, Maine Rural Health Research Center; December, 2013. Research & Policy Brief PB-51.
UnitedHealth Center for Health Reform and Modernization. New Models of Technology—the Promise of Rural Telemedicine. In: UnitedHealth, ed. Modernizing Rural Health Care: Coverage, Quality, and Innovation (Working Paper 6). Minnetonka, MN: UnitedHealth Center for Health Reform and Modernization; 2011:42–52.
Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Affairs. 2008;27(3):759–769.
Weinstein RS, Lopez A, Joseph B, et al. Telemedicine, telehealth, and mobilehealth applications that work: Opportunities and barriers. The American Journal of Medicine. 2014;127(3):183–187.
American Telemedicine Association. Telemental and Behavioral Health: State Medicaid Best Practice. Washington, DC: ATA; August, 2013.
Goldstein E, Myers K. Telemental Health: A new collaboration for pediatricians and child psychiatrists. Pediatric Annals. 2014;43(2):79–84.
Hilty DM, Ferrer DC, Parish MB, et al. The effectiveness of telemental health: A 2013 review. Telemedicine and e-Health. 2013;19(6):444–454.
Benavides-Vaello S, Strode A, Sheeran BC. Using technology in the delivery of mental health and substance abuse treatment in rural communities: A review. Journal of Behavioral Health Services and Research. 2013;40(1):111–120.
Department of Defense. Telemental Health Guidebook. Washington, DC: National Center for Telehealth & Technology, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury; June 9, 2011. Version 1.
Velasquez SE, Duncan AB, Nelson E-L. Technological Innovations in Rural Mental Health Service Delivery. In: Smalley KB, Warren JC, Rainer JP, eds. Rural Mental Health: Issues, Policies, and Best Practices. New York: Springer Publishing Company; 2012:149–172.
Krupinski EA, Weinstein RS. Telemedicine in an academic center—the Arizona telemedicine program. Telemedicine and e-Health. 2013;19(5):349–356.
American Telemedicine Association. Evidence-Based Practice for Telemental Health. Washington, DC: ATA;2009.
Sood S, Mbarika V, Jugoo S, et al. What is telemedicine? A collection of 104 peer-reviewed perspectives and theoretical underpinnings. Telemedicine and e-Health. 2007;13(5):573–590.
Institute of Medicine. The Role of Telehealth in an Evolving Health Care Environment. Washington, DC: National Academies Press; 2012. Workshop Summary.
Annapolis Coalition on the Behavioral Health Workforce. An Action Plan for Behavioral Health Workforce Development. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2007.
Mohatt D, Bradley MM, Adams SJ, et al. Mental Health and Rural America: 1994–2005. Boulder, CO: 2006.
New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in America. Rockville, MD: United States Department of Health and Human Services;2003. DHHS Pub. No. SMA-03-3832.
Gustafson DT, Preston K, Hudson J. Mental health: Overlooked and disregarded in rural America. Lyons, NE: Center for Rural Affairs;2009. No. 4: Series Examining Health Care Issues in Rural America.
Lambert D, Donahue A, Mitchell M, et al. Mental health outreach: Promising practices in rural areas. Rockville, Maryland: Published by U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Center for Mental Health Services; 2003.
MacDowell M, Glasser M, Fitts M, et al. A national view of rural health workforce issues in the USA. Rural and Remote Health. 2010;10(3):1531.
Thomas D, Macdowell M, Glasser M. Rural mental health workforce needs assessment—A national survey. Rural and Remote Health. 2012;12:2176.
Hailey D, Roine R, Ohinmaa A. The effectiveness of telemental health applications: A review. Canadian Journal of Psychiatry. 2008;53(11):769–778.
Hoge MA, Stuart GW, Morris J, et al. Mental health and addiction workforce development: Federal leadership is needed to address the growing crisis. Health Affairs. 2013;32(11):2005–2012.
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA). Report to Congress on the Nation's Substance Abuse and Mental Health Workforce Issues. Rockville, MD: SAMHSA; January 24, 2013.
Brooks E, Turvey C, Augusterfer EF. Provider barriers to telemental health: Obstacles overcome, obstacles remaining. Telemedicine and e-Health. 2013;19(6):433–437.
California Telehealth Resource Center. Telemedicine Reimbusement Guide. Sacramento, CA: The Center; January, 2014.
SAMHSA-HRSA Center for Integrated Health Solutions. A to Z: Developing Telebehavioral Health Capacity to Serve the Needs of Your Patients. Presented at the Telebehavioral Health Training and Technical Assistance Series; June 5, 2013; Webinar.
Center for Connected Health Policy. State Telehealth Laws and Reimbursement Policies. A Comprehensive Scan of the 50 States and District of Columbia. Sacramento, CA: Center for Connected Health Policy; February, 2015.
Center for Connected Health Policy. Telehealth Medicaid and state policy. 2014. Available online at: http://telehealthpolicy.us/telehealth-medicaid-state-policy. Accessed March 31, 2015.
The Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services funded the research on which this article is based.
Conflict of Interest
The authors disclose no conflicts of interest.
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Lambert, D., Gale, J., Hartley, D. et al. Understanding the Business Case for Telemental Health in Rural Communities. J Behav Health Serv Res 43, 366–379 (2016). https://doi.org/10.1007/s11414-015-9490-7
- Mental Health Service
- Organizational Arrangement
- Telehealth Service
- Specialty Mental Health Service
- Telemental Health