Telehealth Models for Increasing Access to Behavioral and Mental Health Treatment
Rural communities are using telehealth to provide mental and behavioral health services — referred to as
telemental health or telebehavioral health. The Rural Mental Health topic
guide describes a significant need for mental health services in rural America and notes that telehealth has
been successful in helping to alleviate the lack of mental health services in rural areas. A large body of
evidence has demonstrated that telemental health
programs help increase access to care in areas with limited mental health resources, provide effective
treatment for mental health conditions, and improve medication adherence.
Changes in regulation due to the COVID-19 pandemic have expanded opportunities for access to behavioral and
mental health services via telehealth. For example, Medicare
expanded coverage for mental health telehealth visits originating in Rural Health Clinics (RHCs) and
Federally Qualified Health Centers (FQHCs), including audio-only telehealth services. Research shows that telehealth
has helped meet the needs of rural communities during the COVID-19 pandemic.
Telemental health interventions typically fall into four domains:
Hospital care – Rural hospitals connect to behavioral and mental health specialists
through telehealth. For example, a psychiatrist can use video telehealth technology to diagnose patients in
a rural emergency department.
care – Patients can receive behavioral and mental health services Relocated
through telehealth in primary care settings. For example, patients at a rural primary care clinic could use
live-video teleconferencing to receive counseling from a remote psychologist.
Mobile health applications or
remote monitoring programs – These can support longer-term interventions or
management of behavioral health conditions. For example, rural patients could use a tablet, smartphone
application, or computer program to track medication adherence, monitor their symptoms, and receive
Direct to consumer
services – These allow rural patients to connect directly to behavioral and
mental health providers using on-demand telehealth applications from any setting, including the home.
Rural communities are using telehealth to provide the following behavioral and mental health services:
Evaluation and diagnosis – Providers can use telehealth technology to observe the
patient; administer scales, assessments, and screenings; and diagnose conditions.
Case consultation – Some telemental health programs enable rural providers to consult with
psychiatrists and psychologists. Consultations can take place by direct video communication, telephone, or
Treatment – Behavioral and mental telehealth programs typically provide counseling
and psychotherapy, which can be delivered to individuals, couples, or groups. Some programs also offer more
specialized therapies such as medication-assisted therapy (MAT), cognitive processing therapy, or prolonged
exposure therapy for post-traumatic stress disorder (PTSD). Programs may also use telehealth to deliver
interventions such as education about mental health conditions and skills coaching.
Medication management – Telehealth can help rural patients adhere to their medication
regimens. Tools that rural communities have used for medication adherence include monitored in-home
dispensing devices, mHealth apps, and telephone counseling.
Continuing care – Some rural programs provide case management services through
telehealth to improve patient outcomes. For example, a nurse care manager could coordinate with family
members, social services agencies, and healthcare facilities through the phone to meet the identified needs
of their patients.
Provider education – Rural providers can receive training or continuing education
about behavioral telehealth through distance learning, telementoring, or webinars.
Examples of Behavioral and Mental Health Telehealth Programs
Summit Healthcare Regional Medical
Center facilitates access to behavioral healthcare in primary care offices across rural
Navajo County, Nevada. Patients in the primary care offices meet with behavioral health providers through
telehealth-enabled tablets or video carts.
Greater Oregon Behavioral Health,
Inc. uses a telehealth platform that allows patients in rural Oregon to connect to
behavioral health services from their personal smartphones, tablets, or computers. Patients use the platform
to communicate with behavioral health clinicians via videoconference or text from any location.
- The Wyoming Trauma Telehealth Treatment Clinic provides
psychotherapy via videoconferencing to rural crisis center clients who have experienced some form of
violence. The University of Wyoming Psychology Department and the University of Wyoming Center for Rural
Health Research and Education partnered to establish the clinic.
- The South Carolina Department of Mental Health (SCDMH) Emergency
Department Telepsychiatry Consultation Program was initially established to connect
patients in dozens of emergency departments across the state with psychiatrists in urban practices. As the
program has grown, SCDMH has expanded the program to include telehealth sites in community mental health
centers and mental health clinics. The program is the largest provider of telepsychiatry in South Carolina.
