1 00:00:00,240 --> 00:00:03,199 Welcome to Becker's Healthcare Podcast. I'm Ella Reuter, 2 00:00:03,199 --> 00:00:05,219 your host, and I'm thrilled to be introducing 3 00:00:05,519 --> 00:00:08,880 our guest today, doctor Carrie Law. She is 4 00:00:08,880 --> 00:00:12,080 associate chief medical officer and board member of 5 00:00:12,080 --> 00:00:14,660 the West Virginia University Health System. 6 00:00:15,125 --> 00:00:17,844 Clinically, she is a professor of adult, child, 7 00:00:17,844 --> 00:00:20,024 and adolescent, and forensic psychiatry, 8 00:00:20,725 --> 00:00:23,765 vice chair of clinical services, and director of 9 00:00:23,765 --> 00:00:24,265 telepsychiatry 10 00:00:24,885 --> 00:00:25,385 for 11 00:00:25,845 --> 00:00:26,984 the WVU 12 00:00:27,769 --> 00:00:28,670 School of Medicine, 13 00:00:28,970 --> 00:00:31,230 Department of Behavioral Medicine and Psychiatry. 14 00:00:31,769 --> 00:00:33,530 Doctor Law, thank you so much for joining 15 00:00:33,530 --> 00:00:34,270 us today. 16 00:00:34,649 --> 00:00:36,729 For our audience who may not be familiar 17 00:00:36,729 --> 00:00:37,929 with you and the work you do, could 18 00:00:37,929 --> 00:00:39,929 you please introduce yourself and tell us a 19 00:00:39,929 --> 00:00:41,549 little bit more about your background? 20 00:00:42,255 --> 00:00:44,575 Absolutely. Thanks, Ella, and and thank you so 21 00:00:44,575 --> 00:00:45,554 much for the invitation. 22 00:00:46,575 --> 00:00:48,655 It's truly an honor to share the good 23 00:00:48,655 --> 00:00:50,414 work that we're doing to serve our state 24 00:00:50,414 --> 00:00:52,914 and region, so I'm I'm happy to. 25 00:00:53,295 --> 00:00:55,840 My name is Carrie Beth Law. I was 26 00:00:55,840 --> 00:00:58,320 born and raised in Southern West Virginia in 27 00:00:58,320 --> 00:00:58,820 Bluefield, 28 00:00:59,520 --> 00:01:02,079 and this state has always been home to 29 00:01:02,079 --> 00:01:02,579 me. 30 00:01:03,039 --> 00:01:05,520 I completed my medical training at West Virginia 31 00:01:05,520 --> 00:01:06,020 University 32 00:01:06,560 --> 00:01:08,659 with additional training in South Carolina, 33 00:01:09,344 --> 00:01:11,584 but, really, I felt a strong pull to 34 00:01:11,584 --> 00:01:12,084 return. 35 00:01:12,704 --> 00:01:15,125 And I've been back at West Virginia University 36 00:01:15,344 --> 00:01:16,704 since 2011 37 00:01:16,704 --> 00:01:17,685 building my career. 38 00:01:18,144 --> 00:01:20,305 I've spent much of my clinical career serving 39 00:01:20,305 --> 00:01:21,444 West Virginia communities 40 00:01:21,984 --> 00:01:22,724 through telepsychiatry. 41 00:01:23,909 --> 00:01:26,810 I've had the opportunity to support and expand 42 00:01:27,030 --> 00:01:28,489 telebehavioral health services 43 00:01:29,109 --> 00:01:31,370 through both federal and state grant funding, 44 00:01:31,909 --> 00:01:34,329 and I've also taken on administration and leadership 45 00:01:34,390 --> 00:01:36,729 roles at the department and health system levels. 46 00:01:37,504 --> 00:01:38,784 But at the core of all of this 47 00:01:38,784 --> 00:01:41,104 is really my passion for rural care and 48 00:01:41,104 --> 00:01:41,604 advocacy. 49 00:01:42,864 --> 00:01:45,364 Telebehavioral health sits right at the intersection, 50 00:01:46,625 --> 00:01:47,284 of those, 51 00:01:48,064 --> 00:01:49,844 both expanding access, 52 00:01:50,209 --> 00:01:53,009 meeting people where they are, and helping ensure 53 00:01:53,009 --> 00:01:53,750 that geography 54 00:01:54,129 --> 00:01:57,189 doesn't determine the care that someone receives. So 55 00:01:57,250 --> 00:01:58,709 I'm happy to be here today. 56 00:01:59,329 --> 00:02:01,349 Wonderful. Thank you so much for that introduction. 57 00:02:02,049 --> 00:02:04,310 First, I'd really like to set the stage. 58 00:02:04,674 --> 00:02:07,415 Can you briefly describe the behavioral health landscape 59 00:02:07,555 --> 00:02:08,854 in rural West Virginia 60 00:02:09,235 --> 00:02:11,895 and what makes access so challenging there? 61 00:02:12,514 --> 00:02:14,675 Sure. So if you've ever been to West 62 00:02:14,675 --> 00:02:15,175 Virginia, 63 00:02:15,634 --> 00:02:16,455 you understand, 64 00:02:17,409 --> 00:02:18,469 the state slogan, 65 00:02:18,849 --> 00:02:20,549 wild, wonderful, West Virginia. 66 00:02:21,250 --> 00:02:24,209 West Virginia really epitomizes beauty from mountains and 67 00:02:24,209 --> 00:02:25,989 forests to the people in the communities, 68 00:02:27,250 --> 00:02:30,209 but, really, that natural beauty contributes to some 69 00:02:30,209 --> 00:02:33,724 of the access challenges that that you mentioned. 70 00:02:34,424 --> 00:02:36,584 So when we talk about behavioral health in 71 00:02:36,584 --> 00:02:38,844 West Virginia and even across Appalachia, 72 00:02:39,784 --> 00:02:42,284 we're really talking about the intersection of geography, 73 00:02:42,664 --> 00:02:43,724 workforce shortages, 74 00:02:44,264 --> 00:02:44,764 stigma, 75 00:02:45,305 --> 00:02:46,044 and socioeconomic 76 00:02:46,905 --> 00:02:47,405 stressors. 