In Sioux Falls, Avera Health Surges Ahead on Delivering Behavioral Healthcare Virtually

June 10, 2021
Matthew Stanley, M.D., clinical vice president of behavioral health service line at the Avera eCARE, speaks to the value of providing virtual care for behavioral health patients

One of the most important learnings coming out of the pandemic has been around the need to improve access to behavioral healthcare and address the mental health professional shortage. In fact, we now have direct evidence suggesting that behavioral health conditions have increased while access to care decreased during the crisis, according to a recent report from the U.S. Government Accountability Office (GAO).

Per the report, Centers for Disease Control and Prevention (CDC) survey data collected from April 2020 through February 2021 found that 38 percent of adults reported symptoms of anxiety or depression. In comparison, using similar questions, CDC found that about 11 percent of U.S. adults reported experiencing these symptoms from January to June 2019.

Of course, like it has on the clinical side, virtual care has played a big role throughout the crisis in meeting the increased demand for behavioral health services. A recent report from Cigna actually found that 60 percent of behavioral health patients are still using virtual services, even though prior to the pandemic, 97 percent of these individuals had never had a single virtual consultation.

Nonetheless, key challenges around shortages of professionals around the U.S. and an increase in patients with such conditions remain. Indeed, data shows the current provider to patient ratio is 1 to more than 30,000, according to Mental Health American (MHA).

To this end, in late April, the American Board of Telehealth announced the launch of a new telebehavioral health certificate program. The program was developed by leaders in the space for a wide range of disciplines (e.g. psychiatrists, psychologists, social workers, nurses, therapists and prevention specialists) and settings, including prevention programs, inpatient treatment programs, primary care health delivery systems, emergency rooms, criminal justice systems and schools. The curriculum consists of seven modules that review current evidence and best practices from highly regarded experts through interactive content, video, and integrated case scenarios, while also addressing special populations, such as older adults and children.

“Telehealth is a powerful medium, but providers need new skills and knowledge to ensure it reaches its full potential. This innovative certificate program delivers next level training, specifically for mental health practitioners, that will enable them to engage with patients on a deeper level to improve outcomes. And it couldn't come at a more critical time given the rise in mental health issues during the pandemic,” said Matthew Stanley, M.D., clinical vice president of behavioral health service line at the Avera eCARE—a telehealth network of the Sioux Falls, S.D.-based Avera Health system—and founding board member of the American Board of Telehealth. 

In a recent interview, Stanley discussed the program in more detail, the most important lessons learned around virtual behavioral health during the crisis, and the significance of Avera’s plans to build a new four-story wing at the Avera Behavioral Health Center in Sioux Falls. Below are excerpts if that conversation.

What have been the biggest lessons learned throughout the pandemic as it relates to telebehavioral care?

From the broader telemedicine perspective, one key lesson learned was that some of the concerns we had around people not being [comfortable] with using technology such as tablets, laptops and cell phones were dispelled in a positive way. At one part-time hospital program for seniors that I was [administering care] for, these folks were over 65 years old, and they really took to the technology and the ability to see me through the use of the tablets, laptops and cell phones. And these were patients who were very isolated by COVID, because if they were in a nursing home, most of them couldn't even have communal dining, or if they were at home, they didn’t leave much. So they appreciated the interaction.

We learned that direct-to-consumer telehealth—so being able to see someone in their home or wherever they are—provided a tremendous benefit. We serve some very rural, impoverished areas where we have a very high no-show rate in large part because of social determinants of health. So, travel is difficult, as is having gas money, getting off of work and childcare; all those things make it very difficult for many populations, but certainly this population.

We saw that when we could go direct-to-consumer with the changes that were made due to the emergency status of the pandemic, our no-show rate dramatically improved. So we made much better connections to our patients, which proved to me that the [issue] wasn't that these patients didn't want to make their appointments; there were just too many barriers in the way for them to be able to get to the appointment. So when we could go directly to them through this medium, they were more than happy to have the appointment. In some ways, direct-to-consumer facilitates a better behavioral health interaction because you can get an idea of the environment that they're living in. And honestly, they're probably a little more candid when they're talking to you from their home rather than from a doctor's office.

