The following is an interview between a psychiatric nurse practitioner who exclusively provides telehealth and a practicing attorney who used telehealth for therapy during the COVID-19 pandemic.
What is telehealth?
Telehealth – sometimes called telemedicine – lets your healthcare provider take care of you without an in-person office visit. Telehealth is done primarily online through internet access on your computer, tablet or smartphone.
What are the benefits of telehealth?
• Ensures you can get health care wherever you are located – at home, at work or even in your car
• Reduces travel time, time off work and the need for childcare
• Can shorten the wait for an appointment
• Increases access to specialists who are located far away from your home
How do I find telehealth providers?
• Contact your insurance provider
• If you currently have a provider, ask if they offer telehealth as an option
• If you are not insured, seek out a health center and also see recommendations in this article
What are the different types of mental health providers?
There are two general categories: therapists and medication managers.
Therapists are licensed providers who work with people to help them overcome the current distress they may be experiencing in their lives using specific therapeutic techniques. Examples of techniques include: “Cognitive Behavioral Therapy,” “Dialectical Behavioral Therapy,” “Play Therapy,” “Parent-Child Interaction Therapy” or even “Eye Movement Desensitization and Reprocessing (EMDR)” therapy.
Therapists can work individually with a patient, or in a group setting with five to seven people working on similar issues. The therapist has a master’s degree and often has the initials “LISW” or “LMHC” after his/her name.
Medication managers are licensed providers who are authorized to prescribe medications. They are usually psychiatrists or psychiatric nurse practitioners. Family physicians and physician assistants may prescribe some psychiatric medications if they have received additional training in pharmacology. In addition to medication management, these providers also administer psychiatric evaluations, but usually do not perform individual therapy. They work in collaboration with therapists.
A comprehensive list of the types of mental health providers can be found at https://www.nami.org/About-Mental-Illness/Treatments/Types-of-Mental-Health-Professionals.
Tell me about your training, education and experience as a mental health provider.
I started my healthcare career as a registered nurse in 1991, first working in the hospital. I later went back to graduate school, and in 1997 began working as a family nurse practitioner in a rural community. It quickly became obvious to me that there were few places to refer patients when they were struggling with mental health issues. Responsibility for the treatment of mental health conditions essentially fell on primary care providers in rural communities. Even after changing jobs several years later, it was clear that children’s mental health care was a huge gap across Iowa. I realized I needed to have more training and education in psychiatry so that I
could better meet the needs of my patients. In 2013, I went back to school and completed a post-graduate degree in psychiatry and then became a psychiatric nurse practitioner specializing in children’s mental health. Several years ago, I decided to start a school-based telehealth business, Classroom Clinic, to help improve access to children’s mental health care in rural communities.
When did you start performing telehealth appointments?
I initially began performing telehealth while working at Child Health Specialty Clinics approximately 15 years ago. For the past three years, I have exclusively provided school-based telehealth services through my business.
If someone doesn’t have a therapist, can they start with a telehealth appointment?
Sometimes patients don’t know if they need to see a therapist or a medication manager. They just know they need help and want to see someone. If they don’t know who to start with, that is okay. If the patient is being seen at a mental health clinic, the intake is usually performed by a therapist. If the therapist feels the patient may benefit from medications, they will refer the patient to the medication manager. The providers in a clinic usually help sort out what level of service the patient needs after their initial assessment has been completed.
Does insurance cover telehealth appointments?
Telehealth appointments are covered by insurance, especially given the public health declaration the past two years. Some private insurance carriers have previously interpreted “telehealth” and “telemedicine” as two different things, creating some struggles for providers to get reimbursed. The federal COVID public health declaration allowed for that requirement to be eliminated.
It should be noted, however, that despite the Affordable Care Act (ACA) requiring that mental health be considered as one of the 10 essential health care services that are mandated to be covered, there are some private insurance carriers that are able to circumvent that payment requirement because the plan was issued before the ACA requirement— meaning it is grandfathered in.
