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
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
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
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 self-management
Direct to consumer
services – These allow rural patients to connect directly to behavioral and
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 programs enable rural providers to consult with
psychiatrists and psychologists. Consultations can take place by direct video communication,
telephone, or email.
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 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 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.
- 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 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
using Project 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
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 addition, the Resource
Document on Telepsychiatry and Related Technologies in Clinical Psychiatry from APA provides an
extensive overview of liability considerations and risk management.
Additional resources from ATA include:
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
are supported in the event of a mental health crisis. Safety planning can involve creating a physical
that identifies triggers, warning signs, coping strategies, and potential interventions. Rural communities
offer home-based telebehavioral or telemental care should be aware of special
considerations for safety planning. For example, the ATA suggests that providers ask patients to
identify a Patient
Support Person who can be called upon in an emergency. The American Telemedicine Society also notes
providers should be aware of high rates of firearm ownership and geographic distances to emergency services
developing safety plans.
Workforce challenges – Some rural programs have experienced challenges with engaging
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.
at the University of Washington developed a
comprehensive set of considerations and recommendations for developing telemental health
between state medical schools and Federally Qualified Health Centers.
Stigma around behavioral and mental health conditions – Rural programs offering
health services may experience challenges with stigma. For example, rural residents might feel discouraged
seeking help for behavioral health due to stigma associated with mental illness and perceived lack of
confidentiality. Additional issues related to stigma are described in the Primary
Care Behavioral Health Model of the Rural Services Integration Toolkit. Rural organizations that
telemental care may choose to emphasize the integrated nature of their services and ensure that patients
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 because they can stay
anonymous. 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
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
A Treatment Improvement Protocol:
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
Center for Technology and Behavioral Health
Reviews the evidence base for behavioral health interventions involving technology. Describes
innovative uses of technology to address behavioral health conditions.
Organization(s): Center for Technology and Behavioral Health, Geisel School of Medicine at
Guidelines for the
Practice of Telepsychology
Describes ethical guidelines for providing psychological services through telehealth, including
standards of care, informed consent, and confidentiality, among other considerations.
Organization(s): American Psychological Association
Improving Behavioral Health Access
& Integration Using Telehealth & Teleconsultation: A Health Care System for the 21st Century
Provides recommendations for overcoming policy and legal challenges that pose barriers to the
implementation of telehealth.
Author(s): Townley, C. & Yalowich, R.
Organization(s): National Academy for State Health Policy
Brief: Rural Behavioral Health: Telehealth Challenges and Opportunities
Describes the ways that rural communities are using telehealth to address the behavioral health
continuum of care. Discusses challenges and opportunities to implementing rural behavioral health
services via telehealth. Addresses differences in state policies for telemedicine coverage through
Organization(s): Substance Abuse and Mental Health Services Administration
Strategies for Rural Hospitals & Clinics
Describes billing considerations and reviews the regulatory environment for telebehavioral health
services. Provides examples of rural telehealth programs and addresses challenges to implementing
telebehavioral health programs.
Organization(s): National Consortium of Telehealth Resource Centers
Telemental Health in Today's Rural Health System
Describes common staffing structures and services provided by rural health programs. Includes
challenges and opportunities of providing rural telemental care.
Author(s): Lambert, D., Gale, J.A., Hansen, A.Y., Croll, Z.T., & Hartley, D.
Organization(s): Maine Rural Health Research Center
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 communities.
Author(s): Mace, S., Boccanelli, A., & Dormond, M.
Organization(s): School of Public Health Behavioral Health Workforce Research Center, University of