Deploying a collaborative telemental healthcare model in Oklahoma

As the American mental health epidemic grows more deadly, mitigating the issue is a top priority nationwide. Numerous factors are driving the epidemic, not least of which are the widespread barriers to accessing mental healthcare. Healthcare stakeholders are developing and piloting various approaches to address the thorny access problem, including some that involve virtual care technologies.

In Oklahoma, a new model of care is bringing together behavioral health clinics and law enforcement using telehealth tools.

The mental health crisis in Oklahoma requires urgent attention. According to the National Institute of Mental Health, 22.8 percent of adults in the United States were living with a mental illness in 2021. And based on 2020 data from the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS), Oklahoma ranks fifth in the nation, with 25.6 percent of state residents living with mental illness. Additionally, the rate of substance abuse disorders was 16.1 percent in Oklahoma in 2020.

To tackle the crisis, Oklahoma has equipped its Certified Community Behavioral Health Clinics (CCBHCs) with telehealth technology, enabling them to connect with law enforcement to support crisis intervention efforts in some counties.

“Clinically, it’s all about access and breaking down barriers to care,” said Larry Smith, CEO of GRAND Mental Health, a CCBHC in Oklahoma. “Instant access through telehealth tools means that patients can access care when and where they need it.”

The model has proved beneficial, bringing CCBHCs and law enforcement together to achieve their goal of mitigating mental health crises in the state.

WHAT IS A CCBHC?                                                

The CCBHC initiative, authorized under the Protecting Access to Medicare Act of 2014, aims to expand access to coordinated and comprehensive behavioral healthcare. Clinics must meet certain standards to be designated as CCBHCs, including providing crisis services 24/7, offering the full spectrum of behavioral healthcare, and ensuring care coordination between behavioral care, physical care, and social services.

The US Department of Health and Human Services (HHS) operates the initiative through the Substance Abuse and Mental Health Service Administration (SAMHSA), the Center for Medicare & Medicaid Services (CMS), and the Office of the Assistant Secretary for Planning and Evaluation.

In 2017, 67 CCBHCs were established in eight states through the Section 223 CCBHC Medicaid Demonstration.

The initiative is growing, with HHS announcing two funding opportunities totaling $123.6 million for CCBHC expansion in March 2023.

“The expansion of Certified Community Behavioral Health Clinics is part of President Biden’s commitment to expand and strengthen equitable access to behavioral health services for all Americans,” said HHS Secretary Xavier Becerra in a news release. “These clinics serve anyone who requests care for mental health or substance use, regardless of their ability to pay, and connect people to the care they need.”

Not only that, but a bipartisan group of House representatives introduced new legislation in May that would permanently authorize the initiative, allowing all states to incorporate the model. The bill would permanently authorize a Medicaid payment system for CCBHCs, establish a new certification and accreditation process for CCBHCs, and create a new infrastructure system for CCBHC data reporting.

Oklahoma was one of the original eight states in the initiative. The number of CCBHCs in the state has grown from three to 13.

GRAND Mental Health is one of the clinics, serving 13 counties across Northeastern and North Central Oklahoma. It provides crisis intervention services, outpatient therapy, and community-based services for adults and children with behavioral health and substance use issues. The organization also has a 20-bed addiction treatment center.

Though the CCBHC’s service area spans more than 10,000 square miles, access is still challenging for the marginalized population it serves.

“We serve many rural parts of the state where transportation and/or life circumstances (job, childcare, health issues) may make it challenging for people to get to a GRAND clinic,” Smith said in an email interview with mHealthIntelligence.

These patient access challenges are not unique to GRAND Mental Health, prompting ODMHSAS to implement telehealth technology across state CCBHCs.

ADDING VIRTUAL CARE TO ENHANCE CCBHC ACCESS

Oklahoma’s CCBHCs use MyCare Technologies’s behavioral health platform to enable telemental health services.

