"Mental health services that they normally weren't able to access...suddenly they can."

Telehealth expansion has revolutionized rural counseling across the region. But is it here to stay?

Ask anyone who’s piled in the car to drive an hour (both ways) to the nearest therapist’s office—or taken off work to ensure their child can complete a school-required, office-based Individual Education Program assessment—and they’ll tell you: Eastern Kentucky is painfully limited when it comes to mental health resources. Between transportation issues, lingering community stigma and the sheer lack of providers, the imbalance between those needing care and those able to receive that care is heavily weighted on the side of individual suffering.

Since the beginning of the pandemic, though, one flickering spot of hope in the ongoing COVID-19 hellscape is the ability of providers to utilize telehealth services in greater capacity—including for mental health—across the region, providing an increase in care during a deeply dark time.

Below, I chat with Eastern Kentucky University professor and psychologist Dr. Michael McClellan, a rural telehealth advocate who supervises a number of clinicians working across the region. (We spoke at the beginning of the pandemic as well about the “rural coronavirus crisis to come” for The New Republic.) I also discuss the issue with Corbin-native and licensed professional counselor Matt Grammer, founder of the (now completely telehealth-based!) Kentucky Counseling Center, which he believes might currently be the “largest practice in the state.”

Read more below to learn how Medicaid expansion has impacted mental health resources, upcoming studies on rural clinician learning curves and what could help providers reach those in the most remote locations. (Hint: you’re using it right now.)

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Dr. Michael McClellan, psychologist

Sarah Baird: How has access to mental health care changed in the most rural parts of Central and Eastern Kentucky over the past year?
Dr. Michael McClellan: We call the most remote locations in Eastern Kentucky “frontier” communities: they're really challenging to get into [with mental health resources] and limited in their access to broadband or cell phone service. For that population, I'm not really sure things have changed since the pandemic started.

But people who are in more remote areas that have some access to the Internet—or even a McDonald's that offers free Wi-Fi where they can pull up into a parking lot and do a session in their car—I think we've seen a lot of growth over the last year or so. This is particularly dependent on how strong their Internet connection is, but for this group, you've seen just an explosion: services that normally they weren't able to access in their small communities, suddenly they can.

One of the things that has changed over the last year or so is Medicaid and Medicare began offering more access. They’ve been more open to phone sessions and phone check-ins, or are more willing to pay for those types of services. They've been very resistant to doing that in the past. That means that if somebody can't access the Internet, there's now maybe another way around through calling their provider on the telephone and having a quick check-in between visits. I think you've seen a growth in that area in particular.

SB: How have rural providers changed their tools and levels of understanding around telehealth?
MM: Over the course of the last year, I completed a study looking at how services have been impacted. [Ed. note: We’ll have a link to this when it comes out.] What I’ve seen is that if you want to survive as a psychologist or a counselor today, you've had to do telehealth since the pandemic began or you've really struggled to make ends meet.

Clinicians are not only interested in telehealth now, but have had experience using it. They reported higher levels of ability to build rapport with clients, and a lot of therapeutic outcomes are based off of the therapeutic alliance—or the relationship—you have with your provider. So, if you live in a rural community that has broader access to the Internet, I think not only the volume of services that suddenly you have access to [goes up] but the quality of those services and the quality of the treatments that are provided there.

We've also seen new services like teleassessment. We're providing psychological testing through the telehealth. Prior to the pandemic, it was something that a few people did, but there was a big barrier. That barrier was that most tests are standardized to be performed in a very specific way, and that very specific way has oftentimes been in person. Now what you've seen is testing companies being more open to developing telehealth-based strategies. In the past, for example, if you needed an ADHD evaluation or learning disability assessment, even if you lived in those rural frontier communities without access, you had to go to wherever those providers were. There just weren't a lot of options. [Telehealth] has allowed for extended services.

SB: Do you think that things have shifted permanently toward more telehealth-friendly mental health resources in Eastern Kentucky?
MM: I think they have. Now, don't get me wrong, there'll always be services provided face-to-face. At least with the agency I studied—this is anonymous data collected from people at that agency—upwards of 85 percent of the clinical staff said that they certainly plan to continue providing services through telehealth. They had invested so much over the last year and learned so much, why in the world do something different? They’ve been able to provide services that they identified as being effective for the clients that they serve. If it ain't broke, why try to fix it?

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Matt Grammer, founder of Kentucky Counseling Center

SB: What were your telehealth offerings like before COVID-19 began?
Matt Grammer: A couple of years before COVID hit we were doing telehealth with our prescribers, because in 2019, telehealth benefits were extended for Medicaid recipients and [Medicaid] is 70 percent of our business. We were allowed to offer not only psychiatry services, but counseling and targeted case management via telehealth.

But before COVID, we couldn't convince patients to do telehealth. I don't know. It was a newer technology for a lot of people who aren't very tech-savvy and they would want to drive to an office that was an hour or hour-and-a-half away sometimes instead of using the phone or computer from their house.

We even set up a pilot telehealth station like a living room in a few of our offices just to try to show people what it looked like and what it felt like to connect with the provider from home. We had to really put a lot of effort into implementing this, like: This is it. This is going to save you so much time, gas and money. Slowly, we would have people convert to telehealth.

SB: How did COVID flip things?
MG: COVID happened, and in a matter of a few days, we close all 11 offices and now 100 percent of the businesses is telehealth. We're busier than ever. We're hiring all over the state, and we're seeing patients all over the state. It's been great for helping patients who are in extremely rural areas, don't have transportation and need to talk to somebody. Pre-COVID we were scheduling about 1,200 appointments a week. Right now, we're scheduling about 1,800 appointments a week—with zero offices. Our whole mentality is we want to do things differently from what people are used to in terms of mental health.

We keep track of where all of our patients are from. Before COVID, almost all of our patients were from the towns where we had offices with maybe a few exceptions. Now, we're seeing [people] from towns that I've never even heard of—towns with fewer than a thousand people in the population. Places where they just don't have access to the healthcare we offer. We're trying to get people connected with mental health professionals just as simply as possible.

Kentucky falls short in a lot of areas on the national scale as far as rankings are concerned, but our Medicaid program is killer. And again, Kentucky’s Medicaid expanded their telehealth benefits before COVID. They opened the doors and said, “Everything that you're doing in the office can be done in telehealth and we're going to cover it.” Medicare has a long way to go to catch up with that. And, of course, there are going to be some commercial payers tightening up on things probably pretty soon. But, overall, we're extremely optimistic. We've gone all in on telehealth.

If you’re looking to read more stories about rural mental health, last month we discussed LGBTQ+ access to care with Kyle May of Open Doors Counseling in Prestonsburg. Subscribe here to read:

These interviews have been edited and condensed.