Telemental Health: Equity, Inclusion, and Access

Learn More about rural subpopulations that may benefit from telehealth.

• 17.1% of rural people have a disability: May have complex health needs or physical limitations; this can make it very difficult to travel to specialized health care providers in particular.
• Higher suicide rates exist in less densely populated areas
• Higher rates of tobacco, methamphetamine, and opioid use in rural areas
• Rural mental health is less accessible, and stigma further complicates the matter
• Prison facilities are frequently located in rural areas: 40% of prisoners and inmates have a chronic health condition and 1 in 7 have a mental health condition of major depression or psychosis
• 1/4 of older adults live in rural areas and many wish to age in place
• Children in rural areas face physical, economic, and social barriers to access to care
  • Children in rural areas have a higher risk for disability and death and are more likely to be overweight or obese
• Deep poverty rates are higher in rural areas:
• 25% of veterans live in rural areas
  • Veterans health administration facilities are often located in urban areas
  • Veterans may struggle with homelessness and substance use disorders
• 1/2 of American Indian/Alaska Natives live in rural areas with significant health disparities compared to other racial and ethnic groups, including risk for suicide
• Island populations may have limited access to on island care, including specialty care
• Residents of rural areas tend to be older with less education and income

Learn more about Rural Health

Legal, ethical and best practice guidelines:

• Assure HIPAA compliance
• Access to health information availability with informed consent and conflict of interest
• Legal and regulatory considerations include licensing, informed consent, clinical privileging/credentialing, internet prescribing, conflicts of interest, malpractice insurance and protected health information

Barriers to telemental health in rural areas:

• Limited access to high-speed internet
• Limited access to smartphones
• Credentialing and licensing
• Reimbursement issues
• Reduced provider participation in asynchronous telehealth
• Malpractice policies may not cover telehealth
• Lack of reliable transportation
• Interoperability with exchange of electronic health information, especially in regard to the sharing of information
• Mistrust of technology and healthcare
• Organizational willingness to provide telehealth access to patients
• Availability of infrastructure
• Implementation of models of reimbursement
• Availability of required training, knowledge, and education for providers
• Implementation of QI models for continuous and feedback processes

Rural Health Information Hub Rural Telehealth Toolkit

• Access to technology is often limited and/or dependent upon the presence of a parent/caregiver who owns a device with audio/visual capabilities
• Access to technology is also limited by age, familiarity with technology, and devices available for telemental health services
• Ensuring safety and privacy are especially challenging, given the need for parental/caregiver involvement to some extent, without invading/hindering privacy and/or willingness to communicate with the provider
• “Treating children in the very settings in which symptoms are most problematic may be critical to improving the generalization of treatment gains, but providers, in turn, have less control over children’s treatment environments and, accordingly, it can be more difficult to ensure safety” (Comer & Myers, 2016).

• “The American Rescue Plan Act, passed in March 2021, included $170 billion for school funding, and many schools used the funding to hire mental health workers” (Abramson, 2022).
• Important to maintain emergency contact information (Comer & Myers, 2016).
• School-based telemental health interventions are a growing area of mental health care
  • Reaching children and adolescents in a setting where they spend most of their time and preclude the necessity of missing extended time away from the academic setting, while ensuring access to technology and a support person/system to facilitate the appointment
  • Providing telemental health in schools requires understanding and respect for school personnel and the structures, policies and cultures of the school setting
  • Providers should work with school personnel to optimize the treatment setting, including taking into account the unique privacy and staffing issues in schools.

Learn More

• Orsolini et al. (2021) offer tables outlining core competencies and tips for getting started in telemental health specific to providing care for children and adolescents
• COVID-19 Tips: Building Rapport with Youth via Telehealth

• Several groups like the IOM have recommended that the sexual orientation and gender identity be part of the electronic health record. This can be accomplished by modifying intake forms to be inclusive.  Words matter and demonstrate that the provider is interested in the whole person.
  • Using gender neutral language like ‘spouse’ rather than ‘husband’ or ‘wife’ – ‘parent’ rather than ‘mother’ or ‘father’
  • Gender identity language can include: male, female, non-binary, transgender (can further designate transman or transwoman), and gender queer. Consider a write in section if their identity does not meet the list you choose to include in the intake.
  • Sexual orientation can straight, gay/lesbian, bisexual, pansexual or something else.
  • Identify preferred pronouns
• At the start of the telehealth visit confirm the preferred pronouns and name.
• Ask the patient if they feel safe and that they are comfortable with the privacy they have on their end of the visit.
• Assist them in finding LGBTQIA+ friendly providers for in person health services in their area if possible.
• HIV/AIDs counseling and therapy may be needed. Identify providers in the patient’s area that provide medical services including PrEP and PEP.

Learn More

• LGBTQ behavioral equity resources and best practices:
  • LGBTQ+ Behavioral Health Equity Center of Excellence
  • SAMHSA LGBTQI+ Resources, Reports, & Initiatives
  • Telehealth for LGBTQ+ Patients
  • LGBT Training Curricula for Behavioral Health and Primary Care Practitioners

• LGBTQIA health education Center
• Planning and implementing sexual orientation and gender identity data collection in electronic health records
• Development of Telemedicine Infrastructure at an LGBTQ+ Clinic to Support HIV Prevention and Care in Response to COVID-19, Providence, RI
• Telehealth Equity Coalition: Increasing Healthcare Access via Telehealth for LGBTQIA+ Americans
• Human Rights Campaign Telemedicine and COVID-19: Tips for the LGBTQ Community