Arbor Place, a non-profit treatment center in western Wisconsin in operation for 50 years, provides prevention, treatment, and recovery services to individuals with substance use and mental health disorders. They offer residential, day, and outpatient treatment, prevention services, family support and education. Arbor Place serves the Eau Claire, Menomonie, and River Falls areas.
The counties within which Arbor Place operates face starkly low levels of access to mental healthcare specialists. Dunn County has a ratio of one mental health provider per 480 people. Pierce County has nearly ten times the ratio of population at 1,420 people per mental health provider.
Wisconsin faces a prevalence of substance use disorder (7.7%) that is similar to the national average (7.4%). According to a 2020 report from the Substance Abuse and Mental Health Services Administration (SAMHSA), “in a single-day count in March 2019, 25,574 people in Wisconsin were enrolled in substance use treatment – an increase from 24,371 people in 2015.” Drug overdose death rates have increased statewide, from 12.1 per 100,000 in 2011 to 31.6 per 100,000 in 2021.
A 2023 report from Mental Health America found that 15.35% of adults reported having a substance use disorder in the past year. Of those, a grand majority did not access treatment (93.5%).
Arbor Place faced difficulties in hiring a master’s degree level therapist to work over the long term with patients in the challenging substance use and recovery space. Retention had been difficult due to burnout and limited ability to attract candidates to more rural areas.
The varied patient journeys through substance use treatment programs could lead to inconsistencies in care. With Arbor Place’s patients often shifting between residential and outpatient settings, sporadic or informal communications between team members could lead to gaps in understanding. Staff at times lacked the full history and treatment plan for an individual, such as someone being discharged to outpatient care and seeking support in their community.
For Arbor Place’s patient population, consistency and continuity are essential to maintaining patient motivation. “Clients aren’t coming to us for short-term services but investing a significant amount of time for working on themselves, their healing from substance use, and their mental health. When they must retell their stories – which can deal with difficult or traumatic parts of their lives – they may be less likely to stay the course or return for treatment,” said Jill Gamez, Executive Director, Arbor Place.
Research supports that better rapport and relationship-building between psychiatrists and their patients leads to improved outcomes.
Array thoughtfully matched Arbor Place with a highly qualified clinician with previous experience treating patient populations affected by substance use, including within primary healthcare settings. Sonja McQuiston, a full-time licensed professional counselor and licensed mental health therapist for Array, provides care across Arbor Place’s service delivery models via telehealth.
Prior to joining Array, McQuiston worked independently and collaboratively with physicians to provide individual therapy services to diagnose, educate, and advocate for patients at Women’s Health Services in Tennessee. Her past experiences also include collaborating with correctional officers, police personnel, family care services teams, and the Cookeville Department of Children’s Services in Tennessee to assess varying mental and behavioral health needs of patients in those communities.
So far, McQuiston has provided over 3,000 hours of clinical service and been one of the longest tenured therapists at Arbor Place.
Executive Director, Arbor Place
McQuiston is included in staff meetings and regularly connects with outpatient and residential clinicians to share and receive case updates. "If there is a case that concerns me as a clinician, I staff it with the clinical team for additional support and guidance. As a team, we identify viable solutions, allowing everybody to be on the same page in terms of care alignment,” said McQuiston.
Gamez says this collaboration and consistency creates better overall care for Arbor Place’s patients who often transition between varying levels of care and require dependable, long-term supports: “As leaders in our organization and in the mental health space, it’s impactful to thoughtfully consider our patient experience and how it can be improved – not just within the walls of our facility but also beyond. There are so many aspects of the mental health system that are siloed and segmented. We are grateful for solutions like Array that generate more consistency in care for our clients,” added Gamez.
Enhanced patient safety and well-being
Patients can feel abandoned when they need to switch care providers and having to retell their story can create stress or trigger previous trauma. Patients at Arbor Place can now access reliable and compassionate mental healthcare within their communities through telehealth with Array. Their mental wellness is addressed in an ongoing, consistent, and proactive way.
Continuity of care across settings
Through telehealth, patients can easily and conveniently be seen by the Array clinician across health settings – from residential to outpatient. This continuity of care bridges substance use recovery and mental health supports in a holistic approach to treating co-occurring conditions.
A focus on continual improvement and measurements-based care
Arbor Place assesses mental health outcomes using a standardized screening tool for all patients. As a consultative and collaborative partner, Array aligns and interfaces with Arbor Place’s existing tools and processes – while identifying further opportunities for improvement in clinical and operational efficiency.
Since opening its doors more than 20 years ago, Utah Navajo Health Services (UNHS) has been contributing to solutions for healthcare challenges in their community. UNHS now serves over 15,000 patients across multiple clinics that provide medical, dental, and behavioral healthcare for children and adults across southeastern Utah.
The region served by UNHS is largely remote, rural, and characterized by a desert landscape, which covers a portion of the Navajo nation and includes the magnificent Monument Park (known as Tsé Biiʼ Ndzisgaii in Navajo language). Some houses do not have access to internet or use postal street addresses and are identified by nearby landmarks. Access to healthcare can be difficult and mental health challenges are common.
Utah has a higher prevalence of mental health illness than any other state. As of 2021, 40.9% of Utah adults reported feeling symptoms of anxiety or depression. Over one quarter (26.4%) were unable to access therapy or treatment according to 2021 stats.
Lack of access to mental health care may impact Utahns disproportionately. Stats from 2020 show that 7.8% of children ages 3-17 in Utah received mental health care, compared to 10.8% of children in the U.S.
While the state ranks low overall on poverty, Utah has pockets of stark inequality with limited access to education, services, and economic opportunity. The county home to the Utah Navajo reservation has a poverty rate five times that of certain other Utah counties, with more than one of every five people living below the poverty line.
Communities served by UNHS contend with many of the same social determinants of health as Native Americans nationwide. These include rurally isolated communities, infrastructure and internet connectivity issues, concurrent health conditions, and discrimination from healthcare institutions or providers. A 2019 study found more than one in five Native Americans reported experiencing discrimination in medical encounters.
Native Americans have disproportionate rates of mental health concerns with possible links to generational and experienced trauma. For about a hundred years starting in the late 1800s, a system of state-led boarding schools forced children from their homes and broke family bonds.