These private insurance companies are essentially taking advantage of the “letter of the law” and not implementing the “intent of the law.” As a result, I have had some telehealth appointments that were denied by insurance providers due to the fact that the patient’s health plan did not cover mental health services.
It is important to contact your insurance provider before attending an appointment to confirm your coverage requirements. Because telehealth is used for a variety of healthcare needs, make sure mental health services are covered by your insurance provider for a telehealth visit.
How would a person find a telehealth provider if they don’t have insurance?
There are several private companies that offer a subscription option for mental health services. This means that the providers don’t accept any insurance payments, as they do not deal with insurance companies at all. This model is essentially all private pay through a subscription.
If a person does not have health insurance and cannot afford private pay, they can seek care from any of the Community Mental Health Centers in Iowa. These centers are federally qualified health centers that must accept people who do not have insurance. The centers offer a sliding fee schedule, based upon the patient’s income. The first visit is often required in person, but follow-up visits may be performed by telehealth.
Here is a link to the community mental health regional centers found in Iowa: https://dhs.iowa.gov/mhds/service-providers
People may also be able to access some mental health services from a community health center. They also have sliding fee scales. Here is a link of the community health centers found in Iowa: https://iowapca.org/why-chc
Is telehealth as effective as face-to-face?
For mental health services, telehealth is just as effective as a face-to-face visit.
Can a telehealth provider perform an assessment for a diagnosis?
Yes, both therapists and medication managers can perform an assessment and provide a diagnosis through telehealth appointments.
What type of healthcare provider can help with stress-related issues and/or addiction or substance abuse?
This depends on the individual healthcare provider’s experience and education. Most frequently it is a mental health provider who has obtained additional training in the addiction specialty field and received certification as an addiction specialist. These providers are often also trained in Medication Assisted Treatment (MAT) and can prescribe the necessary medications to help patients get off the chemicals to which they are addicted. This website provides additional useful information when searching for an addiction specialist: https://alcoholtreatment.niaaa.nih.gov/how-to-find-alcoholtreatment/how-to-search-what-toask/questions-for-addiction-doctors
How does a person determine what type of healthcare provider to use? For example, can a person who is experiencing symptoms of anxiety go to his/her family doctor?
Starting with your family doctor is a great option because the doctor has a longitudinal relationship with patients and will be able to help sort out where the person needs referred to from there. Most specialists like to collaborate with the patient’s primary care provider, so this is a good place to start, especially if living in a rural area. The family doctor and the specialist will work as a team and communicate with each other.
When should a person seek out a telehealth provider?
This just depends on the circumstances the person may be facing. Some people are ashamed and feel the stigma associated with mental health or chemical dependency and like to keep these issues private. They may not even want their family doctor to know. If someone is seeking total anonymity, then telehealth is a great option.
Are there any circumstances where a telehealth provider is not recommended?
During times of crisis, or if the person is suicidal or homicidal. Or if the person has a lot of other co-morbid medical conditions that require a physical exam, labs or x-rays.
About the authors:
Sue Gehling is a psychiatric nurse practitioner from Carroll. She is an experienced children’s mental health provider and a tireless advocate for families living in rural communities. She is the founder of Classroom Clinic, a school-based telehealth business providing rural school districts with timely and convenient access to children’s mental health services using telehealth and related technologies.
Her vision is to improve children’s access to mental health care in rural Iowa by utilizing technology and integrating services into nontraditional places. She has been a champion of establishing cross-sector partnerships with educators and a leader within the school-based telehealth movement here in Iowa.
Hope Wood is an estate planning and probate attorney in Des Moines with a law degree from Drake University Law School and nine years of experience in private practice. In addition to handling probate cases, Hope creates estate planning documents for individuals using her exclusive Will in a Day® flat fee program. Information about Hope’s law firm is at hopewoodjd.com.
