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Telehealth – The Future for Advance Practice Mental Health Nursing

Published:March 16, 2018DOI:https://doi.org/10.1016/j.apnu.2018.03.018
      The enactment of President Obama's landmark Patient Protection and Affordable Health Care Act (ACA) heralded the advent of technology into our nation's health care environment, as it gradually transforms from a historical fee-for-procedure orientation to one emphasizing “quality of care” as measured by client-centered metrics. Integrating mental and behavioral health care into primary care, as well as encouraging interprofessional team-based care, will increasingly become the norm. Numerous studies indicate that a significant proportion of those needing mental health care are simply not receiving care and further, that providers who prescribe psychotropic medications frequently do not possess the appropriate specialty training (
      • DeLeon P.H.
      • De Oliveira F.P.
      • Puente A.E.
      Future directions in theory, research, practice, and policy.
      ). Clients who experience depression, hyperactivity, and the elderly, not to mention those diagnosed with cancer and other chronic illnesses, do not receive treatment which adequately addresses the psychosocial-cultural-economic gradient of care. In our judgment, the systematic utilization of telehealth care by psychiatric mental health nurse practitioners (APRNs) represents the next frontier for the provision of quality and accessible care.

      THE FEDERAL GOVERNMENT AS A CATALYST FOR CHANGE

      As a result of its size, underlying mission (including its humanitarian vision), and the geographically diverse nature of its treatment efforts, the federal government, and in particular the Departments of Veterans Affairs (VA) and Defense (DOD), have been on the cutting-edge of developing and utilizing telehealth. The Secretary of the VA and the military Surgeons General are embracing the rapidly maturing technology's potential for increasing access and providing timely care. Consistently, telehealth's highest reported utilization has been for mental health. A reported shortage of psychiatrists has resulted in DOD's ability to only meet routine mental health appointments 59% percent of the time (
      • Government Accountability Office (GAO)
      Defense health care: DOD is meeting most mental health care access standards, but it needs a standard for follow-up appointments.
      ). Mental health telehealth encounters are conducted across the direct care components, both in garrison and operational environments, using clinical VTC equipment, webcam-based applications, and/or telephone calls allowing for synchronous provider-to-provider encounters. This allows for care to be delivered across a variety of settings, whereas the networks of civilian providers are limited to where they normally offer. The data for the VA is even more compelling with the VA having established 10 Tele-Mental Health hubs and eight Tele-Primary Care hubs. Forty-five percent of its telehealth services are for rural veterans. Overall, last year there were 2.14 million episodes of telehealth care provided to 677,000 veterans, of which 336,000 were TeleMental Health visits.
      Two of the critical elements behind the federal government's movement towards embracing telehealth have been the ever-improving quality of the technology and its increasing affordability. In 2004, reflecting upon the slow use of technology in health care, President
      • Bush G.W.
      Remarks in a discussion on the benefits of health care information technology in Baltimore, Maryland.
      . As our universities discovered over time, the underlying issue is not whether distance learning (or telehealth) results in a lower quality of education than in-person instruction; but instead, what are the conditions and for what populations is it most appropriate. Substantive change is always difficult and not surprisingly for telehealth, provider concerns are the most significant obstacles to change, with perceptions of technology as inconvenient, perceived decreased therapeutic alliance, and perceived lack of support from leadership. Focusing on clinicians must be a key consideration since choice of telehealth vs. other delivery methods is based on clinical judgment and the scope of the work.
      Those mental health colleagues who have utilized telehealth consistently report that their clients are very comfortable with this modality; in fact, their younger clients regularly prefer it to in-person interventions. Similar trends are emerging in the military. The new generation of Service Members gravitates towards technology and use technology daily to communicate with their families and complete military duties. Research studies confirm that Service Members prefer utilizing telehealth for mental health care compared to in-person visits (
      • Stetz M.C.
      • Folen R.A.
      • Van Horn S.
      • Ruseborn D.
      • Samuel K.M.
      Technology complementing military psychology programs and services in the Pacific regional medical command.
      ).

