A pilot program to provide psychiatric assessments to patients in the emergency department is proving so successful that it will be rolled out statewide.
By Amy Ellis
On the eastern edge of our state, a mental health patient who’s been involuntarily committed by his family previously enters a rural hospital emergency department in apparent psychiatric crisis.
After interviewing the patient, the emergency department physician questions whether it’s actually the patient – or one of the patient’s family members – who needs psychiatric treatment. No psychiatrist is available for miles around to make an assessment.
During the past few years, in many Eastern North Carolina hospitals, such a scenario likely would have triggered a hemorrhage of time and resources as hospital staff, having little psychiatric expertise, did everything they could to play it safe. Mental health patients presenting to these rural emergency departments have long experienced excessive wait times, unnecessary involuntary commitments and admissions, extended lengths of stay and disjointed care.
In addition, untold resources have been drained by the local law-enforcement agencies responsible for transporting them to state facilities for specialized psychiatric care.
But when this scenario played out recently at Albemarle Hospital in Elizabeth City, it was a different story, according to Scott Polsky, the hospital’s emergency department medical director.
“Through the hospital’s new telepsychiatry service, we were able to consult with psychiatrists who interviewed both the patient and the family members,” he said. “They quickly determined that involuntary commitment was not needed for the patient – but was needed for the family member who took out the initial paperwork.”
Behavioral health management
This pilot telemedicine program Polsky refers to is vastly improving the delivery of acute psychiatric care, and reducing its delivery costs, in 10 remote Eastern North Carolina hospitals where access to psychiatric expertise was limited or absent before.
As a result, the Joint Legislative Oversight Committee on Health and Human Services has recommended to the N.C. General Assembly that a plan be developed to expand the network statewide.
“We created this program out of a need to assist emergency departments in managing behavioral health patients in crisis,” said project director Sheila Davies.
“When these patients come in to the ED, especially those with an involuntary commitment order, emergency physicians, who aren’t typically psychiatric experts, can be leery of lifting the involuntary commitment, for obvious reasons,” Davies said. “God forbid a patient leaves and kills themselves or someone else. And most rural hospitals don’t have access to psychiatrists to do these assessments.”
The North Carolina Telepsychiatry Network allows “subscribing” hospitals to offer patients psychiatric assessments via two-way, real time, interactive audio and video connections to providers located at Coastal Carolina Neuropsychiatric Center (CCNC) in Jacksonville. The program is funded by a three-year, $1.6 million grant from The Duke Endowment and managed by the Albemarle Hospital Foundation in partnership with Vidant Health and the Brody School of Medicine at East Carolina University.
Although modeled after South Carolina’s successful, Duke-funded Statewide Telepsychiatry Project, North Carolina’s version is promising to be at least three times more cost-effective. And it’s proven itself a boon for hospitals along the state’s Inner and Outer Banks, where critical shortages of mental health professionals have been felt most acutely in recent years.
Now when a patient in behavioral crisis presents to an ED in the Telepsychiatry Network, the emergency physician can request a telemedicine consult with a psychiatrist at any time of day or night.
A nurse rolls a portable cart outfitted with a monitor, camera and microphone into the patient’s bay or room, establishes a secure web link to the psychiatric provider site and introduces the patient to an “intake specialist” on the other end who’s already reviewed the patient’s presentation information and history. This master’s-level psychologist or social worker delves deeper into the patient’s present situation and treatment history and tries to gather more information from family members.[pullquote_left]North Carolina Telepsychiatry Network Participants:
– Albemarle Hospital (Elizabeth City)
– Vidant Bertie Hospital (Windsor)
– Vidant Chowan Hospital (Edenton)
– Vidant Duplin Hospital (Kenansville)
– Vidant Edgecombe Hospital (Tarboro)
– Vidant Roanoke-Chowan Hospital (Ahoskie)
– The Outer Banks Hospital (Nags Head)
– Vidant Pungo Hospital (Belhaven)
– Vidant Beaufort Hospital (Washington)
– Carteret General Hospital (Morehead City)[/pullquote_left]
A psychiatrist then interviews the patient and makes a recommendation back to the referring hospital physician, who is ultimately responsible for care decisions.
