Rural American Indian and Alaska Native veterans’ telemental health: A model of culturally centered care.

Abstract

American Indian and Alaska Native (AI/AN) veterans living in rural areas have unique health care needs and face numerous barriers to accessing health care services. Among these needs is a disproportionate prevalence of posttraumatic stress disorder and other mental illnesses. Since 2001, 14 rural communities have partnered with the U.S. Department of Veterans Affairs and the Centers for American Indian and Alaska Native Health at the University of Colorado Anschutz Medical Campus to extend telemental health clinics to American Indian veterans. Administrative and, to some extent, clinical considerations of these clinics have been reviewed previously. This paper describes a model of care, evolved over a 14-year period, that weaves together evidence-based Western treatment, traditional Native healing, and rural Native communities into 4 main components: mental health care, technology, care coordination, and cultural facilitation. We delineate improvements to care made by addressing barriers such as system transference, provider-patient trust, and videoconferencing. Similarly, the discussion notes ways that the care model leverages strengths within Native communities, such as social cohesion and spirituality. Future steps include selection of appropriate performance indicators for systematic evaluation. The identification of key constructs of this care model will facilitate comparisons with other models of care in underserved populations with chronic and complex health conditions, and eventually advance the state of care for our warriors. (PsycINFO Database Record

Methodology for Evaluating Models of Telemental Health Delivery Against Population and Healthcare System Needs: Application to Telemental Healthcare for Rural Native Veterans

“…We assessed the remaining 13 models, characterizing each in Table 1. No models other than the AITMH clinic model 15,16 were identified for rural AIAN Veterans. We excluded one AI/AN Veteran model because there was no indication of its use after 1995.…”

“…The AITMH model 15,16 unsurprisingly satisfies its own framework. Its emphasis on care coordination to meet basic needs was unique relative to other models.…”

“…Despite extensive searches for care models specific to rural AI/AN Veterans, only one met our inclusion criteria. 15,16 Our searches retrieved many more studies on health disparities of rural AI/AN Veterans than on treatment options for them, underscoring this population's need for more choice in mental health service delivery. Expanding searches to include rural Veterans and AI/AN populations uncovered several additional models of service delivery, most of which miss at least one key element for rural AI/AN Veterans.…”

“…The American Indian Telemental Health (AITMH) model of care comprises four key components: (1) mental healthcare, (2) technology (telehealth connecting a patient site and a provider site), (3) intensive care coordination, and (4) specific cultural facilitation. 15 This comprehensive direct care model is distinct from other models of TMH in that the team providing mental healthcare also does intensive outreach and care coordination. Care coordination addresses barriers to mental wellness like homelessness, food security, and complex physical health needs but is also more resource intensive than other models.…”

“…Cultural facilitation ensures care addresses unique local cultural issues and is appropriate and effective in the eyes of the community through partnerships with local representatives (Tribal Outreach Workers, Tribal Veterans Representatives, traditional healers, tribal councils). 15,16 Although the AITMH clinic model has logged more than 7,500 patient visits since its inception in 2002, 15 with a number of studies showing its feasibility, cost benefit, and efficacy, [17][18][19][20][21][22] clinics outside VISN 19 have struggled with integration into the system-wide VA mental health architecture. Local adaptation challenges operational feasibility because considerable resources are required to identify and maintain physical space and equipment for each patient clinic site.…”