More recently, the COVID-19 pandemic has had globally documented impacts on mental health due to its emotional toll. Native Americans were so affected by COVID that their life expectancy dropped between 2019 and 2021 – from 71.8 years to 65.2.
Alongside primary care, UNHS acknowledges “prevention, early detection and treatment of behavioral health conditions can lead to improved physical and community health.” In the decade from 2013 to 2023, the UNHS behavioral department has grown from 5 to 60 staff.
“We provide a wide range of services including victim services with domestic violence advocates in the community and operate two domestic violence shelters. Other services include specialty services for youth in transition and those between ages 16 to 25 with mental health issues. The program also services the general population with therapy, case management, peer support, medication management, and psychiatry. In addition, we have traditional Navajo practitioners as part of the team,” said Rick Hendy, Director of Behavioral Health with UNHS.
All combined, behavioral care at the UNHS is designed to improve the full spectrum of health outcomes in the patient population. Recognizing strong community and family links within Navajo communities, staff at UNHS clinics serve both patients and families. They also work with Medicine Men, whose approaches to healing are integral to Navajo culture.
UNHS recognized a need to grow access to behavioral care through its clinics. Array was selected for its experience in connecting culturally competent providers with tribal communities. As the leading clinician-centric virtual psychiatry and therapy practice, Array is more than a staffing solution and can offer tools, guidelines, and best practices. This approach ensures optimal quality and caseload management, clinically appropriate care, and seamless integration with onsite staff.
UNHS chose to partner with Array to provide access to virtual behavioral care, psychiatric assessment, and medication management. Through the partnership, Array psychiatrist Brent Griffin joined the onsite care team – bringing decades of experience and familiarity with Najavo people. Dr. Griffin is available remotely to provide psychiatric services.
The positive impact of having Dr. Griffin available to patients has been immediate. When a referral comes through a primary care provider, onsite UNHS clinic staff can refer the patient to their behavioral health team. If appropriate, this team can assess and easily schedule the patient with Dr. Griffin – meaning psychiatric patients are sometimes seen the same day they arrive.
“For our patients to get into clinic, they sometimes have to ask their family for a ride or hitchhike in. Being able to see someone the same day is huge,” said Susan Hendy, Medical Records Director and HIPAA Privacy Officer with UNHS.
For follow-up telehealth visits, patients are advised to find a nearby spot or come into the clinic if they don’t have access to internet at home.
“Since I have largely worked in urban areas, it takes a different approach. Many individuals served by UNHS may not have access to the same supports and amenities. Some may live on land without access to running water and electricity. It’s important to recognize progress when individuals are overcoming barriers in addressing their mental health and continuing with their appointments and treatments,” said Dr. Griffin.
Staff at UNHS often find the means to ensure patients get the care they need, and having a psychiatrist has greatly helped.
Collaboration is also key to enhancing care. Dr. Griffin and Medicine Man Ernest Begay attend a weekly clinical staff meeting to consult with the UNHS on-staff therapist on best practices from psychiatry and traditional Navajo medicine. Patients can access consultations with Medicine Men, Navajo traditional counseling, and community wellness programs.
“Having our Medicine Man as part of the behavioral health team and meeting regularly with Dr. Griffin has helped enormously in working with Navajo patients,” said Susan Hendy.
While outpatient care often involves different providers, patients of Dr. Griffin’s will see him consistently. Facilitated by access to telehealth, the continuity of care through Array can result in better “relationship building” says Hendy. Research supports the idea that a strong therapeutic relationship between physicians and psychiatric patients can influence treatment outcomes.
Dr. Griffin has been known to go above and beyond, once resolving an issue with a pharmacy so that a patient could promptly access medication.
Hendy says that the partnership with Array has allowed patients quicker access to care and the ability to build a rapport with their clinician. “We feel like Dr. Griffin is a part of our team,” she said.
How Array and others are creating a safer tomorrow through a multipronged, systematic approach to suicide prevention.
This eBook explores the story of how the Zero Suicide Model emerged as a strategy to combat suicide, which is a leading cause of death in the United States. We will uncover real life use-case scenarios and detail how Array implements Zero Suicide in its own practice to improve care and save lives.
Read on to dive into the main themes: About the Zero Suicide Model, History and Implementation, and Telepsychiatry's Role
Eastern Aleutian Tribes (EAT), a Tribally-owned Health Organization in Southwestern Alaska, provides medical, dental, and behavioral health services at eight Federally Qualified Health Center locations across the Aleutian Island chain.
In the furthest corner of America’s most remote state, Alaska’s Aleutian Islands are known as some of the most beautiful, secluded and challenging locations in the world. After years of relying on EAT medical staff, mid-level behavioral health clinicians and outside referrals for psychiatric medication management, EAT partnered with Array Behavioral Care to establish a long-term telepsychiatry solution close to home.
The islands extend 1,400 miles off mainland Alaska and are characterized by towering mountains, broad valleys, fjords, tundra and glacial lakes. Located between two tectonic plates, residents of the islands live with the risk of seismic activity like volcanic eruptions, earthquakes and tsunamis. Due to extremely high winds and rugged sea navigation in the Pacific Ocean, the islands are accessed via plane, typically costing over $1200 round trip.
The islands are home to the indigenous Aleut tribal communities. Each of the eight island communities served by Eastern Aleutian Tribes is unique and ethnically diverse, populated by both Aleut natives and Euromericans. Local populations range from 40 residents in the smallest village of Cold Bay to 965 residents in the largest village of Sand Point. Facilities in these areas are extremely minimal with typically just 1-2 stores and restaurants in each town.
The majority of the islands’ residents live subsistence lifestyles – spending their days fishing, hunting or otherwise utilizing the resources of the land to make a living. Other work on the islands includes processing plant workers or jobs in the service and administrative sectors. These separate island populations are unified by their common history, cultural similarities and shared resilience as they collaborate to thrive in such extreme and isolated conditions.
Brenda Wilson, Behavioral Health Manager at Eastern Aleutian Tribes, and her very supportive Supervisor Dr. Shanda Lohse are prime examples of this resilience. Wilson spent the past two years persevering against these challenges to connect Eastern Aleutian communities with high-quality, culturally competent psychiatric care, a resource that is scarce in even the most populated cities of the lower 48 states.
