The National Frontier & Rural ATTC

April, 2013

The National Frontier and Rural (NFAR) ATTC serves as the subject expert and key resource on delivering addiction treatment and recovery services in frontier/rural areas using telehealth technologies. The primary focus of NFAR-ATTC is to develop and strengthen the addiction treatment/recovery workforce by using state-of-the-art culturally-relevant training and technical assistance activities.

Frontier/Rural Treatment and Recovery Services Issues

Over half of the country’s land mass is designated as frontier or rural, which is defined by low population density and geographic remoteness to Census Bureau-defined Urban Areas [1]. Frontier/rural areas are characterized by small population centers that cannot support the type of healthcare services available in more densely populated centers, including substance use disorders (SUDs) treatment [2]. Approximately one quarter of the U.S. population (62 million people) lives in frontier/rural areas, with an estimated 16-20% (15 million) of those individuals experiencing substance dependence, mental illness, or co-morbid conditions [3].

Although individuals residing in frontier/rural areas may have similar prevalence rates of drug/alcohol dependence as their urban colleagues, their mortality rates and risks for suicide are higher [4] and in general their alcohol/drug problems more severe [5].The most significant issue facing individuals with SUDs in frontier/rural areas is access to treatment/recovery services. A 2009 workforce study reported that the lowest concentration of mental health professions was found in frontier/rural areas, especially those counties with less than 10,000 people [6]. Furthermore, the health professional shortage areas (HPSAs) definition of frontier specifies that ‘the time and/or distance to primary care is excessive for residents,’ which includes lack of consistently accessible roads to a healthcare access point [2]. This means that patients may have to drive over 60 minutes one way to receive treatment services. With little or no public transportation in these areas, attending treatment is difficult if not impossible. Consequently, many clients may never receive SUDs treatment.

In addition to accessibility, availability and acceptability of services are issues that prevent or delay individuals with SUDs/mental health disorders from receiving treatment [7]. Availability refers to the presence of treatment and recovery services; acceptability refers to clients’ attitudes towards entering treatment and the perceived or actual lack of confidentiality and community support. Addiction treatment/recovery services in frontier/rural areas also are difficult to sustain due to high delivery costs, a shortage of trained counselors, and in some cases public opposition to drug/alcohol treatment programs related to fear that programs will draw more individuals with SUDs into the area [8]. Remote healthcare services have been shown to provide an excellent vehicle for expanding access to and availability of medical and mental health services in frontier/rural areas, and holds great promise for helping address some of these barriers to SUDs treatment.

Expanding and Enhancing SUD Treatment/Recovery Services

There are a number of terms used when talking about providing remote healthcare services. In general, telehealth refers to ‘the use of telecommunications and information technologies to provide access to health information and services across a geographical distance’ [9], while telemedicine refers to ‘the use of medical information exchanged from one site to another via electronic communications to improve patients' health status’ [10]. Telehealth encompasses both health education activities and clinical services using synchronous communication (video-conferencing, telephone counseling) and asynchronous communication (email, web-based programs) methods.

In response to SAMHSA’s commitment to reducing health disparities, NFAR-ATTC is working to prepare the workforce on using telehealth technologies to expand access and enhance treatment and recovery services for individuals living in frontier/rural areas. A recent literature review found strong support for the use of telehealth technologies in the delivery of SUDs assessment, intervention, treatment, and recovery support services. Specifically, web-based screens are available for adults and college students that provide users an opportunity to review their alcohol use in comparison with other individuals and get advice regarding their drinking behaviors. There are two types of telehealth technologies that utilize the telephone and have demonstrated strong outcomes. The first is Telephone Continuing Care programs, which are used to provide support and counseling after initial treatment episodes. The second is Interactive Voice Response Systems (IVRS), which allow individuals to call in, track their drug/alcohol usage, and participate in brief educational modules. Still other computer-based telehealth technologies help individuals practice their drug refusal skills or relapse prevention techniques.

Most of the telehealth technologies described above are adjuncts to treatment or recovery support, serving as ‘counselor-extenders’ [11,12] by providing additional services to clients without increasing staffing for treatment providers. Furthermore, the anonymity provided by telehealth technologies may be helpful in assuaging privacy concerns held by many individuals residing in frontier/rural areas [13]. With the majority of American adults using the Internet (80%), having cell phones (85%), sending/receiving text messages (80%), and more than half gathering health information from their mobile devices, technology-delivered interventions hold great potential for having a significant public health impact related to SUDs. The significant question then for the SUDs treatment field is not “Do treatment services delivered using telehealth technologies work?” but rather “Which telehealth technologies, delivered under what conditions to which populations increase the effectiveness of services?” [14].

