Running Head: RURAL COLORADO 1

Mental Health Care in Rural Colorado

SOWK 520

Robert Cope

December 9, 2015

School of Social work, Colorado State University

Introduction

RURAL COLORADO

The topic of mental health care is especially important and prevalent in the news right

now. People are pointing fingers at the failing system after the wake of mass shootings in the

public arena. Some people have misconceptions about what people suffer from concerning their

mental health and what policies there are to protect the public. However important the aspect of

protecting people is, another issue concerning policies around mental health are the rights to

receive services in rural parts of Colorado. Our amazing state has many things going for it, but

quality mental health care is concentrated largely in densely populated parts of our state.

Policy history

As early as 1992, Colorado recognized that there was an issue in serving all of its

community members who suffered from mental health issues. In May of that same year, the

state passed House bill 92-1036 which was aimed at ensuring that Medicaid recipients had access

to mental health care within the communities that they lived in. Bloom et al., (1998) described

one of the bills central goals “to improve the public mental health system in Colorado by

expanding community mental health services, particularly those services that can assist

consumers to remain in their communities rather than require services in an inpatient

hospital”(p.4). While this seems like a straightforward solution, it may not be as easy to solve as

they originally thought.

Even before the advent of HB 92-1036, there was largely a serious lack of facilities to

provide care for mental health related illness. Catalano, Libby, Snowden, & Cuellar, (2000)

conveyed “ Colorado’s mental health system consisted of 17 mental health centers, 4 specialty

clinics, and 2 state hospitals”(p.1862). After the passage of HB 92-1036, 14 of these 17,

restructured into 7 new centers called “mental health assessment and service agencies” (Catalano

et al., 2000, p.1862). The 3 lingering centers remained as community mental health centers and

2

RURAL COLORADO

resided to survive as a pay-as-you-go centers otherwise considered Non-profit mental health

centers.

These remaining centers served low-income, Medicaid and Medicare recipients who

received everything from mental health services, case management, and psychiatric assistance.

One of the centers was Larimer county mental health, which is today known as Summit stone,

located in Fort Collins. The core ones are, Community Reach Center in Thornton, Mental Health

Colorado, Denver (MHCD), and North Range Behavioral Health. A further portion of the seven

are Arapahoe Douglas mental health, Aurora community mental health, and Centennial Peaks in

Littleton, Colorado.

Considering the mental health deficiency, Fort Collins, Loveland and Greeley are lucky

in that they are served by Summit Stone and North Range Behavioral Health. However, if you

reside in Craig, Colorado, you may be required to drive for two hours or more to obtain mental

health services at the nearest center. There are some smaller mental health centers in the

community such as Mind Springs Health, which has a location in Craig, and consists of four

therapists, psychiatrists and nurse practitioners. Their website states that they mainly do

substance abuse in seven locations across Northwestern, Colorado. They also appear to do

individual and family therapy, but the services to this extent are not mentioned specifically

(“Mental Health, Psychiatrist, Counseling, Therapy, Psychologist,” 2015). If this center does not

provide a specific client service, Google maps shows that to the nearest center, is over a 4 hour

drive to Summit Stone in Fort Collins or a two hour drive to the nearest Mind Springs center in

Eagle, Colorado (“Google Maps,” 2015).

Background

3

RURAL COLORADO

The central theme is that on the eastern and western plains of Colorado the support for

mental health services, people have a lack of options for care. Over a course of time, a legislative

bill has been passed and was put in action. It was Colorado, House Bill 15-1029, which allowed

people living in communities with less than 150,000 people to see mental health professionals

over the internet and more commonly referred to as Tele-health services (“House Bill 15-1029,”

2015). Whereas there were mental health centers to serve the population, the new bill was voted

almost unanimously into action starting from the time it was introduced in January and signed

into action in March 2015 (http://www.leg.state.co.us).

In comparison, to the prior issues with HB 92-1036 that medical insurance paid for

services; were only to take place when the patient saw a clinical professional in a face-to-face

setting, the new bill changed that. HB 15-1029 required that medical plans pay for services in a

Tele-Health setting where the client can visit with the clinician over a secure internet connection

for example; Skype or Facetime. However the new bill did require the visit to be done over

internet, secure visual interaction, it does not cover visits that are done in other ways such as by

phone, email, or fax communication. This bill also does not allow insurance companies to

placement on limits of the number of services or monetary limits, that insurance companies may

impart of other types of services, for example limits on care for cancer patients (“ HB1029 |

2015 | Regular Session,” 2015).