Eastern Aleutian Tribes was founded in 1991 with a mission to provide and continually improve quality healthcare services for their communities. Wilson, who is also a trained and Certified Behavioral Health Aide Practitioner and holds a Bachelor of Social Work Degree, has been a staple of EAT’s behavioral health department for over 20 years. The department is made up of master’s level Clinicians and Behavioral Health Aides who offer residents 24/7 crisis intervention services, substance use programming and counseling for individuals, groups and families. In areas where staff is present, they offer in-person services. Otherwise, telehealth is utilized.
Without a psychiatrist on staff, the behavioral health team at Eastern Aleutian offered coordination for psychiatric services and medication management via medical staff collaboration or referrals to outside agencies. Neither was ideal. If the staff managed psychiatric medications, they struggled working beyond their scope of practice, but referring patients to mainland facilities often meant long, expensive flights and wait times up to 18 months for care. In 2020, the behavioral health needs of the community reached a boiling point.
“There were incidences where people were on the wrong medication, too much of the medication or too little, and some that really reacted with people terribly,” Wilson described. “They felt like they were going crazy, they didn’t know what was wrong, and their families were noticing.”
Stabilizing these patients in crisis was extremely difficult for the department to manage without a psychiatrist on staff. Seriously mentally ill patients in crisis that required medical stabilization needed to be medically evacuated from the islands to facilities on the mainland, costing about $100,000 per flight. In 2020 alone, Eastern Aleutian had to utilize these medevac services 13 times, costing the region over $1,300,000.
Eastern Aleutian Tribes needed additional behavioral health clinicians who would be sensitive to the residents’ challenges, from understanding the complexities of their location, ongoing substance use issues, to years of intergenerational trauma. Upon recommendations from their tribal network, EAT decided to partner with Array Behavioral Care to bring psychiatric expertise directly to their communities via telepsychiatry in July 2020.
From the start, the two organizations shared a commitment to delivering culturally competent services, personalized for the community’s acuity and unique circumstances. Array matched EAT with a skilled telepsychiatrist, Dr. Karen Jackman, and an experienced Licensed Clinical Social Worker, Wilma Harpole – both of whom were located and licensed in Alaska.
Both clinicians were carefully screened by Array’s partner success team with EAT’s clinical needs in mind. Wilma Harpole, for instance, was a natural fit given her certifications in Substance Use Counseling and her years of experience working with the Alaskan Native population in Kotzebue. EAT leadership met with the clinicians prior to onboarding to confirm they were a good match culturally and to ensure that they shared a similar philosophy of care.
Array staff worked with EAT leadership to understand behavioral health workflows and optimize any new processes that the clinicians would need to integrate with the clinics. Wilma and Dr. Jackman were trained to chart in the partner EMR, coordinate patient scheduling with onsite staff, and procedures were established for prescription delivery to the islands.
Once the clinicians were fully trained, they went live with patients in November 2020 with 16 hours of psychiatry services and 24 hours of therapy services per week. Wilson admits that the Behavioral Health department was nervous to see if the community would connect with off-site telehealth clinicians who are not immersed in the community.
Due to both organizations shared commitment to clinical integration and cultural fit, these doubts were quickly alleviated. The first year of the program has been so overwhelmingly successful that Eastern Aleutian Tribes have expanded services to 4 days a week and are adding another Array psychiatrist to meet the increasing demand for care in their community. The key benefits include:
Since beginning services with Array, the clinics have been able to increase access to behavioral health intervention at preventative stages, reducing the need for psychiatric stabilization services. They are happy to report zero medevac cases in 2021 vs. 13 in the year prior, saving the organization and the region over $1,300,000.
With Array clinicians in place, anyone at any of EAT’s eight communities seeking behavioral health services can be seen within 24 hours. Instead of waiting up to 18 months for care on the mainland, patients can be seen in their homes or at the local clinic – saving the patients so much time and travel expense.
Finally, patients who need coordinated behavioral health care are getting the support they need from EAT and Array clinicians. Plus, the mid-level clinicians at the clinics are growing their skills and confidence in treating BH conditions with consults and supervision from Array’s clinicians.
Brenda Wilson, Behavioral Health Manager at Eastern Aleutian Tribes
The ChallengeBuilding a strong care team to support community mental health is a top priority for Forest County Potawatomi. By turning to telepsychiatry, the community has overcome geographic and cultural barriers to make that vision a reality.
Located in Crandon, Wisconsin, Forest County Potawatomi provides healthcare, education and other services to families living on the reservation. Most staff live more than an hour’s drive away, making it difficult to recruit quality behavioral health professionals on-site. As a result, residents often had to travel up to three hours away to receive care, preventing many from receiving the treatment they needed.
The tribal community also needed mental health clinicians who would be sensitive to the residents’ challenges, from ongoing substance abuse issues to years of intergenerational trauma. After trying unsuccessfully for six months to hire an in-person clinician, Forest County Potawatomi recognized that telepsychiatry could connect the community to a broad range of clinically and culturally appropriate professionals.
Forest County Potawatomi partnered with Array Behavioral Care to expand access to behavioral health. As a leading provider of integrated telepsychiatry services, Array provides the high-quality clinicians, tools and support to improve mental health access for all, regardless of where they live.
From the start, the two organizations have shared a commitment to delivering services personalized for the tribal community’s residents. Array matched Forest County Potawatomi with a skilled telepsychiatrist and advanced practice nurse, and both Array staff and the clinicians visited the community in person to build rapport with the on-site staff. To help address substance abuse issues in the community, Array's clinicians and medical director collaborated with local care teams to prescribe controlled substances only when necessary.
That collaboration extends to all aspects of the program, with Array's clinicians charting directly into Forest County Potawatomi’s EHR and meeting with on-site staff to discuss specific patients and treatments. Patients see the same clinician weekly, helping to build trust and make treatment more effective. Potawatomi’s advanced practice nurse has even provided care on-site as the two organizations continue to strengthen their working relationship. Forest County Potawatomi also collects patient feedback directly through Array's AtHome videoconferencing platform, to monitor and continually improve its services.
