Across the U.S., telehealth is increasingly being seen as a technology that can be used in a wide variety of creative and innovative spaces. The behavioral health field is one area where virtual care services continue to be a natural fit, as nationwide shortages of mental health professionals—especially for children—are consistently reported.
Indeed, a recent comprehensive review from national law firm Epstein Becker Green found that federal and state lawmakers are more gradually supporting coverage for mental health services provided via telehealth, and to that end, a Doximity, an online networking service for medical professionals, also recently found in separate research that radiology and psychiatry were the top two specialties most interested in telemedicine opportunities. Mental health services via telemedicine are used in a variety of settings, including private practice, outpatient clinics, hospitals, schools, nursing homes, and correctional facilities.
In Dallas, Children’s Health, a pediatric health system anchored by two hospitals and several pediatric clinics, embarked on a school-based integrated telehealth program five years ago with an initial goal to connect school nurses with pediatric providers and treat acute care conditions in the school setting. A few years after the pilot project commenced, schools started to ask Children’s Health if the health system had a behavioral health solution it could offer to expand the program outside just traditional physical healthcare, recalls Jason Isham, the director of integrated behavioral health at Children’s Health.
“Children’s Health had been providing integrated behavioral health in primary care pediatric clinics for some time, meaning we had a licensed behavioral health clinician assigned to a pediatric practice, and that provider would asses and intervene with patients—either identified by the primary care physician or nurse practitioner—for their behavioral health issues. “So we took that model and imported it into the school system. Now, rather than receiving a referral from a primary care pediatrician in the school, we receive it from the school counselor,” Isham explains.
After officially launching the behavioral health telehealth program in the fall of 2017 at five high schools, it has since expanded to a few dozen campuses across the region. All told, the program now covers more than 21,000 children, including elementary and middle school students. Since its launch, Children's Health counselors have conducted more than 400 virtual therapy sessions, according to health system officials. The reasons for the therapy sessions vary widely, although Isham says the most common clinical themes revolve around some manifestation of anxiety. Bullying, depression and grieving are also common themes, as is self-identity.
Here’s how the program specifically works, as explained by Isham: the school will identify a student with a potential behavioral health need, and then if deemed necessary, will make a referral to the Children’s Health program. If that handoff occurs, a licensed clinician at the health system will outreach the family, conduct a behavioral health assessment, provide supportive telephonic case management, and when clinically appropriate, will offer behavioral health telehealth therapy sessions in the school setting.
At the end of that initial telephonic behavioral health assessment, if the student is clinically appropriate for telehealth sessions in the school setting, the health system will help link the family with a virtual visit platform from telehealth solutions provider American Well. The student will get set up on that platform with his or her own account, and then Children’s Health will circle back with the school to set up 30-minute telehealth counseling sessions in the school setting, which is delivered via video conferencing through American Well and on an iPad that Children’s Health owns and delivers to the school.
So, the student comes out of class, gets a pass from his or her counselor to go to the counseling office, logs in, and interfaces with the licensed clinician via the American Well platform, Isham explains.
Strong support, thus far
Considering this school-based telehealth program is relatively new—and that it’s still a novel concept across U.S. healthcare—Children’s Health leaders were eager to see how its clinicians and school counselors that it partners with were reacting to the initiative.
“We survey our counselors at the end of each year and without fail, every single one of them has said they believe that the students who received the telehealth sessions in their school have been helped by the program,” Isham says. Additionally, once a family accepts a referral, upwards of 94 percent of families accept and receive an assessment from one of Children’s Health clinicians, he points out. “So, they’re getting access to a licensed mental health clinician when they otherwise might not have.”
Isham notes that Children’s Health also develops patient-centered clinical goals that are worked on with the patients based on the initial assessment. “We ask them to rank themselves and their ability to manage that goal at the beginning of care, then again at several points along the way, and then finally again before they terminate with us. What we see between the first and second administrations of the goal is about a 30 percent improvement of their ratings of their ability to manage their own clinical issues. And we are also seeing a patient’s family telling us that things are getting better for them,” he says.
