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“It’s four and a half hours to see the paediatrician, and what we’re looking at is four and a half hours to see the speechie. Four and a half hours, you get the vibe, the frustration.” [Parent/carer of child with developmental, behavioural and/or mental health needs from a rural area.]
TELEHEALTH is an important way to deliver some health services to support the developmental and mental health needs of children living in rural and remote communities.
Governments, health professionals, researchers and funders are well aware of the imperative to provide children with a healthy start to life. A recent Lancet commission on early childhood stated that a poor start in life limits children’s abilities to benefit from education, and that the economic case for countries to invest in health in childhood is clear. Yet, there is a very large group of children for whom health needs are not able to be consistently met: children in rural locations. This is a big deal in a country like Australia, where approximately 30% of the population lives outside of the major metropolitan areas. Health needs in rural areas are faced with the lack of sufficient and consistent health workforce, making access to effective, efficient and equitable services a real challenge.
The first Australian Medicare Benefits Schedule (MBS) telehealth items were introduced 7 years ago, in 2011. By now, some of you may be getting that 7-year itch! While there has been much bad press about telehealth, eHealth and of course electronic health records, there is also a good news story about how telehealth is being used to meet the needs of rural and remote kids with developmental and mental health needs.
The literature indicates a mismatch between the positive evidence base emerging from experimental trials, and the variable experiences of teams who try to introduce video telehealth services in the real world. While randomised trials have found telehealth consultations to be acceptable, safe and effective, problems with technology, negative views held by clinicians, and legal, ethical and administrative barriers remain a block to using telehealth in real life.
Telehealth may be a tough service delivery modality for some clinical needs and may be more likely to fail. This idea is illustrated well by the “non-adoption, abandonment, scale-up, spread, and sustainability (NASSS) framework”. The framework helps predict the success of telehealth in various contexts. Telehealth succeeds best in low risk clinical conditions, with willing patients and staff, when there is alignment with existing routines and strong, supportive national and local policies.
We propose that an ideal population in which to scale up the use of telehealth is rural and remote children with developmental, behavioural and mental health needs.
Identifying and then supporting children with developmental and mental health needs is vital, given the impact these challenges have on educational attainment and the expensive impacts (eg, addictions, justice system) on individuals, families and communities when these needs are not addressed early.
Enter Royal Far West, a 94-year-old not-for-profit organisation in New South Wales, focused on supporting the health of country kids. Since 2013, Royal Far West has had a sustained, and growing, multidisciplinary paediatric and allied health telehealth service supporting the developmental, behavioural and mental health needs of rural and remote children in Australia. Their service, which they call Telecare, meets the needs of 1000 children each year and is growing to reach 15 000 beneficiaries a year by 2020.
Telehealth services in schools offer a way to potentially reduce inequity and provide more cost-effective care. Telehealth solutions at home or in schools exist for rural children who need health assessment and care (eg, psychology, occupational therapy, speech therapy, psychiatry). Schools play a unique role for families who are unable to seek or schedule attendance for appointments for their child. Care can be provided in a school on an individual basis or to groups of children with similar needs. Telehealth can also be used for capacity development of parents and carers and for professional development for school teachers and support staff. Access and consistency of access (both regularity of sessions and a child having access to the same clinician for the duration of their therapy needs) are spoken about by many schools as a value or benefit of telehealth. Royal Far West already provides allied health services via Telecare into schools where local in-person services and supports can be difficult to access.
Australian Medicare Benefits Schedule items numbers for telehealth
There are 23 MBS items for telehealth covering GPs, nurse practitioners, midwives, practice nurses and Aboriginal Health Workers, and an additional 11 MBS items for specialists (more information is available at MBS Online on the Department of Health website). An expansion of MBS telehealth items for general practitioners would be useful; for example, for writing up mental health plans.
I was curious about how often telehealth was being used in Australia. The Medicare Australia website has a section called Medicare Item Reports, from which data can be extracted to show services, benefits and patient demographics (including sex and age range) by item and by state. On 11 October 2018, I extracted data for the calendar year 2017 which showed that, nationally, a total of 120 271 specialist telehealth services were billed to a total cost to government of $21.8 million and another 52 291 patient-end telehealth support items were billed nationally to a total cost to government of $3.9 million.
From 1 November 2017, additional items were added to the MBS to enhance access to psychology services for people in rural and remote areas via telehealth. The telehealth rebates are only available for those clients located in rural and remote locations, as defined by Modified Monash Model regions 4–7. In addition, the person must not be in hospital at the time of the consultation and must be located at least 15 km by road from the eligible allied health provider. An update on 1 September 2018 means that allied health professionals can deliver all 10 eligible services in a calendar year via videoconferencing. Thankfully, this removed the originally stated requirement for in-person consultations and now truly supports rural people receiving service, without the need to travel.
For allied health providers, there are MBS items for 10 individual telehealth sessions with a clinical psychologist. On top of these individual telehealth sessions, an additional 10 sessions are available for group therapy with six to 10 other patients led by clinical psychologists, occupational therapists (OTs) or social workers. The most frequently used MBS item in 2018 thus far is for individual services with a clinical psychologist (80011).
For all of these MBS items for mental health services provided by allied health professionals, a total of $144 428 in benefits have been paid nationally from January to August 2018. The biggest users per capita in decreasing order are NSW, Western Australia and the Northern Territory. The total number of services billed by MBS code range from 1091 for MBS item 80011 (clinical psychologist to individual patient), to just one billing in 2018 thus far for MBS item 80146 (OT providing psychologically focused sessions via telehealth) and no billings in 2018 thus far for MBS item 80171 (social worker psychologically focused session using telehealth).
This demonstrates how infrequently telehealth is being used for group therapy and by OTs and social workers in particular, perhaps because of a lack of knowledge about how telehealth can be used in this way. Our current NSW Translation Grant has funded our ongoing evaluation of group therapy over telehealth. This is for parents of school children with behavioural and mental health support needs. Results are expected in 2020.
Conclusion
If you are open to trying, we do need health professionals to attempt to deliver some services using telehealth. Just as some trees evolved to thrive on the side of a windy cliff face, so can telehealth grow to thrive. If providing services using telehealth doesn’t suit, you might prefer to play a role in referring children for telehealth services if no appropriate local services exist.
If you are a researcher, we need more information and real-life examples about interorganisational interactions and approaches to sustaining and scaling telehealth.
If you are a funder, we need more block funding for children to receive specialist paediatric, allied health and mental health supports and this could be in partnership with schools. We also need expanded MBS telehealth items for GPs to support people living in rural and remote Australia.
There are ongoing Medicare incentives, and there are new MBS items for psychological assessment and therapy over telehealth for rural and remote settings. If you are starting up a telehealth service, I recommend the Royal Australian College of GPs’ and also the Australian College of Rural and Remote Medicine’s telehealth websites, with a host of support documents including guidelines, case studies, directory of telehealth users, information about Skype for clinical encounters, and more.
Alexandra Martiniuk is a current National Health and Medical Research Council (NHMRC) Translating Research into Practice Fellow, an epidemiologist and previous registered psychologist focused on the health of children. She is an Associate Professor at the Universities of Sydney and Toronto, and an Honorary Senior Research Fellow at the George Institute for Global Health. For the past several years, she has been an embedded research and translation advisor with Royal Far West and the NSW Rural Doctors Network. She can be found on Twitter @AlexMartiniuk
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or MJA InSight unless that is so stated.