By Phyllis Hanlon
The American Hospital Association (AHA) reports that telehealth is becoming increasingly important to health care delivery in this country. In fact, 52 percent of hospitals employed telehealth technology in 2013 and another 10 percent were in the planning stages of adopting the technology at the time of the study. The shortage of medical professionals, access to patients living in rural areas and patient mobility issues has made telehealth an appealing option.
But what about telemental health (also called tele-therapy or telepsychology), especially for older adults? This type of health care delivery is seldom offered in the general population, and for older adults it’s practically non-existent.
Prioritizing mental health of older adults
Mental health has been acknowledged as essential to overall health, and the passage of parity laws and other initiatives suggests that this condition should be treated equally with physical ailments, regardless of age. Healthy People 2010, the 2005 White House Conference on Aging, and the 1999 Surgeon General’s report on mental health identified the mental health of older Americans as a priority.
And with good reason. The American Association of Geriatric Psychiatry reported that in 2008 an estimated 20 percent of people 55 and older were diagnosed with some mental health condition, most commonly anxiety, severe cognitive impairments and/or mood disorder. In some cases, physical ailments can trigger psychological issues. One in four people over the age of 55 experience behavioral health problems that fall outside the realm of normal aging, according to the American Psychological Association (APA).
While telepsychology might help older adults with a mental health diagnosis, a number of obstacles prevent them from engaging in high-tech activities. One of the biggest challenges is reluctance of older adults to adopt the technology. A small 2013 study reported that home telemedicine services are a “relatively unexplored area,” but could prove to be “a promising option for increasing life quality, decreasing healthcare costs, and offering more independent living.” Although the study did not focus specifically on older adults with mental health diagnoses, it did yield some important findings. The authors report that computer anxiety, perceived usefulness, ease of use, security, and ability to effectively use the technology were major stumbling blocks.
Senior technology use
But some older adults are already using technology as part of their health care practices. Those who are comfortable with computers research mental health symptoms on a smartphone or the Internet or access a patient portal. Others send emails to their doctors and refill prescriptions by automated phone systems.
The APA’s Center for Workforce Studies indicated that email use for psychology services more than tripled between 2000 and 2008; however, videoconferencing rose from 2 to 10 percent during this same timeframe, a relatively low percentage.
Those statistics were not broken down by patient demographic, but other studies have targeted older adults and technology use. The Journal of the American Medical Association (JAMA) publishes the National Health and Aging Trends Study, an annual in-home survey of Medicare beneficiaries who live in the community. The survey focused on four factors: percentage of seniors who use the Internet to fill prescriptions, contact a clinician, address insurance matters and/or research health conditions. The survey does not focus strictly on mental health diagnoses, but does provides a general overview of technology use by older adults.
The findings indicate that 76 percent of seniors use cell phones, 64 percent use computers, 16 percent obtain health information online, 8 percent fill prescriptions electronically and 7 percent contact clinicians via phone or computer. In addition, use of technology to access health information or perform health-related tasks increased slightly, from 21 percent in 2011 to 25 percent in 2014.
Photo: Kimberly B. via Flickr
These figures indicate that many older adults, although somewhat familiar with technology, are not using telehealth. According to the authors of the study, this low usage raises questions about technology and its impact on quality, cost and safety of health care for seniors. They note, “future innovations should focus on usability, adherence, and scalability to improve the reach and effectiveness of digital health for seniors.”
Medicare Part B covers services performed by a provider who agrees to be paid directly by Medicare and who will not bill the patient for more than the Medicare deductible and coinsurance. It covers one yearly depression screening, individual and group therapy, family counseling; a psychiatric evaluation, medication management, drugs that are not self-administered (such as injections), diagnostic tests, a one-time preventative visit and an annual “wellness” visit to discuss any changes.
Although the use of technology by the older generation has increased, not all seniors share the same habits, particularly as they age. The Pew Research Center reported that by age 75, Internet use begins to diminish.
