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Becker’s Healthcare Podcast
Kari-Beth Law, MD, on Expanding Telebehavioral Health Access in Rural Appalachia
00:23:30
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- [00:00]
A
Welcome to Becker's Healthcare Podcast. I'm Ella Reuter, your host, and I'm thrilled to be introducing our guest today, Dr. Carrie Law. She is associate Chief Medical Officer and board member of the West Virginia University Health System. Clinically, she is a professor of adult, child and adolescent and forensic psychiatry, vice Chair of Clinical services, and Director of telepsychiatry for the WVU School of Medicine, Department of Behavioral Medicine and Psychiatry. Dr. Law, thank you so much for joining us today. For our audience who may not be familiar with you and the work you do, could you please introduce yourself and tell us a little bit more about your background?
- [00:42]
B
Absolutely. Thanks, Ella. And thank you so much for the invitation. It's truly an honor to share the good work that we're doing to serve our state and regional, so I'm happy to My name is Carrie Beth Law. I was born and raised in southern West Virginia in Bluefield, and this state has always been home to me. I completed my medical training at West Virginia University with additional training in South Carolina. But really I felt a strong pull to return. And I've been back at West Virginia University since 2011, building my career. I spent much of my clinical career serving West Virginia communities through telepsychiatry. I've had the opportunity to support and expand telebehavioral health services through both federal and state grant funding, and I've also taken on administration and leadership roles at the department and health system levels. But at the core of all of this is really my passion for rural care and advocacy. Telebehavioral health sits right at the intersection of those both expanding access, meeting people where they are, and helping ensure that geography doesn't determine the care that someone receives. So I'm happy to be here today.
- [01:59]
A
Wonderful. Thank you so much for that introduction. First, I'd really like to set the stage. Can you briefly describe the behavioral health landscape in rural West Virginia and what makes access so challenging there?
- [02:13]
B
Sure. So if you've ever been to West Virginia, you understand the state slogan, Wild Wonderful West Virginia. West Virginia really epitomizes beauty from mountains and forests to the people in the communities. But really that natural beauty contributes to some of the access challenges that you mentioned. When we talk about behavioral health in West Virginia and even across Appalachia, we're really talking about the intersection of geography, workforce shortages, stigma, and socioeconomic stressors. When I zoom out a little bit, nationally, 65% of rural US counties have no practicing psychiatrist. And so while it's a national crisis, it really is amplified in Appalachia. And in West Virginia, our numbers here in West Virginia are pretty staggering. 50 out of our 55 counties are federally designated mental health professional shortage areas. We have among the lowest per capita availability of child and adolescent psychiatrists in the country. And then for some families, accessing specialty care historically meant driving long distances. That could be two hours up to four hours one way, and that's if care was even available at all. So when you think about that, that distance really hits care children and adolescents especially hard. For both children as well as families, We've seen high rates of depression, anxiety, substance use, trauma. But with fewer child and adolescent psychiatrists per capita, almost anywhere in the country, that presents a huge issue. And then if you add to that the Appalachian context, multigenerational poverty, higher rates of chronic illness, the legacy of the opioid epidemic, and really a cultural tendency to handle problems privately, it becomes clear why access gaps persist, and it is so deeply tied to where people live.
- [04:16]
A
Of course. Thank you so much for sharing that perspective. And as a lot of us know, telehealth really expanded nationwide during COVID But in West Virginia, it really took hold. What were the key moments that made virtual behavioral health not just helpful, but essential in those moments?
- [04:33]
B
Sure. And I think we think about the pandemic as really a pivotal scenario for virtual health care. Even before the pandemic, though, many communities nationally, but certainly here were facing long wait times, provider shortages, and as I mentioned, kind of hours long drives for behavioral health care. So here in West Virginia, we've been using telehealth as a modality for care for years. But the COVID 19 pandemic really seemed to accelerate that for the entire nation, including West Virginia. When you think about it in person, services all but shut down. Telebehavioral health became the only viable way to maintain treatment access and connection. Both of those are really critical for those who are suffering with mental health or substance use disorders. And so when I think about some key issues and key moments. One, West Virginia is a state with heavier health burden and fewer resources. Covid provided an opportunity to demonstrate both the independent spirit of our state's people, but also the innovative minds of our treatment providers. I think about another key moment being related to relaxation of regulatory barriers and reimbursement rules. So nationwide, we saw something surprising. There had been assumptions from some that rural patients wouldn't or couldn't use or access technology due to broadband difficulties and otherwise. We also presumed many of our providers wouldn't try virtual care, whether because of their own personal preference or because of the type of care that they provided. And what we realized was that many of those assumptions were wrong. Patients showed up, engagement improved, and for many families, actually, virtual visits were easier and less disruptive. That's something we'd seen in West Virginia for years. And the pandemic allowed for this to flourish. You imagine a family here in a pretty mountainous area, having the access to virtual visits was the difference between getting care or skipping it. Whether that was because you had been exposed to Covid and were in isolation because you were snowed in, or because of a weather event, because your parent or your guardian couldn't afford to miss work, had a broken down car, and you had no way to get there. So I think that's absolutely a few of the key moments. And lastly, you know, pediatric demand has been rising nationally. Rural states like West Virginia have experienced severe workforce constraints pre pandemic. And so telepsychiatry has allowed us to extend the expertise of a limited number of specialists across a pretty large footprint. And that's critical both in allowing better access to limited resources, but then also to supporting and collaborating with our community providers.