Julie Beeney, Interim Director Health Division and Clinical Services Administrator, Forest County Potawatomi
Through its partnership with Array, Forest County Potawatomi now has a strong integrated care team to meet its population’s significant mental health needs. Key benefits include:
Communities across the nation face a shortage of behavioral health providers. Approximately 123 million Americans live in a mental health professional shortage area[1] and 96% of counties in the U.S. have an unmet need for psychiatric prescribers.[2]
In order to address the increasing number of individuals seeking mental health care from primary care practices, many organizations turn to behavioral health integration. Behavioral health integration brings mental health specialists into the primary care setting and creates teams of mental health and primary care providers working together with individuals and their families to provide the best possible treatment.
Fifty-five percent of counties in the United States currently have no psychiatrists available, according to a new report.[3] This severe shortage is impacting the country’s health care system, particularly for primary care providers and nurse practitioners, who increasingly have to treat and/or prescribe for mental or behavioral health conditions.
Moreover, the delivery of specialized mental healthcare can be out of the realm of expertise or exceed their comfort level for many primary care providers. When the scenario arises, it makes sense to refer care to a psychiatrist or other mental health provider. Yet, due to the current shortage of psychiatrists, patients often wait weeks—sometimes even months—to be seen by a local psychiatry provider.
In the U.S., one in four primary care visits are for mental health conditions. Primary care providers write 70% of antidepressant prescriptions, which is approximately 30 million prescriptions annually.[4]
Telepsychiatry allows primary care practices to connect with remote psychiatric providers, including specialists such as child and adolescent psychiatrists, and offer mental health care to individuals in their office. Array Behavioral Care has several primary care integration programs. Highlighted here is an innovative collaborative care pilot program located in a health system.
Morris Hospital and Healthcare Centers has been serving the Chicago area since 1906. Located in Morris, Illinois, their 89-bed hospital serves residents in five counties. Along with their main hospital, they have offices in 25 other locations.
In 2018, they implemented a telepsychiatry program within their emergency department to serve individuals presenting with a mental health concern. The next year, they started a collaborative care pilot program after recognizing the mental health need in the primary care setting. This program was developed in collaboration with the AIMS Center at the University of Washington. During this time, Morris Hospital and Healthcare Centers also worked closely with the Collaborative Family Healthcare Organization (CFHA). This national integrated care association advocates for behavioral health integration in the primary care setting and has served as a mentor for Morris Hospital and Healthcare Centers. Through implementation coaching and support services, the collaborative care pilot program was launched in February 2019. A licensed social worker serves as a care manager and splits their time between two offices. The program utilizes a telepsychiatry provider to serve as a consultant on mental health cases.
The aim of this program is to improve behavioral healthcare services by placing social workers and mental health professionals in primary care offices. Morris Hospital and Healthcare Centers employs 37 primary care providers and has approximately 109,000 outpatient visits per year. With the mental health professional shortage, many individuals seek mental health services from their primary care providers. However, primary care providers are not adequately equipped to treat mental health disorders.
The collaborative care team addresses mental health concerns in the primary care setting as opposed to referring off-site for those services. They track a defined patient population in a registry to ensure patients do not fall through the cracks. The care manager discusses patient cases with a consulting psychiatrist on a weekly basis and the psychiatrist makes treatment recommendations. The telepsychiatry provider meets with the treatment team of primary care doctors and clinical social workers to do chart reviews for four hours each week via video. The telepsychiatry provider does not work with patients directly, but helps to advise and support primary care providers with their cases.
Then, the care manager relays the recommendations to the primary care provider and patient. The care manager also provides the patient with psychotherapy using techniques such as behavioral activation and problem-solving therapy, both of which have been shown to be effective in the primary care setting.
To date, Morris Hospital and Healthcare Centers has seen patients in the pilot program become more engaged in their treatment plans. In order to determine success of the program, Morris Hospital and Healthcare Centers uses a caseload tracker to track information such as PHQ-9 scores, GAD-7 scores, weeks in treatment and number of sessions to see how a patient evolves over time and how involved they are in their care. Since implementation, patients are more involved and are more likely to follow through with appointments and treatment plans.
Patients have truly embraced this model and have commented that it helps to decrease the stigma associated with mental health issues. In addition to the patients, the primary care providers have embraced the Collaborative Care model as well. By having a team member who can help address mental health concerns, primary care providers are more comfortable learning to treat mental health concerns and manage medications that were previously outside of their comfort zones.
The main goal for this program was to serve patients visiting their primary care providers with mental health concerns. Eventually, Morris Hospital and Healthcare Centers would like to see Collaborative Care services available at all primary care sites. In Illinois, there was recently an exciting development. Gov. J.B. Pritzker signed into law a Senate bill that requires private insurance companies and Medicaid to reimburse for Collaborative Care services. This is a win for integrated care and supports the Collaborative Care programs that are ensuring individuals have access to mental health services. Morris Hospital and Healthcare Centers is excited to see Collaborative Care continue to grow and impact the lives of individuals in their communities.
In order to promote this program to encourage replication, Morris Hospital and Healthcare Centers has presented on their Collaborative Care model in a variety of settings including at a special telemental health workshop during the ATA2020 virtual conference and the Caravan Health’s ACO Symposium. Additionally, Becker’s Hospital Review recently interviewed Dr. Jennifer Thomas, a family medicine physician and Doctor of Integrated Care at Morris Hospital and Healthcare Centers, to learn more about their innovative program.
[1] Peterson-Kaiser Health System Tracker. (2019). Retrieved from https://www.healthsystemtracker.org/?sfid=4356&_sft_category=access-affordability,health-well-being,spending,quality-of-care
[2] Konrad, T., Ellis, A., Thomas, K., Holzer, C., & Morrissey, J. (2009). County-Level Estimates of Need for Mental Health Professionals in the United States. Psychiatric Services, 60(10). doi:10.1176/appi.ps.60.10.1307
[4] Barkil-Oteo, A. (2013). Collaborative Care for Depression in Primary Care: How Psychiatry Could “Troubleshoot” Current Treatments and Practices. The Yale Journal Of Biology And Medicine, 86(2), 139. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3670434/
Prior to COVID-19, regulatory and reimbursement challenges limited the use of telehealth. The COVID-19 crisis presented an opportunity for telehealth to demonstrate its value. An FQHC in New Jersey, a COVID-19 hotspot, describes how telehealth allowed them to maintain patients’ access to care during the pandemic and advocates for keeping the telehealth-friendly regulations in place even after the crisis is over.
