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24 | COLUMBIA SOCIAL WORK REVIEW, VOL. IX 

KEEP UP: ALIGNING POLICIES AND PRACTICES TO 
OPTIMIZE TELEMENTAL HEALTH POTENTIAL

ANGELICA FRANCES CULLO

Currently, the United States health care system is undergoing a 
transformation in health care delivery. Innovative strategies are 
needed to increase access to evidence-based mental health care and 
make progress on the goals of the health care “triple aim” of reducing 
per capita costs, improving health outcomes, and increasing patient 
satisfaction (Berwick, 2008 p. 760; McWilliams, 2016). Barriers 
including a shortage of mental health providers, lack of delivery 
infrastructure, state licensing limitations, and inconsistent 
insurance coverage must be addressed before telemental health can 
become viable. By 2025, social workers are anticipated to experience 
one of the largest shortages of the mental health provider types (Health 
Resources & Services Administration, 2016). Telehealth services 
have the potential to improve mental health care access, efficiency, 
and outcomes by reaching people who don’t seek treatment because 
of distance, cost of transportation, stigma, or disability, and by 
sharing clinical expertise and medical documentation to more people 
in less time. With decreasing costs and increasing acceptability by 
payers, providers, and patients, telehealth is more viable than ever 
before. Social workers are particularly well positioned to make use 
of telehealth opportunities because their training prepares them 
to work with individuals marginalized by issues such as stigma, 
disability, and socioeconomic status. To begin to address this gap 
in mental health care access, states should pass full parity laws for 
insurance coverage of telemedicine services so that social workers 
can provide care to clients regardless of where they are located.

BACKGROUND
By 2025, shortages are projected 

of psychiatrists; clinical, counseling, 
and school psychologists; and mental 
health and substance abuse social 
workers (Health Resources & Services 
Administration, 2016). Rural areas in 
particular face persistent shortages 
in mental health practitioners (Hoeft, 
2018). Rural counties comprise two-
thirds of all counties and approximately 
20% of the United States (U.S.) 
population but contain fewer than 
10% of the mental health workforce 

“Telehealth services have 
the potential to improve 
mental health care access, 
efficiency, and outcomes 
by reaching people who 
don’t seek treatment 
because of distance, 
cost of transportation, 
stigma, or disability, 
and by sharing clinical 
expertise and medical 
documentation to more 
people in less time.” 



COLUMBIA SOCIAL WORK REVIEW, VOL. IX | 25 

ANGELICA FRANCES CULLO

(Hoeft, 2018). Even when rural location is not a barrier to care, individuals 
with mental illnesses are not getting the care they need (American 
Psychological Association [APA], 2018). Among 8.9 million adults with any 
mental illness and a substance use disorder, 44% received mental health 
treatment or substance use treatment in the past year, 13.5% received 
both mental health treatment and substance use treatment, and 37.6% 
did not receive any treatment (APA, 2018). Evidence suggests that travel 
time, cost, convenience, and stigma may play a role (Substance Abuse and 
Mental Health Services Administration, 2014).

According to the American Telemedicine Association’s (ATA)
guidelines, telemental health consists of using video conferencing for 
mental health care (Thomas & Capistrant, 2014). Services that can be 
delivered using telemental health include mental health assessment, 
counseling, substance abuse treatment, medication management, 
education/training, monitoring, and collaboration (McWilliams, 2016). 
Mental health care is particularly 
subject to complex sociocultural factors 
due to challenges in quantifying mental 
illness, cultural beliefs about mental 
health, and attribution of mental illness 
to personal failures or weaknesses. 
As such, social workers are uniquely 
poised to address the limited access 
to mental health services. Telemental 
health is now making it possible for 
social workers to provide care to those 
who encounter barriers such as cost, 
location, scheduling, language, and 
other circumstances that perpetuate 
disparities in access to care. However, 
historically practitioner reimbursement, particularly from private payers, 
has limited the viability of telehealth (Antoniotti, Kenneth, & Nancy, 2014). 
Insurance companies are beginning to respond to consumer needs by 
expanding the services and provider types that they reimburse (AHA, 2016). 

Morland et al. (2014) suggest that telemental health is as or more 
effective than face-to-face (FTF) treatment at monitoring medications and 
symptoms due to ease of scheduling, reduction of no-show appointments, 
and communication among other caregivers or family members (Hubley, 
Lynch, Schneck, Thomas, & Shore, 2016). A number of studies have 
also shown the same or higher rates of satisfaction among telemedicine 
patients as compared to traditional FTF services (Morland et al., 2014; 
O’Reilly et al., 2007). Telemental health makes accessing mental health 
care more convenient, allows individuals with physical disabilities or who 
lack of transportation to more easily receive care, prevents patients from 

“...social workers are 
uniquely poised to 
address the limited 
access to mental health 
services. Telemental 
health is now making 
it possible for social 
workers to provide care 
to those who encounter 
barriers such as cost, 
location, scheduling, 
language, and other 
circumstances that 
perpetuate disparities in 
access to care.”