      PRIVATE SECTOR CONCERNS

      The private sector should begin to consider the multiple issues surrounding telehealth. As is frequently the case with substantive change, successful resolution of seemingly “little steps” will ultimately modify the overall environment, probably in ways that cannot be predicted. It is important not to allow seeking the “perfect” solution to become the excuse for inactivity. One of the first challenges, which will require state level legislation, is addressing the issue of licensure portability. Providers are limited, in most cases, to providing telehealth in the state(s) where they are licensed which can limit care to clients living in different jurisdictions (i.e., state). Licensing of telehealth providers is frequently cited as one of the biggest barriers to the national use of telehealth. In our judgment, this requirement simply does not reflect the realities of future practice. How is the public being protected? This is the underlying rationale behind licensure. Psychology is in the beginning stages of establishing its Psychology Interjurisdictional Compact (PSYPACT), which specifically proposes an “E-Passport” to allow the provision of psychological services via electronic means across jurisdictional boundaries, without additional licensure. Since this approach requires legislation to be enacted by both states, this will undoubtedly take time unless a number of health professions agree to collaborate on a generic approach.
      Federal agencies, like the VA and DOD, have valuable “lessons learned” on how they moved forward with licensing. In 2016, DOD issued a policy memorandum addressing the various credentialing, privileges, and requirement barriers for the practice of telehealth. The federal law allows for a standardized approach. This directive allows providers to complete telehealth visits within a client's home, as long as the client is enrolled at a Military Treatment Facility (MTF). This allowed the Military Health System (MHS) to overcome the barrier of crossing state lines to practice care and dramatically changed the direction of delivery of care. Admittedly, however, providers still face credentialing and privileging issues between individual MTFs.
      In January 2018 nursing transitioned from its previously adopted Nurse Licensure Compact (NLC) that allowed nurses to practice across NLC state lines without additional licensure to the “enhanced NLC” (eNLC), which has now been enacted by 29 states. As its name indicates, the eNLC further enhances state-level protections for the public while increasing client access and reducing unnecessary licensing duplication. Furthermore, given the success of this multistate compact at the registered nurse level, state boards of nursing – who spearhead public protection – met in 2015 and are now leading a similarly directed undertaking at the advanced practice level via the “APRN Compact.” The new compact would provide a multistate license that enables APRNs to provide affordable and quality care to their clients across state lines whether physically and/or electronically and reduce unnecessary licensing redundancy (
      • National Council of State Boards of Nursing (NCSBN)
      Licensure Compacts.
      ).
      In the same way that an individual is deemed safe to drive across state lines using their primary state of residence-issued driver's license while still being held accountable for any law violations, one's violations in another state would be reported by that state to the licensing board of their primary state of residence to take action. Modern health care needs and technological advances demand a viable licensure solution. However, the APRN Compact will only come into effect after at least 10 states enact the legislation. So far, Idaho, North Dakota, and Wyoming have enacted the APRN Compact. APRNs have a distinct role and responsibility in propelling this modern solution forward by making their voices known to their state boards and state legislators. We would rhetorically ask: What better way to move the APRN Compact forward and enhance care than via telehealth? And, of course, this raises the critical issue of APRNs establishing a national scope of practice licensure, as our colleagues have successfully accomplished within the VA. As actions progress towards greater unified licensure agreements, the next concern for those in the private sector will undoubtedly be reimbursement. Various organizations, Medicare, and third-party insurers currently place stipulations on telehealth and only cover a patch-work of services.

      PREPARING THE NEXT GENERATION

      Last summer the USU faculty partnered with the National Center for Telehealth and Technology to develop an intensive class to prepare military Doctor of Nursing Practice (DNP) students (future PMHNPs) to effectively leverage telehealth technology in the clinical setting, with discussions of care in garrison and in the deployed setting. Additional topics covered in this course included policy and medical ethics, human elements and etiquette of synchronous telehealth, and client simulation. Following the course, DNP students reported increased confidence and interest in using telehealth with their clients. Clinical experiences are currently being coordinated for them to build on the didactic and simulation experiences with the goal that all military PMHNP graduates will be capable of delivering care utilizing telehealth. Telehealth is the future for those with vision and the dedication necessary to effectively serve one's clients.

      REFERENCES

        • Bush G.W.
        Remarks in a discussion on the benefits of health care information technology in Baltimore, Maryland.
        Weekly Compilation of Presidential Documents. 2004, April 27; 40: 697-702
        • DeLeon P.H.
        • De Oliveira F.P.
        • Puente A.E.
        Future directions in theory, research, practice, and policy.
        in: Evans S.E. Carpenter K. APA handbook of psychopharmacology. American Psychological Association, Washington, DC2018 (in press)
        • Government Accountability Office (GAO)
        Defense health care: DOD is meeting most mental health care access standards, but it needs a standard for follow-up appointments.
        (Washington: D.C. Retrieved from)
        • National Council of State Boards of Nursing (NCSBN)
        Licensure Compacts.
        (Retrieved from)
        • Stetz M.C.
        • Folen R.A.
        • Van Horn S.
        • Ruseborn D.
        • Samuel K.M.
        Technology complementing military psychology programs and services in the Pacific regional medical command.
        Psychological Services. 2013; 10: 283-288https://doi.org/10.1037/a0027896