Latest / Becker’s Healthcare Podcast / Kari-Beth Law, MD, on Expanding Telebehavioral Health Access in Rural Appalachia

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Kari-Beth Law, MD, on Expanding Telebehavioral Health Access in Rural Appalachia · Becker’s Healthcare Podcast

0:00
Welcome to Becker's Healthcare Podcast. I'm Ella Reuter,
0:03
your host, and I'm thrilled to be introducing
0:05
our guest today, doctor Carrie Law. She is
0:08
associate chief medical officer and board member of
0:12
the West Virginia University Health System.
0:15
Clinically, she is a professor of adult, child,
0:17
and adolescent, and forensic psychiatry,
0:20
vice chair of clinical services, and director of
0:23
telepsychiatry
0:24
for
0:25
the WVU
0:27
School of Medicine,
0:28
Department of Behavioral Medicine and Psychiatry.
0:31
Doctor Law, thank you so much for joining
0:33
us today.
0:34
For our audience who may not be familiar
0:36
with you and the work you do, could
0:37
you please introduce yourself and tell us a
0:39
little bit more about your background?
0:42
Absolutely. Thanks, Ella, and and thank you so
0:44
much for the invitation.
0:46
It's truly an honor to share the good
0:48
work that we're doing to serve our state
0:50
and region, so I'm I'm happy to.
0:53
My name is Carrie Beth Law. I was
0:55
born and raised in Southern West Virginia in
0:58
Bluefield,
0:59
and this state has always been home to
1:02
me.
1:03
I completed my medical training at West Virginia
1:05
University
1:06
with additional training in South Carolina,
1:09
but, really, I felt a strong pull to
1:11
return.
1:12
And I've been back at West Virginia University
1:15
since 2011
1:16
building my career.
1:18
I've spent much of my clinical career serving
1:20
West Virginia communities
1:21
through telepsychiatry.
1:23
I've had the opportunity to support and expand
1:27
telebehavioral health services
1:29
through both federal and state grant funding,
1:31
and I've also taken on administration and leadership
1:34
roles at the department and health system levels.
1:37
But at the core of all of this
1:38
is really my passion for rural care and
1:41
advocacy.
1:42
Telebehavioral health sits right at the intersection,
1:46
of those,
1:48
both expanding access,
1:50
meeting people where they are, and helping ensure
1:53
that geography
1:54
doesn't determine the care that someone receives. So
1:57
I'm happy to be here today.
1:59
Wonderful. Thank you so much for that introduction.
2:02
First, I'd really like to set the stage.
2:04
Can you briefly describe the behavioral health landscape
2:07
in rural West Virginia
2:09
and what makes access so challenging there?
2:12
Sure. So if you've ever been to West
2:14
Virginia,
2:15
you understand,
2:17
the state slogan,
2:18
wild, wonderful, West Virginia.
2:21
West Virginia really epitomizes beauty from mountains and
2:24
forests to the people in the communities,
2:27
but, really, that natural beauty contributes to some
2:30
of the access challenges that that you mentioned.
2:34
So when we talk about behavioral health in
2:36
West Virginia and even across Appalachia,
2:39
we're really talking about the intersection of geography,
2:42
workforce shortages,
2:44
stigma,
2:45
and socioeconomic
2:46
stressors.
2:48
When I zoom out a little bit, nationally,
2:51
65%
2:51
of rural US counties have no practicing psychiatrist.
2:56
And so while it's a national crisis, it
2:58
really is amplified in Appalachia and in West
3:01
Virginia.
3:02
Our numbers here in West Virginia are pretty
3:04
staggering.
3:05
50 out of our 55 counties are federally
3:08
designated mental health professional shortage areas.
3:12
We have among the lowest per capita availability
3:15
of child adolescent psychiatrists in the country.
3:18
And then for some families, accessing specialty care
3:21
historically meant
3:22
driving long distances. That could be two hours
3:25
up to four hours one way, and that's
3:27
if care was even available at all.
3:29
So when you think about that, that distance
3:31
really hits children and adolescents especially hard.
3:35
For both
3:37
children as well as families, we've seen high
3:39
rates of depression,
3:40
anxiety,
3:41
substance use,
3:43
trauma.
3:44
But
3:45
with fewer child and adolescent psychiatrist per capita
3:48
almost anywhere in the country,
3:51
that presents
3:52
a huge issue.
3:54
And then if you add to that the
3:55
Appalachian context,
3:57
multigenerational
3:58
poverty,
3:59
higher rates of chronic illness,
4:01
the legacy of the opioid epidemic,
4:03
and
4:04
really a cultural tendency,
4:06
to handle problems privately.