Examples of Telemental Health Programs Focused on Racial and Ethnic Populations that Experience Health
The Madison Outreach and Services through
Telehealth (MOST) Network provides counseling services to the growing Latino population
of rural Brazos Valley in Texas. Counselors at Texas A&M University offer psychotherapy to patients in
rural clinics via telephone and live video. Local community health workers help facilitate telehealth
appointments by transporting residents to rural clinics and providing other outreach services.
The Arrowhead Telepresence
Coalition increases access to behavioral healthcare in seven rural Minnesota counties
and three tribes. The coalition contracts with a range of providers, such as chemical dependency specialists
and pharmacists, to provide virtual appointments for diagnosis and treatment at county jails, schools, rural
hospitals, community health centers, crisis response centers, and tribal health and human services agencies.
Examples of Programs Focused on Children
- The University of Kansas Medical Center's Telehealth
ROCKS program offers a range of telebehavioral health services to rural children and
their families. Providers from the University of Kansas connect with children and their families through
live-video telehealth at schools and primary care practices, including community health centers.
Telebehavioral services include parenting programs, therapy, medication management, behavior analysis, and
assessments, including autism assessments and psychological evaluations. In addition, Telehealth ROCKS is
ECHO to build the capacity of rural providers, school personnel, and other child-serving systems to
manage behavioral health conditions among children.
Examples of Programs Focused on Veterans
Alaska Veterans Telehealth and Biofeedback
Services uses telehealth and provides veterans with trauma-informed treatment services.
Veterans enrolled in the program take an 8-week stress reduction training that uses biofeedback to address
trauma. Veterans can also access ongoing counseling services to receive treatment for depression, anxiety,
PTSD, and other physical and emotional concerns.
- The Indiana Veterans Behavioral Health Network connects
rural veterans at community mental health centers to providers at the VA Medical Center for diagnosis and
Another rural pilot project assessed the Telepsychology-Service
Delivery for Depressed Elderly Veterans intervention, which used in-home
videoconferencing technology to provide psychotherapy to participants. The pilot found no significant
differences between the outcomes of the control group, which received in-person care, and the telehealth
group. The in-home telehealth intervention was successful in reducing the symptoms of depression among the
participants, who lacked access to in-person care due to transportation and mobility issues.
Examples of Programs Focused on Older Adults
The American Psychiatric Association (APA) and the American Telemedicine Association (ATA) have developed
official guidelines and resources for advising programs that are implementing telemental and telebehavioral
care. Together, the organizations released the Best
Practices in Videoconferencing-Based Telemental Health. These best practices describe comprehensive
administrative, technological, and clinical considerations for providing behavioral and mental health services
through videoconferencing technology.
APA also offers an extensive online Telepsychiatry Toolkit
with considerations for training, legal issues, and clinical practice, including a discussion of telemental
health in rural
and remote practice settings. In 2021, the Substance Abuse and Mental Health Administration (SAMHSA)
also released Telehealth
for the Treatment of Serious Mental Illness and Substance Use Disorders, which provides a comprehensive
overview of the evidence base and provides examples of rural telemental health programs.
The Telehealth Resource Centers also provide helpful
resources and tools for rural communities seeking to implement or expand telemental and telebehavioral health
programs. For example, the Mid-Atlantic Telehealth Resource Center hosts the Telebehavioral Health Center of Excellence, which offers a wealth of
information to help programs implement or expand telebehavioral health services.
Additional considerations by topic area include:
Safety planning – Providers often work with patients and their families to ensure
that patients are supported in the event of a mental health crisis. Safety planning can involve creating a
physical document that identifies triggers, warning signs, coping strategies, and potential interventions.
Rural communities that offer home-based telebehavioral or telemental care should be aware of the importance
planning in case of an emergency.