Ethics and Confidentiality

Although telehealth provides a viable solution to expanding access to SUDs treatment and recovery services, using technology also creates new ethical challenges surrounding client confidentiality. First and foremost, it is crucial to implement policies and procedures that restrict access to, protect the integrity of, and guard against unauthorized access to electronic Protected Health Information (PHI) (HHS Office for Civil Rights). Federal and State regulations (i.e., HIPAA, 42 CFR Part II, HITECH, Privacy Rule) require that treatment providers maintain client privacy and confidentiality related to their PHI. Those standards are clear in terms of handling hard copy files (e.g., de-identifying client information and files stored in locked cabinets). But how are those same safeguards upheld in the virtual world?

A prime example of a privacy/confidentiality issue regarding telehealth technology is text messaging. Routine Short Message Service (SMS) text messaging is non-secure and non-compliant with HIPAA safety and privacy regulations because those messages are retained by both the sender’s and receiver’s phone and cellular provider server(s). Thus, text messages containing PHI remain unencrypted and accessible by anyone interested in that information. Likewise, the privacy and confidentiality of email messages or video-conferencing using public Wi-Fi networks cannot be ensured as these networks do not use secure portals. Therefore, it is imperative that treatment providers and counselors be aware of the new ethical dilemmas associated with using telehealth technologies.

Two other issues associated with ethics and the use of telehealth technologies are competence and license portability. Ethical codes for each professional association provide a standard that addresses and defines "competence" for that particular discipline. Several professional associations (e.g., NADAAC, NASW, APA, NBCC, AAMFT) are starting to re-write standards that make counselors, therapists, psychologists, and social workers ethically bound to demonstrate competence in using telehealth technologies. License portability remains a significant problem when it comes to providing telehealth services as most states require that the treatment professional be licensed in the state in which the client resides. Although some healthcare professions are beginning to address this issue, it appears that the addiction treatment profession is still lagging behind [3,15,16].

Making Decisions about Using Telehealth Technologies

It is important to remember that telehealth is not about the technology itself but functions as a bridge, reaching out to the client so services that support behavior change are available [13]. The decision to expand and enhance treatment services using telehealth technologies needs to be based ultimately on the extent to which it benefits the client. Likewise, providers need to understand both the costs and revenue issues (reimbursement) associated with providing telehealth technologies. When implemented correctly, telehealth can serve as a force multiplier by mitigating workforce shortages, thereby making treatment services more available [18].


According to a 2009 NASADAD study, addiction treatment providers in fewer than 16 states reported offering services using telehealth [19]. In order to strengthen the addiction treatment workforce, it is essential that training/TA activities be designed and implemented to increase telehealth-related knowledge, skills, and abilities. The following goals will guide NFAR-ATTC’s work:

  1. Build and maintain collaborative relationships with key national/regional stakeholders;
  2. Serve as the national expert and key resource on delivering addiction treatment/ recovery services in frontier/rural areas using telehealth;
  3. Develop a strategic plan that will guide the delivery of training/Technical Assistance (TA) services;
  4. Utilize innovative technology transfer strategies to promote awareness, use, and implementation of telehealth technologies;
  5. Synthesize/distill research to create products, materials, and curricula for promoting the use of telehealth;
  6. Provide leadership and sponsor meetings with national/regional stakeholders to create telehealth competencies and make recommendations for a national license portability policy; and
  7. Evaluate the impact and effectiveness of NFAR-ATTC activities.

Partnerships and Collaborations

The other National ATTC Focus Centers and Regional ATTCs play a critical role in NFAR-ATTC’s ability to accomplish the identified goals. NFAR-ATTC’s focus will include providing instruction on telehealth for counselors, clinical supervisors, administrators, recovery specialists, and students through training/TA services designed specifically for each population. Introductory training events focused on knowledge awareness will be offered, along with other trainings that promote skill-building in order to provide a linked suite of learning experiences. Finally, a Training of Trainers will be provided to develop regional experts to continue to offer telehealth trainings to the SUDs/behavioral health workforce.

NFAR-ATTC will incorporate SAMHSA’s 8 Strategic Initiatives into its training/TA activities. By focusing on the expansion of telehealth services to include delivery of SUDs treatment in frontier/rural areas, NFAR-ATTC will touch on aspects of each Initiative. Specifically, NFAR-ATTC will assist SUDs treatment providers, clinical supervisors, students, recovery specialists, and administrators on using telehealth to provide state-of-the-art, culturally competent SUDs treatment/recovery services by offering training/TA and products that raise awareness, increase knowledge and access to information, and improve/develop skills. These services will be based on technology transfer principles/strategies, and include multiple exposures to trainings and materials using several formats (in-person, web-based, audio/video learning events); opportunities to practice new interventions; and coaching sessions with performance feedback to promote routine use and organizational implementation.

Attend the ATTC Network’s Third Thursday iTraining:

Telehealth: It’s Not about the Technology - It’s About Expanding Access and Enhancing Care

April 18, 2013, 2:00-3:30p.m. Eastern

Presenters: Nancy Roget, MS, MFT, LADC
Register at:

For more information please visit our website:


Nancy Roget, MS
Principal Investigator/Project Director

Terra Hamblin, MS
Project Manager

Wendy Woods, MS
Project Manager-Curriculum

Joyce Hartje, PhD

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