Telehealth for Rural Diverse Populations: Cultural and Telebehavioral Competencies and Practical Approaches for Clinical Services
Rural health care settings are challenged to provide timely and evidence-based care, particularly for culturally diverse patients with behavioral health disorders. Telepsychiatry and telebehavioral health improve access to care and leverage scarce resources like specialty expertise and language interpreters. This paper focuses on the three questions, particularly related to medical settings: (1) What are the components of culturally competency clinical care and what fundamental approaches help providers? (2) What fundamental approaches like the cultural formulation interview and the bio-psycho-socio-cultural model help providers achieve it? (3) How do we link outcomes with culturally competent and telepsychiatric competencies? Rural underserved patients need culturally competent care, which requires skills by all health care team members. Skill-focused training based on practical everyday practices, cases, and pedagogic methods can improve care and engage participants. Telepsychiatric care is similar to in-person care, either requires integrated cultural and telepsychiatric skills. Educational and administrative adjustments are needed to promote culturally competent care, particularly by telehealth. Rural populations need culturally competent care and teams with telepsychiatric skill sets increase access. More quantitative and qualitative research is suggested to improve the approach and better evaluate, administer, and finance services.
KeywordsTelepsychiatry Behavioral health Academic health centers Culture Competencies Models Approaches
American Association of Directors of Psychiatry Residency Training, Coalition for Technology in Behavioral Science (CTIBS), Telebehavioral Behavioral Health Institute (TBHI), and UC Davis School of Medicine and Department of Psychiatry and Behavioral Sciences were acknowledged, including Drs. Francis Lu, Russell Lim, and Hendry Ton.
- Accreditation Council for Graduate Medical Education (2007). Residency Review Committee, Guidelines for Psychiatric Residencies. Retrieved from www.acgme.org/acWebsite/downloads/RRC_progReq/400pr07012007.pdf.
- Accreditation Council on Graduate Medical Education (2013). Common program requirements. Retrieved from https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf.
- Agency for Healthcare Research and Quality: National Healthcare Disparities Report, 2006. Rockville, MD, Agency for Healthcare Research and Quality, 2006. Retrieved from http://www.ahrq.gov/qual/nhdr06/nhdr06.htm.
- American Association for Family and Marital Therapy (2004). Core Competencies. Retrieved from: https://www.aamft.org/imis15/Documents/MFT_Core_Competencie.pdf.
- American Association for Family and Marital Therapy (2015). Code of Ethics. Retrieved from: http://www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/Code_of_Ethics.aspx.
- American Association of Directors of Psychiatry Residency Training (2017). Training Directors Curricula. Retrieved from http://www.aadprt.org/training-directors/curriculum.
- American Association of Medical Colleges, Core Medical Student Competencies (2015). Retrieved from https://www.aamc.org.
- American Counseling Association. (1992). Cross-cultural competencies and objectives. Retrieved from http://www.counseling.org/Publications/.
- American Psychiatric Association Cultural Formulation Interview (2013). Patient Version. Website: http://www.dsm5.org/Pages/Feedback-Form.aspx, and Informant Version, at: http://www.multiculturalmentalhealth.ca/wp-content/uploads/2013/10/2013_DSM5_CFI_InformantVersion.pdf.
- American Psychiatric Association, Cultural Formulation Interview Supplementary Modules 2013. Website: http://www.multiculturalmentalhealth.ca/wp-content/uploads/2013/10/2013_CFI_supplementarymodules.pdf.
- American Psychological Association (2002). APA guidelines on multicultural education, training, research, practice and organizational change for psychologists. Retrieved from: http://www.apa.org/pi/oema/resources/policy/multicultural-guidelines.aspx.
- American Psychological Association (2017). Guidelines for providers of psychological services to ethnic, linguistic, and culturally diverse populations. Retrieved from: http://www.apa.org/pi/oema/resources/policy/provider-guidelines.aspx.
- Americans with Disabilities Act 1990. Public law 101–336. (1990). Retrieved from http://library.clerk.house.gov/reference-files/PPL_101_336_AmericansWithDisabilities.pdf.
- Association of American Medical Colleges (2000). The AAMC Initiative for Cultural Competence in Medical Education. Retrieved from http://www.aamc.org/meded/tacct/culturalcomped.pdf.
- Brown, M. T., Bussell, J. K. (2011). Medication adherence: WHO cares? Mayo Clinic Proceedings. 86(4), 304–314.Google Scholar
- Brua, C. (2008). Role-blurring and ethical grey zones associated with lay interpreters: Three case studies. Communication & Medicine, 5(1), 73-79.Google Scholar
- California Department of Mental Health DMH Information Notice No: 02–03 (1997). Addendum for Implementation Plan for Phase II Consolidation of Medi-Cal Specialty Mental Health Services—Cultural Competence Plan Requirements; 2003, superseding (California) DMH Information Notice No: 97–14. Addendum for implementation plan for phase II consolidation of Medi-Cal specialty mental health services—cultural competence plan requirements; 1997. Retrieved from http://www.dmh.cahwnet.gov/DMHDocs/docs/notices02/02–03_Enclosure.pdf.