Veterans have the edge
The U.S. Department of Veterans Affairs (VA) is one sector that has made significant inroads with virtual visits. Since the mid-1990s, the VA has led the way in health care technology innovation, covering a wide variety of medical specialties that include mental health.
The VA has implemented telehealth in 151 medical centers and more than 700 community-based outpatient clinics across the country. The VA’s telemental health services address all mental health diagnoses, but places special emphasis on post-traumatic stress disorder, depression, bipolar disorder, behavioral pain and evidence-based psychotherapy, according to a report by Adam Darkins, a chief consultant for telehealth services.
In FY 2013, more than 600,000 patients participated in 1.7 million telehealth episodes of care. That included 2,893 video encounters with the VHA National Telemental Health Center to patients at 53 sites in 16 Veterans Integrated Service Networks and 24 states.
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A 2009 study examined the use of telepsychology for older veterans diagnosed with depression (particularly those living in rural areas) who might face access problems and may present with comorbid illnesses and complex health profiles. The authors found three distinct benefits:
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Telepsychology improved access to care.
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It reduced stigma often associated with traditional in-office mental health care.
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It minimized transportation issues, including travel time and costs.
The study also found that telepsychology programs might be less expensive than face-to-face encounters.
Depression has been associated with increased morbidity, utilization of health care services and health care costs, so the VA conducted a four-year prospective study to explore the use of telepsychology for veterans diagnosed with depression. The study, which ended in July 2012, enrolled veterans 60 years and older who had been diagnosed with a major depressive disorder. The findings showed that in-home therapy via videophone proved an effective way to deliver services. Moreover, results were sustained at a 12-month follow up examination
Challenges for practitioners
Even if elder adults were interested and willing to take advantage of telemental health services, they might have difficulty finding a practitioner who is comfortable and knowledgeable with this method. In 2013, a telepsychology task force, using APA’s Guidelines for the Practice of Telepsychology, attempted to address potential issues that might arise for practitioners offering telepsychology services. These issues included the practitioner’s knowledge and competence in offering the services using the technology and the need to ensure that the client fully understands potential security and confidentiality risks. The task force finding emphasized that the guidelines are not a legal document and that other factors may need to be considered.
Even with these guidelines and the desire to offer telemental health services to older clients, psychologists and mental health practitioners face stumbling blocks. Licensure laws vary by state and could prevent a therapist from practicing across state lines even when it involves virtual visits. Each state also has its own reimbursement policies, so the rates might not be favorable to the therapist, presenting another barrier to delivering telemental health services.
Just as house calls have (for the most part) become passé, in-office visits may someday become a rarity. Improvements in technology are making electronic health care delivery a viable option. For older adults with mental health issues, virtual visits could provide a lifeline of sorts and improve outcomes by reducing the stigma associated with mental illness, bringing treatment literally to their doorstep and eliminating transportation/mobility issues.
Organizations and other resources
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AIMS Center (Advancing Integrated Mental Health Solutions)
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Area Agencies on Aging (AAA)
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Brief Intervention and Treatment for Elders (Florida BRITE Project)
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Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors) from the National Center for Telehealth and Technology)
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PEARLS (an evidence-based program for depression)
Questions to ask
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What obstacles prevent older adults from seeking mental health services via electronic means? How can these barriers be eliminated? What role can geriatricians play in reducing resistance?
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How does an in-office visit differ from an electronic encounter and what type of training does a practitioner need to provide effective telemental health services? What should a patient know before engaging in a virtual visit?
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How effective is telepsychology in reducing or preventing exacerbation of mental health conditions in older adults, particularly those with comorbid illnesses?
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What impact might telemental health services have on residents and staff at nursing homes and assisted-living facilities?
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What role should insurance companies play in updating reimbursement policies to cover telemental health services?
Phyllis Hanlon is an independent writer specializing in topics that include business; alternative, medical, mental and respiratory health; spirituality; business and individual profiles.
