A Critical Assessment of Virtual Mental Health Care for Rural Nova Scotians

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August 1, 2023
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The COVID-19 pandemic has had devastating impacts on mental health and healthcare systems across Nova Scotia and the country. While demand for mental health services escalated in response to the pandemic, many in-person services were shut down (MacIvor 2021; government of Nova Scotia 2022b; Pulok et al. 2022, 4). During the pandemic, there was increased demand for mental healthcare services in Nova Scotia, placing additional strain on an already overburdened system that now faces escalating wait lists, staff shortages, and emergency department closures (Thomas 2022; MacIvor 2021; Nova Scotia Health 2022).

In response to accelerating demand and spiralling wait times, the Nova Scotia government launched a new suite of virtual care programs and forwarded new policies prioritizing virtual care’s expansion (Al-Hakim 2020; Doctors Nova Scotia 2020; Nova Scotia Health Authority 2020). The Houston government has heralded virtual care as a success, providing access for most Nova Scotians, improving wait times, and addressing physician shortages (Nova Scotia Health Authority 2021; government of Nova Scotia 2022a). As a result, virtual care has become a core focus of Nova Scotian healthcare policy. Virtual care is set to expand because of its perceived cost-effectiveness and accessibility. However, the Nova Scotia government has not evaluated if new virtual care policies meet the mental healthcare needs of rural Nova Scotians, particularly those in rural areas who were already facing mental healthcare barriers before the pandemic.

As I discuss below, although recent policies offer benefits that respond to several rural mental healthcare concerns, the government’s focus on virtual mental healthcare does not fully meet rural Nova Scotians’ needs. In fact, new virtual care policies may exacerbate the mental healthcare barriers many rural Nova Scotians face. Moreover, the government’s current emphasis on virtual care removes mental healthcare from publicly funded clinical environments, downloading responsibility onto non-profit organizations, families, and communities to provide care without adequate funding or support resources. Moving forward, to improve virtual care’s ability to attend to rural Nova Scotians’ needs, the government must also consider the unique barriers rural residents face in accessing mental healthcare when designing new policies, ensuring Nova Scotians can access comprehensive, publicly funded care administered through the provincial healthcare system.

Nova Scotia’s Virtual Care Policies

            Virtual mental healthcare is familiar to Nova Scotia. Since the 1990s, the Nova Scotia government has advocated for virtual care based on potential cost reductions and accessibility benefits, becoming a provincial priority by the 2000s (Province of Nova Scotia 1999). Before the pandemic, the McNeil government had proposed a gradual and cautious roll-out and refinement of new virtual mental healthcare solutions between 2020-2022 (Mental Health and Addictions Program 2019; Centre for Addiction and Mental Health 2020). However, faced with a dramatic increase in demand for services during the pandemic, coupled with an inability for Nova Scotians to access in-person care, the government (first under the Liberals and then Progressive Conservatives) rapidly expanded virtual care services, sacrificing the more cautious and gradual approach previously prioritized. In 2019, the Mental Health and Addictions Program (MHAP) (2019) also released its five-year plan, Direction 2025, which detailed its vision of a five-tier continuum of care (4), with the MHAP providing services from tiers 3-5 (5). The MHAP proposed that general practitioners, online tools, and community organizations would be able to handle the bulk of Nova Scotians’ needs (Tiers 1-2), and the MHAP would limit their delivery to formal, intensive, and specialized care (Tiers 3-5) (4). The model adopted by Nova Scotia envisioned a flexible, integrated continuum of care equipped to handle a range of needs most cost-effectively, with virtual care complementing (and sometimes replacing) in-person alternatives (Nova Scotia Health Authority 2017, 11). Two years later, the provincial Mental Health and Addictions Program introduced various new virtual mental healthcare tools, made available through the MHAhelpNS.ca website, to provide care at the lower end province’s care continuum (Nova Scotia Health Authority 2021). Today, virtual care is a primary provincial and federal healthcare priority, with virtual alternatives to in-person mental healthcare set to expand in the coming years (McLachlan 2021; Mental Health Commission of Canada 2022b, 2; government of Nova Scotia 2022a, 1). While virtual care was initially introduced to lower costs and improve healthcare access for Nova Scotians, the practitioners I interviewed stated that virtual care’s implementation worsened a range of preexisting barriers across the province.