In most cases, psychiatric consultants can access the referring hospital’s electronic medical record for the patient. They can also document their findings, medication and disposition recommendations directly into the EMR system. A patient still in the hospital 24 hours after an initial assessment is reevaluated via a follow-up telemedicine consult.
The carts, valued at $24,000 each, are provided by The Duke Endowment. The hospitals’ monthly “subscription fees” are based on volume of usage and range from $275 (for approximately 12 assessments) to $2,000 (around 80 assessments).
“It’s an incredibly affordable way for these hospitals to have seven-day-a-week, 365-day psychiatric coverage in their emergency departments,” said Davies.
She noted that hospitals have had an especially rough time over the past decade as the delivery of mental health care has shifted from institutionalized care to community-based care.
“This shift has led to many inpatient facilities closing nationwide,” she said. “A certain number of people still require inpatient care, but only a limited number of beds are available. This has created waits, sometimes three or four days, for patients to transfer to a state or inpatient facility.”
Today, in Telepsychiatry Network hospitals, only patients in critical need of institutionalized care are waiting that long. And they’re receiving ongoing, specialized psychiatric treatment while they wait.
In fact, one third of them improve so drastically after a day or two that their involuntary commitments (IVCs) can be overturned, and the patient is redirected to community outpatient treatment. Furthermore, the experts at CCNC are generally able to place patients in inpatient facilities more quickly than could a hospital nurse or unit secretary, who’s typically overburdened already and not usually a mental health expert.
“Outcomes across the 10 participating hospitals are trending like we’d hoped,” said Davies. “Not only have we seen a big reduction in unnecessary IVCs but the average length of stay has also dropped for patients presenting to the ED with a mental health-related primary diagnosis.”
While the statewide average length of stay for these patients is more than 13 hours, she said, the network hospitals’ average length of stay for them has dropped from 48 hours to 8.4 over the span of the project.
Davies said the biggest challenges with the project have centered around billing structure and contract negotiations with the various local management entities (LMEs) involved. Most LMEs, the private agencies state-authorized to oversee all mental health care within specific geographical areas, now control both the Medicaid funding for psychiatric patients and the dollars designated for indigent psychiatric care.
Project funding allows for up to 10 more hospitals in various LME catchment areas to join the network this year.
Further complicating things is the state’s requirement that a provider be credentialed with the LME where the patient lives, even though the hospital a patient presents to might be represented by another. Davies said state legislators could facilitate network expansion by streamlining the provider credentialing process.
But overall, she said, there are no significant hurdles to prevent a statewide expansion of the network. “The technology’s there, the financial sustainability, the protocols. It meets the needs of the patient and the provider. It’s a user-friendly, quality way of delivering health care.”
‘This is the future’
Ashraf Mikhail, CEO and lead psychiatrist of CCNC, affirmed that his providers consider the telepsychiatry technology to be user friendly and the patient interaction to be high quality. The only training required was familiarizing his staff with the various hospital EMR systems.
“Some of our older providers without telemedicine experience were ambivalent at first,” he said, “worried about liability issues and patient safety. But we’re all very happy with the experience now.
“We’re excited about the success we’ve had in getting [length of stay] numbers down, relieving ED physicians from suffering over treatment decisions and preventing patients from waiting a week to get into a state facility.”
An added bonus: This project has helped ED physicians understand more about psychiatric care, and vice versa, said Mikhail.
Network providers are seeing an 85 percent or better patient satisfaction rate, especially impressive for a patient population that is generally unhappy about their circumstances to begin with.
“This is the future,” said Mikhail. “Trying to become more efficient in providing care will not be a simple solution; it will take more creative ways of treating people. Of course, that’s the nature of psychiatry; we’ve always had to consider out-of-the-box thinking.”
Polsky is impressed by the untold time and resources the project saves in rural emergency departments like his own.
But, while quick to sing telepsychiatry’s praises, he just as readily cautions that it’s no match for the critical shortage of psychiatric services still plaguing northeastern North Carolina.
“While the service has helped our flow,” he said, “it doesn’t substitute for having adequate inpatient bed space and psychiatric care for the disadvantaged.
“We need those things, and especially we need more treatment facilities specializing in total diagnosis – care for patients with both addiction problems and psychiatric problems.”