4:09
It becomes clear why access gaps persist and
4:12
it is so deeply tied to where people
4:14
live.
4:15
Of course. Thank you so much for sharing
4:17
that perspective.
4:18
And as a lot of us know, telehealth
4:20
really expanded nationwide during COVID,
4:23
but in West Virginia, it really took hold.
4:26
What were the key moments that made virtual
4:28
behavioral health not just helpful but essential in
4:31
those moments?
4:33
Sure. And and, you know, I think we
4:36
we think about
4:37
the pandemic as really a a a pivotal
4:41
scenario,
4:43
for virtual health care.
4:46
Even before the pandemic, though,
4:48
many communities,
4:50
nationally but certainly here, were facing long wait
4:53
times,
4:54
provider shortages,
4:56
and, as I mentioned, kind of hours long
4:58
drives for behavioral health care. So here
5:01
in West Virginia, we've been using telehealth as
5:04
a modality for care for years.
5:07
But
5:08
the COVID nineteen pandemic
5:10
really seemed to accelerate that for the entire
5:12
nation, including West Virginia.
5:15
When you think about it, in person services
5:17
all but shut down.
5:19
Telebehavioral
5:20
health became the only viable way to maintain
5:23
treatment access and connection.
5:25
Both of those are really critical for those
5:27
who are suffering with mental health or substance
5:29
use disorders.
5:31
And so when I think about some key
5:33
issues and key moments,
5:36
one,
5:37
West Virginia is a state with heavier health
5:39
burden
5:40
and fewer resources.
5:42
COVID provided an opportunity
5:44
to demonstrate
5:46
both the independent spirit of our state's people,
5:48
but also the innovative minds of our treatment
5:50
providers.
5:51
I think
5:53
about another key moment being related to relaxation
5:56
of regulatory barriers and reimbursement rules.
6:00
Though nationwide, we saw something surprising.
6:03
There had been assumptions from some that rural
6:05
patients wouldn't or couldn't
6:08
use or access,
6:09
technology due to broadband
6:11
difficulties and otherwise.
6:13
We also presumed many of our providers wouldn't
6:16
try virtual care, whether because of their own
6:18
personal preference
6:19
or because of the type of care that
6:22
they provided.
6:23
And what we realized was that many of
6:26
those assumptions were wrong.
6:28
Patients showed up.
6:30
Engagement improved.
6:32
And for many families, actually, virtual visits were
6:34
easier and less disruptive.
6:37
That's something we'd seen in West Virginia for
6:39
years,
6:40
and
6:41
the pandemic allowed for this to flourish.
6:44
You imagine a family here in a pretty
6:47
mountainous area.
6:50
Having the access to virtual visits was the
6:52
difference between getting care or skipping it, whether
6:55
that was because
6:57
you had been exposed
6:58
to COVID and were in isolation,
7:01
because you were snowed in or because of
7:03
a a weather event,
7:05
because your parent or your guardian couldn't afford
7:07
to miss work, had a broken down car,
7:09
and you had no way to get there.
7:12
So
7:13
I think that's
7:15
absolutely,
7:17
a few of the key moments. And lastly,
7:19
you know, pediatric demand has been rising nationally.
7:22
Rural states like West Virginia
7:24
have experienced severe workforce constraints
7:27
pre pandemic.
7:29
And so telepsychiatry
7:32
has allowed us to extend the expertise of
7:34
a limited number of specialists
7:36
across a pretty large footprint,
7:38
and that's critical both in allowing better access
7:41
to limited resources, but then also to supporting
7:43
and collaborating with our community providers.
7:47
Of course. I love that collaboration piece. Of
7:49
course. And and in terms of execution,
7:53
how did your team actually operationalize
7:55
virtual behavioral health in a rural setting?
7:59
Sure.
8:00
So I am proud to say that WVU
8:03
Medicine has been a leader in virtual care
8:06
for decades.
8:07
That originally began,
8:09
with Mountaineer Doctor of Television or MDTV,
8:12
which
8:13
initiated in the the early nineteen nineties.
8:16
We approached telebehavioral health and the Department of
8:19
Behavioral Medicine and Psychiatry
8:21
as a pilot
8:22
in 2009.
8:25
And then this quickly evolved into a system
8:27
strategy when we recognized the value that access
8:30
to care brought for our patients at all
8:32
ends of the state for mental health services.