77 00:02:48,840 --> 00:02:50,700 When I zoom out a little bit, nationally, 78 00:02:51,080 --> 00:02:51,960 65% 79 00:02:51,960 --> 00:02:55,819 of rural US counties have no practicing psychiatrist. 80 00:02:56,439 --> 00:02:58,760 And so while it's a national crisis, it 81 00:02:58,760 --> 00:03:01,000 really is amplified in Appalachia and in West 82 00:03:01,000 --> 00:03:01,500 Virginia. 83 00:03:02,614 --> 00:03:04,854 Our numbers here in West Virginia are pretty 84 00:03:04,854 --> 00:03:05,354 staggering. 85 00:03:05,814 --> 00:03:08,875 50 out of our 55 counties are federally 86 00:03:08,935 --> 00:03:11,594 designated mental health professional shortage areas. 87 00:03:12,294 --> 00:03:14,875 We have among the lowest per capita availability 88 00:03:15,014 --> 00:03:17,435 of child adolescent psychiatrists in the country. 89 00:03:18,349 --> 00:03:21,310 And then for some families, accessing specialty care 90 00:03:21,310 --> 00:03:22,449 historically meant 91 00:03:22,830 --> 00:03:25,310 driving long distances. That could be two hours 92 00:03:25,310 --> 00:03:27,310 up to four hours one way, and that's 93 00:03:27,310 --> 00:03:29,250 if care was even available at all. 94 00:03:29,789 --> 00:03:31,569 So when you think about that, that distance 95 00:03:31,629 --> 00:03:34,794 really hits children and adolescents especially hard. 96 00:03:35,735 --> 00:03:36,474 For both 97 00:03:37,094 --> 00:03:39,094 children as well as families, we've seen high 98 00:03:39,094 --> 00:03:40,074 rates of depression, 99 00:03:40,455 --> 00:03:40,955 anxiety, 100 00:03:41,735 --> 00:03:42,794 substance use, 101 00:03:43,175 --> 00:03:43,675 trauma. 102 00:03:44,375 --> 00:03:44,875 But 103 00:03:45,810 --> 00:03:48,389 with fewer child and adolescent psychiatrist per capita 104 00:03:48,930 --> 00:03:50,469 almost anywhere in the country, 105 00:03:51,090 --> 00:03:51,909 that presents 106 00:03:52,530 --> 00:03:53,509 a huge issue. 107 00:03:54,050 --> 00:03:55,409 And then if you add to that the 108 00:03:55,409 --> 00:03:56,629 Appalachian context, 109 00:03:57,250 --> 00:03:57,750 multigenerational 110 00:03:58,210 --> 00:03:58,710 poverty, 111 00:03:59,415 --> 00:04:00,875 higher rates of chronic illness, 112 00:04:01,335 --> 00:04:03,034 the legacy of the opioid epidemic, 113 00:04:03,814 --> 00:04:04,314 and 114 00:04:04,615 --> 00:04:05,915 really a cultural tendency, 115 00:04:06,854 --> 00:04:08,314 to handle problems privately. 116 00:04:09,094 --> 00:04:12,055 It becomes clear why access gaps persist and 117 00:04:12,055 --> 00:04:14,294 it is so deeply tied to where people 118 00:04:14,294 --> 00:04:14,794 live. 119 00:04:15,810 --> 00:04:17,649 Of course. Thank you so much for sharing 120 00:04:17,649 --> 00:04:18,310 that perspective. 121 00:04:18,930 --> 00:04:20,689 And as a lot of us know, telehealth 122 00:04:20,689 --> 00:04:22,870 really expanded nationwide during COVID, 123 00:04:23,250 --> 00:04:25,829 but in West Virginia, it really took hold. 124 00:04:26,449 --> 00:04:28,814 What were the key moments that made virtual 125 00:04:28,875 --> 00:04:31,834 behavioral health not just helpful but essential in 126 00:04:31,834 --> 00:04:32,574 those moments? 127 00:04:33,514 --> 00:04:36,154 Sure. And and, you know, I think we 128 00:04:36,154 --> 00:04:37,375 we think about 129 00:04:37,834 --> 00:04:40,574 the pandemic as really a a a pivotal 130 00:04:41,759 --> 00:04:42,259 scenario, 131 00:04:43,199 --> 00:04:45,220 for virtual health care. 132 00:04:46,319 --> 00:04:48,259 Even before the pandemic, though, 133 00:04:48,720 --> 00:04:49,540 many communities, 134 00:04:50,720 --> 00:04:53,120 nationally but certainly here, were facing long wait 135 00:04:53,120 --> 00:04:53,620 times, 136 00:04:54,084 --> 00:04:54,904 provider shortages, 137 00:04:56,164 --> 00:04:58,404 and, as I mentioned, kind of hours long 138 00:04:58,404 --> 00:05:01,305 drives for behavioral health care. So here 139 00:05:01,685 --> 00:05:04,164 in West Virginia, we've been using telehealth as 140 00:05:04,164 --> 00:05:06,664 a modality for care for years. 141 00:05:07,444 --> 00:05:07,944 But 142 00:05:08,610 --> 00:05:10,149 the COVID nineteen pandemic 143 00:05:10,769 --> 00:05:12,930 really seemed to accelerate that for the entire 144 00:05:12,930 --> 00:05:14,629 nation, including West Virginia. 145 00:05:15,250 --> 00:05:17,329 When you think about it, in person services 146 00:05:17,329 --> 00:05:18,470 all but shut down. 147 00:05:19,410 --> 00:05:19,910 Telebehavioral 148 00:05:20,290 --> 00:05:23,504 health became the only viable way to maintain 149 00:05:23,504 --> 00:05:25,205 treatment access and connection. 150 00:05:25,904 --> 00:05:27,904 Both of those are really critical for those 151 00:05:27,904 --> 00:05:29,745 who are suffering with mental health or substance 152 00:05:29,745 --> 00:05:30,564 use disorders. 153 00:05:31,584 --> 00:05:33,665 And so when I think about some key 154 00:05:33,665 --> 00:05:34,964 issues and key moments, 155 00:05:36,240 --> 00:05:36,740 one, 156 00:05:37,120 --> 00:05:39,199 West Virginia is a state with heavier health 157 00:05:39,199 --> 00:05:39,699 burden 158 00:05:40,240 --> 00:05:41,379 and fewer resources. 