In West Virginia, 50 of 55 counties are federally designated mental health professional shortage areas, and some families must travel two to four hours for specialty behavioral healthcare — if it is available at all.
Keri Law, MD, a child and adolescent psychiatrist and vice chair of clinical services at WVU Medicine in Morgantown, W.Va., connected with Becker’s to outline the realities of delivering behavioral healthcare in one of the nation’s most rural states. She discussed how geography, workforce shortages and the legacy of the opioid epidemic continue to shape access — and how WVU Medicine built a telebehavioral health infrastructure that now accounts for more than half of its department’s roughly 100,000 annual visits.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: Can you briefly describe the behavioral health landscape in rural West Virginia and what makes access so challenging there?
Dr. Keri Law: When we talk about behavioral health in West Virginia and even across Appalachia, we’re really talking about the intersection of geography, workforce shortages, stigma and socioeconomic stressors. When I zoom out a little bit nationally, 65% of rural U.S. counties have no practicing psychiatrist. So while it’s a national crisis, it really is amplified in Appalachia and West Virginia.
Our numbers here in West Virginia are pretty staggering. Fifty out of our 55 counties are federally designated mental health professional shortage areas, and we have among the lowest per capita availability of child adolescent psychiatrists in the country. Then for some families, accessing specialty care historically meant driving long distances that could be two hours up to four hours one way, and that’s if care was even available at all. But when you think about that, that distance really hits children and adolescents, especially hard for both children as well as families.
We’ve seen high rates of depression, anxiety, substance use, trauma, but with fewer child and adolescent psychiatrist per capita almost anywhere in the country that presents a huge issue. And then, if you add to that the Appalachian context, multigenerational poverty, higher rates of chronic illness, the legacy of the opioid epidemic, and really a cultural tendency to handle problems privately, it becomes clear why access gaps persist, and it is so deeply tied to where people live.
Q: Telehealth expanded nationwide during COVID-19, but in West Virginia it really took hold. What were the key moments that made virtual behavioral health not just helpful but essential?
KL: When I think about key issues and key moments, first West Virginia is a state with heavier health burden and fewer resources. The pandemic provided an opportunity to demonstrate both the independent spirit of our state’s people, but also the innovative minds of our treatment providers.
I think about another key moment being related to relaxation of regulatory barriers and reimbursement rules. Nationwide we saw something surprising. There had been assumptions from some that rural patients wouldn’t or couldn’t use or access technology due to broadband difficulties and otherwise. We also presumed many of our providers wouldn’t try virtual care, because of their own personal preference or because of the type of care they provided. We realized that many of those assumptions were wrong. Patients showed up, engagement improved, and for many families, actually, virtual visits were easier and less disruptive. That’s something we’d seen in West Virginia for years, and the pandemic allowed for this to flourish.
Imagine a family here in a pretty mountainous area, having the access to virtual visits was the difference between getting care or skipping it, whether that was because you had been exposed to COVID-19 and were in isolation because you were snowed in, or because your parent or your guardian couldn’t afford to miss work, had a broken down car and you had no way to get there.
And lastly, pediatric demand has been rising nationally. Rural states like West Virginia have experienced severe workforce constraints pre-pandemic, and so telepsychiatry has allowed us to extend the expertise of a limited number of specialists across a large footprint, and that’s critical both in allowing better access to limited resources, but then also to supporting and collaborating with our community providers.
Q: How did your team operationalize virtual behavioral health in a rural setting?
KL: I am proud to say that WVU Medicine has been a leader in virtual care for decades. That originally began with Mountaineer Doctor TeleVision, or MDTV, which initiated in the early 1990s. We approached telebehavioral health and the department of behavioral medicine and psychiatry as a pilot in 2009, and then this quickly evolved into a system strategy when we recognized the value that access to care brought for our patients at all ends of the state, for mental health services. That included seeing adults and children, whether it was for diagnostic or ongoing treatment, medication management, individual therapy, group therapy, addiction treatment and so on.
But I think a few of the pieces that are important when we think about how we operationalized it were that we leveraged our academic medical center as a hub, and we extended care outward. And were non-selective with that. This was to community mental health centers, federally qualified health centers, clinics, critical access hospitals, emergency departments, schools and then ultimately, after the pandemic, into patients’ homes. That requires pretty intentional design, though, and we partnered closely with local primary care providers, pediatricians and emergency departments. It was important they felt that the telehealth behavioral health services were integrated and not external, both for the providers but also the patients.
We invested heavily in workflows and scheduling and training, both for clinicians but also for patients and families. It was really important for us that this was not just giving them a virtual link and calling it a day. It was about building relationships and buying in. It was about identifying a champion at each site who believed in the modality, and that is both before, during and after the pandemic. I think about some of the broadband and technology literacy challenges, and they were very real. Some families did not have reliable internet or had never used video visits before. If families didn’t have internet access, we had to be really creative with them.
I remember a family that would regularly drive to their local McDonald’s parking lot because that was the place locally that had the internet and they joined their appointment from there. So during the pandemic, we leaned on much of the experience that our team had had over the prior decade. We converted nearly all of our visits within our department to virtual within about two weeks, and that’s pretty impressive in a time when community support was limited, people were isolated and scared, and overdose deaths were nearly doubled.
Q: Can you share examples that show what this model has changed for patients?
KL: There are two that really stand out. This was one of my clinical patients, a child who had a neurodevelopmental disorder that had been diagnosed as a very young child. But because of where they lived in a very rural county, they had minimal access to treatment providers who could help with management of their symptoms. It was so severe that they were on the verge of being unable to attend school, even in a self-contained classroom. Their parents were at their wit’s end, and they saw a person who as a provider with child adolescent psychiatry training, they were able to meet with me regularly, provide some diagnostic clarification, but ultimately treatment that, unfortunately, their their primary care provider didn’t feel comfortable with but also with recommendations for the school, this child stayed in school. They began to do better and it was a huge relief for the family and for the patient.
On the other end of the spectrum, we had a patient with substance use disorder who actually was admitted here at our academic medical center for an infection in their heart valve that was related to drug use. It required surgical interventions that had also required IV antibiotics for a long time and so pretty significant comorbidities related to their substance use. They ultimately were discharged. When they were discharged from our academic medical center, they were to return to their home community, and they happened to live in a community where we were providing virtual addiction treatment, so they were able to transition from inpatient consult psychiatric services to outpatient care where they participated in treatment. They maintain their sobriety. And interestingly, this patient got pregnant, and because of that, moved to be near to their family in another location. In that second location, we also were providing treatment in that community so they were able to transition care from one community clinic to another community clinic, deliver the child in their custody, and continue to have treatment within their community, which is really critical.
Q: What are you seeing in the data?
KL: The data is exciting. Just to provide some reference points, when I think about the last three years in terms of just our volumes, the number of total patient visits that we’re seeing virtually in our clinic, within the department of behavioral medicine and psychiatry are still lingering a little over 50%. And that’s with having about 100,000 patients per year, and with kids they’re a little bit less, but still at around a third of our children are seen virtually.
In our system, we’ve seen improved access, faster time to first appointment, and better continuity of care, particularly for pediatric patients and those in remote areas. No-show rates are often lower for virtual visits, especially in rural populations, where transportation and weather can be major barriers. Engagement improves when the care fits into people’s lives rather than requiring them to reorganize their lives around care. I think finally we’re seeing gains in healthcare equity, so we’re reaching patients who previously would not have accessed specialty behavioral health services at all.