Discussion

Numerous studies have been done explaining the benefits and drawbacks to telemedicine.

One of these such studies by Handley et al., (2013) specifically examines how viable

telemedicine could be. His study focused primarily on the mental health side of care, considering

the need for mental health and medical health, this study provides valuable insight into just how

4

RURAL COLORADO

feasible it is. The study utilized twelve hundred participants living in rural Australia, who were

over the age of 50 and had internet access with some vague understanding of online use.

Researchers found that individuals who were more familiar with internet use were more

comfortable and that if educated, the other participants would be just as likely to use internet

health services.

Whereas the older generation may be shunning the new technology, with education, they

be more susceptible to using the technology. Handley et al., (2013) proclaimed “feasibility was

significantly higher among people with recent mental health problems…indicating a greater

willingness to access internet-delivered treatments among those who are most likely to benefit

from them”(p.278). A large weakness that was pointed out by the researchers is that while the

preponderance of the participants agreed to use the internet-derived treatment, those that did had

recent mental health issues. As explained by the researchers, they found that those who were

likely to shun the service, had a lack of mental health disparities over the last few months and did

not feel a benefit or need to use the service.

With regard to the expansion of telemedicine in Colorado, there are considerations to

make with regard to potential weaknesses. Such as people who decline to use the internet service

due to a lack of desire or failure to feel their mental health issues need to be resolved. A further

thought that could be another potential weakness is that there may be rules, and regulations that

need to be abided by. These may go beyond the scope of HB 15-1029 as well. Kramer, Kinn, &

Mishkind, (2015) explain that the greatest benefit of telemedicine is its ability to reach people in

the farthest reaches of the rural community and ensure that they receive care. Unless a mental

health facility is willing to undertake the financial responsibility to cover program design,

technology protections and compensation for nurses to travel to do minimal and routine medical

5

RURAL COLORADO

care (blood pressure, weight, and medication management); the center may need to be contracted

with larger medical providers.

As such, Kramer et al., (2015) justified “ compliance with appropriate laws regarding

health care licensure is one of the most immediate concerns raised prior to engaging in TMH

(telemedical health)practice” (p.259). Specifically looking at corporations that are outside

Colorado, contracting with them could cause the local nonprofit to undertake costs of licensure

for out of state practitioners, psychologists, and psychiatrists. This would be different if the

provider is local and licensed by state regulators, but if they are out of state, they may not have

state-to-state license reciprocity.

Largely a weakness of HB 15-1029 is that it only mandates coverage by medical health

insurance and payments to providers and leaves out licensing and costs associated with it. If this

is to fall on the small non-profit, it could cause budgeting issues. A strength of the policy is that

more people will have access to care and it will be paid for if they use tele-medical care. One

large positive to the law is that by using telemedicine, a patient can avoid a stigmatizing

experience by going into a facility and possibly being seen in a small town where neighbors may

notice. By using telemedicine, they can seek much needed care with a reduction in feeling

stigmatizing effects (Burfeind, Seymour, Sillau, Zittleman, & Westfall, 2014).

In large support of HB 15-1029 is Ben Price, who is the Executive Director of the

Colorado Association of Health Plans. He feels that it is an opportunity to explore modern

technology and reach out to populations that need it most. However, Mr. Price also feels that a

shortcoming of the bill is the question of how prescriptions and therapeutic exercise will be

implemented and that further legislation will be needed to address the issue. Also there is the

issue that the initial intake of the client is still needed on a face-to face bases before telemedicine

6

RURAL COLORADO

can be started (Murphy, 2015). The face-to-face problem might be resolved if only the initial

intake and monthly check-ins are required while clinical services are done via tele-med

connection.

Impact on the social problem and at-risk populations

Support of tele-medicine, video conferencing is quite extensive, from websites such as

“The American Telemedicine association” and research has shown that this new form of

therapeutic service is very valuable. Shealy, Davidson, Jones, Lopez, & de Arellano, (2015)

explained how mental health illness may be higher in rural settings and the opportunity to access

quality care is less than people in urban environments. Shealy et al., (2015) asserts that a relative

amount of research has been done that shows the benefit to telemedical mental health support

and that it is just as valuable as in-person care. This assertion is valuable evidence to the point

that despite being in separate locations, the clinician is still able to gain the view of patient

physical changes that the office environment would have provided.

