Tele-Behavioral Health on the Frontier: Southern Plains Behavioral Health Services Relies on Telehealth to Care for Diverse Rural Populations
When you hear the term “American frontier,” you probably think of the stories from your history books—a time long ago when this country was first being settled. The reality, however, is that many parts of rural America are still very different from our typical U.S. city.
“We are extremely rural,” said Sandra Fortuna, clinical director at Southern Plains Behavioral Health Services (SPBHS) in South Dakota. “In fact, we’re so rural that we’re actually classified as ‘frontier’. We serve four counties and about 17 schools throughout those counties. Prior to COVID, it was not uncommon for one of our therapists to drive 90 minutes to get to a service area.”
SPBHS has a dozen therapists, a nurse practitioner, and one psychiatrist who serve about 600 clients, ranging from children to elderly patients. The practice provides psychiatric care; individual, family, and group counseling; case management; parenting education; and a wealth of other services.
gpTRAC Provides Critical Training and Support
Although SPBHS actually began offering psychiatric services remotely around 2006 and is one of the providers in South Dakota that has done telehealth the longest, the practice wanted to improve its use of telehealth in 2019.
Just before COVID began, SPBHS team members attended a Great Plains Telehealth Resource & Assistance Center (gpTRAC) training session and then arranged for gpTRAC staffer Mary DeVany to come out and do in-person training on-site.
“Mary actually came out and trained all our staff on-site before COVID started so we were ahead of the game,” Fortuna said. “Those who couldn’t attend could watch the recorded sessions online. After the sessions, Mary met with everyone individually.”
SPBHS used gpTRAC resources to create index cards to allow therapists to easily run through a checklist before a telehealth session.
“Mary helped us select the right equipment, learn how to use it, pick appropriate backgrounds, and manage things like camera placement and lighting,” Fortuna explained. “We went through things like what to ask at the beginning of every session, emergency plans, and how to establish a safety word if someone dangerous entered the patient’s room.”
A Pleasant Surprise
One of the first areas that SPBHS wanted to grow was in serving its elderly population. However, Fortuna had some trepidation about that effort initially.
“Originally, we thought our elderly population would struggle the most,” she explained. “Many residents in nursing homes were not used to technology. However, we found that this population loves telehealth. Our nurse has developed great relationships with our long-term care facilities, and the residents are so isolated right now, that they love the interaction and look forward to connecting virtually.”
SPBHS works with three nursing homes and five assisted living facilities. “In some cases, the nursing staff at these long-term care facilities will sit in on the appointment while in other cases, they will just help the residents get connected and leave the iPad with them.”
Expanding Services to Students and Parental Involvement
Besides serving the elderly population, SPBHS therapists also work with 17 schools in the area. Before COVID, therapists usually drove out to the schools to meet with the students who needed services.
“When the schools closed down in the spring, we had to use telehealth to connect with the kids in their homes,” Fortuna said. “In some cases, the kids loved being able to ‘bring the therapist’ home. They would wander around their house with the camera to show off their rooms, belongings and pets. It sometimes made the therapists a little dizzy!
One result of home telehealth visits was that some of the parents became more involved in their children’s care. “In some cases, we were able to interact with the parents more,” Fortuna said. “That experience helped us realize the benefit of parental involvement where possible. In fact, when the schools opened back up this fall, we started incorporating parents into our school visits. Now, when our therapists travel to schools to meet with the students, they often bring parents in with a video call. If the schools shut down again, that will help bring some consistency to the therapy.”
Telehealth also allowed the SPBHS psychiatrists to reach more students during the pandemic. “If psychiatrist appointments are necessary, we usually have the parents meet the child at school and use Zoom to connect to our psychiatrist remotely,” Fortuna said.
The entire experience during the pandemic has helped the SPBHS staff rethink its overall operations. “In the future, we won’t be traveling as much,” Fortuna said. “We’ve realized that by having our therapists working from home, they can start their day at 8 a.m. instead of driving 90 minutes. That means more people can be seen in a day. We have not seen our productivity decrease at all, but our costs are way down. We don’t need to pay for remote facilities or fuel when telehealth services are used.”
Overcoming Barriers on the Reservation
SPBHS therapists also care for clients who live in a South Dakota Indian reservation, which brings its own unique challenges. “They usually don’t have reliable internet service, which makes telehealth difficult, if not impossible,” Fortuna said. “In addition, their financial situation often means frequent phone number changes, which makes it difficult to connect at all.”
However, before COVID, SPBHS secured some computer equipment that could be moved around on carts for the schools on the reservations. “As long as the schools had internet service, this facilitated our communication with them,” Fortuna said. “Although the schools on the reservations will probably stay closed until Spring 2021, the equipment will be waiting for them when they go back.”
New Opportunities for Group Therapy
Telehealth technology has allowed SPBHS to expand its ability to provide group therapy services as well. Previously, several clients were actually driving two hours in order to participate in a group that was physically meeting in a more distant location.
“Usually, we don’t have enough referrals in our tiny towns to have a facilitator run a group locally,” Fortuna said. “However, our facilitators are now combining people from multiple areas. We can incorporate group members from four counties in the same group without any windshield time for anyone. Through telehealth technology, they can simply Zoom into the same virtual space for group work.”
SPBHS has had particular success with its moral reconation therapy (MRT) group, which is a kind of behavioral therapy that works to help individuals avoid returning to substance abuse.
“The MRT group definitely used telehealth to its advantage,” Fortuna said. “One of our therapists was physically present in one school with those students, and that group could virtually connect to another therapist who was physically in a second school in a completely different school system.”
Remote Connections Improve Staff Communications
Besides protecting its clients and staff during the global pandemic by offering more non-contact options for mental health care, SPBHS also relied on video technology to connect to one another.
“We usually have a weekly staff meeting with all 22 of us in our main office,” Fortuna said. “When the pandemic began, we, like most others, moved to virtual staff meetings. Interestingly enough, we all feel like that it’s actually improved our employee communication.
“As clinical director, I need to meet with staff regularly,” she added. “Before COVID when everyone was traveling so much, I’d often only get a quick phone call from the road to check in. However, with less traveling and Zoom, I feel like I’m more connected with my staff than ever before.”