Rural Telemental Health (RTMH) Program
- Need: To provide high-quality mental healthcare to rural veterans.
- Intervention: The Rural Telemental Health (RTMH) program, stationed at the Portland VA Medical Center, reaches rural veterans in Idaho, Oregon, and Washington via telehealth.
- Results: From 2010 to 2013, 1,754 veterans received diagnoses, therapy, medication management, and other mental health services.
Effective (About evidence-level criteria)
A significant portion of veterans are in need of mental health services. According to the VA National Suicide Data Report 2005-2016, the age- and gender-adjusted rate of suicide among veterans was 26.1 per 100,000, compared to 17.4 among non-veterans. Many veterans are also struggling with post-traumatic stress disorder, anxiety, and depression, among other conditions. Rural veterans risk going without any or adequate treatment, since their communities may lack mental health services or they may live a considerable distance from the nearest facility.
Since 2009, the Rural Telemental Health (RTMH) program has been improving access to mental healthcare for rural veterans in Idaho, Oregon, and Washington. The RTMH program, stationed at the Portland VA Medical Center, was started with funding from the VA Office of Rural Health. Instead of needing to drive long distances to a Veterans Administration (VA) facility, veterans can meet with a RTMH provider via telehealth, either at a VA community-based outpatient clinic or, in some cases, in veterans' homes.
Rural veterans enrolled at several VA facilities serving Idaho, Oregon, and Washington are eligible for RTMH services. Through telehealth, RTMH can provide:
- Assessments/diagnostic interviews (psychiatric and psychological)
- Case consultation for rural providers
- Cognitive processing therapy (CPT) or prolonged exposure therapy (PE) for PTSD
- Cognitive rehabilitation for traumatic brain injury
- Medication management
- Nursing outreach, medication follow-up, and care management by phone
- Psychoeducation, skills coaching, and motivational interventions
- Psychotherapy (individual, couples, and group)
- Other evidence-based psychotherapies as indicated
From 2010 to 2013, RTMH reached 1,754 veterans via phone, email, and video-conferencing. In 2013 alone, RTMH saved patients 1,089,037 miles of travel and recorded:
- 193 group psychotherapy encounters
- 363 diagnostic interviews
- 952 therapist/MD phone calls
- 961 sessions of psychotherapy/medication management
- 1,755 nurse phone calls
- 2,076 sessions of individual therapy
RTMH providers were able to diagnose and treat conditions associated with suicide risk, such as post-traumatic stress disorder (41% of diagnoses), depressive disorder (32%), and anxiety disorders (17%).
For more information on program results:
Lu, M.W., Woodside, K.I., Chisholm, T.L., & Ward, M.F. (2014). Making Connections: Suicide Prevention and the Use of Technology with Rural Veterans. Journal of Rural Mental Health, 38(2), 98-108. Article Abstract
The CDC lists RTMH as a case study in its Suicide Policy Brief: Preventing Suicide in Rural America.
Despite the advantages of in-person care, a telehealth program may be some veterans' only access to mental health services. Safety planning for high-risk patients can be more difficult for providers at a distance and can be enhanced through multidisciplinary support and coordination with local services when feasible.
In order to establish telehealth services in rural clinics, partnerships with local staff must be developed and technical infrastructure established. Protocols for emergencies, provider credentialing, scheduling, and charting must be implemented.
For in-home services, some patients may have less familiarity or comfort with technology than others. In addition, some veterans may not be able to afford technology or internet access. To address some of these concerns, providers may ask patients to identify a patient support person who can help with computer use, treatment planning, or both. Also, the Home-Based Telemental Health (HBTMH) program, funded by a VA Innovation Grant, provides tech support, equipment, and internet connections to veterans in need.
Each rural area may vary with regard to availability of internet connectivity, local resources, emergency services, and VA services. As with any electronic transmission of sensitive patient information, security is a high priority. Information technology staff should be consulted in order to minimize the risk of security or privacy breaches.
Telehealth should be considered an additional resource and not a replacement for all in-person care. For example, telehealth may not be a good fit for patients with:
- Difficulties tolerating occasional interruptions in service
- Significant cognitive impairment
- Hearing impairment that cannot be corrected
- Immediate need for hospitalization (like acute danger to self)
- Severe psychotic or manic symptoms
- Uncontrolled, severe substance use disorders
The possibility of face-to-face visits may be taken into consideration when designing the structure of a telehealth program and the location of providers. Patients who live up to 1-2 hours away often choose to schedule occasional face-to-face visits with the telehealth provider if they establish a longer-term relationship. Face-to-face visits may be combined with telehealth visits for patients who may receive specialty care at the VA facility where the telehealth provider works. For VA telehealth prescribers seeing patients in the patients' homes, the Ryan Haight Act prohibits prescribing any controlled substances unless the patients have been previously evaluated in person.
Derek Burks, PhD, Psychologist
VA Portland Health Care System
Suicide and suicide prevention
Idaho, Oregon, Washington
July 19, 2016
July 31, 2018
Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.