8:35
And that included seeing adults and children, whether
8:38
it was for diagnostic or ongoing treatment, medication
8:41
management,
8:43
individual therapy, group therapy, addiction treatment, and and
8:46
so on.
8:47
But I think a few of the pieces
8:49
that are that are important when we think
8:51
about how we operationalized it was we leveraged
8:55
our academic medical center as a hub, and
8:58
we extended care outward.
9:00
And that was we were nonselective with that.
9:02
So this was to community mental health centers,
9:05
federally qualified health center clinics,
9:07
critical access hospitals, emergency departments, schools, and then
9:11
ultimately,
9:12
after the pandemic, into patients' homes.
9:15
That required some pretty intentional design, though.
9:19
We partnered closely with
9:22
local primary care providers, pediatricians,
9:25
and emergency departments. It was important that they
9:28
felt that the telebehavioral
9:31
health services were integrated
9:33
and not external, both for the providers, but
9:36
also the patients.
9:37
We invested heavily in workflows and scheduling and
9:41
trainings,
9:42
both for clinicians, but also for patients and
9:44
families.
9:45
It was really
9:47
important for us that this was not just
9:49
giving them
9:51
a virtual link and calling it a day.
9:54
It was about building relationships and buy in.
9:57
It was about identifying a champion at each
9:59
site who believed in the modality,
10:02
and that is both
10:03
before and and during and after the pandemic.
10:07
You know, I think about
10:10
some of the broadband and technology literacy challenges,
10:13
and they were they were very real.
10:15
Some families did not have reliable Internet or
10:17
had never used video visits before.
10:21
If if families didn't have Internet access, we
10:24
had to be really creative with them. And
10:26
I remember,
10:27
a family that would regularly drive to their
10:30
local McDonald's parking lot because that was the
10:33
place locally that had Wi Fi,
10:36
and they joined their appointment from there.
10:39
So
10:40
during COVID, we leaned on much of the
10:42
experience that our team had had over the
10:44
prior decade. We converted nearly all of our
10:46
visits within our department to virtual within about
10:49
two weeks,
10:51
and and that's pretty impressive in a time
10:53
when community supports were limited, people were isolated
10:57
and scared.
10:58
Overdose deaths were nearly doubled.
11:00
It was important to meet our patients where
11:02
they were. Mhmm. We, We, at that time,
11:05
offered phone based visits when they were needed,
11:07
used clinic based telehealth rooms,
11:09
and had staff walk family through the technology
11:12
step by step.
11:14
So the goal
11:16
when we think about operationalizing
11:18
and executing even now is to reduce friction
11:22
points
11:22
Mhmm. By being creative and flexible
11:25
while still adhering to an evidence based care
11:27
model.
11:28
And would you be able to share an
11:30
example or two that really show what this
11:33
model has changed for patients?
11:36
Absolutely.
11:37
You know, I think
11:39
this is the best part. We could talk
11:41
about this,
11:42
for days. I mean, we've seen stories of
11:44
children
11:46
with
11:47
with symptoms that receive specialty evaluation and treatment
11:50
instead of waiting months
11:51
or longer,
11:53
and and adults
11:55
who have really complex comorbidities
11:58
that have been able to finally establish continuity
12:02
and and maybe for the first time feel
12:04
like they've been consistently connected.
12:07
So I think about
12:08
there are two that really stand out.
12:11
One, and this was actually one of my
12:13
clinical patients.
12:16
This was
12:17
a child who had a neurodevelopmental
12:20
disorder
12:21
that had been diagnosed
12:24
as a very young child,
12:25
but because of where they lived in a
12:28
very rural county, they had minimal access to
12:30
treatment providers
12:32
who could help with
12:34
management of their,
12:36
their symptoms.
12:39
It was
12:40
so severe that they were on the verge
12:43
of being unable to attend school
12:46
even in a self contained classroom.
12:49
Their
12:50
parents were at their wit's end,
12:53
and they
12:55
saw
12:56
a person who
12:57
you know, for myself as a provider with,
13:00
child adolescent psychiatry training,
13:03
they were able to
13:06
meet with me
13:07
regularly,
13:09
provide some diagnostic clarification, but, ultimately,
13:12
treatment
13:13
that,
13:14
unfortunately, their their
13:17
primary care provider just at the time didn't
13:19
feel comfortable with,
13:21
but also assistance with recommendations for the school.
13:24
This child
13:26
stayed in school.
13:28
They began to do better,
13:30
and and it was a huge relief for
13:32
the family and for the patient.
13:35
So that was pretty exciting.