He does admit that some folks have raised questions of how students will respond to getting counseling from what essentially amounts to an iPad, even though there is a real person at the other end. “Anecdotally, we are hearing from students and parents that our students are responding very well to receiving counseling from our therapists via video conferencing. It’s almost as if that video connection provides a sense of psychological safety, or buffer, that makes it safe for students to be able to share with their therapists what’s going on with their lives,” Isham relays.
“Doing that in the same room with adults can be scary for students. So we are seeing the virtual visit is providing a greater ease of access into that child’s inner world than we might have expected initially,” he adds.
To this point, Lindsay Henderson, a clinical psychologist with American Well—a company that just recently purchased Aligned Health, one of the largest providers of behavioral telehealth—says that in her experience, behavioral health lends itself nicely to a telehealth platform or modality because there isn’t a constant need to touch, feel, or put hands on patients. “As a psychologist, I am doing all of the diagnosing, ‘prescribing’ and ‘treatments’ with my eyes, words, and conversations. And so, as a provider, it’s nice to be able to communicate with someone using a screen instead of sitting in the same room,” she contends.
What’s more, Henderson adds that with behavioral health, it’s important to note that treatment involves ongoing, repeated visits, which takes time and resources away from patients to fit regular mental healthcare into what might be very busy lives. “So unlike a unique, freestanding physician appointment, or a procedure that needs a prescribed amount of follow-up, behavioral health needs are often more frequent, reoccurring, and longstanding, in a way that makes convenience and accessibility more important,” she opines.
Ultimately, a core goal of all stakeholders involved is to make behavioral healthcare a part of everyday healthcare. But that has been historically challenging due to the many stigmas attached to mental health. When a patient receives a referral to an orthopedist, for example, there is no stigma, nor is there a long period of waiting around to get services, Isham points out. With behavioral health, on the other hand, people may feel ashamed for something that is out of their control, often leading them to avoid seeking care.
But through this program, Children’s Health is able to take behavioral health services to patients and provide them in a context in which they are familiar with and in which they trust, which then can reduce some of that stigma, Isham says. To this point, a key protocol the health system has when it goes into schools is to inspect the physical layout of the school and make sure the place where the sessions will take place are safe, private, and confidential, and that in the event of a crisis, the school has proper protocols in place, says Isham.
On the provider side, meanwhile, an essential factor in integrating this type of program is making sure that clinicians are properly trained, for a few core reasons. First, it’s likely that this tele-behavioral health experience also represents unchartered waters for them, in addition to for their patients. And second, it’s vital to establish patient-provider trust from the onset for the behavioral health services to have an impact. One way Children’s Health works to ensure this is by confirming that each interaction and patient a clinician is working with is appropriate for telehealth and can be safely managed in a specific setting. Further, Isham and Henderson both attest that clinicians must develop a “web-side” manner for patients since these virtual visits are different than a typical face-to-face encounter.
In the end, in Texas, just like in many other U.S. states, there is a lack of behavioral health providers—particularly child psychiatrists. But Isham insists that this program is not something that Children’s Health is forcing to the market; rather, the market is coming to the health system with a need. “That’s particularly true in Texas with a lot of our schools located in rural areas, meaning it could be difficult to get a provider to that location. Virtual services provide an amazing access point,” he says.
Isham also notes that when Children’s Health provides a tele-behavioral health session in a school through a virtual counseling session, the parent doesn’t have to get off work to take the child out of school into the provider’s office, which could be in the next town over, if not further. “They can receive that service in a setting that is convenient for them. And we are minimizing the disruption to instructional time, so there is a win for schools, too. We’re taking behavioral health [services] and bringing them to the places where people already are. Telehealth is a great and cost effective way to do that.”