159 00:05:42,720 --> 00:05:44,339 COVID provided an opportunity 160 00:05:44,800 --> 00:05:45,459 to demonstrate 161 00:05:46,079 --> 00:05:48,420 both the independent spirit of our state's people, 162 00:05:48,560 --> 00:05:50,720 but also the innovative minds of our treatment 163 00:05:50,720 --> 00:05:51,220 providers. 164 00:05:51,915 --> 00:05:52,654 I think 165 00:05:53,115 --> 00:05:56,415 about another key moment being related to relaxation 166 00:05:56,475 --> 00:05:59,295 of regulatory barriers and reimbursement rules. 167 00:06:00,154 --> 00:06:02,415 Though nationwide, we saw something surprising. 168 00:06:03,194 --> 00:06:05,915 There had been assumptions from some that rural 169 00:06:05,915 --> 00:06:07,535 patients wouldn't or couldn't 170 00:06:08,050 --> 00:06:09,030 use or access, 171 00:06:09,730 --> 00:06:11,110 technology due to broadband 172 00:06:11,490 --> 00:06:12,790 difficulties and otherwise. 173 00:06:13,810 --> 00:06:16,290 We also presumed many of our providers wouldn't 174 00:06:16,290 --> 00:06:18,290 try virtual care, whether because of their own 175 00:06:18,290 --> 00:06:19,189 personal preference 176 00:06:19,730 --> 00:06:22,050 or because of the type of care that 177 00:06:22,050 --> 00:06:22,790 they provided. 178 00:06:23,985 --> 00:06:26,064 And what we realized was that many of 179 00:06:26,064 --> 00:06:27,524 those assumptions were wrong. 180 00:06:28,305 --> 00:06:29,524 Patients showed up. 181 00:06:30,305 --> 00:06:31,365 Engagement improved. 182 00:06:32,305 --> 00:06:34,785 And for many families, actually, virtual visits were 183 00:06:34,785 --> 00:06:36,324 easier and less disruptive. 184 00:06:37,680 --> 00:06:39,680 That's something we'd seen in West Virginia for 185 00:06:39,680 --> 00:06:40,180 years, 186 00:06:40,639 --> 00:06:41,139 and 187 00:06:41,840 --> 00:06:44,100 the pandemic allowed for this to flourish. 188 00:06:44,960 --> 00:06:47,680 You imagine a family here in a pretty 189 00:06:47,680 --> 00:06:48,740 mountainous area. 190 00:06:50,004 --> 00:06:52,245 Having the access to virtual visits was the 191 00:06:52,245 --> 00:06:55,845 difference between getting care or skipping it, whether 192 00:06:55,845 --> 00:06:56,824 that was because 193 00:06:57,285 --> 00:06:58,425 you had been exposed 194 00:06:58,725 --> 00:07:00,985 to COVID and were in isolation, 195 00:07:01,925 --> 00:07:03,685 because you were snowed in or because of 196 00:07:03,685 --> 00:07:04,824 a a weather event, 197 00:07:05,550 --> 00:07:07,949 because your parent or your guardian couldn't afford 198 00:07:07,949 --> 00:07:09,949 to miss work, had a broken down car, 199 00:07:09,949 --> 00:07:11,490 and you had no way to get there. 200 00:07:12,189 --> 00:07:12,689 So 201 00:07:13,389 --> 00:07:14,370 I think that's 202 00:07:15,550 --> 00:07:16,050 absolutely, 203 00:07:17,824 --> 00:07:19,584 a few of the key moments. And lastly, 204 00:07:19,584 --> 00:07:22,564 you know, pediatric demand has been rising nationally. 205 00:07:22,785 --> 00:07:24,324 Rural states like West Virginia 206 00:07:24,704 --> 00:07:27,125 have experienced severe workforce constraints 207 00:07:27,745 --> 00:07:28,644 pre pandemic. 208 00:07:29,504 --> 00:07:30,485 And so telepsychiatry 209 00:07:32,019 --> 00:07:34,419 has allowed us to extend the expertise of 210 00:07:34,419 --> 00:07:35,879 a limited number of specialists 211 00:07:36,659 --> 00:07:38,279 across a pretty large footprint, 212 00:07:38,899 --> 00:07:41,139 and that's critical both in allowing better access 213 00:07:41,139 --> 00:07:43,779 to limited resources, but then also to supporting 214 00:07:43,779 --> 00:07:45,959 and collaborating with our community providers. 215 00:07:47,044 --> 00:07:49,365 Of course. I love that collaboration piece. Of 216 00:07:49,365 --> 00:07:51,944 course. And and in terms of execution, 217 00:07:53,125 --> 00:07:55,224 how did your team actually operationalize 218 00:07:55,764 --> 00:07:58,664 virtual behavioral health in a rural setting? 219 00:07:59,430 --> 00:07:59,930 Sure. 220 00:08:00,949 --> 00:08:03,110 So I am proud to say that WVU 221 00:08:03,110 --> 00:08:05,770 Medicine has been a leader in virtual care 222 00:08:06,069 --> 00:08:06,810 for decades. 223 00:08:07,590 --> 00:08:09,050 That originally began, 224 00:08:09,830 --> 00:08:12,090 with Mountaineer Doctor of Television or MDTV, 225 00:08:12,470 --> 00:08:12,970 which 226 00:08:13,415 --> 00:08:15,754 initiated in the the early nineteen nineties. 227 00:08:16,615 --> 00:08:19,175 We approached telebehavioral health and the Department of 228 00:08:19,175 --> 00:08:20,555 Behavioral Medicine and Psychiatry 229 00:08:21,334 --> 00:08:22,154 as a pilot 230 00:08:22,855 --> 00:08:24,314 in 2009. 231 00:08:25,339 --> 00:08:27,980 And then this quickly evolved into a system 232 00:08:27,980 --> 00:08:30,620 strategy when we recognized the value that access 233 00:08:30,620 --> 00:08:32,860 to care brought for our patients at all 234 00:08:32,860 --> 00:08:35,360 ends of the state for mental health services. 