13:37
And I think,
13:39
on the other end of the spectrum,
13:41
we had a patient with
13:44
substance use disorder who actually was admitted here
13:47
at our academic medical center for an infection
13:50
in their heart valve that was related to
13:52
drug use. That it required surgical interventions. It
13:55
had required IV antibiotics for a long time,
13:58
and and so
14:00
pretty significant
14:02
comorbidities
14:03
related to their substance use.
14:05
They ultimately were discharged.
14:07
When they were discharged from our academic medical
14:10
center, they were to return to their home
14:12
community,
14:13
and they happen to live in a community
14:15
where we were providing virtual addiction treatment.
14:18
So they
14:20
were able to transition from
14:22
inpatient consult psychiatric services
14:25
to outpatient care
14:28
where
14:29
they participated in treatment,
14:31
they maintained their sobriety,
14:33
And interestingly, this patient got pregnant and because
14:36
of that, moved to be near to their
14:38
family in another location.
14:40
In that second location,
14:42
we also were providing treatment in that community.
14:45
So they were able to transition care from
14:48
one community clinic
14:50
to another community clinic,
14:53
deliver their child
14:55
their child in their custody,
14:57
and continue to have treatment within their community,
15:01
which is is really critical. So it these
15:04
are are two of of many stories that
15:06
we have, but it's just it's really powerful
15:09
to see how that translates for patients and
15:11
families.
15:12
Of course. I feel like that is a
15:13
huge part of behavioral health is the stories
15:16
behind
15:17
the care that you're giving. So thank you
15:19
so much for providing those examples and and
15:22
opening up.
15:23
I'm curious too, what are you seeing on
15:25
the data side of things?
15:28
The data is exciting.
15:30
And so just to provide some some,
15:34
reference points,
15:35
when I think about the last three years
15:38
in terms of
15:40
just our volumes, the number of patients that
15:43
we're seeing
15:44
virtually
15:45
in our clinic within,
15:47
within the department of behavioral medicine and psychiatry,
15:51
total
15:52
visits
15:53
are are still lingering a little over
15:56
a little over fifty percent.
15:58
And that's
16:00
with having
16:02
about a 100,000
16:03
patients per year
16:05
theme.
16:06
And with kids
16:08
that
16:09
they're a little bit less, but still at
16:11
around
16:12
a third of our patients, our children are
16:15
seen,
16:16
are seen virtually.
16:17
And
16:18
and I say that just to sort of
16:20
share that this isn't,
16:21
you know, this isn't a small one off.
16:24
What we're seeing internally really mirrors the national
16:27
trends, and it's exciting.
16:29
So across the country, studies have shown that
16:33
telepsychiatry
16:34
produces outcomes that are comparable to in person
16:37
care,
16:37
and that's for multiple conditions.
16:40
There's lower no show rates
16:43
and higher patient satisfaction.
16:46
One of those studies was conducted here, and
16:48
it's been replicated nationally.
16:50
So it's it's really, really amazing.
16:54
In our system, we've seen improved access,
16:58
faster time to first appointment, and better continuity
17:01
of care, particularly for pediatric patients and those
17:04
in remote areas.
17:07
No show rates are often lower for virtual
17:09
visits, especially in rural populations,
17:12
where, as I said before, transportation
17:14
and weather
17:15
are
17:16
and can be major barriers.
17:19
And engagement improves when the care fits into
17:22
people's lives
17:23
rather than requiring them to reorganize their lives
17:26
around care.
17:28
And I think finally and equally important,
17:30
we're seeing gains in health care equity.
17:34
So we're reaching patients who previously would not
17:36
have accessed specialty behavioral health services at all.
17:40
So really, really exciting times, and I think
17:42
that that's only going to to continue.
17:46
And in terms of, like, policy or reimbursement
17:48
factors,
17:50
that help make this work,
17:52
can you kinda describe those and what still
17:54
creates
17:55
friction in spots?
17:57
Sure. Policy matters, and it matters enormously
18:01
in rural telebehavioral health.
18:03
I am excited to say that West Virginia
18:07
really has long since been a leader in,
18:10
telebehavioral health care
18:12
long before,
18:14
COVID. And and, again, I think that speaks
18:16
to
18:17
the rurality of our state and the need
18:19
to be innovative with how our our patients
18:22
receive care,
18:23
Allowing patients
18:25
a patient home to be an appropriate,
18:28
originating site is is one of the the
18:31
legislative pieces that has recently been passed here,
18:35
and will continue to be maintained post pandemic,
18:37
which I think is really impressive, specifically for
18:40
behavioral health care.