 Benefits and Drawbacks

            Approximately 43% of Nova Scotians live in rural areas, over double the national 18% average (Russ 2022). These rural communities experience significant healthcare gaps, affected by geographic, societal, and material conditions. Experts identify various mental healthcare issues associated with rural living linked to the social determinants of health. Service centralization in urban areas (Health Association Nova Scotia 2013, 20-21), transportation issues, a lack of high-quality, affordable internet (Goodwin et al. 2021, 5; National Collaborating Centre for Determinants of Health 2021, 3), and stigma (Church et al. 2020, 2) are all impactful barriers. Additionally, rural Nova Scotia is home to larger elderly and low-income populations, who face additional socio-economic challenges that negatively affect mental health (Goodwin et al. 2021, 5; Health Association Nova Scotia 2013, 4; Laurent 2002, 4).  

            The practitioners I interviewed identified many benefits of virtual care for rural Nova Scotians. Many participants explained that new virtual care policies could increase rural access to a diverse range of specialists, improve residents’ ability to find a practitioner they feel comfortable with and combat the isolation many rural residents face (a phenomenon exacerbated during the pandemic). Participants reported that virtual care minimizes the chance that practitioners and clients will have overlapping, dual relationships, seeing each other in both clinical and everyday environments. Financially, it helps reduce costs associated with long commutes to access treatment. Practitioners also identified stigma as a significant barrier to rural residents’ willingness to seek out and receive mental healthcare. In turn, virtual care can be a helpful tool in ameliorating stigma, allowing rural residents increased anonymity. According to many participants, accessing care within a familiar space is another vital benefit, helping clients feel more at ease during appointments and offering new opportunities for residents who feel uncomfortable in clinical environments.

Despite these benefits, according to the participants I interviewed, virtual care also runs the risk of exacerbating preexisting barriers and presents a variety of drawbacks for rural residents. Many participants flagged that even with expanded accessibility for some, virtual care policies negatively affect the unique geographic, societal, and material mental healthcare barriers rural Nova Scotians face. The persistent digital divide in Nova Scotia causes slow internet speeds and grainy video connections, which frequently cut in and out, affecting the delivery of virtual mental healthcare. Because virtual care depends on internet access, having a stable internet connection becomes a significant barrier for many rural residents. Moreover, device costs, monthly internet payments, charges to hook up internet routers, and phone plans are essential to virtual care but also cost-prohibitive, excluding some rural residents from virtual care.

Practitioners highlighted isolation as another major issue within rural Nova Scotian communities. Living in rural or remote areas without close connections to peers, neighbours, or family members can adversely affect mental health. Members of racialized and other minority communities, including Indigenous, Black, neurodiverse, and LGBTQIA2S+ communities, may struggle to find peer support networks. Moreover, interview participants noticed that the pandemic intensified mental healthcare needs and negatively impacted many rural Nova Scotians' mental health. Many practitioners expressed that disconnection between caregivers and clients during virtual appointments can further isolate residents and result in difficulties in accurately assessing symptoms or caring for moderate to severe needs. Multiple practitioners mentioned that aversion to virtual formats has contributed to some clients halting therapy, waiting to resume until in-person formats were available. Practitioners also emphasized rural Nova Scotia’s large elderly population and remarked that elders who live alone, struggle to access transportation or engage in limited social activities, and are easily isolated. New policies may further isolate elderly populations if they lack the technology literacy to use virtual formats effectively.

Virtual modalities rely on the assumption that users have a private, safe space to access services, which interviewees reported is not always the case, particularly in rural communities. A lack of privacy can jeopardize clients’ ability to get help, negatively impacting their mental health. Participants also noted concerns about the appropriateness of virtual care for rural residents and diverse groups within rural communities, questioning the cultural competence and applicability of new programs to rural ways of life. Further issues arise if practitioners are unfamiliar with rural identities and ways of life or generalist practices.

By shifting mental healthcare to virtual modalities, care is being further removed from clinical environments, such as public practitioners’ offices, emergency departments, and outpatient clinics, and pushed into the private sphere. The shift from in-person to virtual formats is an extension of privatization, limiting available government-funded services and forcing Nova Scotian residents to rely on alternative resources for care, such as private-practice practitioners or unpaid caregivers, including family, friends, or community members. Additionally, the costs associated with buying new devices, internet plans, and cell phone payments to access virtual modalities can be cost-prohibitive, downloading care costs onto care-receivers, representing a partial privatization of ostensibly public services. Virtual modalities shift the responsibility onto Nova Scotians to find private, confidential spaces to access care, which can prove incredibly challenging, particularly for those who experience housing insecurity, intimate partner violence or who have parenting and other caregiving responsibilities.