A recent Cigna report found that 60 percent of behavioral health patients are still using virtual services. Prior to the pandemic, 97 percent of these individuals had never had a single virtual consultation. Are you experiencing similar trends?

We’re waiting to see how many of these [government-granted flexibilities around providing virtual care] stick [beyond the pandemic], but I think from the consumer side, they're very clear in telling us that they like this [option] better. Of course, that’s not everyone; some people still prefer a more traditional approach. But there's a pretty strong group of patients that are more comfortable getting virtual care. Thinking about behavioral health, some of the people who we are treating are dealing with things like social anxiety—so getting out of the house and driving a car—or patients that have delusional disorder—so they're uncomfortable and paranoid about things around them. The other thing is that obviously, a lot of our interactions are primarily performed through verbal skills and discussion. So it doesn't feel like we lose a lot when we're doing these meetings through telemedicine. 

Across the U.S., there has been an increase in patients with behavioral conditions, but not enough professionals in the field. How do you think this gap could be filled in the future?

We are seeing increased numbers of people with behavioral health needs. Yet, we already had access challenges prior to the pandemic, so we're getting further behind the eight ball. We need to better stratify the level of care patients need, which means evaluating and plugging them into the right level of care. Not everyone needs to see a psychiatrist because they have depression; we have primary care doctors who actually do write a majority of antidepressants. But we have behavioral health nurse practitioners, and consistent with that, there are counselors that could do the screenings. For many patients, once I see them, they aren't necessarily interested in a medication.

At the same time, we do have to build more providers. I know there have been efforts in Congress to expand the residency slots, but those have been frozen [for 25 years]. So we haven't been expanding our pool of psychiatrists or other providers to keep up with population growth and need. That would be a step in the right direction.

I do think the system is a little bit fragmented in how we approach care; it can be hard for patients to navigate the system. There are apps and online screening tools that could be utilized to help patients have a better understanding of where they would best insert into the system so that we can more efficiently meet the specific needs of that patient. Too often by default, the patient gets rolled up to the highest level of care, which is the specialist in this case.

To that end, can you discuss the importance of the American Board of Telehealth’s new telebehavioral health certificate program?

We are experiencing an explosion in telemedicine. I would say that the forced use through the pandemic has launched telemedicine five or 10 years into the future compared to where we would have been. One of the driving forces and visions behind the idea [of the program] was that this is a unique medium of patient care. So there are good ways and bad ways to use that medium. We wanted to make sure that we were advocating for the patient, so they have the best provider experience [possible], and we wanted to create some degree of standardization or uniformity to the idea of practicing telemedicine.  Many professional societies have touched on this, but what we felt was lacking was just a truly well-designed, comprehensive, educational approach to this for providers, so that the provider could feel like by taking this course, he or she is fully competent and understands all the ramifications of telemedicine practice.

Can you share thoughts on the significance of the new wing being built at the Avera Behavioral Health Center in Sioux Falls?

Emergency rooms weren't necessarily designed for folks with behavioral health problems in mind. Patient experiences are often difficult, sometimes even traumatic, in traditional approaches. We wanted to create a fast-track, highly patient-centered approach to emergent behavioral healthcare. We have to be careful not to call ourselves an emergency room, because that entails other things from a regulatory standpoint, but this is a walk-in, drop-off, EMS service, and scattered drop-off service, so that we can take in everyone with behavioral health needs.

For our local emergency rooms, it's a welcome addition, too; they would acknowledge it's not really their forte to deal with behavioral health patients. From a system and a community standpoint, access can be quite difficult. Well, this is a tremendous expansion of patient access for those that have a behavioral health concern or emergency.

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