235 00:08:35,740 --> 00:08:38,534 And that included seeing adults and children, whether 236 00:08:38,534 --> 00:08:41,754 it was for diagnostic or ongoing treatment, medication 237 00:08:41,815 --> 00:08:42,315 management, 238 00:08:43,014 --> 00:08:46,214 individual therapy, group therapy, addiction treatment, and and 239 00:08:46,214 --> 00:08:46,954 so on. 240 00:08:47,334 --> 00:08:49,434 But I think a few of the pieces 241 00:08:49,575 --> 00:08:51,654 that are that are important when we think 242 00:08:51,654 --> 00:08:55,350 about how we operationalized it was we leveraged 243 00:08:55,409 --> 00:08:58,289 our academic medical center as a hub, and 244 00:08:58,289 --> 00:08:59,669 we extended care outward. 245 00:09:00,129 --> 00:09:02,370 And that was we were nonselective with that. 246 00:09:02,370 --> 00:09:04,629 So this was to community mental health centers, 247 00:09:05,014 --> 00:09:07,434 federally qualified health center clinics, 248 00:09:07,894 --> 00:09:11,975 critical access hospitals, emergency departments, schools, and then 249 00:09:11,975 --> 00:09:12,475 ultimately, 250 00:09:12,855 --> 00:09:14,794 after the pandemic, into patients' homes. 251 00:09:15,654 --> 00:09:18,475 That required some pretty intentional design, though. 252 00:09:19,659 --> 00:09:21,440 We partnered closely with 253 00:09:22,379 --> 00:09:24,639 local primary care providers, pediatricians, 254 00:09:25,500 --> 00:09:28,460 and emergency departments. It was important that they 255 00:09:28,460 --> 00:09:30,720 felt that the telebehavioral 256 00:09:31,100 --> 00:09:32,960 health services were integrated 257 00:09:33,745 --> 00:09:36,144 and not external, both for the providers, but 258 00:09:36,144 --> 00:09:37,045 also the patients. 259 00:09:37,665 --> 00:09:41,184 We invested heavily in workflows and scheduling and 260 00:09:41,184 --> 00:09:41,684 trainings, 261 00:09:42,384 --> 00:09:44,545 both for clinicians, but also for patients and 262 00:09:44,545 --> 00:09:45,045 families. 263 00:09:45,679 --> 00:09:47,139 It was really 264 00:09:47,679 --> 00:09:49,919 important for us that this was not just 265 00:09:49,919 --> 00:09:50,819 giving them 266 00:09:51,120 --> 00:09:53,620 a virtual link and calling it a day. 267 00:09:54,079 --> 00:09:56,740 It was about building relationships and buy in. 268 00:09:57,279 --> 00:09:59,654 It was about identifying a champion at each 269 00:09:59,654 --> 00:10:01,195 site who believed in the modality, 270 00:10:02,295 --> 00:10:03,355 and that is both 271 00:10:03,815 --> 00:10:07,274 before and and during and after the pandemic. 272 00:10:07,975 --> 00:10:09,195 You know, I think about 273 00:10:10,215 --> 00:10:13,175 some of the broadband and technology literacy challenges, 274 00:10:13,175 --> 00:10:14,715 and they were they were very real. 275 00:10:15,139 --> 00:10:17,860 Some families did not have reliable Internet or 276 00:10:17,860 --> 00:10:20,120 had never used video visits before. 277 00:10:21,139 --> 00:10:24,019 If if families didn't have Internet access, we 278 00:10:24,019 --> 00:10:26,100 had to be really creative with them. And 279 00:10:26,100 --> 00:10:26,840 I remember, 280 00:10:27,554 --> 00:10:30,035 a family that would regularly drive to their 281 00:10:30,035 --> 00:10:33,394 local McDonald's parking lot because that was the 282 00:10:33,394 --> 00:10:36,054 place locally that had Wi Fi, 283 00:10:36,355 --> 00:10:38,535 and they joined their appointment from there. 284 00:10:39,394 --> 00:10:39,894 So 285 00:10:40,220 --> 00:10:42,620 during COVID, we leaned on much of the 286 00:10:42,620 --> 00:10:44,220 experience that our team had had over the 287 00:10:44,220 --> 00:10:46,860 prior decade. We converted nearly all of our 288 00:10:46,860 --> 00:10:49,820 visits within our department to virtual within about 289 00:10:49,820 --> 00:10:50,480 two weeks, 290 00:10:51,500 --> 00:10:53,915 and and that's pretty impressive in a time 291 00:10:53,915 --> 00:10:56,975 when community supports were limited, people were isolated 292 00:10:57,115 --> 00:10:57,774 and scared. 293 00:10:58,554 --> 00:11:00,335 Overdose deaths were nearly doubled. 294 00:11:00,955 --> 00:11:02,875 It was important to meet our patients where 295 00:11:02,875 --> 00:11:05,449 they were. Mhmm. We, We, at that time, 296 00:11:05,449 --> 00:11:07,529 offered phone based visits when they were needed, 297 00:11:07,529 --> 00:11:09,629 used clinic based telehealth rooms, 298 00:11:09,929 --> 00:11:12,190 and had staff walk family through the technology 299 00:11:12,409 --> 00:11:13,309 step by step. 300 00:11:14,250 --> 00:11:15,149 So the goal 301 00:11:16,329 --> 00:11:17,709 when we think about operationalizing 302 00:11:18,565 --> 00:11:22,085 and executing even now is to reduce friction 303 00:11:22,085 --> 00:11:22,524 points 304 00:11:22,965 --> 00:11:24,825 Mhmm. By being creative and flexible 305 00:11:25,285 --> 00:11:27,764 while still adhering to an evidence based care 306 00:11:27,764 --> 00:11:28,264 model. 307 00:11:28,884 --> 00:11:30,884 And would you be able to share an 308 00:11:30,884 --> 00:11:33,285 example or two that really show what this 309 00:11:33,285 --> 00:11:35,059 model has changed for patients? 