Initial impact on the social problem of access to care and how it can aid the rural

population. Shealy et al., (2015) delivered a case study where the researchers supplied

therapeutic care to a 13-year-old patient who had been through a traumatic event. The initial

intake was completed in the office, but the consistent weekly care was completed via tele-

medical videoconference. Since the care providers used a network that allowed for workbook

exercises to be downloaded and completed by the patient, the full therapy experience was able to

be provided to this case study. The researchers found that the client made huge improvements

over 10 sessions, and the only issue was with consistent internet connection.

Due to driving time and distance Shealy et al., (2015) were able to provide care to an

individual that would not have had 3 plus hours to dedicate to driving to the clinic once a week.

7

RURAL COLORADO

The use of tele-medicine allowed the clinicians to keep up to date and do continuous weekly

treatment meetings, and allow the client an access to care that they may not have accessed

otherwise. One issue that could impact attainment of services through telemedicine is having the

care covered by insurance. Luckily HB 15-1029 requires that medical insurance plans cover

these services for people living in areas where the population is less than 150,000. However

Shealy et al., (2015) stated “the federal government does not require Medicaid to reimburse for

telemedicine, hence each state determines if it will provide Medicaid reimbursement for

telemedicine services’(p.341). HB 15-1029 has already addressed the issue and appears to

require that all medical plans cover tele-medicine, and it is assumed that Medicaid is covered in

this requirement, the bill does not make a statement about this as such.

Impact on social work

As social workers we have the unique declaration to work toward social welfare for all

people. In the context of HB 15-1029, this bill allows people in rural communities the ability to

use tele-health to access care that may be far away and out of reach, and now those services are

required to be covered by medical insurance. Social workers have the ability to provide social

welfare through education of people rights and the policies that protect them. While providing

the connections to accessible tele-health providers and services.

Frueh, (2015) provides insight into the positives of tele-medicine but also states that the

largest obstacle that we as social workers face is ensuring that our clients receive evidence-based

treatment. By way of educating consumers to ask questions about treatment and safeguarding

that the treatment prescribed has been tested across a variety of situations. While also having

adequate clinical backing to the community it is being prescribed. HB 15-1029 allows services

in rural communities, which clients may not have knowledge of what the services are and which

8

RURAL COLORADO

ones are appropriate for their condition. The profession of social work, should make education

about common mental health disparities accessible to the populace and make sure people know

its ok to change providers if they do not feel like they connect with the provider on a personal

level. One of the hardest is issues is feeling comfortable with the person providing mental health

care, whether its online or in person. If people are educated on appropriate relationships they are

more likely to continue care.

Shealy et al., (2015) stipulated “ some studies comparing telemedicine to treatment

provided in person have reported that telemedicine may in fact be a superior route of treatment

administration for children and adolescents noting novelty of the therapeutic interaction via

technology”(p.333). Their assertion provides fodder for the thought that if the younger

generation grasps utilizing technology, social workers can employ this to help educate parents

and other care providers. If youth are provided pamphlets and access to websites, they can be an

alternative to outreaching parents about HB 15-1029’s benefits and what is available to the

parents. As well as allowing for tabs on the website that lead to providers of tele-medicine

services that can be accessed from the potential patients home.

Suggestions to improve the policy

Though HB 15-1029 has evolved from HB 92-1036, one major issue remains that was

pointed out previously by Ben Price is the need for pharmaceutical legislation added to the bill.

Murphy, (2015) quoted Mr. Price as stating that he see medication treatment as being left on the

table and the need to be included on future revision of the bill. This mainly covers psychiatrists

and practitioners that prescribe and less so those who do mental health care. If a client sees a

physician, they may be likely to have a prescription, which could be required to be mailed or

electronically sent to a participating pharmacy. However, if the pharmacy does not recognize the

9

RURAL COLORADO

physician’s credentials or questions the prescription there may be a drop in communication as the

physician is outreached. This could cause the patient to be denied medication for a time being

that they desperately need the medication.

A further concern that was noticed is the assertion that the medical and mental health

being provided over the Internet is fully functional and secure. Some parts of the country still are

not fully wired for internet, for example Wellington, Colorado still has spotty internet service

that could cause drops in service. If the service is consistent, the bill does not provide a provision

for security. With the large business hacking issues in the news recently, it leaves one to wonder

how secure the individual’s appointment would be. HIPAA rules cover confidentiality of health

information, but the rules do not specifically state that internet services are covered (“HHS.gov,”

2015). This could allow hackers to do whatever they choose should they hack into a tele-

medical appointment. Also, allowing the hacker to circumvent papers and release forms that are

transferred via Internet. A future provision of HB 15-1029 would probably need to ensure that

security and confidentiality is enforced and applicable to all parts of Colorado tele-medicine.

