According to the U.S. Department of Health and Human Services' Health Resources and Services Administration (HRSA), 5.3 million Americans have a traumatic brain injury (TBI). With military personnel returning from the wars in Iraq and Afghanistan with head injuries (see sidebar), the prevalence of TBI continues to rise.
While primary treatment for TBI typically occurs at urban or suburban rehabilitation centers or, in the case of returning soldiers, Veterans Administration (VA) facilities, many patients return home to rural areas with scarce resources to continue their TBI treatment. The federal government recognizes the difficulty of treating TBI in rural areas and through HRSA has established the Traumatic Brain Injury Program, which through planning and implementation grants helps states to establish TBI networks for treatment and information dissemination.
One of the difficulties state officials have faced in these planning efforts is the training of local behavioral healthcare providers to treat TBI. The complex and often chronic health condition has not routinely fallen within the purview of mental healthcare providers because treatment usually is initiated in rehabilitation or VA centers. For patients returning home to rural areas, however, rehab and VA centers typically are not feasible options for continuing care.
“It's not a service system that serves the needs of rural, especially rural and impoverished, patients,” says Laura H. Schopp, PhD, of the Department of Health Psychology at the University of Missouri–Columbia.
States increasingly are turning to telehealth technology to train providers in rural communities on how to treat patients with TBI. Dr. Schopp and two colleagues at the University of Missouri–Columbia began a project in 1998 that used telehealth technology to train and consult with psychologists and other mental health clinicians in rural areas on the finer aspects of treating patients with TBI. That project constructed a telehealth network that continues to grow.
In 16 rural communities throughout Missouri, Dr. Schopp's project matched TBI patients being transferred from acute rehab settings with providers her team trained in individual videoconference sessions. “The telehealth training is great because it enables you to reach out to a single clinician, talking about the needs of a single patient and his family, so it's a really nice opportunity to transfer a case to a rural clinician and have him feel very well briefed in the particular needs of the patient,” says Dr. Schopp.
While Dr. Schopp and her colleagues trained rural providers on treating TBI, it's the knowledge of local resources that makes the role of the rural clinician critical. “I draw on their great knowledge of local resources, and that's the thing that no specialist from the city can ever replace,” says Dr. Schopp, noting that local providers know about other supports that TBI patients often require, such as vocational training and employment, housing assistance, and transportation.
Dr. Schopp believes that community mental health centers (CMHCs) in rural areas would be ideal settings for people with TBI to receive services because of their connection to their area's wider service array. “If they're given the appropriate financial and training resources, I think the system of care that CMHCs provide for underserved and rural communities is in some ways an ideal network for people with brain injuries,” says Dr. Schopp. “But I also think that we need to support the clinicians and CMHCs so that they feel like they have the tools, knowledge, and resources to deal with the unique needs of this population.”
When Dr. Schopp approached CMHCs in Missouri about the telehealth project, CMHCs were in the midst of a significant budget crunch. CMHCs feared that if they began to undergo training for treating TBI patients, they would be overwhelmed with these patients' needs, says Dr. Schopp. There was also a sense that TBI patients were going through vocational rehab or disability services and should be covered by those sectors. “It was really an administrative funding issue,” says Dr. Schopp.
In Idaho, CMHCs are involved in the state's Traumatic Brain Injury Project. Russell C. Spearman, MEd, director of the project run by Idaho State University's Institute of Rural Health, says that CMHCs have disseminated information on the project to their providers in newsletters, e-mail discussion lists, and flyers. The program includes a telehealth component that trains providers on TBI issues through videoconferencing and an online virtual program center.
Idaho's program has been providing educational opportunities, called virtual rounds, since 2003. Using both in-state and out-of-state experts, the virtual rounds are broadcast to different remote sites around Idaho and sometimes neighboring states. Each session is presented in a classroom setting and includes a proctor and question-and-answer period, and have been used to train a range of healthcare providers (such as psychologists, rehab specialists, clinical social workers, RNs, and speech and language pathologists). TBI presenters have included experts from the Centers for Disease Control and Prevention as well as Duke University. The presentations are archived online at http://www.idahotbi.org.
“Most providers want to know the best practices that are out there in the field,” says Spearman. “They want to know low-tech strategies that they can employ.”
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