310 00:11:36,559 --> 00:11:37,059 Absolutely. 311 00:11:37,759 --> 00:11:38,660 You know, I think 312 00:11:39,040 --> 00:11:41,040 this is the best part. We could talk 313 00:11:41,040 --> 00:11:41,779 about this, 314 00:11:42,320 --> 00:11:44,879 for days. I mean, we've seen stories of 315 00:11:44,879 --> 00:11:45,379 children 316 00:11:46,080 --> 00:11:46,580 with 317 00:11:47,254 --> 00:11:50,294 with symptoms that receive specialty evaluation and treatment 318 00:11:50,294 --> 00:11:51,514 instead of waiting months 319 00:11:51,894 --> 00:11:52,634 or longer, 320 00:11:53,654 --> 00:11:54,794 and and adults 321 00:11:55,815 --> 00:11:57,914 who have really complex comorbidities 322 00:11:58,695 --> 00:12:01,355 that have been able to finally establish continuity 323 00:12:02,190 --> 00:12:04,590 and and maybe for the first time feel 324 00:12:04,590 --> 00:12:06,290 like they've been consistently connected. 325 00:12:07,470 --> 00:12:08,450 So I think about 326 00:12:08,830 --> 00:12:10,690 there are two that really stand out. 327 00:12:11,389 --> 00:12:13,790 One, and this was actually one of my 328 00:12:13,790 --> 00:12:14,850 clinical patients. 329 00:12:16,110 --> 00:12:16,850 This was 330 00:12:17,794 --> 00:12:19,894 a child who had a neurodevelopmental 331 00:12:20,355 --> 00:12:20,855 disorder 332 00:12:21,794 --> 00:12:23,095 that had been diagnosed 333 00:12:24,115 --> 00:12:25,574 as a very young child, 334 00:12:25,954 --> 00:12:28,115 but because of where they lived in a 335 00:12:28,115 --> 00:12:30,834 very rural county, they had minimal access to 336 00:12:30,834 --> 00:12:31,815 treatment providers 337 00:12:32,340 --> 00:12:33,639 who could help with 338 00:12:34,180 --> 00:12:36,200 management of their, 339 00:12:36,740 --> 00:12:37,559 their symptoms. 340 00:12:39,460 --> 00:12:40,120 It was 341 00:12:40,660 --> 00:12:43,320 so severe that they were on the verge 342 00:12:43,379 --> 00:12:45,480 of being unable to attend school 343 00:12:46,095 --> 00:12:47,875 even in a self contained classroom. 344 00:12:49,375 --> 00:12:49,875 Their 345 00:12:50,574 --> 00:12:52,754 parents were at their wit's end, 346 00:12:53,375 --> 00:12:54,115 and they 347 00:12:55,054 --> 00:12:55,554 saw 348 00:12:56,095 --> 00:12:56,894 a person who 349 00:12:57,615 --> 00:13:00,190 you know, for myself as a provider with, 350 00:13:00,589 --> 00:13:02,610 child adolescent psychiatry training, 351 00:13:03,789 --> 00:13:05,089 they were able to 352 00:13:06,269 --> 00:13:07,250 meet with me 353 00:13:07,870 --> 00:13:08,370 regularly, 354 00:13:09,629 --> 00:13:12,129 provide some diagnostic clarification, but, ultimately, 355 00:13:12,669 --> 00:13:13,169 treatment 356 00:13:13,964 --> 00:13:14,464 that, 357 00:13:14,924 --> 00:13:16,625 unfortunately, their their 358 00:13:17,004 --> 00:13:19,164 primary care provider just at the time didn't 359 00:13:19,164 --> 00:13:20,384 feel comfortable with, 360 00:13:21,084 --> 00:13:23,904 but also assistance with recommendations for the school. 361 00:13:24,764 --> 00:13:25,584 This child 362 00:13:26,750 --> 00:13:27,649 stayed in school. 363 00:13:28,269 --> 00:13:29,809 They began to do better, 364 00:13:30,750 --> 00:13:32,830 and and it was a huge relief for 365 00:13:32,830 --> 00:13:35,250 the family and for the patient. 366 00:13:35,710 --> 00:13:37,090 So that was pretty exciting. 367 00:13:37,789 --> 00:13:38,610 And I think, 368 00:13:39,070 --> 00:13:40,529 on the other end of the spectrum, 369 00:13:41,774 --> 00:13:44,194 we had a patient with 370 00:13:44,495 --> 00:13:47,615 substance use disorder who actually was admitted here 371 00:13:47,615 --> 00:13:50,115 at our academic medical center for an infection 372 00:13:50,334 --> 00:13:52,574 in their heart valve that was related to 373 00:13:52,574 --> 00:13:55,309 drug use. That it required surgical interventions. It 374 00:13:55,309 --> 00:13:58,209 had required IV antibiotics for a long time, 375 00:13:58,909 --> 00:14:00,289 and and so 376 00:14:00,669 --> 00:14:01,649 pretty significant 377 00:14:02,190 --> 00:14:02,690 comorbidities 378 00:14:03,149 --> 00:14:05,330 related to their substance use. 379 00:14:05,985 --> 00:14:07,524 They ultimately were discharged. 380 00:14:07,904 --> 00:14:10,625 When they were discharged from our academic medical 381 00:14:10,625 --> 00:14:12,464 center, they were to return to their home 382 00:14:12,464 --> 00:14:12,964 community, 383 00:14:13,264 --> 00:14:14,964 and they happen to live in a community 384 00:14:15,024 --> 00:14:17,365 where we were providing virtual addiction treatment. 385 00:14:18,304 --> 00:14:18,964 So they 386 00:14:20,259 --> 00:14:22,279 were able to transition from 387 00:14:22,580 --> 00:14:25,000 inpatient consult psychiatric services 388 00:14:25,700 --> 00:14:27,159 to outpatient care 389 00:14:28,339 --> 00:14:28,839 where 390 00:14:29,220 --> 00:14:30,919 they participated in treatment, 391 00:14:31,539 --> 00:14:32,919 they maintained their sobriety, 392 00:14:33,825 --> 00:14:36,865 And interestingly, this patient got pregnant and because 393 00:14:36,865 --> 00:14:38,384 of that, moved to be near to their 394 00:14:38,384 --> 00:14:39,764 family in another location. 