Conclusion

In HB 15-1029, there has been an advancement in the access to care for people in rural

Colorado. The bill allows people to also see care providers in the privacy of their home,

preventing undo costs and also preventing stigma in small towns. While the bill has its pluses

and has evolved over the last twenty plus years from the inception of HB 92-1036, it is not

without its oversights. One is internet security, and the other is prescription access over internet.

However large the oversights are, HB 15-1029 provides care to a segment of the population that

would be otherwise left without access to care. Rural health has traditionally been left off the

10

RURAL COLORADO

table, HB 15-1029 brings rural health to the table and gives voice to people providing food to the

nation.

References

11

RURAL COLORADO

Bloom, J. R., Hu, T., Wallace, N., Cuffel, B., Hausman, J., & Scheffler, R. (1998). Mental health

costs and outcomes under alternative capitation systems in Colorado: Early results. The

Journal of Mental Health Policy and Economics, 1(1), 3–13.

Burfeind, G., Seymour, D., Sillau, S. H., Zittleman, L., & Westfall, J. M. (2014). Provider

Perspectives on Integrating Primary and Behavioral Health: A Report from the High

Plains Research Network. The Journal of the American Board of Family Medicine, 27(3),

375–382. http://doi.org/10.3122/jabfm.2014.03.130152

Catalano, R., Libby, A., Snowden, L., & Cuellar, A. E. (2000). The effect of capitated financing

on mental health services for children and youth: the Colorado experience. American

Journal of Public Health, 90(12), 1861–1865.

Colorado HB1029 | 2015 | Regular Session. (2015) Retrieved October 12, 2015, from

https://legiscan.com/CO/text/HB1029/id/1159840

Frueh, B. C. (2015). Solving Mental Healthcare Access Problems in the Twenty-first Century.

Australian Psychologist, 50(4), 304–306. http://doi.org/10.1111/ap.12140

Google Maps. (2015). Retrieved November 15, 2015, from

https://www.google.com/maps/dir/SummitStone+Health+Partners,

+525+West+Oak+Street,+Fort+Collins,+CO+80521/439+Breeze+St,+Craig,

+CO+81625/@40.7058294,-107.4976998,8z/data=!3m1!4b1!4m13!4m12!1m5!1m1!

1s0x87694a5de5109833:0x7dc032bdfa6e65cc!2m2!1d-105.0856963!2d40.5853967!

1m5!1m1!1s0x8743a6e9bb44d6f9:0xc975bd24fa9ed445!2m2!1d-107.5483548!

2d40.5136107?hl=en

Handley, T. E., Kay-Lambkin, F. J., Inder, K. J., Attia, J. R., Lewin, T. J., & Kelly, B. J. (2013).

Feasibility of internet-delivered mental health treatments for rural populations. Social

12

RURAL COLORADO

Psychiatry and Psychiatric Epidemiology, 49(2), 275–282.

http://doi.org/10.1007/s00127-013-0708-9

HHS.gov. (2015). [Text]. Retrieved November 30, 2015, from http://www.hhs.gov/

House Bill 15-1029. (2015). State of Colorado Legislature.

Kramer, G. M., Kinn, J. T., & Mishkind, M. C. (2015). Legal, Regulatory, and Risk Management

Issues in the Use of Technology to Deliver Mental Health Care. Cognitive and

Behavioral Practice, 22(3), 258–268. http://doi.org/10.1016/j.cbpra.2014.04.008

Mental Health, Psychiatrist, Counseling, Therapy, Psychologist. (2015). Retrieved November 15,

2015, from http://mindspringshealth.org/

Murphy, K. (2015). Colorado Telehealth Legislation Moves to Governor’s Desk [Health].

Retrieved November 15, 2015, from http://mhealthintelligence.com/news/colorado-

telehealth-legislation-moves-to-governors-desk

Shealy, K. M., Davidson, T. M., Jones, A. M., Lopez, C. M., & de Arellano, M. A. (2015).

Delivering an Evidence-Based Mental Health Treatment to Underserved Populations

Using Telemedicine: The Case of a Trauma-Affected Adolescent in a Rural Setting.

Cognitive and Behavioral Practice, 22(3), 331–344.

http://doi.org/10.1016/j.cbpra.2014.04.007

13