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Stepping It Up: Innovation to the Stepped Care Model to fit Rural Settings

Posted By Jodi Polaha, Thursday, January 10, 2013
Rural blog series logo
Jamie and Jeff's
blog is the second post
in a month-long series
on integrated care in
rural settings.

Read the entire
series here.


Jamie Tedder, M.S.

East Tennessee
State University

I’ve 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.

Within a 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.

There 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.

Jeff Ellison, M.S.

East Tennessee
State University

Through 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.

Our 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 each "step.”

Jeff Ellison and Jamie Tedder are advanced students in the doctoral program in Clinical Psychology at East Tennessee State University, which has a focus on rural, integrated care. 


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