Promoting Assessment and Management of Depression in Rural Communities Through Telehealth

The project emerged in response to the urgency of call for psychiatric care by patients diagnosed with depression. In one particular poignant story, a patient who had been recently released from prison after serving 20 years required help in managing his symptoms of depression. The patient lived in a small town and did not have a car. There was only one specialist in the area with a long waiting period. The primary care provider sent a routine referral to the psychiatrist; the wait was for several months. The primary care provider was aware of the telehealth but failed to inform the patient about the telehealth psychiatric service option. The patient could not attend another psychiatrist office in a different town due to inability to drive.

Approximately 16.2 million adults living in the U.S. experienced one major depressive episode in the year 2016; 44% received medications and were managed by a professional, while 37% did not receive treatment. It affects a person emotionally, physically, and their outlook on life. Mental illness, such as depression is one of the leading causes of disability and death in the United States.

A South Florida Federally Qualified Community Health Center (FQCHC) identified a need to provide psychiatric care for patients with depression that are living in rural communities. In order to meet the needs of the patient population, a telehealth psychiatric program was initiated in 2017 in collaboration with an external psychiatric service to assess and manage patients with mental health illness. From observations, it was identified that some healthcare providers and patients were not fully aware that the telehealth program for psychiatric care existed. When a patient shows symptoms of depression, the primary care provider completed the Patient Health Questionnaire (PHQ-9). Based on the PHQ-9 score, providers prescribed an antidepressant and sent a psychiatric referral at the patient’s request. From January to May 2018 there were no referrals sent to the telehealth service while at least 20 patients were screened and diagnosed with depression.

The primary care providers, medical assistants, and other healthcare professionals received a “Tele-to Me” telehealth education session on evidence-based impact of telehealth for psychiatric evaluation according to the Theory of Planned Behavior (TPB) by Icek Ajzen. According to the theory, the three key concepts of attitude, subjective norms, and perceived behavioral control predicted the likelihood for an individual to have intention to perform a behavior. In addition participants were provided with a pre and post survey to compare each participant’s response on interaction with patients with depression, amount of time they heard about telehealth, recommendation for telehealth, the amount of time they made or suggested telehealth referrals, and the ease of filling the telehealth referral form before and after the project “Tele-to-Me” presentation.

Objectives for this project included that by the beginning of June 2018, 75% or more primary healthcare providers and medical assistants at the FQCHC site would attend a 30 minutes or less information session on telehealth during their lunch break; more than 50% primary healthcare providers and medical assistants participants would summarize what they learned at the end of the group information session. By the end of August 2018, more than 50% of eligible individuals would receive telehealth referrals and primary care providers and would be able to identify barriers to telehealth service. By the end of June, July, and August 2018, there would be more than 50% increase of referrals sent compared to 3 months prior to intervention.

The medical software used in the project site contained a feature that filtered a list of adult patients that were screened with a PHQ-9 tool from March to August 2018. The software listed each patient’s date of visit, PHQ-9 score, age, and gender. The patient’s chart was reviewed to identify who was eligible to receive telehealth referrals. Eligibility was based according to the software’s treatment recommendation after calculating the PHQ-9 score. The software advised the provider to use their clinical judgment to determine the need for treatment for patients that scored a 5 or greater on the PHQ-9. Patients that request to see a mental health specialist were also eligible for telehealth referrals. Each patient’s chart was reviewed to identify if the provider made or suggested a telehealth or in-person psychiatric evaluation referral.

As a result, 75% of primary healthcare providers and medical assistants participated in the session. All participants demonstrated awareness of the purpose of the telehealth service by summarizing what they learned at the end of the group education session. A total of 35.7% of eligible individuals were suggested or referred to telehealth. The education session increased awareness of the telehealth service available at FQCHC and the purpose of telehealth by 100%. In addition, there was a 500% increase of telehealth referrals. Healthcare providers were 1.6 times more likely to send a referral after an education session. Patient reluctance and limited insurance coverage were identified as major barriers for telehealth in the clinic.