It became clear that adding a tele-education program for providers working in IHS and tribal rural/frontier clinics would also increase access to care. Through these educational opportunities, rural and frontier providers would have increased capacity and confidence in providing care to those with more complex behavioral health conditions and have a system for additional consultation and training as necessary. After several unsuccessful trials using regular face-to-face video connections, the decision was made to switch to a Web-based learning system. Although this change proved to be challenging, time has shown it to be the correct choice. Growth within this tele-learning community was extraordinary. Hourlong webinars were now provided on behavioral health topics routinely encountered in primary care and behavioral health clinics, as well as sessions on crisis management and risk assessment. Most of the presenters were from CRCBH and represent clinicians and public health professionals from a broad interdisciplinary background with experience working in rural and Native American communities. The focus of the seminars has been to provide specific and pragmatic information with a culturally sensitive approach for providers working in rural/frontier area communities serving Native Americans. Dr. Fore facilitated the majority of these sessions using a conversational and interactive approach to encourage participation and critical thinking from attendees. Learners were encouraged to use the online chat and survey functions to engage with the presenters during the webinars. In addition to providing current clinical information on behavioral health, the interactive nature of these webinars helped to develop a sense of community among providers working in rural and isolated settings. During the first quarter of the program (fiscal year 2012, quarter 3), 135 providers were trained. During the last quarter of fiscal year 2013, 3050 providers were trained, an increase of 2260 % in 16 months (Fig. 6.2). During fiscal year 2013, the 156 educational seminars held trained more than 8700 providers, and more than 5000 free continuing medical education (CME) credits and continuing education units (CEUs) were provided.

Within the clinical telebehavioral program we have noted that patients are 2.5 times more likely to come for their telepsychiatry appointment than an “in-person” psychiatry session. This is particularly surprising given that they have to travel to the clinic for either type of session. When asked about this, the vast majority of patients said they feel that the telepsychiatry session is more confidential than “in-person.” They know that they will not run into their provider at the local school or grocery store and therefore feel that the chances of confidentiality breaches are less. Although the telecounseling component is relatively new, there is also strong anecdotal evidence to support it. For example, during the first 2 weeks of the program the psychologist was told by three different women, “If you were in the room I wouldn’t tell you this.” All three then went on to disclose histories of childhood sexual abuse, which were extremely relevant to the treatment.