In a recent interview, Lee Ruszczyk, Senior Director of Behavioral Health at Henry J. Austin Health Center (HJAHC), an FQHC in Trenton, New Jersey, shares how HJAHC responded to the COVID-19 pandemic by quickly converting from an in-office, clinic-based model of care delivery to an at-home virtual model in a matter of days, so that patients could continue to receive the care they need without having to physically come into the facility. He explains how their organization was able to successfully pivot to telehealth, how patients have responded to the changes, and why it’s important that telehealth-friendly regulations remain even after the immediate threat of the coronavirus has passed.
To help reduce unnecessary exposure and contain the spread of the virus in our community, we closed 3 of our 4 locations and turned to telehealth as a solution to maintain patients’ access to care. One of our sites remains open for necessary in-person visits or emergency medical or dental care. All other services are now provided virtually.
It was an organization-wide, all-hands effort, but we were able to successfully switch to telehealth within one week. We quickly restructured existing workflows, designed new workflows, adopted new platforms for teleconferencing and telemedicine and shifted staff responsibilities to make this happen. We also had to convert our call center to a virtual operation so that inbound calls are automatically routed to the appropriate remote team member.
We started using Doxy.me and Doximity Dialer, to enable our patients and clinicians to connect virtually. Both Doxy.me and Doximity Dialer are free, secure and easy to use telemedicine solutions that allow patients to meet and communicate with their regular healthcare provider from the safety and comfort of home through their phone, tablet or any device that has internet access. Both applications have been instrumental in allowing us to rapidly shift from clinic-based services to remote care during COVID-19.
Fortunately, this was not our first foray into telehealth. About 2 years ago, we launched a telepsychiatry program in partnership with Array Behavioral Care, to help address the growing need for mental health care in our community. This telepsychiatry program supplements the care provided by our onsite mental and behavioral health team and gives our adult patients access to a psychiatric nurse practitioner to help diagnose and treat anxiety, depression, addiction and other behavioral issues. Prior to COVID-19, patients receiving psychiatry services would come to the clinic at their scheduled appointment time to meet virtually with their telepsychiatry clinician. However, in the wake of the coronavirus pandemic, we had to quickly shift these services from clinic-based to at-home care so patients can continue to get the behavioral health they need without having to come into the office. To help centralize scheduling and management of our medical and mental telehealth services, we moved our telepsychiatry clinician into Doxy.me as well.
Since we are in an underserved area, not all our staff have access to internet services, or the technology and infrastructure needed to provide remote care and administrative services. Therefore, we provided computers and Zoom phones for all staff members without access.
There were a lot of moving pieces to juggle and a lot of new processes to put into place in a short period of time. However, we were able to make these changes with little to no interruption in patient care. We are operating at 100% productivity even in this current environment. All our clinicians are still able to see their target number of patients per day, just virtually now instead of in-person.
Patients have really embraced our new telehealth services. They appreciate the convenience and safety of being able to access care from home. We’ve noticed that show rates are higher, and attendance is more stable with telehealth. An HJAHC staff member reaches out to patients the day before a scheduled session to remind them of their upcoming appointment, educate them on telehealth, explain the process and what to expect during a virtual visit and answer any questions. They also send patients a unique URL for their telehealth visit or a text invite with a link to join their virtual session.
Patients without internet or technology that supports videoconferencing have the option to come into the clinic for services or receive care over the phone.
Our staff has certainly risen to the occasion during these challenging times. Every member of our team has been extremely resilient and flexible in adapting to the operational changes that were quickly put into place in response to the COVID-19 crisis. Their commitment to the patients we serve has not wavered, even as they juggle unexpected changes and additional responsibilities in their own lives.
It is worth noting that behavioral health clinicians may be experiencing many of the same mental health effects of COVID-19 as the patients they are treating. That’s an unprecedented situation. For example, in the aftermath of September 11, behavioral health clinicians who were personally affected by the tragedy could excuse themselves if a patient’s story hit too close to home. Similarly, our call center representatives are on the frontline answering calls from patients who are grieving the loss of a loved one due to COVID-19, while they, too, may have lost their own loved ones. This is unchartered territory for all of us. We’re unable to distance ourselves. We’re living it just as our patients are.
People choose to work in an FQHC because they want to help vulnerable patients who face significant health inequities. From the security guard to the CEO, everyone here at HJAHC has the same purpose and commitment to care. That has become even more evident during all of this. Our staff may be dealing with their own hardships and loss, but they show up, every day to continue to serve the underserved in our community.
The senior leadership at HJAHC has been extremely thoughtful, transparent, responsive, open-minded and inclusive. All staff members have been invited to participate in the planning and execution of the operational changes that we put into place as a result of the pandemic. It has been an all-hands, collaborative effort, not a siloed approach broken down by seniority, discipline (e.g., medical, dental, behavioral health) or job function (e.g., clinical versus administrative).
We’re all in this together and we need each other to define new workflows, implement changes and continually refine our processes. A problem or bottleneck in one area doesn’t just affect one person or department, it has a ripple effect. To be effective and efficient, we recognized that we needed to brainstorm solutions and problem solve as a group.
Early on, we met twice a day on Zoom to determine the most appropriate path forward and plan accordingly. Together we would create a daily to-do list, identify needs, assign responsibilities and discuss what was working and what needed to be improved.
Now, we hold staff meetings three times a week to check in on each other and to collectively troubleshoot and resolve any problems that may have arisen since we last met. We are constantly evaluating and refining our processes to make sure every patient has access to the care that they need when they need it. It’s like we’re building the plane as we’re flying it.
Moving forward, I envision a hybrid model that includes at-home virtual care and in-person, clinic-based services. It will be driven by regulations, but my hope is that after COVID-19 the regulations would still allow the clinician to be at home and the patient to be at home rather than requiring one or both to be physically present onsite.
Prior to COVID-19, telehealth was only a covered benefit for Medicare beneficiaries located in a rural or health professional shortage area and they had to travel to a local medical facility to receive services from a clinician in a remote location. However, in response to COVID-19, CMS expanded access to telehealth services to waive the geographic and originating site requirements so Medicare beneficiaries could receive services in their own homes without having to travel to a health care facility.