According to Smith, the platform offers access to the CCBHC’s behavioral health professionals, specifically trained for crisis situations, and licensed therapists for routine counseling. The MyCare app has also been made available to all law enforcement officials across the 12 rural counties GRAND serves. The app will soon be deployed in the 13th county.

“This access supports police and first responders who are called out to mental health crisis calls by providing de-escalation support and assistance in connecting those in crisis with treatment services rather than incarceration,” Smith said.

Lieutenant Gene Bradley, mental health coordinator in the Oklahoma County Sheriff's Department, said that intervening early and connecting people experiencing mental health crises to care has proved effective for the county.

In the first quarter of 2020, the Sheriff’s Department implemented a more hands-on approach to managing individuals who most frequently called 911 for help with a mental health crisis.

“What I started doing was just going out, and instead of waiting for the 911 call, I would go out and do a welfare check on them,” said Bradley in an interview with mHealth Intelligence. “Some of them were once a week, and some of them were a couple of times a week. And I would beat the 911 call and go to the door, knock on their door, see how they were doing.”

Bradley also connected these individuals to local mental health providers and medication. By July 2020, the calls from those frequent callers had dropped to zero, indicating that care access is critical in addressing mental health needs.

Now armed with the MyCare app, Bradley and his fellow law enforcement officers can more quickly connect people with mental health issues to care. Officers are provided with tablets that enable them to communicate with one of three local mental healthcare providers.

“I always have our officers de-escalate the situation, move away from the mental health consumer, call the therapist, let the therapist know what they're out on so they've got a little bit of information, and then say, ‘Do you want to talk to the individual?’ And 100 percent of the time, the therapist says absolutely,” Bradley said.

Officers are instructed to give the mental health patient privacy while they speak with the therapist and then follow up to see if the patient needs more help.

CCBHCs like GRAND Mental Health use a stair-step approach to care, where patients are encouraged to reduce their level of care as they achieve agreed-upon outcomes. GRAND stays in contact with the patients via telehealth or in-person care after the initial therapist visit, Smith noted.

IMPLEMENTATION AND RESULTS

Successfully deploying the virtual care model hinged on two critical factors: familiarizing law enforcement with the telehealth technology and gaining their buy-in for the partnership.

According to GRAND Mental Health’s Smith, forging a strong partnership required zeroing in on the shared mission of mental health professionals and law enforcement.

“We are privileged to work with the finest officers and first responders in the country — all of whom want the best for the people in their communities who struggle with mental health issues,” Smith said. “It is through this shared focus on service that we have, collectively, created a partnership that works for all involved.”

To enhance law enforcement officer buy-in, Bradley emphasized to officers that the new technology did not fundamentally change their role in mitigating mental health crises.

“We're still going to go to the crisis call,” he said. “We're still going to evaluate if they meet the criteria to go to the crisis center or the emergency room. We're still going to do those things, but if we need a professional view on things — maybe we're not sure what we're looking at, or we just need assistance in de-escalating a situation — then let's go ahead and utilize this tablet.”

Though officers are not required to use the tool, it is popular among them. Bradley said that many are using it on a weekly basis for a wide array of crises, including violent situations involving suicidal people.

From the patient perspective, the tool appears to be a refreshing new approach. According to Bradley, mental health consumers are more surprised than anything else at the shift in strategy.

 “I think they've been so used to, ‘Hey, go ahead, let's put you in my car. We'll take you downtown, get you in front of a therapist, or take you to the emergency room,’” Bradley said. “And so, they're just waiting for that to be the response from the officer and for you to say, ‘Hey, would you like to talk to a therapist right here in your living room?’ I think that immediately calms the situation down.”

Further, officers can use the tool to seek mental healthcare themselves after intense crisis calls.

“They can sit in their car, talk to a therapist, get that out, and then go on about their shift,” Bradley said. “So, they've got immediate peer support for what they're going through.”

The virtual care model is piquing interest in other areas of law enforcement in the state. According to Bradley, city officers who see the county officers using the tablet for telemental healthcare services have asked how they can get their own.

“Once you see [the tablets] work and see the results that they yield, they speak for themselves,” Bradley said.