- [07:47]
A
Of course, I love that collaboration piece, of course. And in terms of execution, how did your team actually operationalize virtual behavioral health in a rural setting?
- [07:59]
B
Sure. So I am proud to say that WVU medicine has been a leader in virtual care for decades. That originally began with Mountaineer Doctor Television, or MDTV, which initiated in the early 1990s. We approached Telebehavioral Health and the Department of Behavioral Medicine and Psychiatry as a pilot in 2009, and then this quickly evolved into a system strategy when we recognized the value that access to care brought for our patients at all ends of the state for mental health services. And that included seeing adults and children, whether it was for diagnostic or ongoing treatment, medication management, individual therapy, group therapy, addiction treatment, and so on. But I think a few of the pieces that are important when we think about how we operationalized it was we leveraged our academic medical center as a hub and we extended care outward. And that was, we were non selective with that. So this was to community mental health centers, federally qualified health center clinics, critical access hospitals, emergency departments, schools, and then ultimately after the pandemic, into patients homes. That required some pretty intentional design. Though we partnered closely with local primary care providers, pediatricians and emergency departments, it was important that they felt that the telebehavioral health services were integrated and not external, both for the providers, but also the patients. We invested heavily in workflows and scheduling and trainings, both for clinicians but also for patients and families. It was really important for us that this was not just giving them virtual link and calling it a day. It was about building relationships and buy in. It was about identifying a champion at each site who believed in the modality. And that is both before and, and during and after the pandemic. You know, I think about some of the broadband and technology literacy challenges and they were, they were very real. Some families did not have reliable Internet or had never used video visits before. If, if families didn't have Internet access, we had to be really creative with them. And I remember a family that would regularly drive to their local McDonald's parking lot because that was the place locally that had WI fi and they joined their appointment from there. So during COVID we leaned on much of the experience that our team had had over the prior decade. We converted nearly all of our visits within our department to virtual within about two weeks. And that's pretty impressive. In a time when community supports were limited, people were isolated and scared, overdose deaths were nearly doubled. It was important to meet our patients where they were. We at that time offered phone based visits when they were needed, used clinic based telehealth rooms, and had staff walk family through the technology step by step. So the goal when we think about operationalizing and executing even now is to reduce friction points by being creative and flexible while still adhering to an evidence based care model.
- [11:29]
A
And would you be able to share an example or two that really show what this model has changed for patients?
- [11:36]
B
Absolutely. You know, I think this is the best part. We could talk about this for days. I mean we've seen stories of children with, with symptoms that receive specialty evaluation and treatment instead of waiting months or longer. And, and adults who have really complex comorbidities that have been able to finally establish continuity and, and maybe for the first time feel like they've been consistently connected. So I think about there are two that really stand out. One, and this was actually one of my clinical patients. This was a child who had a neurodevelopmental disorder that had been diagnosed as a very young child. But because of where they lived in a very rural county, they had minimal access to treatment providers who could help with management of their, their symptoms. It was so severe that they were on the verge of being unable to attend school even in a self contained classroom. Their parents were at their wits end and they saw a person who, you know, for myself, as a provider with child adolescent psychiatry training, they were able to meet with me regularly, provide some diagnostic clarification but ultimately treatment that unfortunately their, their primary care provider just at the time didn't feel comfortable with, but also assistance with recommendations for the school. This child stayed in school, they began to do better, and it was a huge relief for the family and for the patient. So that was pretty exciting. And I think on the other end of the spectrum, we had a patient with substance use disorder who actually was admitted here at our academic medical center for an infection in their heart valve that was related to drug use that had required surgical interventions, it had required IV antibiotics for a long time. And so pretty significant comorbidities related to their substance use. They ultimately were discharged. When they were discharged from our academic medical center, they were to return to their home community. And they happened to live in a community where we were providing virtual addiction treatment. So they were able to transition from inpatient consult psychiatric services to outpatient care where they participated in treatment, they maintained their sobriety, and interestingly, this patient got pregnant and because of that, moved to be near to their family in another location. In that second location, we also were providing treatment in that community. So they were able to transition care from one community clinic to another community clinic, deliver their child, their child in their custody, and continue to have treatment within their community, which is really critical. So these are two of many stories that we have, but it's just, it's really powerful to see how that translates for patients and families.