The pre-COVID-19 originating site requirement represents a significant barrier for our patients who may lack transportation or cannot get to the clinic for care. With the currently relaxed telehealth regulations during COVID-19, these patients can now access the care that they need from home.
Given that we're considered an essential service, there was no other option for us. We either had to pivot to telehealth or close our doors. We are now seeing more patients each day through telehealth than we were previously able to see in-person at the clinic. Telehealth has allowed us to serve more patients more efficiently.
I don’t think you can put the genie back into the bottle now. Our patients have enjoyed the flexibility of being able to access care at home. There are times when they cannot come to the clinic for a visit because they have a sick child or parent at home, cannot take off from work or don’t have transportation; however, they still need care despite these logistical challenges. There are also times when they may need care from a specialist who may not be immediately available. For example, maybe there’s a specialist in our community, but they aren’t accepting new patients or have extremely long wait times for an appointment. Or, maybe the closest specialist is in another city hundreds of miles away and our patients have limited ability to travel. Telehealth is the ideal solution in both scenarios as it helps to expand access to care for underserved communities and populations.
As an FQHC, our mission is to provide high-quality care to underserved populations, particularly those who are economically and medically vulnerable. The relaxed telehealth regulations that were put into place in response to COVID-19 have allowed our patients to continue to have access to primary health care services.
It would be unjust and unfair to take away the flexibility and access to care that telehealth affords once the pandemic is over. At HJAHC, we serve an underserved and uninsured patient population. Our patients have enough to deal with. They struggle with poverty, transportation, food scarcity, and health disparities. Can't we just give them a break? They have enough inequities and barriers to deal with, access to healthcare should not be one of them.
Henry J. Austin Health Center is a private, non-profit, Federally Qualified Health Center (FQHC) in Trenton, New Jersey, that provides primary care, mental health, substance abuse treatment services and more to uninsured, underinsured and medically underserved individuals in the Greater Trenton community. Established in 1969, their mission is to provide patient-centered, comprehensive, accessible, efficient, quality care to vulnerable patient populations with poor social determinants of health. HJAHC is the largest non-hospital based ambulatory care center in the city, serving approximately 13,000 individuals per year across their four locations.
To maintain patients’ access to mental health care during the pandemic, an FQHC in Pennsylvania expands their clinic-based telepsychiatry program to include at-home services. No-show rates have dropped and patient satisfaction has improved as a result.
River Valley Health & Dental is an independent, non-profit, Federally Qualified Health Center (FQHC) in Williamsport, PA that provides medical, dental and behavioral health care and social services to underserved residents in central Pennsylvania. In 2019, they introduced integrated telepsychiatry services to supplement their onsite behavioral health and social services team in order to help address the growing need for mental health care in their community. This telepsychiatry program gives patients access to an adult psychiatrist as well as a child and adolescent psychiatrist who specializes in ADHD and Autism Spectrum Disorder.
Prior to COVID-19, patients would come to the clinic to meet virtually with their telepsychiatry clinician. Now, in the wake of the coronavirus pandemic, patients have the ability to access these telepsychiatry services from home. Medical providers at the clinic are now also using telehealth – phone and televideo – to provide care for patients.
In a recent interview, Susan King, LCSW, Program Coordinator at Community Services Group and behavioral health coordinator at River Valley Health & Dental, describes how River Valley swiftly implemented technology to allow for at-home telehealth visits in order to provide ongoing support for patients during the COVID-19 pandemic. This has allowed them to minimize patients’ exposure to the virus while continuing to meet their healthcare needs. Medical and behavioral health care clinicians deliver care via telephone or web-enabled video for most patients. If necessary, in-person visits are still an option and are scheduled appropriately to minimize traffic in the facility and maintain social distancing.
We are a busy FQHC. We provide primary health care, including medical, dental, behavioral and reproductive health services to the most vulnerable members of our community. As such, we have been designated as essential for both medical and behavioral health services. Not taking care of our community is not an option. Continuing to deliver care was not a question of if, but rather of how. While COVID-19 has had a frightening impact on the nation as whole, our team has risen to the occasion, moving quickly to telehealth visits, adjusting staffing patterns and schedules and working with patients and families to adapt to the new technology and new model of care delivery. While we certainly miss the day-to-day camaraderie of staff and patients interacting together in-person, we are grateful that technology allows us to connect virtually so that patients can continue to receive the medical and mental health care they need during this time. We’re proud that as a healthcare organization, we were able to adapt to the challenges posed by COVID-19 and make things work for the benefit of our patients.
Many of our patients have been flexible enough to adapt to the idea of a phone visit. Those who have access to smart phones and computers have been also able to utilize televideo visits through our portal. Since we are essential, our physical clinic space also remains open for visits for patients without access to technology. We have worked hard to ensure a variety of ways to meet patient needs.
Our clinic remains open for needed or emergent in-person visits for both physical and behavioral health care; however, we have adjusted provider and support staff schedules to reduce foot traffic in the building. Many clinical staff are working full- or half-time from home. Staffing changes have also helped conserve valuable personal protective equipment (PPE). We implemented physical health monitoring for staff for early detection of signs of illness. We also adapted our mobile dentistry RV to serve as a respiratory triage unit to ensure that patients with COVID-19 symptoms are safely assessed and tested while minimizing exposure of staff in the physical clinic space.
The biggest difference we have noticed is that patients who are unable to leave their home, for various reasons, or patients who work and for whom taking time off to come to the office for a visit, are better able to engage in services. Prior to COVID-19, we had a lot of no-shows. We’re finding that now, given the convenience of at-home virtual care, there are fewer missed appointments. Patients are more likely to attend their appointments and are logging in on time for their scheduled sessions. Patients' time investment in the visit is much shorter when they are able to access these services remotely. And, we are able to serve more people more efficiently.
Simply put, people are able to continue accessing quality psychiatric care when chronic or persistent mental health needs are exacerbated by fear associated with the pandemic. The expanded allowance for telehealth has also allowed our medical staff to continue to take care of our patients during the pandemic without missing a beat.
