How a free virtual clinic is boosting mental health access in Virginia

THE FREE VIRTUAL CLINIC PILOT

According to KFF, there are 97 mental health professional shortage areas in Virginia. Thus, only 30.6 percent of mental health needs are met. And the need is pressing — between February 1 and 13, 2023, 32 percent of adults in Virginia reported symptoms of anxiety and/or depressive disorder, compared to 32.3 percent of adults in the United States.

These figures reflect the challenges of mental healthcare access in the state.

“…there was a significant wait time and tremendous difficulty in terms of being able to access mental health services of any kind,” Servaites said.

Given the demonstrated sticking power of telemental healthcare, the Virginia Telehealth Network, a nonprofit membership organization that supports telehealth efforts in the state, launched a pilot for VTMHI, a free virtual mental health clinic for Virginians.

VTMHI is supported through a collaboration between the Virginia Department of Behavioral Health and Developmental Services, the Virginia Association of Free and Charitable Clinics, the University of Virginia Karen S. Rheuban Center for Telehealth, and the Mid-Atlantic Telehealth Resource Center.

Currently, VTMHI provides virtual mental health services through the Virginia Association of Free and Charitable Clinics, a network of homegrown clinics that address healthcare needs specific to their community.

“They provide free or low-cost primary healthcare services to the medically underserved, whether that be uninsured individuals, [those] who are underinsured, or some free clinics are serving patients who have Medicaid,” Servaites said.

When the pilot began, VTMHI partnered with 10 free and charitable clinics. It grew to partnerships with 22 clinics over the course of the pilot. Clinic staff identify patients needing mental health services through a series of screenings and conversations, referring them to VTMHI. Once VTMHI patient care coordinators have determined that the patient meets the criteria for virtual mental health services — including having access to the technology required for telehealth — the patient is connected with the virtual clinic’s pre-licensed mental health professional volunteers. Licensed counselors supervise the pre-licensed volunteer professionals.

“These [pre-licensed] individuals are folks that have graduated from their graduate program, and they're in the process of earning all the necessary hours that they need to have to be fully licensed within the state,” Servaites explained. “So sometimes they're akin to medical residents. It's a similar type of situation, where they receive some supervision and then they accumulate their hours, and then be able to be fully licensed.”

According to Shannon Raybuck, the mental health coordinator at Fauquier Free Clinic, the clinic and patient experience with the pre-licensed mental health professionals has been highly positive.

“One thing that I've always been super impressed with their clinicians is their willingness to take on our folks with a lot of complex medical conditions,” Raybuck said in an interview with mHealthIntelligence. “There's a lot of complex mental health conditions, dual diagnosis, and lots of social drivers of health barriers, whether it's food insecurity, homelessness, but they've never shied away from taking on these really tough cases. And we've gotten amazing feedback from our patients as well in terms of feeling heard and supported and helped.”

Fauquier Free Clinic was the first to join the VTMHI pilot in December 2022. The clinic had experience providing telemental healthcare prior to this, resulting in a smooth transition to VTMHI’s platform and processes.

The clinic offers medical, dental, and mental healthcare in Virginia’s Falk and Rappahannock counties. The patient population it serves faces numerous SDOH barriers, including being uninsured or underinsured, lacking English proficiency, and facing transportation challenges. Raybuck noted that the clinic uses the PRAPARE Screening Tool to identify SDOH barriers and shares that information with VTMHI.

She also stays in touch with VTMHI’s mental health professionals in case patients' circumstances change during their therapy journey, and they require additional social support.

“We are able to then immediately access the community resources and get them pointed in the right direction so that they don't have to use their counseling sessions to, kind of, put out those basic need fires,” she said. “They can still stay focused on the mental health diagnoses, symptoms, and coping skills while we kind of take over the care coordination.”

Further, the clinic provides resources to patients facing digital divide-related challenges like technology access and digital health literacy hurdles. For instance, the clinic, which is on a public bus route, includes three consult rooms set up for private telehealth appointments with all the technology needed.

“We have a lot of folks that live in homeless shelters, and they're like, ‘I don't really have a quiet private space to really feel like I can open up,’” Raybuck said. “So, we made sure that we have those consult rooms set up here.”

Servaites emphasized that the availability of these resources has been one of the biggest boons of working with the free and charitable clinics on this initiative.

“It's really nice to have that kind of wraparound service available to our patients and to us as well,” she said.

PILOT RESULTS AND LESSONS LEARNED

The pilot underscored the benefits of free virtual mental healthcare for underserved communities; however, it also highlighted areas for improvement.

Since December 2022, VTMHI has scheduled nearly 2,000 telemental health sessions with an average of 11 days between referral and a patient’s first appointment.

“One piece that I am really proud of is because of the [nationwide workforce] shortages that we're experiencing, the wait time to be able to actually get a first appointment or be able to actually see a provider could be quite long — perhaps three-plus months is what the American Psychological Association estimates is the average wait time to get an appointment,” Servaites said. “So, we were able to get patients in much more quickly than they would in the private market.”

Raybuck added that shortening the wait time is critical in getting patients the mental healthcare help they need, as longer wait times could scare off patients who are willing to try counseling. Telemental health visit attendance has improved since the VTMHI program launched, with consistent outreach from the VTMHI team to remind patients about appointments and offer follow-up care, she noted.

Further, VTMHI’s model of pre-licensed volunteer mental health professionals provides a novel solution to the mental healthcare workforce shortage problem. Enabling pre-licensed individuals to grow their skillset and expertise in the field under appropriate supervision and complete the hours needed to earn their license helps get mental health professionals into medically underserved areas faster, Servaites said.

This model could also help encourage mental health professionals to continue to work with underserved populations after getting their licenses.

“We've learned that the sooner we can get these young professionals, whether it's medical professionals, therapists, psychiatrists — get them connected with this very vulnerable, very underserved, sometimes very complicated client base, they're more likely to volunteer once they receive that license,” Raybuck said. “They're more likely to want to go give back to their community through a free clinic or to accept Medicaid in their own private practice.”

Additionally, VTMHI’s interpreter services have helped the free and charitable clinics better care for their fast-growing non-English-speaking patient populations.

“That's been something that I'm really excited about as we move forward and get more non-English speaking patients at the clinic, knowing that I will be able to support them with not only quality therapy services but also quality interpreting services,” Raybuck said.

The urgent need for multilingual therapy services was a vital lesson learned for VTMHI, which aims to add more volunteer mental health professionals who speak multiple languages to its roster.

SCALING THE VIRTUAL CLINIC

Following the successful pilot, VTMHI plans to invite 30 more Virginia clinics and 75 new volunteer mental health professionals to join the program.

While VTMHI aims to remain committed to the outcome metrics it has established, Servaites noted that getting funding to keep up with the demand for telemental health services is challenging.  

“I think just keeping up with the demand will probably be the biggest challenge of just making sure we have enough staff and enough volunteers to be able to stick with the metrics that we think are important of getting patients in a timely manner and being able to provide them with the services that they need,” she said.

However, Servaites is encouraged by feedback from pre-licensed volunteers who have worked with VTMHI. She noted that positive word-of-mouth has led to several new connections, boosting VTMHI’s ongoing recruitment efforts.

Not only that, but some pre-licensed mental health professionals who received their licenses have come back to volunteer as fully licensed clinicians, she said.

As the mental health crisis intensifies nationwide, a multi-pronged approach involving federal and state agencies, healthcare providers, and payers will be vital. Other state governments have approached VTMHI to discuss replicating its success.

“I think there's a lot of lessons to be learned, and we would love to talk to other states as they try to think about ways in which they could approach this for their own individual state,” Servaites said.