- Carlson, J. (2010). Breaking down language barriers. Hospital interpreters get credentialed with new certification programs. Modern Healthcare, 15;40(46), 32–34.Google Scholar
- Civil Rights Act of 1964, Public Law 88-352 (1964).Retrieved from https://www.gpo.gov/fdsys/pkg/STATUTE-78/pdf/STATUTE-78-Pg241.pdf.
- Coalition for Technology in Behavioral in Behavioral Science (CTIBS) (2018). Retrieved from http://ctibs.org.
- Committee on the Accreditation of Canadian Medical Schools (2017). Retrieved from https://www.afmc.ca/accreditation/committee-accreditation-canadian-medical-schools-cacms/.
- Cross, T.L., Bazron, B.J., Dennis, K.W., et al. (1989). Towards a culturally competent system of care, volume 1. Washington, DC: CASSP Technical Assistance Center, Georgetown University Child Development Center. Retrieved from https://spu.edu/~/media/academics/school-of-education/Cultural%20Diversity/Towards%20a%20Culturally%20Competent%20System%20of%20Care%20Abridged.ashx.
- Flexner, A. (1910). Medical education in the United States and Canada: a report of the Carnegie Foundation of the advancement of teaching. Bulletin 4. Boston: Updyke.Google Scholar
- Frank, J. R. (2005) The CanMEDS 2005 Physician Competency Framework. Retrieved from http://rcpsc.medical.org/canmeds/CanMEDS2005/CanMEDS2005_e.pdf.
- Frank, J.R., Mungroo, R., Ahmad, Y., Wang, M., De Rossi, S., Horsley, T. (2010). Toward a definition of competency-based education in medicine: A systematic review of published definitions. Medical Teacher, 32(8), 631-637. https://doi.org/10.3109/0142159X.2010.500898.
- Geller, J. M., & Muus, K. J. (2000). The role of rural primary care physicians in the provision of mental health services. Journal of the Washington Academy of Sciences, 86, 131–142.Google Scholar
- Ghaemi, S. N. (2011). The biopsychosocial model in psychiatry: a critique. Existenz 2011. Spring, 6(1). http://www.bu.edu/paideia/existenz/volumes/Vol.6-1Ghaemi.html.
- Gifford, V., Niles, B., Rivkin, I., Koverola, C., & Polaha, J. (2012). Continuing education training focused on the development of behavioral telehealth competencies in behavioral healthcare providers. Rural Remote Health, 12(2108), 1–15 Retrieved from file:///Users/user/Downloads/article_print_2108.pdf.Google Scholar
- Hilty, D. M., Ton, H., Lu, F., & Yager, J. (2014). Revising Engel’s biopsychosocial model to the biopsychosocialcultural model? Suggestions and implications. Keystone: Workshop, American Directors of Medical Student Education in Psychiatry.Google Scholar
- Hilty, D. M., Lim, R. F., Nasatir-Hilty, S. E., Koike, A. K., Ton, H., & Nesbitt, T. S. (2015a). Planning for telepsychiatric consultation: a needs assessment for cultural and language services at rural sites in California. Journal of Rural Mental Health, 39(3–4), 153–161 https://doi.org/10.1037/rmh0000035.CrossRefGoogle Scholar
- Hilty, D. M., Crawford, A., Teshima, J., Chan, S., Sunderji, N., Yellowlees, P. M.,. .. Li, S. (2015b). A framework for telepsychiatric training and e-health: competency-based education, evaluation and implications. International Review of Psychiatry, 27(6), 569–592. doi: https://doi.org/10.3109/09540261.2015.1091292.CrossRefPubMedGoogle Scholar
- Hilty, D. M., Ton, H., St. George, C., & Lim, R. (2015c). The ‘how to’ on training medical students on culture and diversity: interviewing tips, brief cultural formulation, biopsychosociocultural treatment planning, and psych OSCE options. Workshop presented at the meeting of the Association of Directors of medical student education in psychiatry, Stowe, VT.Google Scholar
- Hilty D.M., Maheu, M., Doarn, C., Ommen, S., Nesbitt T.S. (2016a). A framework for telemedicine trainineg and E-health: competency-based education, Evaluation and Implications . Short Course presented at the meeting of the American Telemedicine Association, Minneapolis.Google Scholar
- Hilty, D. M., Shoemaker, E., Chan, S., O’Neill, P., Snowdy, C., Torous, J., DeJong, S. (2016b). A framework for telepsychiatric, social media and other technologies: competency-based education, evaluation and implications. Education Workshop Session presented at the meeting of the American Association of Directors of Psychiatry Residency Training, Austin, TX.Google Scholar
- Hilty, D. M., Maheu, M., Drude, K., Hertlein, K., Long, R., Luoma, T., & Ford, D. (2017a). Telebehavioral health, telemental health, e-therapy and e-health competencies: the need for an interdisciplinary framework. Journal of Technology in Behavioral Science, 2, 171–189. https://doi.org/10.1007/s41347-017-0036-0.CrossRefGoogle Scholar