As is the case nationwide, psychiatry is a specialty in short supply in our area. The community we serve struggles with significant socioeconomic risk factors and is among the most physically unwell population in our state. We implemented telepsychiatry in our clinic as part of our commitment to treating the whole person, mind and body. Access to telehealth helps our center uphold that value.
One of our existing patients is a gentleman who struggles with psychotic symptoms. Because of his diagnosis, he is extremely reluctant when it comes to technology, particularly phones and computer screens. We were worried about how he would respond to the switch to online care. However, he has been remarkably receptive to it since it allows him to access care at home, with his mom nearby to comfort and reassure him. Our hope is that telepsychiatry will help keep him out of a long-term in-patient psychiatric hospital.
The addition of telepsychiatry has enhanced the behavioral health services that are available to our patients. Since psychiatrists are in short supply in our rural area, a return to requiring patients to physically present in our office for care amounts to putting a barrier back in place. A rollback is akin to making work, transportation, symptom presentation, childcare responsibility etc. a barrier to specialty mental health care for our 17,000 medical patients.
Our Health and Human Services Department recently put out a request for comments to learn what’s working and what’s not in terms of healthcare delivery. They are also seeking provider recommendations on what healthcare delivery should look like post-COVID-19. Telehealth has certainly proven its value in maintaining patients’ access to care during the pandemic; so hopefully it is here to stay. I cannot imagine that we’ll return to traditional service models after the pandemic ends. I envision some type of hybrid approach that blends the best of in-person and virtual care so patients can access the care they need how and when it works for them.
As many clinics across the country have had to close or temporarily suspend services during the COVID-19 crisis, the Fauquier Free Clinic in rural Virginia was able to quickly convert to in-home virtual care so their patients could continue to receive much-needed mental health services.
The Fauquier Free Clinic in Warrenton, Virginia, provides comprehensive medical, dental and mental health care to uninsured and under-insured residents in Fauquier and Rappahannock counties. Founded in 1993, their mission is to help local families who cannot afford health insurance or health care by creating a community where all individuals, regardless of income, have the resources they need to be healthy.
In 2017, with funding support from the PATH Foundation, the Fauquier Free Clinic launched a telepsychiatry program to help address the growing need for mental and behavioral health care in their community. This program supplements the care provided by the in-person volunteer therapists at the clinic as well as gives patients access to a Spanish-speaking psychiatrist, Dr. Alicia Azpiri.
According to Shannon Raybuck, LPC and mental health care coordinator at Fauquier Free Clinic, the clinic brings much needed care to underserved patients living in rural areas of Virginia. Raybuck explains, “we serve a vulnerable patient population with poor social determinants of health. Like many rural communities, we have a critical shortage of psychiatric and mental health providers and none of our local psychiatrists speaks Spanish fluently. Therefore, the value of this telepsychiatry program cannot be overstated. Not only does it increase access to behavioral health care in our area, but it also allows the Spanish-speaking residents of our community to have access to these important services. It’s amazing that through this program, our free clinic in rural Virginia is able to provide vulnerable patients access to a Harvard-trained, Spanish-speaking psychiatrist on the other side of the country in California.”
The team at Fauquier Free Clinic recognizes that patients’ mental health, physical health, and overall well-being are inseparable. Therefore, they screen all patients for depression. Approximately half of all patients receiving mental health services at the clinic are referred from these screenings; the remaining patients seek out mental health services directly. Through telepsychiatry and onsite behavioral health care services, the clinic is able to provide comprehensive mental health support for patients, including counseling and medication management. The onsite and remote mental health clinicians collaborate with the medical and dental teams for collaborative patient care, ensuring that all patients’ health needs are addressed.
Prior to COVID-19, patients receiving psychiatry services would come to the clinic at their scheduled appointment time to meet virtually with Dr. Azpiri in a private room using a computer equipped with a large monitor, camera and microphone. However, in the wake of the coronavirus pandemic, the clinic had to quickly shift to in-home virtual care in order to maintain patients’ access to behavioral health care while taking steps to help contain the spread of COVID-19 and comply with social distancing protocols. The entire team at Fauquier Free Clinic was able to swiftly and successfully pivot their operations and adapt their workflows to accommodate this new model of care. Now, patients can continue to get the behavioral health they need from Dr. Azpiri, a remote clinician with whom they are already familiar, without having to come into the office.
Patients who do not have access to a computer or fast or reliable internet service at home, are invited to come to the clinic for their scheduled session. Alternatively, if patients have a mobile device, but poor or no internet access, they can also visit mobile hotspots that have been set up around the community, such as the local high school or aquatic center parking lots. This allows them to receive the help they need from the safety and privacy of their vehicles. Given the limited availability of broadband service in this rural area, these mobile hotspots were established in response to the increased need to connect online rather than in-person for school, work and/or healthcare during the pandemic.
Raybuck admits that she was initially unsure how to reconcile the new direct-to-consumer model with the clinic’s collaborative approach to care. However, she and Dr. Azpiri developed a plan where instead of entering the room physically at the end of a session as she would have done previously when visits took place at the clinic, she now enters the room virtually by joining the online session at the end to discuss next steps and coordinate follow up care with the patient. And, although fortunately she has not had to do so, Raybuck notes if a behavioral health patient posed an imminent safety risk to himself or others, Dr. Azpiri could alert her and she could step into the room virtually to help intervene and connect the patient with local crisis resources.
Dr. Azpiri concurs that the shift to in-home virtual care has given her a unique and valuable perspective into patients’ lives and living spaces. “I am so grateful that patients have been so receptive to this new approach. They have been so welcoming and inviting and flexible, which is a big reason we’ve been able to pivot so quickly and successfully to in-home virtual care. Delivering care directly to patients in their homes gives me a glimpse inside their private worlds, without being overly intrusive. I can assess environmental cues such as the orderliness and cleanliness of their surroundings, appearance, food needs, etc. This allows me to really see how they are doing physically, emotionally and mentally and determine if additional support is needed.”
Dr. Azpiri shares a touching story from a recent session with a patient who was excited to finally be able to introduce her – albeit virtually – to his dog. “Previously we had discussed the emotional benefits of having a pet and, at my suggestion, he decided to adopt a dog. He has really benefited from the companionship and I am so glad I finally got to meet his dog and see firsthand the loving relationship they have developed!”