- [15:12]
A
Of course, I feel like that is a huge part of behavioral health is the stories behind the care that you're giving. So thank you so much for providing those examples and opening up. I'm curious too, what are you seeing on the data side of things?
- [15:28]
B
The data is exciting. And so just to provide some reference points, when I think about the last three, three years in terms of just our volumes, the number of patients that we're seeing virtually in our clinic within, within the Department of Behavioral Medicine and Psychiatry, total visits are. Are still lingering, a little over. A little over 50%. And that's with having about 100,000 patients per year theme and with kids that they're a little bit less, but still at around a third of our patients, our children are seen, are seen virtually. And, and I say that just to sort of share that this isn't, you know, this isn't a small one off. What we're seeing internally really mirrors the national trends and it's exciting. So across the country, studies have shown that telepsychiatry produces outcomes that are comparable to in person care, and that's for multiple conditions. There's lower no show rates and higher patient satisfaction. One of those studies was conducted here and it's been replicated nationally. So it's really, really amazing. In our system we've seen improved access and faster time to first appointment and better continuity of care, particularly for pediatric patients and those in remote areas. No show rates are often lower for virtual visits, especially in rural populations where, as I said before, transportation and weather are and can be major barriers and engagement improves when the care fits into people's lives rather than requiring them to reorganize their lives around care. And I think finally and equally important, we're seeing gains in healthcare equity. So we're reaching patients who previously would not have accessed specialty behavioral health services at all. So really, really exciting times. And I think that that's only going to continue.
- [17:46]
A
And in terms of like policy or reimbursement factors that help make this work, can you kind of describe those and what still creates friction in spots?
- [17:57]
B
Sure. Policy matters and it matters enormously in rural telebehavioral health. I am excited to say that West Virginia. West Virginia really has long since been a leader in telebehavioral health care long before COVID And again, I think that speaks to the rurality of our state and the need to be innovative with how our patients receive care. Allowing patients a patient home to be an appropriate originating site is one of the legislative pieces that has recently been passed here and will continue to be maintained post pandemic, which I think is really impressive specifically for behavioral health care. So certainly Medicaid policy has always played a critical role in sustaining access for children and families. During the pandemic, expanded reimbursement parity and then licensing flexibility made rapid scaling possible. Without that, we really could not have done what was done and what was needed. Expanding reimbursement for services that previously hadn't been covered, such as collaborative care or behavioral health integration really was essential. And that's one aspect that's vital to maintaining the access that was created into post pandemic virtual behavioral healthcare. But there's still uncertainty around long term reimbursement and that remains a challenge. I think other flexibilities, including online prescribing of controlled substances to appropriate patients in an evidence based way is really, this is something that is a daily issue, particularly for those who do not have local access to care. But the deadline for the national level to identify a policy both for DEA and Health and Human Services has been extended through the end of 2026, and we certainly have hopes that they will be able to navigate how to allow appropriate safeguards while also minimizing access issues. The relaxation of and the allowance of virtual supervision was really critical. So when you think about licensure requirements and what's needed for specific types of healthcare providers, whether that be providers in training like residents or fellow physicians, or even advanced practice providers, counselors and therapists, supervision plays a large role in this. And during the pandemic, virtual supervision was allowed, meaning you may be able to have a very highly trained specialist who is able to provide supervision to one of your providers without even being in the same state. We took advantage of that here, here at WVU and really have found that it has been a hugely positive, a hugely positive variable when it comes to training as well as helping to improve access. And then I think finally, health systems really need clarity and stability to be able to invest in technology, staffing and training. But I think going forward, we need to continue to engage and engage early with state policymakers and payers, align telehealth strategy with population health goals, and continue to track outcomes rigorously so that we can continue to demonstrate the value that we have done thus far that virtual care has allowed.
- [21:45]
A
Wonderful. And for our Last like minute 30 seconds, I'm wondering if you can give a few takeaways for behavioral health leaders, especially those in rural systems.
- [21:58]
B
Absolutely. You know, I think telebehavioral health isn't about replacing in person care. It's about matching the right modality to the right patient at the right time. And rural health systems don't need to wait for perfect conditions to improve access. And whether that's starting by integrating with local primary care or focusing on relationships with local providers, exploring collaborative care models and beginning to develop to engage in workforce development, those are all critical. I think extending scarce specialty expertise while also supporting local providers through consultation and education is so important for rural states. Sustainability is going to depend upon policy alignment, on broadband investment and continued investigation innovation. But the foundation is firmly in place. And so while our experience is rooted in Appalachia, I think these lessons are applicable everywhere. As workforce shortages grow nationally, what we've learned in rural West Virginia really has relevance for urban and suburban systems alike throughout the Nation.
- [23:08]
A
Wonderful. Well, Dr. Carrie Law, thank you so much for being here and sharing. How to telebehavioral health is expanding access in rural Appalachia and for the practical lessons leaders can apply elsewhere. Thanks to all of our listeners for tuning in to Becker's Healthcare podcast. We'll see you next time.