18:42
So, certainly, Medicaid policy has always played a
18:44
critical role in sustaining access for children and
18:47
families.
18:48
During the pandemic,
18:50
expanded reimbursement parity
18:53
and then licensing flexibility
18:55
made rapid scaling possible. Without that, we really
18:58
could not have done,
19:00
what was done and what was needed.
19:03
Expanding reimbursement for services that previously hadn't been
19:06
covered, such as collaborative care or behavioral health
19:09
integration, really was essential.
19:11
And and that's one aspect that's
19:14
vital to maintaining
19:15
the access that was created
19:17
into post pandemic virtual behavioral health care.
19:20
But there's still uncertainty
19:22
around long term reimbursement, and that remains a
19:24
challenge.
19:25
I think other flexibilities,
19:27
including online prescribing of controlled substances
19:31
to appropriate patients in an evidence based way,
19:34
is really,
19:36
this is something that
19:37
is
19:39
a a daily issue, particularly
19:41
for those who do not have local access
19:44
to care.
19:45
But,
19:46
the
19:47
the deadline
19:48
for
19:49
the national level to to identify a policy
19:52
both for DEA and, health and human services
19:56
has been extended through the 2026.
19:59
And we certainly have hopes that they will
20:02
be able to navigate how to allow appropriate
20:04
safeguards while also minimizing access issues.
20:07
The relaxation of and the allowance
20:09
of virtual supervision
20:12
was really critical.
20:14
So when you think about,
20:16
licensure requirements
20:18
and what's needed
20:19
for
20:20
specific types of health care providers, whether that
20:23
be,
20:24
providers in training like residents or fellow physicians
20:28
or
20:29
even advanced practice providers,
20:31
counselors, and therapists.
20:33
Supervision,
20:35
plays a large role in this.
20:37
And during
20:38
the pandemic,
20:39
virtual supervision was allowed,
20:42
meaning
20:43
you may be able to have a very
20:45
highly trained,
20:47
specialist who is able to provide supervision to
20:51
one of your,
20:52
one of your providers
20:54
without even being in the same state.
20:57
Mhmm. We took advantage of that here at
21:00
WVU and and really have found that it
21:02
has
21:03
been, a hugely positive,
21:06
a hugely positive variable when it comes to
21:09
training as well as as helping
21:12
to, improve access.
21:14
And then I think,
21:15
finally, health systems really need clarity and stability
21:19
to be able to invest in technology, staffing,
21:21
and training.
21:23
But I think
21:24
going forward,
21:26
we need to continue to engage and engage
21:28
early with state policymakers and payers,
21:31
align telehealth strategy with population health goals, and
21:35
continue to track outcomes rigorously so that we
21:38
can continue to demonstrate the value that that
21:40
we have done thus far that virtual care
21:42
has allowed.
21:44
Wonderful.
21:45
And for our last, like, minute thirty seconds,
21:49
I'm wondering if you can
21:51
give a few takeaways for behavioral health leaders,
21:55
especially those in rural systems.
21:58
Absolutely.
21:59
You know, I think telebehavioral health isn't about
22:02
replacing in person care.
22:04
It's about matching the right modality to the
22:06
right patient at the right time.
22:09
And rural health systems
22:11
don't need to wait for perfect conditions to
22:13
improve access.
22:15
And whether that's starting by integrating with local
22:18
primary care or focusing on relationships with local
22:21
providers,
22:23
exploring collaborative care models,
22:26
and beginning to develop
22:28
to engage in workforce development, those are all
22:30
critical.
22:31
I think extending
22:33
scarce specialty expertise while also supporting local providers
22:37
through consultation
22:38
and education is so important.
22:41
For rural states, sustainability
22:43
is going to depend upon policy alignment, on
22:45
broadband investment,
22:47
and continued invested innovation.
22:49
But the foundation is firmly in place.
22:52
And so
22:54
while our experience is rooted in Appalachia, I
22:56
think these lessons are applicable everywhere.
22:59
As workforce shortages grow nationally, what we've learned
23:02
in rural West Virginia really has relevance for
23:04
urban and suburban systems alike throughout the nation.
23:08
Wonderful.
23:09
Well, doctor Cary Law, thank you so much,
23:12
for being here and sharing how telebehavioral
23:14
health is expanding access in rural Appalachia
23:18
and for the practical lessons leaders can apply
23:20
elsewhere.
23:21
Thanks, to all of our listeners for tuning
23:23
in to Becker's Healthcare Podcast.
23:26
We'll see you next time.