26 | COLUMBIA SOCIAL WORK REVIEW, VOL. IX 

KEEP UP: OPTIMIZING TELEMENTAL HEALTH POTENTIAL

having to take off time from work or other responsibilities, and reduces 
barriers for those who might not get care because of the stigma associated 
with visiting a psychiatrist or counselor’s office. In addition to delivering 
services via videoconferencing, social workers can obtain and provide 
training, supervision, and consultation with specialized mental health 
providers, such as psychiatrists and clinical psychologists (Hoeft, 2018). 
Technology is proving to be such an instrumental part of social work that 
the most recent revision of the National Association of Social Work Code 
of Ethics was revised to incorporate practice guidelines related to the use 
of technology (NASW, 2017).

CLINICAL OUTCOMES
There is evidence that telemental health may produce better health 

outcomes and be more cost-effective than FTF (Moraland, 2014). One 
study comparing utilization data for telemental health appointments 
and FTF appointments found that patients kept more telepsychiatry 
appointments than FTF appointments, were less likely to cancel 
telemental health appointments, and were significantly less likely to no-
show (Leigh, Cruz, & Mallios, 2009). Remote monitoring of patients via 
telemedicine has also allowed practitioners to check in with patients more 
regularly, in some cases providing evening and weekend appointments not 
traditionally possible for FTF service provision (Hubley, Lynch, Schneck, 
Thomas, & Shore, 2016; Khasanshina, Wolfe, Emerson, & Stachura, 
2008; Uscher-Pines & Mehrotra, 2014). Telemental health may be less 
disruptive to patients’ schedules, more cost-effective because of reduced 
transportation costs, more appealing to those who feel stigmatized for 
accessing mental health services, and perhaps even the only option for 
individuals with disabilities or other physical limitations. While more 
research is needed to fully understand the causes of improved patient 
compliance with telemental health when compared with FTF, findings 
suggest that telemental health patients more consistently utilized mental 
health services than FTF patients (Leigh, Cruz, & Mallios, 2009).

COST
Telemental health has already proven to be more cost-effective for 

patients, providers, and the health system as a whole. Cost savings include 
those from reduced travel and lost workdays, appointment cancellations 
and no-shows, clinical and administrative staff costs, and hospital 
admissions (Rabinowitz, 2010; Loh, 2013). According to data from the 
Veterans’ Health Administration (VHA) - one of the country’s pioneers in 
telemedicine - the annual cost to fund their telehealth program in 2012 was 
$1,600 per patient, per year, compared to over $13,000 for traditional care 



COLUMBIA SOCIAL WORK REVIEW, VOL. IX | 27 

ANGELICA FRANCES CULLO

(American Hospital Association [AHA], 2016). Some of these savings come 
from a reduction in the number of required follow-up visits (see Figure 
1). One study of the California Public Employees Retirement System 
found that patients seen by a telehealth provider were less likely than 
those who received their initial consult in the emergency department or 
a physician’s office to require a follow-up visit (AHA, 2016). Significantly, 
data suggest that telemental health increased quality of life adjusted life 
years (QALYs) when compared to FTF services (Hubley, Lynch, Schneck, 
Thomas, & Shore, 2016). Telemedicine was also associated with a 25% 
reduction in the number of bed days of care and a 19% reduction in hospital 
admissions across all VHA patients utilizing telehealth. The VHA achieved 
significant reductions in hospitalizations, including over 40% for mental 
health patients (AHA, 2016). The state of Vermont saved $63,804 per 
patient through the use of home-based telehealth and telemonitoring that 
eliminated expenses related to preventable illnesses and time and travel 
expenses (AHA, 2016). Overall, the VHA (2016) estimates an average 
annual savings of $6,500 for each patient who participated in the telehealth 
program, which translates to nearly $1 billion in system-wide savings. 
The South Carolina Department of Mental Health and the South Carolina 
Hospital Association established a statewide telepsychiatry network that 
allows patients, emergency department physicians, and psychiatrists to 
communicate via video-based and wireless communications. Since its 
inception, the program has resulted in an estimated cost savings of $3,320 
per inpatient hospital patient (South Carolina Telehealth Alliance, 2016). 
These are just a few of the encouraging examples of health care providers 
already embracing the use of telemental health services as part of the care 
continuum.

