Providing access to telehealth for addiction therapy and schyopharmacology in rural america

Introduction: The United States declared a national emergency in 2017. 150 citizens were dying daily from opioid overdose, and 7.5% of the population older than 12 years (20.1 million persons) have a substance use disorder. It’s estimated 10% receive treatment. Concurrently 4% of the population (10 million persons) lives with a severe mental health condition, and 30% do not receive treatment. Such conditions are particularly challenging within rural communities like Western Colorado (38% of state’s area, but 10% of state’s population) where higher rates of poverty, underinsurance, substance use related deaths, and suicide rates are complicated by fewer available services and longer distances traveled for treatment.

Practice change implemented: The Providing Access to TeleHealth (PATH) project was started to assist rural primary care teams in addressing substance use and mental health disorders. PATH provides 12 integrated primary care clinics with telehealth access to a board-certified addiction medicine specialist and a doctorate level pharmacist for 4 hours/month. Sites participate in case reviews, co-visits, and quality improvement. While similar approaches have been effective for tele-psychiatry (IMPACT and DIAMOND) and population management (ECHO), PATH is a relatively new approach that combines these services with an interdisciplinary team.

Aim/theory of change: The PATH project aims to: 1) develop telehealth infrastructure, 2) expand knowledge, and 3) keep patients in their community (where possible) to decrease barriers and to increase likelihood of care being received.

Population/stakeholders: Rural integrated primary care teams within Western Colorado with a focus on substance use disorders and mental health care. Funding by Colorado Health Access Fund and Colorado Health Foundation for initiation and development of PATH.

Timeline: September 2017 - September 2019

Highlights: Use of online platforms allowed all clinics to participate with existing equipment and minimal training before implementation. At the one-year mark, 153 unique patients, including pregnant patients, had been seen that otherwise may have required referral to an outside provider. Additionally, 5 sites have had provider(s) obtain training to prescribe buprenorphine, which was not a direct aim of the project.

Sustainability: Co-visits with the physician/behavioral health provider(s) present limits interruption to the team’s workflow and allows for the patient to be seen in the existing clinic schedule. These workflows allow for participation in other telehealth services if desired.

Transferability: Each of the 12 sites have clinic and staffing structures unique to their communities. Lessons learned from the sites have been shared collaboratively to allow accommodation of PATH within all of the sites.

Conclusion/discussion: Rural primary care physicians are addressing substance use and mental health disorders out of necessity, despite feeling unprepared to do so. PATH has implemented practices that have resulted in positive patient clinical outcomes and satisfaction, provider and site development, and improved continuity of care. Telehealth is becoming an efficient and reproducible model in rural Colorado.

Lessons learned: The strongest sites have a telehealth coordinator and a streamlined PATH consultation process to identify patient cases in real time. Structured use of PATH time maximized patient co-visits as well as provider and site development.