395 00:14:40,705 --> 00:14:42,085 In that second location, 396 00:14:42,465 --> 00:14:45,045 we also were providing treatment in that community. 397 00:14:45,830 --> 00:14:48,710 So they were able to transition care from 398 00:14:48,710 --> 00:14:50,009 one community clinic 399 00:14:50,389 --> 00:14:51,929 to another community clinic, 400 00:14:53,029 --> 00:14:54,250 deliver their child 401 00:14:55,190 --> 00:14:56,649 their child in their custody, 402 00:14:57,429 --> 00:15:00,490 and continue to have treatment within their community, 403 00:15:01,174 --> 00:15:04,054 which is is really critical. So it these 404 00:15:04,054 --> 00:15:06,534 are are two of of many stories that 405 00:15:06,534 --> 00:15:08,634 we have, but it's just it's really powerful 406 00:15:09,014 --> 00:15:11,174 to see how that translates for patients and 407 00:15:11,174 --> 00:15:11,674 families. 408 00:15:12,294 --> 00:15:13,829 Of course. I feel like that is a 409 00:15:13,829 --> 00:15:16,569 huge part of behavioral health is the stories 410 00:15:16,629 --> 00:15:17,129 behind 411 00:15:17,509 --> 00:15:19,269 the care that you're giving. So thank you 412 00:15:19,269 --> 00:15:22,309 so much for providing those examples and and 413 00:15:22,309 --> 00:15:23,209 opening up. 414 00:15:23,669 --> 00:15:25,589 I'm curious too, what are you seeing on 415 00:15:25,589 --> 00:15:26,889 the data side of things? 416 00:15:28,014 --> 00:15:29,554 The data is exciting. 417 00:15:30,815 --> 00:15:33,394 And so just to provide some some, 418 00:15:34,095 --> 00:15:35,075 reference points, 419 00:15:35,534 --> 00:15:38,274 when I think about the last three years 420 00:15:38,654 --> 00:15:39,875 in terms of 421 00:15:40,600 --> 00:15:43,159 just our volumes, the number of patients that 422 00:15:43,159 --> 00:15:43,899 we're seeing 423 00:15:44,519 --> 00:15:45,019 virtually 424 00:15:45,799 --> 00:15:47,419 in our clinic within, 425 00:15:47,799 --> 00:15:50,139 within the department of behavioral medicine and psychiatry, 426 00:15:51,240 --> 00:15:51,740 total 427 00:15:52,120 --> 00:15:52,620 visits 428 00:15:53,325 --> 00:15:56,144 are are still lingering a little over 429 00:15:56,524 --> 00:15:58,225 a little over fifty percent. 430 00:15:58,845 --> 00:15:59,585 And that's 431 00:16:00,205 --> 00:16:01,024 with having 432 00:16:02,445 --> 00:16:03,745 about a 100,000 433 00:16:03,804 --> 00:16:05,024 patients per year 434 00:16:05,500 --> 00:16:06,000 theme. 435 00:16:06,779 --> 00:16:07,759 And with kids 436 00:16:08,139 --> 00:16:08,639 that 437 00:16:09,019 --> 00:16:11,660 they're a little bit less, but still at 438 00:16:11,660 --> 00:16:12,160 around 439 00:16:12,779 --> 00:16:15,500 a third of our patients, our children are 440 00:16:15,500 --> 00:16:15,899 seen, 441 00:16:16,300 --> 00:16:17,200 are seen virtually. 442 00:16:17,899 --> 00:16:18,399 And 443 00:16:18,725 --> 00:16:20,404 and I say that just to sort of 444 00:16:20,404 --> 00:16:21,625 share that this isn't, 445 00:16:21,925 --> 00:16:24,024 you know, this isn't a small one off. 446 00:16:24,485 --> 00:16:27,365 What we're seeing internally really mirrors the national 447 00:16:27,365 --> 00:16:28,665 trends, and it's exciting. 448 00:16:29,684 --> 00:16:32,665 So across the country, studies have shown that 449 00:16:33,129 --> 00:16:33,629 telepsychiatry 450 00:16:34,009 --> 00:16:37,049 produces outcomes that are comparable to in person 451 00:16:37,049 --> 00:16:37,549 care, 452 00:16:37,929 --> 00:16:39,709 and that's for multiple conditions. 453 00:16:40,889 --> 00:16:42,589 There's lower no show rates 454 00:16:43,289 --> 00:16:44,909 and higher patient satisfaction. 455 00:16:46,115 --> 00:16:48,835 One of those studies was conducted here, and 456 00:16:48,835 --> 00:16:50,534 it's been replicated nationally. 457 00:16:50,914 --> 00:16:53,575 So it's it's really, really amazing. 458 00:16:54,434 --> 00:16:57,335 In our system, we've seen improved access, 459 00:16:58,329 --> 00:17:01,610 faster time to first appointment, and better continuity 460 00:17:01,610 --> 00:17:04,490 of care, particularly for pediatric patients and those 461 00:17:04,490 --> 00:17:05,549 in remote areas. 462 00:17:07,210 --> 00:17:09,450 No show rates are often lower for virtual 463 00:17:09,450 --> 00:17:11,390 visits, especially in rural populations, 464 00:17:12,065 --> 00:17:13,765 where, as I said before, transportation 465 00:17:14,144 --> 00:17:14,884 and weather 466 00:17:15,585 --> 00:17:16,085 are 467 00:17:16,384 --> 00:17:18,164 and can be major barriers. 468 00:17:19,105 --> 00:17:22,144 And engagement improves when the care fits into 469 00:17:22,144 --> 00:17:23,045 people's lives 470 00:17:23,664 --> 00:17:26,545 rather than requiring them to reorganize their lives 471 00:17:26,545 --> 00:17:27,525 around care. 472 00:17:28,100 --> 00:17:30,359 And I think finally and equally important, 473 00:17:30,740 --> 00:17:33,480 we're seeing gains in health care equity. 