Posted By Jodi Polaha,
Thursday, January 10, 2013
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|Jamie and Jeff's |
blog is the second post
in a month-long series
on integrated care in
Read the entire
Tedder, M.S.East Tennessee
always viewed the stepped care approach (e.g., see Bower & Gilbody, 2005)
to mental and behavioral health service delivery as being like a relay race
where the participants are various health and mental health providers. The professionals at each stage provide
treatment within their area of expertise and within the constraints of their
practice before "passing the baton” to the next provider. This was the image I had in mind when I
walked into my first external placement; a rural pediatric clinic with a
co-located mental health specialty service. I was to practice population-based care -- the
first runner on the mental health relay team.
few patient contacts I realized I was more like the Lone Ranger than a relay
racer. I felt many of my patients could
benefit from more lengthy and frequent treatment than I was able to provide in
population-based model, but the co-located service and the community mental
health center in town is typically "booked out” about 8 weeks. The nearest "next best” referral source is
over 30 miles away. By the end of that
first day I was overwhelmed, to say the least.
are no easy solutions for the challenges, such as this one, that are raised in
a rural setting. This year, we are
experimenting with a creative solution that builds in technology. Thus, one day each week I travel about 60
miles to the rural clinic described above, in Rogersville, Tennessee, to
provide behavioral health consultation services. Three other days a week I (along with my
colleague, Jeff) staff a telehealth clinic based out of Johnson City, where we
are based, at East Tennessee State University.
Several rural primary care clinics across the state have access to our
services through the telehealth clinic, including my site in Rogersville. This allows me greater flexibility to
schedule follow-up visits for patients who need more frequent treatment, longer
sessions, or who simply can’t make it into the clinic on the day I’m
there. I also access supervision and
consultation through telehealth as needed.
New and innovative treatment modalities such as the one described above
give rural behavioral health consultants more options in underserved areas, and
decrease the feeling of professional isolation often experienced by
practitioners in rural areas.
my graduate training, I have had the opportunity to work on-site as a
Behavioral Health Consultant (BHC) in two rural Appalachian primary care
practices and via telehealth at several others.
These experiences have shown me that, while every primary care clinic faces
unique challenges (e.g. the types of patients seen, the physical space
available, the workflow, etc.), the lacking availability of community resources
is a constant challenge among rural practices.
As a BHC in non-rural settings, I have enjoyed my role as a component in
a stepped care approach, where more intensive outpatient services are available
to patients who do not benefit from brief, problem-focused treatment in the
primary care setting. In rural
communities, however, I quickly learned that lacking specialty services made
such referrals impossible. Thus, in rural practice I feel a pull to treat
a much broader spectrum of problem types and severities than would ideally be
the case in population based mental/behavioral health care. It is a challenge to navigate
this dilemma, allocate clinical time, and prioritize clinical services to make
the greatest impact.
attempts to make this dilemma more manageable have led us to experiment with a
variety of possible solutions, some novel and innovative and others
common-sense. One way that we have risen
to this challenge has been by developing a telehealth infrastructure in the
clinics in which we provide service.
This has allowed us to allocate more of our time to clinic coverage (due
to reduced travel time to and from these rural clinics) and has reduced the "lone-wolf”
feeling when we are providing on-site services (because of the potential to
access additional consultation, supervision, and support via video).
We have also experimented with setting aside
dedicated time each day for brief appointments with patients requiring longer
term management (e.g., specialty services) while making it clear to providers
that appointments can be interrupted for consultation and warm handoffs as
needed. Although we have had some
success with interventions such as these, rural practice as a BHC is a daunting
calling and one that begs persistence, flexibility, and creative thinking at
Ellison and Jamie Tedder are advanced students in the doctoral program
in Clinical Psychology at East Tennessee State University, which has a
rural, integrated care.
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