PERCENTAGE OF TELEHEALTH, PHYSICIAN OFFICE, AND EMERGENCY 
DEPARTMENT VISITS WHERE FOLLOW-UP IS REQUIRED FOR SIMILAR CONDITION, 
APRIL 2012 - FEBRUARY 2013 (USCHER-PINES 2014)

TELEHEALTH

PHYSICIAN
OFFICE

EMERGENCY
DEPARTMENT3%

13%

20%

Figure 1: Telehealth decreases utilization in the long run.



28 | COLUMBIA SOCIAL WORK REVIEW, VOL. IX 

KEEP UP: OPTIMIZING TELEMENTAL HEALTH POTENTIAL

CURRENT LEGISLATION
Already, states are seeing the value in using telemedicine to fill provider 

shortage gaps and ensure access to specialty care. Medicaid, Medicare, and 
a growing number of third-party payers are beginning to cover telemental 
health (Deslich, Stec, Tomblin, & Coustasse, 2013). Private insurers such 
as Aetna, Anthem, and United Healthcare are incorporating telehealth into 
their Medicare Advantage, commercial, and individual benefit packages 
(AHA, 2016). Despite progress, however, patients and mental health 
providers still encounter a patchwork of inconsistent service delivery, 
legislation, and insurance requirements that make it difficult for both 
patients and providers to reap the full benefits of telemental health. 

State licensing regulations remain a barrier to providing telemental 
health. Currently, providers must have separate licenses for each state 
in which they provide services. In some cases, this is not possible due to 
conflicting regulations from state to state (Thomas & Capistrant, 2014). 
Providers and patients bear the burden of informing themselves of legal 
and financial limitations on practicing across multiple jurisdictions. They 
also have to consider in which jurisdictions laws apply, which professional 
codes of ethics apply, and whether the practitioner’s liability insurance 
covers services provided when the client, practitioner, or agency are in 
different jurisdictions (Barsky, 2017). For instance, if an agency is located 
in New York, the client is in Connecticut, and the social worker is traveling 
in California, the social worker would have to know regulations and 
technology policies pertaining to each jurisdiction.

According to an analysis of 13 indicators related to coverage and 
reimbursement, the ATA found that more than half of U.S. states received 
a failing score for the quality of their statewide insurance coverage and 
reimbursement for telemedicine (Thomas & Capistrant, 2014). While 
availability and coverage of telemental health has gained traction, full legal 
parity with FTF services—defined as insurance coverage for telemental 
health that is comparable to that of in-person, FTF services—is still 
lacking and varies across state borders (Thomas & Capistrant, 2014). 
Encouragingly, full parity has been achieved in 19 states and the District 
of Columbia (DC), and nine states and DC have laws mandating statewide 
coverage and reimbursement for telemedicine-provided services under 
their Medicaid programs (Weinstein et al., 2014). 

TECHNOLOGY

Other concerns with telemental health are technological privacy and 
costs. Depending on the provider and their setting, initial costs may be 
several thousand dollars for software, hardware, and other infrastructure. 
The U.S. Federal Communications Commission’s Universal Service Fund 
subsidizes high bandwidth telecommunications to rural health care 



COLUMBIA SOCIAL WORK REVIEW, VOL. IX | 29 

ANGELICA FRANCES CULLO

providers, schools, and libraries that require a large network connection 
and technologies not available for free (McGinty, 2006). If large providers 
are able to front the technology cost, findings indicate that these expenses 
can be recovered through long-term telehealth savings. One study found 
that the threshold at which video conferencing became less costly than FTF 
was between five and six telemedicine episodes per year (Harley, 2006). 

For others, however, audio-visual conferencing systems that are 
compliant with the Health Insurance Portability and Accountability Act 
(HIPAA) such as doxy.me, VSee.com, and Polycom can be used at no cost 
to the provider or patient. Most conferencing systems require the patient 
and provider to have just a computer with a video camera, microphone, 
and speakers or a headset, and many systems allow providers to access 
electronic health records while video conferencing (McGinty, 2006). 
Confidentiality concerns can be addressed via encryption technology that 
enable compliance with HIPAA. The use of encrypted codes or the setup 
of a virtual private network and/or virtual local area networks function to 
prevent interception of audio, video, and other data during transmission. In 
the future, FaceTime and similar applications may even be a viable HIPAA-
compliant option if WPA2-Enterprise and 128-bit encryption is used over 
a Wi-Fi connection (Magno, Santos, Tucay, Flores, & Cuyco, 2014). 