Workforce challenges – Some rural programs have experienced challenges with engaging
and retaining behavioral and mental healthcare providers to offer telehealth services. Several rural
programs addressed this challenge by partnering with psychiatry and psychology programs at medical and
graduate institutions in their states. These telehealth partnerships allow future mental health providers to
gain experience practicing in rural healthcare settings while completing clinical practice requirements.
Researchers at the University of Washington developed a comprehensive set of considerations
and recommendations for developing telemental health partnerships between state medical schools and
Federally Qualified Health Centers.
Stigma around behavioral and mental health conditions – Rural programs offering
telemental health services may experience challenges with stigma. For example, rural residents might feel
discouraged from seeking help for behavioral health due to stigma associated with mental illness and
perceived lack of privacy or confidentiality. Additional issues related to stigma are described in the Primary Care Behavioral Health
Model of the Rural Services Integration Toolkit. Rural organizations that offer telemental care may
choose to emphasize the integrated nature of their services and ensure that patients have private and
confidential spaces to meet with remote providers.
Confidentiality – Some rural programs report that patients prefer receiving
telemental health services over the telephone instead of through video. Rural programs may also consider the
possibility of making counseling and other services available through text messaging, which can also address
connectivity issues that arise from limited broadband availability.
Additional implementation considerations including licensing and reimbursement are discussed in Module 4: Implementation and Module 6: Funding & Sustainability.
Program Clearinghouse Examples
Resources to Learn More
Center for Technology and Behavioral Health
Reviews the evidence base for treating substance use disorders and co-occurring disorders using technology, and
describes innovative uses of technology to address these disorders and other behavioral health conditions.
Organization(s): Center for Technology and Behavioral Health (CTBH)
Webinar Series Part 3 – Telehealth And Mental/Behavioral Health
Provides Federally Qualified Health Centers (FQHCs) with resources and suggestions for delivering mental and
behavioral healthcare through telehealth.
Author(s): Neufeld, J., Steffensen, A., & Weatherill, S.
Organization(s): National Consortium of Telehealth Resource Centers (TRC), HORIZON Health Care
Guidelines for Telemental Health with Children and Adolescents
Includes considerations for providing behavioral and mental health services to youth through real-time
Author(s): Myers, K., Nelson, E.L., Rabinowitz, T., et al.
Location: Telemedicine and e-Health, 23(10), 779-804
Rural Behavioral Health: Telehealth
Challenges and Opportunities
Discusses ways that rural communities are using telehealth to address behavioral health continuum of care.
Identifies challenges and opportunities to implementing rural behavioral health services via telehealth.
Addresses differences in state policies for telemedicine coverage through private insurance.
Organization(s): Substance Abuse and Mental Health Services Administration (SAMHSA)
Telebehavioral Health Strategies for Rural Hospitals &
Presents information on the provision of behavioral health services through live interactive video. Reviews
billing considerations and the regulatory environment for these services. Identifies sustainable telebehavioral
models for integrating into rural primary care and hospital settings, and addresses challenges to implementing
telebehavioral health programs.
Author(s): Neufeld, J.
Organization(s): National Consortium of Telehealth Resource Centers (TRC)
Tips: Managing Suicidal Clients During the COVID-19 Pandemic
Provides basic guidelines and other considerations when treating patients with suicidal ideation or intent using
telehealth interventions. Discusses assessing suicide risk, clinical management, safety planning, follow-up and
monitoring, and documentation.
Organization(s): Center for Practice Innovations
Use of Telehealth Within Behavioral Health Settings: Utilization, Opportunities, and Challenges
Analyzes data collected from behavioral health providers across the U.S. to describe challenges specific to
providing telehealth in rural and underserved communities.
Author(s): Mace, S., Boccanelli, A., & Dormond, M.
Organization(s): School of Public Health Behavioral Health Workforce Research Center, University of Michigan
Using Technology-based Therapeutic
Tools in Behavioral Health Services
Describes the use of technology in providing behavioral health services. Covers case studies of telebehavioral
health programs, including a rural telephone- and videoconference-based intervention for substance use
Organization(s): Substance Abuse and Mental Health Services Administration (SAMHSA)