474 00:17:34,100 --> 00:17:36,740 So we're reaching patients who previously would not 475 00:17:36,740 --> 00:17:40,039 have accessed specialty behavioral health services at all. 476 00:17:40,585 --> 00:17:42,825 So really, really exciting times, and I think 477 00:17:42,825 --> 00:17:45,164 that that's only going to to continue. 478 00:17:46,265 --> 00:17:48,605 And in terms of, like, policy or reimbursement 479 00:17:48,985 --> 00:17:49,485 factors, 480 00:17:50,585 --> 00:17:52,045 that help make this work, 481 00:17:52,345 --> 00:17:54,505 can you kinda describe those and what still 482 00:17:54,505 --> 00:17:55,005 creates 483 00:17:55,380 --> 00:17:56,680 friction in spots? 484 00:17:57,539 --> 00:18:00,519 Sure. Policy matters, and it matters enormously 485 00:18:01,059 --> 00:18:03,240 in rural telebehavioral health. 486 00:18:03,940 --> 00:18:07,000 I am excited to say that West Virginia 487 00:18:07,779 --> 00:18:10,039 really has long since been a leader in, 488 00:18:10,605 --> 00:18:12,065 telebehavioral health care 489 00:18:12,444 --> 00:18:13,265 long before, 490 00:18:14,204 --> 00:18:16,365 COVID. And and, again, I think that speaks 491 00:18:16,365 --> 00:18:16,865 to 492 00:18:17,325 --> 00:18:19,565 the rurality of our state and the need 493 00:18:19,565 --> 00:18:22,045 to be innovative with how our our patients 494 00:18:22,045 --> 00:18:22,865 receive care, 495 00:18:23,579 --> 00:18:24,480 Allowing patients 496 00:18:25,099 --> 00:18:27,279 a patient home to be an appropriate, 497 00:18:28,380 --> 00:18:31,980 originating site is is one of the the 498 00:18:31,980 --> 00:18:35,039 legislative pieces that has recently been passed here, 499 00:18:35,500 --> 00:18:37,980 and will continue to be maintained post pandemic, 500 00:18:37,980 --> 00:18:40,244 which I think is really impressive, specifically for 501 00:18:40,244 --> 00:18:41,384 behavioral health care. 502 00:18:42,244 --> 00:18:44,724 So, certainly, Medicaid policy has always played a 503 00:18:44,724 --> 00:18:47,845 critical role in sustaining access for children and 504 00:18:47,845 --> 00:18:48,345 families. 505 00:18:48,724 --> 00:18:49,625 During the pandemic, 506 00:18:50,805 --> 00:18:52,505 expanded reimbursement parity 507 00:18:53,039 --> 00:18:54,740 and then licensing flexibility 508 00:18:55,440 --> 00:18:58,480 made rapid scaling possible. Without that, we really 509 00:18:58,480 --> 00:18:59,619 could not have done, 510 00:19:00,400 --> 00:19:02,420 what was done and what was needed. 511 00:19:03,600 --> 00:19:06,559 Expanding reimbursement for services that previously hadn't been 512 00:19:06,559 --> 00:19:09,045 covered, such as collaborative care or behavioral health 513 00:19:09,045 --> 00:19:10,744 integration, really was essential. 514 00:19:11,444 --> 00:19:13,704 And and that's one aspect that's 515 00:19:14,005 --> 00:19:14,984 vital to maintaining 516 00:19:15,365 --> 00:19:16,904 the access that was created 517 00:19:17,605 --> 00:19:20,184 into post pandemic virtual behavioral health care. 518 00:19:20,565 --> 00:19:21,865 But there's still uncertainty 519 00:19:22,390 --> 00:19:24,549 around long term reimbursement, and that remains a 520 00:19:24,549 --> 00:19:25,049 challenge. 521 00:19:25,829 --> 00:19:27,450 I think other flexibilities, 522 00:19:27,829 --> 00:19:30,650 including online prescribing of controlled substances 523 00:19:31,509 --> 00:19:34,410 to appropriate patients in an evidence based way, 524 00:19:34,710 --> 00:19:35,369 is really, 525 00:19:36,335 --> 00:19:37,555 this is something that 526 00:19:37,934 --> 00:19:38,434 is 527 00:19:39,454 --> 00:19:40,994 a a daily issue, particularly 528 00:19:41,694 --> 00:19:44,335 for those who do not have local access 529 00:19:44,335 --> 00:19:44,994 to care. 530 00:19:45,535 --> 00:19:45,934 But, 531 00:19:46,494 --> 00:19:46,994 the 532 00:19:47,775 --> 00:19:48,595 the deadline 533 00:19:48,974 --> 00:19:49,474 for 534 00:19:49,809 --> 00:19:52,930 the national level to to identify a policy 535 00:19:52,930 --> 00:19:55,830 both for DEA and, health and human services 536 00:19:56,130 --> 00:19:58,950 has been extended through the 2026. 537 00:19:59,490 --> 00:20:01,830 And we certainly have hopes that they will 538 00:20:02,015 --> 00:20:04,335 be able to navigate how to allow appropriate 539 00:20:04,335 --> 00:20:06,914 safeguards while also minimizing access issues. 540 00:20:07,615 --> 00:20:09,555 The relaxation of and the allowance 541 00:20:09,855 --> 00:20:11,315 of virtual supervision 542 00:20:12,654 --> 00:20:14,275 was really critical. 543 00:20:14,809 --> 00:20:16,089 So when you think about, 544 00:20:16,650 --> 00:20:17,710 licensure requirements 545 00:20:18,089 --> 00:20:19,150 and what's needed 546 00:20:19,849 --> 00:20:20,349 for 547 00:20:20,809 --> 00:20:23,690 specific types of health care providers, whether that 548 00:20:23,690 --> 00:20:24,190 be, 549 00:20:24,890 --> 00:20:27,869 providers in training like residents or fellow physicians 550 00:20:28,569 --> 00:20:29,069 or 551 00:20:29,714 --> 00:20:31,335 even advanced practice providers, 552 00:20:31,954 --> 00:20:33,255 counselors, and therapists. 