PATIENT & PROVIDER SATISFACTION

On average, patient satisfaction with telemental health is the same as 
or better than with comparable FTF care (Khasanshina, Wolfe, Emerson, 
& Stachura, 2008; Hilty, 2013; Hubley et al., 2016). Satisfaction ratings 
were higher for both patients and providers in rural versus suburban 
settings (Hubley et al., 2016). This finding further underscores the viability 
of telemental health for rural regions where mental health disparities are 
greatest. Interestingly, patient satisfaction rates tended to be higher than 
providers perceived them to be, suggesting that provider concerns about 
quality of telemental health care are largely unfounded. No significant 
differences were seen in treatment efficacy and telemental health patients 
report disclosing the same information they would to a FTF provider 
(Hubley et al., 2016; Khatri, Marziali, Tchernikov, 2014; Stubbings, Rees, 
& Roberts, 2013). 

Diagnosis accuracy also does not decline for telehealth as compared 
to FTF services (Khasanshina, Wolfe, Emerson, & Stachura, 2008; Hubley 
et al., 2016). Although telemental health may not be appropriate for 
someone in imminent risk of self-harm, it has been shown to be effective 
for assessing and managing suicidal threats (Godleski, Nieves, Darkins, & 
Lehmann, 2008; Jong, 2004).



30 | COLUMBIA SOCIAL WORK REVIEW, VOL. IX 

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RECOMMENDATIONS

To help close gaps in mental health care, state legislatures should 
pass full parity laws that regulate coverage provided by public and private 
insurers. Regional and state government officials should also introduce 
bills to reform existing parity laws. Full parity laws would allow more 
uniform mental health service provision regardless of parameters such as 
provider type, health condition, and patient location. 

Barriers to practicing across state lines also need to be reduced. 
Currently, there is no interstate portability agreement surrounding 
telemental health. Social work licensing agencies should offer licensure 
mobility solutions or a national license, similar to those seen in Medical 
and Nurse Licensure Compact legislation (Maheu, Pulier, McMenamin, & 
Posen, 2012; HHS, 2016). National licensure could coordinate standards, 
yet allow each state to retain their ability to monitor practice and administer 
disciplinary actions for clinicians who engage in egregious behavior. 
National licensure could also require demonstration of competence with 
telemental health technologies and their best practices. Lastly, professional 
associations should provide specific guidelines for using telemental 
health technologies with varying clinical populations, conditions, and 
circumstances, as well as standards required for competency (Maheu, 
Pulier, McMenamin, & Posen, 2012).

DISCUSSION/CONCLUSION

Regions with provider shortages, including rural, low-income, 
minority, elderly, and disabled communities, are important areas to target 
for mental health care improvement efforts. Travel time, costs, convenience, 
and stigma associated with seeking many health care services discourage 
these and other populations from seeking adequate care. A number of 
states have partial telemental health parity laws. However they limit 
insurance coverage of telemedicine to certain geographic areas, services, 
and provider types. While recent efforts signify steps in the right direction, 
individuals with the highest need will likely not be reached without full 
parity laws. 

Inclusion of telehealth in value-based payment innovations can help 
with continued efforts to assess the value of telehealth for health systems 
working to optimize quality improvement, patient satisfaction, and cost 
savings. While there is a growing body of evidence to support the idea 
that telemental health results in cost savings, more data are needed to 
identify what makes these programs successful so that their practices 
can be generalized to other places in the U.S. Currently, the VHA is one 
of the only organizations that has used telehealth for long enough to have 
a sizable body of publicly available data about the costs and benefits of 



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ANGELICA FRANCES CULLO

telehealth. Reflective of a larger challenge in clinical research, studies 
that examine telehealth treatment outcomes relative to FTF treatments 
disproportionately sample white individuals (Khasanshina, Wolfe, 
Emerson, Stachura, 2008). Future research should focus on clarifying best 
practices for implementing and sustaining telemental health in populations 
with diverse backgrounds and mental health needs, including provider 
training specific to the sociodemographic characteristics of the patient 
and the provider. Sustainable solutions to our nation’s mental health care 
challenges require improved equity in access to care and quality of care. 
Telemental health represents a highly promising approach to reduce the 
gap between mental health care demand and access.

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ANGELICA FRANCES CULLO grew up in the Hudson Valley and is a 
Masters of Science in Social Work candidate in Advanced Clinical Practice 
at Columbia University’s School of Social Work, where she is also in the 
Dialectical Behavior Therapy (DBT) Training Program. Angelica received 
her B.A. from Cornell University where she was involved with the mental 
health community. Her first year placement was at The Door: Bronx Youth 
Center where she helped youth earn their High School Equivalencies 
and develop training and skills needed to succeed in the workplace and 
college. Her research interests include increasing access to mental health 
care through telemedicine and treatment of anxiety, depression, eating 
disorders, and NSSI in adolescents, particularly through the use of DBT.


