During and after the height of the COVID-19 pandemic, telehealth appointments became a more common part of the American health care system. But even as telehealth options grow, barriers such as long waitlists or a lack of a stable internet connection mean many communities still do not have access to care, particularly for mental health services.
The University of Cincinnati, the Adams County Health Department (ACHD) and other local partners are testing a new collaborative care model that aims to remove these barriers and provide more students access to telemental health care. The team recently received a $1.75 million grant from the Health Resources and Services Administration (HRSA) to continue a project called Operation Better Together that could become a model for rural communities nationwide.
Getting everyone to the table
In 2017, the ACHD conducted a community health assessment that for the first time found that mental health and substance abuse were the leading public health problems in the south-central Ohio county.
ACHD’s Danielle Poe said the assessment showed mental health was a “local public health crisis” compounded by limited resources and barriers to mental health care. The U.S. Census Bureau reports Adams County is the second poorest county in Ohio, and at the time of the assessment there was not a single psychiatrist operating there.
“It was either telehealth options, which we also just didn’t have, or up to 45 minutes to an hour drive to get access to that kind of care,” said Poe, ACHD director of behavioral health. “And we recognized we could have telehealth services available, but for our community members to have real access, we needed to be in the places where they are.”
Poe recalled the initiative that became Operation Better Together really gained steam when Adams County Common Pleas Court Judge Brett Spencer called an emergency community meeting that brought leaders from local organizations, the school district, ACHD and small businesses together to discuss the impact of mental health on the youth of Adams County.
“We recognized that there was a need for us to break silos. We’re not going to be able to really have an impact through public health without all of these different organizations being involved in solving the same problem,” Poe said. “After that meeting, it became a much easier task to grow Operation Better Together.”
William Hablitzel, MD, the county’s health commissioner at the time, then reached out to UC’s Melissa DelBello, MD, to discuss how the Department of Psychiatry’s faculty could help.
Tiered approach to care
UC faculty members began providing telemental health services for adults through a partnership with ACHD and Adams County Courts, and eventually the program grew to include serving students in the Adams County Ohio Valley School District. The new HRSA grant will specifically focus on growing the youth program.
UC’s Melissa Wagner, MD, PhD, said Operation Better Together is a unique collaborative care model due to its three-tiered approach to care.
The first tier aims to serve the most students and features school counselors, resource officers, school-wide initiatives and classroom interventions to support students’ initial access to mental health services. For students needing expert one-on-one therapy, the second tier includes local licensed therapists embedded in the schools, courthouse juvenile services and the health department.
Students accessing third-tier services meet via telehealth appointments with UC experts like Wagner and Kaitlyn Bruns, PhD. Students can also be prescribed medications and schedule regular check-ins to manage their medications.
“Anybody that’s getting tier three services has gone through tier one and tier two,” said Wagner, associate professor in the Department of Psychiatry and Behavioral Neuroscience in UC’s College of Medicine and a UC Health physician. “Not every tier one person needs to access the higher tier services, and then once we get them stable, they can de-escalate down the tiers so other kids could access the other services.”
Importantly, most of the telehealth appointments happen during the school day via a HIPAA-compliant version of Zoom.
“They’re at school and the counselors get them from class, so they don’t have to go anywhere,” Wagner said. “Really, it removes the burden from this very high-need community where transportation and reliable internet connection can be really challenging for some of these families.”
Strengthening the program
Bruns said the grant will allow the team to formalize partnerships within the program, including a new partnership with local pediatricians.
“They’re involved very informally right now, but this will be a very formal collaborative care model where we’re actually having meetings with pediatricians and children’s services and getting everyone on board,” said Bruns, assistant professor in the Department of Psychiatry and Behavioral Neuroscience in UC’s College of Medicine. “A lot of this is going to be about community visibility, outreach and really expanding the program.”
The team hopes these more formalized partnerships will allow more students to tier up and down through available services based on their needs. For example, Wagner noted that when a pediatrician can take over medication management for a student, a slot will open up for Wagner to see another student.
“This approach will allow us to really target more pressing or acute kiddos and then use the support of our other colleagues, like our case managers, to do check-ins. It’s such a holistic wraparound care model,” Bruns said. “It’s a relief the kiddo is not just relying on me with this tier-modeled support system. They have five people on their treatment team, five people they can go to, which takes some of the pressure and stress off of a single provider.”
Poe said over the five-year grant period, the team will measure the number of students accessing mental health services compared to previous years as well as what tier of resources were needed. Since Operation Better Together expanded to youth patients, it has already served more than 3,000 children in the Adams County community.
“All of those children who signed up for services don’t necessarily need to remain in services, so we’re tracking things like how many were referred and had an evaluation for mental health but it was recognized that really the family just had some barriers related to poverty,” Poe said. “And once we were able to provide appropriate resources to address some of those needs, it’s recognizing there wasn’t a mental health disorder, there was stress related to the family’s environment or situation.”
Additionally, the team will analyze the effectiveness of telemental health compared to in-person mental health services.
“We believe telehealth is just as impactful as in-person services,” Poe said. “We’re seeing positive outcomes. We’re here, we’re getting thank-yous from parents all the time, but we do want to track whether or not we need to continue to grow more capacity for in-person services.”
Success stories
Operation Better Together is already having an impact on Adams County students who otherwise would have little to no access to mental health care.
“For some of them, I don’t know what would have happened to them,” Wagner said. “Some of them might have ended up in group homes, been removed from their families, and grades would’ve definitely suffered.”
One student Bruns began working with about two years ago was having trouble functioning at school, facing possible suspensions and experiencing other issues that are not common symptoms of mental health disorders.
“This kiddo is such a good kid. It was clearly a mental health crisis that was happening,” Bruns said.
After initial evaluations, Wagner and Bruns connected the student to UC psychiatry colleagues for a formal diagnostic evaluation that helped diagnose the exact condition.
“Diagnosis helps inform treatment most of the time,” Bruns said. “Are we treating autism spectrum disorders or are we treating schizophrenia or are we treating obsessive-compulsive disorder?”
Now a year after diagnosis, Bruns said the student is getting better through a specific treatment plan, no longer has anxiety and panic attacks every day, is stable with medications managed by Wagner and has a group of friends at school. Therapy sessions have decreased from twice weekly to once every other week or once a month.
“This kid is such a different kid. It’s just such an extreme success story,” she said. “I don’t know who they would’ve gone to for a mental health crisis like that.”
A model for others
Operation Better Together is one of 20 HRSA-funded sites across the country with a goal of demonstrating the success of different models of telemental health and an ability to fund the programs through Medicaid, Medicare and private insurance instead of with long-term grant funding. The hope is that these successful models can then be replicated across the country.
“I think our multitiered approach speaks for itself,” Wagner said. “If you really work with it, we could provide the most access for the most number of kids, and we don’t turn any family away from tier one services.”
Poe recalled taking members of the Adams County Youth Coalition to a rally in Columbus and to meet with state legislators to advocate for their peers about a decade ago. A sign one student held, reading “Please don’t forget about Adams County,” still gives her goosebumps, Poe said.
“Our kids at the time felt forgotten in our community. They felt like we’re suffering down here, we don’t have resources, we need help and we’re being forgotten about by the people who might have the power to help us,” Poe said. “So to think about that sign that they were holding up that day at the Statehouse to now, where we’re being recognized even at a national level for having a model that can be replicated, and now we have so many resources that our kids certainly don’t feel forgotten — from that moment to now, it’s a feeling honestly I can’t even put it into words.”