553 00:20:33,714 --> 00:20:34,214 Supervision, 554 00:20:35,154 --> 00:20:36,855 plays a large role in this. 555 00:20:37,234 --> 00:20:38,054 And during 556 00:20:38,434 --> 00:20:39,095 the pandemic, 557 00:20:39,714 --> 00:20:41,654 virtual supervision was allowed, 558 00:20:42,035 --> 00:20:42,535 meaning 559 00:20:43,420 --> 00:20:45,660 you may be able to have a very 560 00:20:45,660 --> 00:20:46,559 highly trained, 561 00:20:47,420 --> 00:20:50,720 specialist who is able to provide supervision to 562 00:20:51,019 --> 00:20:51,920 one of your, 563 00:20:52,539 --> 00:20:53,680 one of your providers 564 00:20:54,059 --> 00:20:56,400 without even being in the same state. 565 00:20:57,164 --> 00:21:00,045 Mhmm. We took advantage of that here at 566 00:21:00,045 --> 00:21:02,365 WVU and and really have found that it 567 00:21:02,365 --> 00:21:02,865 has 568 00:21:03,245 --> 00:21:05,265 been, a hugely positive, 569 00:21:06,845 --> 00:21:09,085 a hugely positive variable when it comes to 570 00:21:09,085 --> 00:21:11,424 training as well as as helping 571 00:21:12,839 --> 00:21:13,980 to, improve access. 572 00:21:14,440 --> 00:21:15,500 And then I think, 573 00:21:15,880 --> 00:21:18,859 finally, health systems really need clarity and stability 574 00:21:19,480 --> 00:21:21,640 to be able to invest in technology, staffing, 575 00:21:21,640 --> 00:21:22,299 and training. 576 00:21:23,079 --> 00:21:23,900 But I think 577 00:21:24,279 --> 00:21:25,099 going forward, 578 00:21:26,035 --> 00:21:28,835 we need to continue to engage and engage 579 00:21:28,835 --> 00:21:31,335 early with state policymakers and payers, 580 00:21:31,954 --> 00:21:35,474 align telehealth strategy with population health goals, and 581 00:21:35,474 --> 00:21:38,035 continue to track outcomes rigorously so that we 582 00:21:38,035 --> 00:21:40,580 can continue to demonstrate the value that that 583 00:21:40,580 --> 00:21:42,900 we have done thus far that virtual care 584 00:21:42,900 --> 00:21:43,559 has allowed. 585 00:21:44,740 --> 00:21:45,240 Wonderful. 586 00:21:45,859 --> 00:21:49,700 And for our last, like, minute thirty seconds, 587 00:21:49,700 --> 00:21:51,160 I'm wondering if you can 588 00:21:51,940 --> 00:21:55,065 give a few takeaways for behavioral health leaders, 589 00:21:55,065 --> 00:21:56,924 especially those in rural systems. 590 00:21:58,424 --> 00:21:58,924 Absolutely. 591 00:21:59,704 --> 00:22:02,265 You know, I think telebehavioral health isn't about 592 00:22:02,265 --> 00:22:03,724 replacing in person care. 593 00:22:04,184 --> 00:22:06,585 It's about matching the right modality to the 594 00:22:06,585 --> 00:22:08,845 right patient at the right time. 595 00:22:09,950 --> 00:22:11,650 And rural health systems 596 00:22:11,950 --> 00:22:13,950 don't need to wait for perfect conditions to 597 00:22:13,950 --> 00:22:14,849 improve access. 598 00:22:15,549 --> 00:22:18,349 And whether that's starting by integrating with local 599 00:22:18,349 --> 00:22:21,789 primary care or focusing on relationships with local 600 00:22:21,789 --> 00:22:22,289 providers, 601 00:22:23,575 --> 00:22:25,434 exploring collaborative care models, 602 00:22:26,375 --> 00:22:27,755 and beginning to develop 603 00:22:28,295 --> 00:22:30,695 to engage in workforce development, those are all 604 00:22:30,695 --> 00:22:31,195 critical. 605 00:22:31,894 --> 00:22:33,035 I think extending 606 00:22:33,335 --> 00:22:36,955 scarce specialty expertise while also supporting local providers 607 00:22:37,015 --> 00:22:37,674 through consultation 608 00:22:38,410 --> 00:22:40,430 and education is so important. 609 00:22:41,529 --> 00:22:42,990 For rural states, sustainability 610 00:22:43,289 --> 00:22:45,609 is going to depend upon policy alignment, on 611 00:22:45,609 --> 00:22:46,670 broadband investment, 612 00:22:47,130 --> 00:22:49,150 and continued invested innovation. 613 00:22:49,849 --> 00:22:52,109 But the foundation is firmly in place. 614 00:22:52,984 --> 00:22:53,724 And so 615 00:22:54,184 --> 00:22:56,744 while our experience is rooted in Appalachia, I 616 00:22:56,744 --> 00:22:58,924 think these lessons are applicable everywhere. 617 00:22:59,465 --> 00:23:02,025 As workforce shortages grow nationally, what we've learned 618 00:23:02,025 --> 00:23:04,424 in rural West Virginia really has relevance for 619 00:23:04,424 --> 00:23:07,644 urban and suburban systems alike throughout the nation. 620 00:23:08,320 --> 00:23:08,820 Wonderful. 621 00:23:09,440 --> 00:23:12,000 Well, doctor Cary Law, thank you so much, 622 00:23:12,320 --> 00:23:14,660 for being here and sharing how telebehavioral 623 00:23:14,960 --> 00:23:17,380 health is expanding access in rural Appalachia 624 00:23:18,000 --> 00:23:20,480 and for the practical lessons leaders can apply 625 00:23:20,480 --> 00:23:20,980 elsewhere. 626 00:23:21,611 --> 00:23:23,851 Thanks, to all of our listeners for tuning 627 00:23:23,851 --> 00:23:25,791 in to Becker's Healthcare Podcast. 628 00:23:26,171 --> 00:23:27,471 We'll see you next time.