Many of the lower-level virtual mental healthcare services offered to Nova Scotians through the MHAhelpNS.ca website are outsourced from outside organizations such as the Canadian Mental Healthcare Association, Therapy Assistance Online (TAO), or Togetherall, downloading the responsibility for mental healthcare onto non-governmental organizations and companies. One of the support group facilitators interviewed pointed out that in doing so, they are “pushing the responsibility down” to non-governmental groups to provide care without adequately supporting them. Silos between government and non-government organizations and physical and mental health services exacerbate these issues.  As one participant, a private-practice psychologist in the Annapolis Valley, expressed, many practitioners I interviewed felt that “most people felt like some care was better than no care.”  However, they expressed concerns about the devolution of care to virtual care, funnelling Nova Scotians out of the public system and placing pressure on non-profit organizations, families, and communities to provide care without adequate governmental support.

Addressing Rural Care Deficits

Understanding and responding to rural Nova Scotians’ needs will require long-term investments, attentiveness, and responsiveness, ensuring rural Nova Scotians have access to comprehensive public mental healthcare within their communities. To effectively address care deficits and to ensure that virtual care authentically meets the unique needs of rural Nova Scotians, practitioner-participants recommended that the Nova Scotia government:

  1. Implement core funding for the CMHA NS Division and other non-governmental organizations. Many rural Nova Scotians rely on these organizations for care within their community, especially when they cannot access treatment in the public system due to lengthy wait times. Core funding agreements ensure that mental healthcare organizations can access stable and continuous funding.
  2. Establish new provincial initiatives to spread awareness about available virtual care services. Several interviewees identified a lack of awareness about virtual services as a critical issue undermining virtual care’s uptake in rural regions. New awareness initiatives would deepen rural residents’ knowledge about where and how to access virtual care.
  3. Ensure access to ‘touchstone providers’ who can provide rural residents with information about virtual services and direct them to the appropriate programs. Touchstone providers could also help troubleshoot technological issues, which would be especially helpful for senior populations.
  4. Expand hybrid options that combine in-person and virtual modalities. Clinicians noted some hesitancy towards virtual care among rural Nova Scotians. Prioritizing hybrid formats would help ensure that rural residents who are uncomfortable using solely virtual formats can access in-person treatment when necessary.
  5. Create new spaces for rural practitioners and communities to participate in mental healthcare policy and program design, supported by government funding. Increased rural participation in policymaking could provide vital feedback about recent policy changes, improving the responsiveness and effectiveness of virtual care in addressing rural residents’ needs.
  6. Expand MSI insurance coverage classifications to include registered counselling therapists. Many Nova Scotians do not have insurance coverage for registered counselling therapists, who are also not covered by MSI. Extending insurance classifications would expand rural access to affordable mental healthcare, combatting long waitlists.
  7. Research alternative community-based treatment and support programs, such as Assertive Community Treatment. Alternative treatment forms could aid rural communities without access to appropriate numbers of physicians or in-person treatment facilities, bolstering access and combatting rural wait times.
  8. Increase internship opportunities, financial incentives, and funding in rural communities to attract and retain new and diverse mental healthcare practitioners to rural areas who can meet the mental healthcare needs of rural Nova Scotians.

For decades, Nova Scotia has gradually moved away from institutional care, downloading care from in-patient services to virtual formats (Fingard and Rutherford 2005; 2011). Successive Nova Scotia governments have for decades emphasized creating new virtual programs to devolve strain from in-person services to virtual modalities, but in turn, have exacerbated rural mental healthcare barriers. Moving forward requires further data about rural Nova Scotians' views to inform new policy alternatives. To do so, the government must collaborate with those who know rural needs best, including rural healthcare practitioners, social workers, non-governmental organizations, and rural Nova Scotians. As a peer support group facilitator stated during their interview, it is crucial that “people with lived experience and knowledge play a major role… our voices need to be heard. They’re getting there; it’s more receptive now than ever, but it ought to be even more so.”

About the author: Robin Lauzon is a 2023 Acadia University graduate, graduating with an Honours Bachelor of Arts in Political Science and a minor in Legal Studies. Raised in Mi’kma’ki (Nova Scotia), her research interests include mental healthcare policy/politics and the social determinants of health.

This article is drawn from Lauzon’s honours thesis, which can be accessed via Acadia Scholar.

  

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