Sgt. Nicholas Brown, NCOIC for Army Substance Abuse Program Clinical Services at Schofield Barracks, Hawaii, simulates a soldier engaged in a virtual behavioral health assessment interview via Defense Connect Online, in one of 10 specially designed booths that were assembled before the Virtual Behavioral Health pilot project conducted in October and November. (Liana Mayo / 311th Signal Command)
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Tele-behavioral health offers a powerful means to reach and treat soldiers as the Army grapples with a wide range of behavioral health needs and a shortage of practitioners in some geographic regions, say Army officials close to the effort.
A recent Army study found telehealth is effective in bringing a wide range of behavioral health therapies to soldiers who are dispersed or geographically isolated, such as members of the National Guard and Reserve. Those therapies largely target post-traumatic stress disorder.
As one measure of those needs, the service is on track to reach its highest suicide rate yet — 29 suicides per 100,000 soldiers per year, more than three times the rate in 2004 and a more than a 25 percent increase over last year.
At the same time, behavioral health providers are in demand. Since 2007, as behavioral health screenings for soldiers have become more regular and comprehensive, the service has doubled its inventory of civilian providers.
Army telehealth, which encompasses 20 medical disciplines, is rapidly expanding; it operates across 19 time zones and 30 countries and territories. And behavioral health is among its fastest-growing and most important applications, said Dr. Colleen Rye, chief of telehealth for the Office of the Army Surgeon General.
"Tele-behavioral health helps us get out to our geographically dispersed soldiers and their family members in a way that we never have been able to achieve before, and we are also able to recruit clinicians in a way that we never have before," Rye said. "Distance is not a factor."
Rye said the biggest challenge for the Army's tele-behavioral health efforts has been keeping up with the demand.
A full range of services
Dr. Michael Lynch, chief of Tele-Health for Northern Regional Medical Command, described how it works at NRMC. A provider sits in his or her office at a military facility and the patient — a soldier, a dependent or both — sits in another federal facility, often hundreds of miles away, and the two sides see and speak with one another by video teleconference (VTC).
"What if a soldier's issue is compounded by family issues, and there aren't any child psychologists where they are?" Lynch said. "Well, I have those. Bring the child in. We'll evaluate the child."
The providers are all civilians and contractors, and they include psychiatrists, psychologists, nurse practitioners and social workers. To evaluate and treat traumatic brain injuries, the program has neuropsychiatrists, physical therapists, speech and language therapists and neurologists.
Not all of the providers are at the program's facility in Arlington, Va., a warren of small offices in a nondescript Army office building. Some work out of other federal facilities, which makes it easier to attract and retain them.
"I found a great neuropsychologist and she didn't want to drive down to Washington, D.C.," Lynch said, "so we gave her a spot at Aberdeen [Proving Ground]," which is 75 miles away in Maryland.
NRMC's 53 providers see roughly 4,000 patients each month, Lynch said. Lynch's providers perform intakes, routine psychotherapy, group therapy, follow-up care and medication management much like their counterparts elsewhere who see patients in person.
Some patients will say more in a VTC than in person, Lynch said. Once, via VTC, a patient told him — but not the patient's own provider — about an instance in which the person had "frolicked" naked in a field. As a result, the patient's diagnosis was changed.
"It's much faster," Lynch said. "You're talking to a TV set, you blurt stuff out."
It's an asset particularly when dealing with PTSD patients who can display paranoia in social interactions. For a provider dealing with an aggressive patient, Lynch said, "you don't worry about getting hit."
It's also more convenient, Lynch said. In areas where the only provider is a social worker, for instance, a patient in need of more advanced care would be booked an appointment through the clinic's staff, which would have access to NRMC's templates and schedules.
"I would come in on a Monday, and my 8 o'clock slot was at Fort Drum (N.Y.), my 10 o'clock slot was at Carlisle (Pa.), my 1 o'clock slot was at Fort Hood (Texas) and my 3 o'clock slot was at Fort Eustis (Va.)," he said. "But it was just like anybody down the street."
VTC therapy is versatile, Lynch said. NRMC has provided split groups, where groups are in different locations, all speaking with each other by VTC.
There still need to be physical safeguards in place if, for instance, a patient was acutely suicidal and being evaluated by VTC. Providers have to know the procedures, and the emergency contacts for that place are displayed for a provider on screen.
"Every location has [its] own culture, and we have 34 cultures to adapt to," Lynch said. "We have to be very flexible, so ... you can't go into one of these places and say, ‘Here's how we're going to do it.'"
NRMC provides care at 34 different locations, including Schofield Barracks, Hawaii, as well as Army, Air Force and Navy sites in the continental U.S.
If a post needs more resources because a surge of troops is returning home, NRMC can easily assign resources to that location and then pivot to a new location as needed.
After the Fort Hood shootings in 2009, the program took over its medical and disability evaluations, to allow the post's behavioral health providers to deal with the aftermath in person.
"We gave them 100-something appointments and took any military-oriented evaluations so they could focus their resources on the ground, dealing with the families," Lynch said.
Reaching into the home
The passage of new laws has opened the possibility of extending tele-behavioral health's reach into the home. Previously, the law only allowed providers to speak with patients if both parties were in federal facilities out of respect for state licensure laws. A provision of the 2012 National Defense Authorization Act works around state licensure requirements.
The Defense Department is in the process of updating its policies to take advantage of the new law and guarantee patient privacy.
Rye said one exciting possibility is providing care through national armories, which are state property.
"Our focus is always trying to extend access to care for our beneficiaries within boundaries that ensure our patients' safety," Rye said.
NRMC is planning a research project that would allow soldiers to receive treatment in their homes using nothing more than an iPad.
Lynch said the idea came to him after a soldier living in rural Virginia was flown to Carlisle Barracks to speak with him by VTC. The government paid for the soldier's flight and a hotel room for a cost of around $1,800, all for a one-hour appointment.
"It happens all the time because they send people all over the place for evaluations," Lynch said. "If I get a $700 iPad and I FedEx it to his house, why can't I do it from there? For ten bucks, I just saved $1,800 for the government."
The idea is for patients to receive care sooner and with more ease. For example, it might save a patient who suffers from PTSD or a brain injury from a long trip across many states.
There are concerns with the new law, Lynch said. What happens if a patient records and posts his session online? What happens in case of an emergency? How do you give providers the emergency contacts for the patient's area?
Once the policy issues are resolved, Lynch said he anticipates tele-behavioral health efforts will encompass pre-clinical or preventative care.
"We can be anywhere," Lynch said. "All the issues you see now aren't going away. If Fort Drum needs 10 psychiatrists and they only have two, who's going to move to Watertown, N.Y.? We will become the gap filler."