- Hilty, D. M., Zalpuri, I., Stubbe, D., Snowdy, C., Shoemaker, E. Z., Myint, M., Liu, H. (2017b). Social media/networking as part of e-behavioral health and psychiatric education: competencies, teaching methods, and implications. Journal of Technology in Behavioral Science, in press.Google Scholar
- Hiratsuka, V., Delafield, R., Starks, H., Ambrose, A. J., & Mau, M. M. (2013). Patient and provider perspectives on using telemedicine for chronic disease management among native Hawaiian and Alaska native people. International Journal of Circumpolar Health, 72(1), 21401. https://doi.org/10.3402/ijch.v72i0.21401.CrossRefGoogle Scholar
- Kim, G., Aguado Loi, C. X., Chiriboga, D. A., Jang, Y., Parmelee, P., & Allen, R. S. (2010). Limited English proficiency as a barrier to mental health service use: a study of Latino and Asian immigrants with psychiatric disorders. Journal of Psychiatric Research, 45(1), 104–110.CrossRefPubMedGoogle Scholar
- Lewis-Fernández, R., Aggarwal, N. K., Bäärnhielm, S., Rohlof, H., Kirmayer, L.J., Weiss, M.G., … & Lu, F. (2014). Culture and psychiatric evaluation: Operationalizing cultural formulation for DSM-5. Psychiatry, 77(2), 130-154.Google Scholar
- Liaison Committee on Medical Education Competencies Revision 2015. At: https://www.lcme.org/publications/2015-16-functions-and-structure-with-appendix.pdf.
- Loue, S., Wilson-Delfosse, A., & Limbach, K. (2014). Identifying gaps in the cultural competence/sensitivity components of an undergraduate medical school curriculum: a needs assessment. Journal of Immigrant and Minority Health, 17(5), 1412–1419. https://doi.org/10.1007/s10903-014-0102-z.CrossRefGoogle Scholar
- Maheu, M., Drude, K., Hertlein, K., Lipschutz, R., Wall, K., Long, R., ... & Hilty, D. M. (2018). An interdisciplinary framework for telebehavioral health competencies. Journal of Technology in Behavioral Science. https://link.springer.com/content/pdf/10.1007%2Fs41347-018-0046-6.pdf.
- Marcin, J. P., Nesbitt, T. S., Struve, S., Traugott, C., & Dimand, R. J. (2004). Financial benefits of a pediatric intensive care unit-based telemedicine program to a rural adult intensive care unit: impact of keeping acutely ill and injured children in their local community. Telemedicine Journal and e-Health, 10(Supplement 2), 1–5.CrossRefGoogle Scholar
- McLaren, N. (1998). A critical review of the biopsychosocial model. Australian and New Zealand. Journal of Psychiatry, 32:86–92.Google Scholar
- National Association of Social Workers (2001). Standards for cultural competence in social work practice. Retrieved from http://www.socialworkers.org/sections/credentials/cultural_comp.asp.
- New York State Office of Mental Health (1997). Cultural and linguistic competency standards. New York, Office of Mental Health. Retrieved from http://www.ct.gov/dmhas/LIB/dmhas/OMA/guidelines.pdf.
- Office of the Surgeon General Center for Mental Health Services and National Institute of Mental Health (2001). Mental health: culture, race, and ethnicity: a supplement to mental health: a report of the surgeon general. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK44242/.
- Perez-Stable, E. J. (2007). Language access and Latino health care disparities. Medical Care, 45, 1009-1011.Google Scholar
- Rost, K., Zhang, M., Fortney, J., Smith, J., & Smith, G. R. Jr. (1998). Rural-urban differences in depression treatment and suicidality. Medical Care, 36(7), 1098–1107.Google Scholar
- Royal College of Physicians and Surgeons, CanMEDS Framework (2005). Retrieved from http://www.royalcollege.ca/portal/page/portal/rc/canmeds/framework/.
- Telebehavioral Behavioral Health Institute (TBHI) (2017). TBHI Professional Training Certification Programs. Retrieved from https://telehealth.org/certified/andtelehealth.org/courses/.
- United States Center for Mental Health Services. (2000). Cultural competence standards in managed care mental health services: four underserved/underrepresented racial/ethnic groups (publication no. SMA00–3457). Washington, DC: Substance Abuse and Mental Health Services Administration.Google Scholar
- United States Department of Agriculture (2015). What is rural? Retrieved from http://ric.nal.usda.gov/what-is-rural/.
- United States Department of Health and Human Services (2001). Mental Health: culture, race, and ethnicity. A supplement to mental health: a report of the surgeon general. Rockville, MD, DHHS. Retrieved from http://www.ct.gov/dmhas/lib/dmhas/publications/mhethnicity.pdf.