Although it’s too soon to quantitatively measure the effectiveness of the switch from clinic-based to in-home telebehavioral health care, Raybuck and Dr. Azpiri agree the transition has been successful as evidenced by fewer missed appointments and high patient satisfaction and engagement. According to Raybuck, patients appreciate the safety, convenience and cost savings associated with being able to access care online from home. During this time, patients can continue to get the care they need without having to worry about exposure to COVID-19 or having to find reliable transportation or incur travel expenses, such as gas money, to get to the clinic for their scheduled sessions. Raybuck adds, “there are fewer missed appointments now because we are able to reach out to patients who have not logged into their session at the appointed time and remind them of their visit. They can then join their online session, even if a few minutes late, to connect with Dr. Azpiri. Previously, a forgotten appointment would have to be re-scheduled for a later date due to the travel time needed to get to the clinic.”
While their primary focus is on patient care, Raybuck notes that they would be remiss if they did not consider the mental and physical wellness and resiliency of their staff during these challenging times as well. In addition to taking measures to reduce staff members’ exposure risk and to keep them safe, the Fauquier Free Clinic is offering all staff and volunteers access to their telebehavioral health services in what Raybuck describes as a “makeshift Employee Assistance Program (EAP).” "We’re more than coworkers here at Fauquier Free Clinic; we’re family. We support each other. We’ve found that we’re texting and connecting with each other a lot more outside of work hours. We’re checking in on each other to make sure our buckets are full. You can’t fill from an empty bucket,” says Raybuck quoting the metaphor from the popular book by author Tom Rath.
Raybuck concludes by sharing two poignant examples of patients who benefited from telepsychiatry during the pandemic. One is a gentleman with a variety of cardiac and pulmonary health conditions who has long suffered from extreme anxiety about doctors, having lab work done, and going to the hospital. With Dr. Azpiri’s help, he had made significant progress in controlling this anxiety. However, his anxiety resurfaced during the COVID-19 crisis, and was exacerbated by his job as a deliveryman for a popular local restaurant. Dr. Azpiri recognized the predicament he was in – his job put him at increased risk of exposure but he needed to work to support his family – so she spearheaded a joint effort with his medical and mental health care team to issue an out of work notice to temporarily excuse him from work to protect his health, while still allowing him to keep his job long-term. During this time, he also experienced some significant medical issues and, with the support of Dr. Azpiri, was able to manage his anxiety and go to the emergency room on his own to get the medical care he needed.
The second story is of a mother who is an established patient of Dr. Azpiri's who has a young child with health issues and a history of respiratory illness and had to be ventilated in the past. The COVID-19 crisis, particularly the pulmonary effects on vulnerable patients, has triggered the mother’s PTSD trauma. Through Fauquier Free Clinic’s now in-home telepsychiatry program, Dr. Azpiri has been able to continue to meet with her to help her cope with the anxiety and emotions that have reemerged as a result of the pandemic.
“Unfortunately, some community clinics have had to close their doors, or temporarily suspend services in order to develop an alternative service plan during the pandemic. It pains me to think of all of the interventions, like the ones I described above, that would have been missed had we not been able to convert to in-home telehealth services. Because of telehealth, we have been able to continue to serve some of the patients in greatest need during these critical times. I cannot emphasize enough how important telehealth is in general, but especially in rural communities like ours. If there is any silver lining to this, it’s that telehealth is finally getting the recognition it deserves; everyone is realizing what we’ve known to be true for some time – telehealth is instrumental in expanding access to care for underserved communities and populations,” Raybuck emphasized.
Established in 2006, the Whiteside County Community Health Clinic (WCCHC) in Rock Falls, Illinois, was created to answer a long-standing need for medical, dental and behavioral healthcare among county residents. In 2018 alone, the clinic provided services to over 13,000 patients during more than 50,000 visits. As a federally qualified health center (FQHC), the clinic provides services to patients on a sliding fee scale, ensuring residents can access care regardless of their ability to pay.
By 2018, WCCHC’s behavioral healthcare team had grown to 11 therapists and one part-time psychiatrist, who served an ever-growing number of patients in need of specialized mental healthcare and medication management. Despite this high demand, the clinic’s psychiatrist stopped seeing patients, creating a pressing need to find a replacement. In-house staff were not equipped to handle complex patient needs, so the clinic was forced to refer patients elsewhere, losing thousands of dollars in patient billings to external providers.
WCCHC needed a clinician to fill a unique set of needs: someone young and energetic who could handle complex cases, engage easily with patients and staff, onboard quickly, and have the flexibility to adjust their hours as needed over time. After local recruitment efforts proved challenging, the clinic looked for an experienced telepsychiatry partner to help fill this tall order
WCCHC ultimately chose Array Behavioral Care, a leading provider of integrated telepsychiatry services. Array's broad clinician network gave WCCHC access to a large pool of highly specialized quality clinicians. In addition, the ability to provide comprehensive support services, including deployment, IT, reimbursement and regulatory insight, made Array an ideal partner.
Array identified a psychiatrist who met all of WCCHC’s criteria, helping the clinic launch its telepsych program in just two months. Once on board, the teleclinician quickly embedded herself in operations, working closely with the on-site care team to adapt to workflows and develop care plans for patients. She was an instant hit with patients and staff alike and has become a seamless part of clinic operations.
To maximize telepsych utilization, WCCHC focused on ways to reduce the patient no-show rate and improve access to care. Clinic staff identified potential barriers to patients in need and sought to address them in a variety of ways using funding from federal grants. If transportation is preventing patients from getting to appointments, the clinic offers them gas cards to pay for fuel. If affordability is preventing patients from taking needed medications, the clinic offers them pharmacy gift cards. To accommodate patient requests for same-day and soonest-available appointments, the clinic maintains a waitlist and contacts patients as time slots become available.
WCCHC uses ArrayConnect to ensure the best possible video quality for patient sessions, and has also used the platform to collect feedback through patient surveys to make sure it’s meeting patient needs. In addition to IT support, Array helps oversee all related program needs, including clinician management, compliance support and reimbursement.
Since implementing its telepsychiatry program with Array, WCCHC has been able to meet the behavioral healthcare needs of its community more efficiently and effectively. Key benefits include:
