Mental Health Research

Telepsychiatry in NC: Mental Health Care Comes to You

An emergency department patient talks with a psychiatrist via a secure network.

This article on Telepsychiatry in NC was published in North Carolina Insight in July 2014.  We are highlighting our previous work on mental health as part of mental health awareness month. 

 

Getting mental health care to the rural areas of North Carolina has never been easy. Twenty-eight counties across the state still do not have a psychiatrist. (See updated numbers here)

This work force shortage is real, and it has a real impact on the lives of those needing mental health treatment in places that are far away. In northeastern North Carolina, mental health care providers tell stories about “the 18-hour work day.” A psychiatrist would wake up early in the morning to take a three-hour ferry to the Outer Banks. If the psychiatrist took the ferry back, then he would only be able to provide treatment services for one hour. So he took the long way back, resulting in an 18-hour work day to provide these important services to people in need in our rural counties. No one questions the existence of the problem, but solutions have been hard to find. Until now. Telepsychiatry is changing the way mental health care is provided to people in need in very rural areas all across our state.

Telepsychiatry is part of a growing national trend called telemedicine, in which physicians can see patients from remote locations using secure video and audio- streaming technology called videoconferencing. A psychiatrist or other health care professional can talk to and physically view the patient through a video screen with a web camera and microphone. On the other end, the patient can view the psychiatrist through a similar audio-visual system. North Carolina is a national leader in the use of telepsychiatry, thanks to the leadership, hard work, and determination of a group of professionals committed to this solution.

Telepsychiatry with the Eastern North Carolina School for the Deaf
Telepsychiatry with the Eastern North Carolina School for the Deaf, photo courtesy of East Carolina University

Dr. Sy Saeed, the chairman of the Department of Psychiatric Medicine at the Brody School of Medicine at East Carolina University, pioneered the use of this technology. The ECU Telemedicine Center has been addressing that problem since 1992, making it one of the longest continuously running telemedicine centers in the world. ECU’s Telemedicine Center provides telepsychiatry services at a variety of sites, ranging from state psychiatric hospitals to family doctors to pediatricians to residential schools for the deaf and blind. Saeed says, “There is no health without mental health. And, if you don’t have professionals in the area, you have a problem.” 

REACH-TV, Rural Eastern Carolina Health-Network Telemedicine Clinical Sites
Photo courtesy of East Carolina University

Expanding the Use of Telepsychiatry in Northeastern North Carolina

For Phil Donahue, the former vice president of the Albemarle Hospital Foundation in Elizabeth City, the mental health work force shortage became all too real in February 2009. The Albemarle local mental health management entity (LME) — an organization funded by the state to oversee the referral and payment for mental health services for a 10-county region in northeastern North Carolina — became financially insolvent, leaving area hospitals and free clinics without much-needed psychiatric services. Those 10 counties served in the northeastern part of the state were Camden, Chowan, Currituck, Dare, Hyde, Martin, Pasquotank, Perquimans, Tyrrell, and Washington counties.1

“Because of some improprieties of the director, the LME went under, it just collapsed,” says Donahue. “What happened then was that the psychiatrists they employed all left because they weren’t getting paid, and they took other jobs. So we were left with no psychiatric services for the entire 10-county region.”

“We live in a time when the treatment of mental illness has never been more effective.
Recovery is possible and within reach! Unfortunately, many of our patients don’t have access to treatment. It’s not uncommon for me when I’m in the clinic to hear from the patient that the reason they can’t come to the clinic is because they can’t afford the gas. Telepsychiatry offers the promise of bridging the distances between providers and patients.”
— Dr. Sy Saeed, Chairman of the Department of Psychiatric Medicine, Brody School of Medicine, East Carolina University

Located in Elizabeth City in Pasquotank County, the Albemarle Hospital Foundation was created in 2003 as a part of the Albemarle Health system, and it currently oversees 12 programs in northeastern North Carolina. The Foundation’s Community Care Clinic in Elizabeth City offers free primary care and prescription services to the region’s indigent and uninsured population. Other clinics in Gatesville and Tyner offer services on a sliding scale based on family income. The Albemarle Health System also operates the Albemarle Hospital in Elizabeth City and a regional medical center in Kitty Hawk.

Albemarle Hospital in Elizabeth City, NC.
Albemarle Hospital in Elizabeth City, NC. Photo courtesy of Albemarle Hospital Foundation

“We had an agreement with the LME that we would see all of their uninsured patients through our pharmacy programs,” says Donahue. “So, we had all of these patients who all of a sudden needed refills on their prescriptions and no doctor to authorize it.”

The result was an increasing number of uninsured patients arriving at the doors of the region’s hospital emergency rooms. Psychiatric lengths of stay for patients presenting to local emergency rooms with mental health issues began to burden the capacities of local hospitals. According to Donahue, many patients entering emergency rooms for psychiatric services only need a psychiatric evaluation or a change in their medications. However, many emergency medical providers are not trained properly to provide those psychiatric services, so they admit the patient and hold them until they can obtain a psychiatric consultation or have them admitted to one of the state’s psychiatric hospitals.

“When we’re holding a patient, we have about one or two staff people who have to drop what they’re doing to (1) physically watch this patient and make sure they don’t hurt themselves or someone else, and (2) start that whole committal process — of writing all the papers and making all the phone calls, doing all the things you have to do to get this person committed into an institution,” says Donahue. “Sometimes we can get it done in a day or two, sometimes it takes three or four days to do it. And we have had patients being held up to six days in our hospital. That wait comes at a huge cost for the hospital, the family, and most importantly, the patient.”

“The need for more and more care will increase. So we just have to be smart and use technology to tie the number of providers to the growing need and number of patients.”
— Dr. Robin Cummings, Director, Division of Medical Assistance And Deputy Secretary for Health Services,
N.C. Department of Health and Human Services

The number of admissions to hospital emergency departments statewide continues to increase for those with a mental health, developmental disability, or substance abuse diagnosis from 132,214 in 2009 to 156,661 in 2012, an 18.5 percent increase. The N.C. Hospital Association collected data in 2012 for about 40 percent of the hospitals across the state on persons with mental health and substance abuse diagnoses, including wait times by disposition. For those admitted to a community hospital psychiatric bed, the wait time was 24.5 hours. For those admitted to a state psychiatric hospital the wait time was more than 78 hours. In the first half of 2013, the average wait time for state hospital admissions had increased to more than 85 hours.2

“I have met with every county manager in these 10 counties, and it’s the biggest single problem they face,” says Donahue. “They either have to send their sheriffs to stay with the patient in the hospital or to drive the patient to the state institution where they can get a commitment. Nine times out of 10, these patients don’t need to be committed. They are evaluated there, and they are sent home. We have had cases where the patient gets back to town before the sheriff does.”3

Sheila Davies demonstrates how the telepsychiatry unit functions
Sheila Davies demonstrates how the telepsychiatry unit functions. Photo by Rose Hoban

The Albemarle Hospital Foundation’s foray into telepsychiatry has been a success. The hospital-based telepsychiatry program expanded to serve 18 hospitals in 30 counties covering more than 1 million people.4 Donahue is quick to note that the success of the program would not have been possible without funders like The Duke Endowment and Kate B. Reynolds Charitable Trust, health care providers like ECU’s Telemedicine Center and Coastal Carolina Neuropsychiatric Center, skilled professionals like his former director of telepsychiatry Sheila Davies, who figured out how to make this idea work on the ground, and the patients who were willing to give it a try.

Phil Donahue
Photo courtesy of Albemarle Hospital Foundation

“We have the nurse prepare the patient, tell them what to expect, tell them they are going to talk to a psychiatrist in a different location. They have the option to have a member of their family with them, if they choose to, but most of them do not. And then we close the door and let them interact with the psychiatrist. Of course, we are there if they need us for any reason.”

— Phil Donahue, former Vice President of the Albemarle Hospital Foundation

The program has improved patient outcomes. The length of stay (LOS) in the emergency rooms for patients waiting to be discharged to inpatient treatment has declined from 48 hours to 22.5 hours. The percentage of patients returning for treatment within 30 days at Albemarle Hospital declined from 20 percent to 8 percent. The number of involuntary commitments to local hospitals or state psychiatric hospitals decreased by 33 percent. Readmissions to psychiatric hospitals of those with severe and persistent mental illness also declined.5 Eighty- eight percent of patients agree or strongly agree that they were satisfied with the telepsychiatry services they received. See Table 1 for additional information on outcomes at different telepsychiatry programs in North Carolina.

 

Table 1
Table 1

South Carolina’s Experience with Telepsychiatry

Definition of Telepsychiatry
The definition of telepsychiatry is the delivery of acute mental health or substance abuse care, including diagnosis or treatment, by means of a secure, two-way real-time interactive audio and video by a health care provider in a remote location to an individual needing care at a referring site. “The term does not include the standard use of telephones, facsimile transmissions, unsecured electronic mail, or a combination of these in the course of care,” according to N.C. General Statute § 143B-139.4B.

In looking for solutions to the lack of psychiatric services in the Albemarle region, Phil Donahue visited South Carolina to study their telepsychiatry system, which has been in operation since 2007 when it was first funded by The Duke Endowment in Charlotte. It had proven to be a valuable service for communities that do not have the psychiatric professionals necessary to meet their mental health consumers’ needs. The use of telepsychiatry in South Carolina not only has increased access to care for rural communities, but it also has contained costs by decreasing the number of people admitted to state institutions from hospital emergency rooms. In three years, from 2010–13, the number of patients treated using telepsychiatry increased from 8.7 to 12.3 per day. The length of stay in emergency departments waiting for treatment has decreased from 48–72 hours to less than six hours in July 2013.6

After visiting South Carolina, the Albemarle Hospital Foundation initially provided the necessary technology to allow patients at two free clinics to have access to Dr. Sy Saeed and a group of psychiatric professionals at East Carolina University in Greenville, more than 100 miles from Elizabeth City. Unable to afford high-end tele- psychiatry technology, which Phil Donahue estimated to cost $35,000–40,000 per unit, he used some older equipment from the local mental health management entity and the local hospital. “We made it work,” Donahue says. “Patients seemed to be ok with it, even though the screens were rather small, and it was not ideal for telepsychiatry.” Once a week, patients at the free clinics could see a psychiatric professional for medication management, evaluations, and basic mental health check-ups. “Our hope in doing this,” says Donahue, “is that we avoid having these same people in our emergency departments later on.” The telepsychiatry program at the clinics is not operational anymore, but it was the building block for the Foundation’s hospital-based telepsychiatry program, which in turn was the building block for North Carolina’s new statewide telepsychiatry program.

SC Goals for Telepsychiatry

Using Telepsychiatry To Increase Access to Mental Health Services in Rural Areas

Electronic information and telecommunication technologies provide new ways to deliver medical care and can ease the pressure on North Carolina’s mental health work force shortage. In a handful of North Carolina settings, telepsychiatry allows rural health care providers to connect to mental health experts in other parts of the state. Interactive technologies like videoconferencing, the Internet, store- and-forward technology,7  and streaming media make it possible for mental health providers to be “in two places at once.”8  The American Psychiatric Association says telepsychiatry is “one of the most effective ways to increase access to psychiatric care for individuals living in underserved areas.”9  And, as part of its mission to assure quality health care for underserved, vulnerable, and special needs popula- tions, the U.S. Department of Health and Human Services promotes the use of telehealth technologies for health care delivery.10 

In 2013, the Sheps Center for Health Services Research at UNC-Chapel Hill released data for 2011 on the number of physician specialists by county. Twenty-eight counties in North Carolina do not have a psychiatrist (compared to 30 the year before in 2010), and an additional 18 counties have only one psychiatrist. Seventy counties do not have a child psychiatrist, and an additional 14 only have one. Only six counties have a geriatric psychiatrist. Only five counties have addiction psychiatrists, and only 13 counties have physicians specializing in addiction and chemical dependency. See Table 2. (Click here to see updated Table)

Table 2
Table 2

Using federal data, in August 2013, 58 counties in North Carolina were designated as Health Professional Shortage Areas because they do not have enough mental health providers.11 Telepsychiatry is part of the solution for providing mental health and substance abuse care to North Carolinians in rural areas.

Telepsychiatry networks typically have a “regional medical center or state psychiatric hospital” as a hub, with community organizations and providers connected like spokes. Consultations and evaluations are sent from the hub to the various spokes through telecommunication mechanisms, such as videoconferencing. At the central hub site is the mental health specialist. At the spoke site with the patient, is a “community mental health staff member who provides case management, information, and support.” Many spoke sites have a nurse physically present in the room during the consultation to observe the patient and assist with ordering medications and other medical services. 12

How Telepsychiatry Works

Research on Telepsychiatry

Telepsychiatry improves collaboration between practitioners and can improve patient satisfaction.13  The American Psychiatric Association has reported nationally that patients are generally satisfied with the experience.14 Dr. Sy Saeed of ECU says he has found no evidence that “patient satisfaction or outcomes with telepsychiatry are inferior to those seen in comparable face-to-face treatment.”15

A survey of children and their parents using telepsychiatry services in rural Kentucky found similar patient satisfaction. All the respondents in Kentucky felt that telepsychiatry allowed greater access to care and “almost all” did not prefer an in-person consultation to a telepsychiatry visit. Interestingly, some of the children participating in the service found it easier to be open with a provider in a telepsychiatry consultation than in a traditional in-person consultation.16
A review by the California Telemedicine and eHealth Center of multiple studies found high patient satisfaction with telepsychiatry. In addition to patient satisfaction, research on telepsychiatry noted an increase in access to care and specialty consul- tations. Good clinical outcomes also are indicated using telepsychiatry, but more research is needed. While telemedicine has been expensive for providers to set up at the start, it often results in cost savings for patients and their employers, specifically by decreasing travel time and time off work and increasing worker productivity.17

CTEC ReportA 2004 study showed that telepsychiatry can be an effective means of treating adults with depression, particularly in small medical practices. The study found that when telepsychiatry is used in a collaborative care approach in rural settings, patients were more likely to take their medications. This reduced the severity of depression and increased their “mental health status, health-related quality of life, and satisfaction.”18

Barriers To Acceptance and Implementation of Telepsychiatry

While telepsychiatry has shown great promise, policymakers in North Carolina need to be aware of barriers to patients and practitioners that prevent widespread acceptance and implementation of telepsychiatry. The California Center’s review identified the following barriers:

“The down side of teleservices is the loss of face-to-face interaction. It can be difficult to build trust. This can compound disposition problems when there is a disagreement. Overall, though, I would say that the utilization of telepsychiatry has been an asset. Initial disposition plans are established quickly. Patient medications can be actively managed. The telepsychiatry notes are available for all providers to review. My hope for the future of telepsychiatry is that it can be expanded to local clinics, not just emergency departments. The service should be expanded to agencies such as mobile crisis units to assist with stabilization as a crisis is occurring with the patient in the community.”
— Dr. Jody Osborne, Director of the Emergency Department at Randolph Hospital

Barriers to Patients
Patients don’t know about it. Patients usually learn about new services and procedures through physician referrals. Research has shown that “patients are likely to use telemedicine if their healthcare providers recommend it.” However, telemedicine is used mostly by specialists currently, so many patients are not aware of the service.19

Patients worry about privacy. The telemedicine literature review notes that “patient uncertainty about privacy protections [is] another frequently highlighted barrier to diffusion of telemedicine.”20

Older patients may be uncomfortable with technology. Some elderly patients tend to be more socially isolated as they age. Therefore, the personal, face-to-face interaction of a traditional office visit has extra meaning. Additionally, elderly patients are typically not as comfortable with “computer-assisted technologies.”21

Barriers for Health Care Providers

What is the standard of care? Are there risks of malpractice lawsuits and liability for violating privacy laws? An important concern for providers is having an accepted standard of care for telemedicine services and protection from malpractice liability. The question is whether delivering health care services through tele-technologies should require new standards. In Canada, for example, there is consensus that new standards are not required.22  In North Carolina, telepsychiatry providers and psychiatrist will be required to carry liability insurance. Minimum coverage for providers will be $1 million to $3 million, and minimum coverage for consultant and referring sites will be $3 million to $5 million. “The liability will reside as it usually does within the medical practice or individual provider.”23 Additionally, the “nature of IT technologies used in transmitting personal medical records creates heightened concern …” regarding complying with privacy laws.24

What are the costs? Incorporating telemedicine into a medical practice can require a significant up-front investment of capital and resources.25 According to the website of the American Academy of Child and Adolescent Psychiatry, “A wide range of video systems are used for telepsychiatry practice. They vary in cost of the system, the cost of use and in the degree of resolution of the video image. More expensive systems use personal computers, video cameras at both ends of the connection, computer based video monitors and ISDN cable wiring between sites.”26 The Fiscal Research Division of the N.C. General Assembly estimates $9,000 for consultant desktop units and $19,000 for mobile telemedicine carts.27 However, as security and privacy concerns are addressed through advances in technology, the use of iPads, for instance, in telemedicine may lower the costs of this type of service.

“There will never be a virtual substitute for the human touch or voice in promoting healing. Thus, an even greater role exists for physician extenders who know their business.”
— Former Rep. Jim Fulghum
(R-Wake), Physician

Will the psychiatrists get paid? Typically, psychiatrists are reimbursed based upon “patient encounters,” which is defined as the patient and provider being in the same room when care is given.28 With telepsychiatry services, the patient and provider are not in the same room and may even be hundreds of miles apart. In the best case scenario, getting reimbursement for a telepsychiatry consultation may require some additional paperwork, and it will cover an assessment for a diagnosis, medication management, and psycho- therapy.29 In the worst case, it means that providers may not get paid. The American Psychiatric Association suggests “reimbursement for telepsychiatry should follow customary charges for delivering appropriate current procedural terminology code(s),” and “a structure for reimbursement of collateral charges, such as technician and line time….”30  According to the National Conference of State Legislatures, 19 states require private insurance plans to cover telehealth services. Blue Cross Blue Shield of North Carolina opposes mandatory reimbursement policies for telemedicine.

 

“I love [telepsychiatry] because it’s real health care reform, and it changes the way health care is delivered. This is an innovative way to provide care.”
— Rep. Susan Martin (R-Wilson), As quoted in The News & Observer

However, restrictions on telemedicine reimbursements are easing. Some states, including North Carolina, have led the way in including telemedicine and telepsychiatry as billable Medicaid services.31 “Medicare started reimbursing providers for telemedicine in 1999,”32 and Medicaid now pays for telepsychiatry in 40 states.33 “We’ve opened it up a lot, so traditional services can be provided by telepsychiatry and billed under Medicaid,” says Dr. Michael Lancaster, former chief of clinical policy for the state Division of Mental Health, Developmental Disabilities and Substance Abuse Services. “That has yet to really move into the private sector. We really would like to see third party payors be more supportive of telepsychiatry.”

Benefits of Telepsychiatry

Aldona Wos, Secretary of the N.C. Department of Health and Human Services (standing), and Governor Pat McCrory at ECU in August 2013;
Aldona Wos, Secretary of the N.C. Department of Health and Human Services (standing), and Governor Pat McCrory at ECU in August 2013; Photo courtesy of the Office of the Governor

North Carolina’s New Statewide Telepsychiatry Initiative

Governor Pat McCrory
Photo courtesy of the Office of the Governor

“No matter where you live in North Carolina, you will soon have better access to mental health providers with the expansion of telepsychiatry across our state. Technology will help us connect people with appropriate treatment programs so patients can avoid long waits in the emergency room. North Carolina can be a national leader with this program.”
— Governor Pat Mccrory

Awareness of these barriers to patients and mental health providers will help the state implement a statewide telepsychiatry system worthy of national recognition. In July 2013, the N.C. General Assembly established a statewide telepsychiatry program in North Carolina.34  The North Carolina Statewide Telepsychiatry Program (NC-STeP) is administered by East Carolina University’s Center for Telepsychiatry and e-Behavioral Health (CTeB). It will be substantially similar to the Albemarle Hospital Foundation Telepsychiatry Project. The legislature appropriated $2 million for the program for Fiscal Year 2013–14 and $2 million for 2014–15.

In August 2013, the N.C. Department of Health and Human Services presented a plan to the legislature to implement a statewide telepsychiatry program. Initially, the primary objective of the program is to improve access to telepsychiatry in hospital emergency rooms across the state.35 Many stakeholders participated in a year-long process to develop the plan. See Table 3 for members of the N.C. Telepsychiatry Program Advisory Group.36

Table 3
Table 3

The state’s new statewide telepsychiatry initiative launched on January 1, 2014.37  By May 2014, 24 hospitals were participating in the state’s telepsychiatry program. An additional 23 hospitals are scheduled to begin participating between June and September 2014. These 47 hospitals will serve 53 counties. Thirty additional hospitals are on the waiting list and are likely to join the program between November 2014 and June 2015. When these 30 hospitals participate, the program will serve 81 counties across North Carolina.38

Sy Saeed
Photo courtesy of East Carolina University

“It is not about technology. It is about relationship.”
— Dr. Sy Saeed, Chairman of the Department of Psychiatric Medicine, Brody School Of Medicine, East Carolina University

Under the direction of Dr. Sy Saeed, and with the assistance of Phil Donahue and Sheila Davies who are both now on contract with ECU to facilitate the implementation of the statewide telepsychiatry network,39 ECU’s Center for Telepsychiatry is required to develop and administer an oversight process. The process will include quality management as well as the monitoring and reporting of outcomes for the state’s telepsychiatry program. Currently, the Center for Telepsychiatry is required to report quarterly and annually to the DHHS Office of Rural Health and Community Care on (a) the number of consultant sites and referring sites participating in the program, (b) the number of psychiatric assessments conducted under the program, reported by site or region, (c) the length of stay of patients receiving telepsychiatry services in the emergency rooms of hospitals participating in the program, reported by disposition, and (d) the number of involuntary commitments (IVCs) as a result of telepsychiatry assessments, reported by site/region and year, compared to the number of IVCs prior to implementation of this program. Additionally, all clinical providers are required to participate in a peer review process.

Gwen Newman, a patient that uses telepsychiatry in Hyde County, says, “Driving an hour and a half to go to the doctor or to get one of my family members there is exhausting and frustrating. This telemedicine program makes a huge difference for all of us. I know we’re healthier because of it.”40 That’s the promise of telepsychiatry…mental health care comes to you, even if you live in rural North Carolina.

The Center’s Findings and Recommendations

Based on our research, the N.C. Center for Public Policy Research finds that for many people living in rural North Carolina, access to mental health care is the biggest barrier to recovery. Telepsychiatry will increase access to treatment across the state, and it may reduce the amount of time patients have to wait in emergency rooms for treatment, reduce the likelihood that patients will have to return for treatment, reduce the number of involuntary commitments to hospitals for psychiatric care, and reduce readmissions to psychiatric hospitals for those with severe and persistent mental illness. Patient satisfaction with telepsychiatry appears to be high. Dr. Sy Saeed says he has found no evidence that “patient satisfaction or outcomes with telepsychiatry are inferior to those seen in comparable face-to-face treatment.

Based on our findings, the N.C. Center for Public Policy Research recommends that the Governor, the N.C. General Assembly, the Office of Rural Health and Community Care in the N.C. Department of Health and Human Services (DHHS), and the N.C. Telepsychiatry Program Advisory Group consider the following actions to implement the state’s new telepsychiatry program and make it a national model:

  1. The Office of Rural Health and Community Care in the N.C. Department of Health and Human Services and East Carolina University’s Center for Telepsychiatry should conduct a public campaign to raise awareness about telepsychiatry in rural and under-served communities. This should include patient stories that specifically address patient concerns about their privacy, the confidentiality of their personal health information, and any discomfort older adults may feel about technology.
  2. The DHHS Office of Rural Health and Community Care should provide technical in- formation directly to rural health care providers and health centers describing expected costs, funding sources, legal restrictions, and clear reimbursement rates for telepsychiatry services.
  3. The N.C. General Assembly should pass legislation requiring a study of telemedicine, including whether private insurers should be required to fully reimburse health care providers for telepsychiatry services. House Bill 704, which passed the N.C. House in 2013 and is pending in the Senate for the 2014 legislative session, would require the Joint Legislative Oversight Committee on Health and Human Services to conduct a study of telemedicine. According to the state’s plan, this bill would be “a first step for possible enactment of legislation to require full payment by third party payors for services provided via telemedicine.”41 The Legislative Research Commission Study Committee on Health Care Provider Practice Sustainability and Training/Additional Transparency in Health Care is conducting a “comprehensive review of all existing State programs that are designed to improve access to health care provider care using telemedicine, including the name of the program, a description of the program, and details on program performance.”42 The commission may make an interim report of recommendations to the 2014 legislature and is required to make a final report to the 2015 legislature. According to the National Conference of State Legislatures, 19 states (not including North Carolina) require private insurance plans to cover telehealth services.
  4. The DHHS Office of Rural Health and Community Care should provide technical and financial assistance to rural health care providers who want to incorporate telepsychiatry into their practices. The Office should assess the need for a one-time subsidy to hospitals, community health departments, and rural providers to update their telecommunication capabilities. If needed, the legislature should appropriate funds to implement the subsidy. The Mental Health Subcommittee of the Joint Legislative Oversight Committee on Health and Human Services recommended in a March 2014 report that the legislature provide funding to expand the telepsychiatry program to primary care providers. In April 2014, the Joint Legislative Oversight Committee on Health and Human Services included this recommendation in its report to the N.C. General Assembly.
  5. The N.C. General Assembly should increase funding to the state’s medical schools, nursing programs, schools of social work and psychology programs, as needed, to incorporate telemedicine and telepsychiatry as part of the their curriculum. The UNC Board of Governors should decide where to focus the funding, which programs will take a leadership role, and the number of campuses involved.
  6. The DHHS Office of Rural Health and Community Care should partner with medical schools in North Carolina to incorporate telepsychiatry into the residency programs at East Carolina University, Duke University, UNC-Chapel Hill, and Wake Forest University and partner with local Area Health Education Centers (AHECs) to connect psychiatric residents under appropriate faculty supervision with rural providers via centralized telepsychiatry services.
  7. As part of its implementation of North Carolina’s statewide telepsychiatry program, the N.C. Department of Health and Human Services should adopt in its rules the practice guidelines for video-based online mental health services developed by the American Telemedicine Association in May 2013. 43  The Association established these practice guide- lines and technical standards for telemedicine, based on clinical and empirical evidence, “to help advance the science and to assure the uniform quality of service to patients.” These guidelines serve as both a reference guide for operations and an educational tool to provide appropriate care for patients. Implementing these guidelines for telepsychiatry will improve clinical outcomes and ensure informed and reasonable patient expectations.
  8. The N.C. Department of Health and Human Services should develop criteria and out- come measures to evaluate the successes and failures of the state’s telepsychiatry program. Currently, ECU’s Center for Telepsychiatry is required to develop and administer an oversight process, including quality management as well as monitoring and reporting of out- comes for the state’s telepsychiatry program. The Center for Telepsychiatry is already required to report quarterly and annually to the DHHS Office of Rural Health and Community Care on (a) the number of consultant sites and referring sites participating in the program, (b) the number of psychiatric assessments conducted under the program, reported by site or region, (c) the length of stay of patients receiving telepsychiatry services in the emergency rooms of hospitals participating in the program, reported by disposition, and (d) the number of involuntary commitments as a result of telepsychiatry assessments, reported by site/region and year, compared to the number of involuntary commitments prior to implementation of this program. Additionally, all clinical providers are required to participate in a peer review process.

ECU’s Center for Telepsychiatry also should be required to track and report these additional outcomes: (a) satisfaction of emergency room staff, the psychiatrist, and the patient, and (b) recidivism data on the number of patients who return to the emergency room within 30 days.

The DHHS Offce of Rural Health and Community Care should implement its goals for the telepsychiatry program, including among others increasing the number of patients served with telepsychiatry, reducing the average length of stay of telepsychiatric patients in the emergency departments of local hospitals and state psychiatric hospitals, increas- ing the number of psychiatrists and psychiatric residents trained to use telepsychiatry, and reducing the cost of mental health care. The Offi should adopt additional outcome mea- sures that evaluate: (a) whether the patients’ mental health status actually improves; (b)whether involuntary commitments from telepsychiatric patients are reduced; and (c) whether more patients are served after the state’s telepsychiatry initiative is implemented than was true before; and (d) especially whether more are served in rural counties or in medically underserved areas.

Show 43 footnotes

  1.  These counties currently are served by East Carolina Behavioral Health, a managed care organization that oversees the provision of mental health services, serving 19 counties.
  2.  N.C. Department of Health and Human Services, “Mental Health Crisis Management Report, March 2013-May 2013: Status Report,” Raleigh, NC, October 1, 2013, p. 7. On the Internet at http:// www.ncleg.net/documentsites/committees/JLOCHHS/Handouts%20 and%20Minutes%20by%20Interim/2013–14%20Interim%20 HHS%20Handouts/October%208,%202013/Reports/LME%20 Crisis%20Report-10-01-2013.pdf, accessed October 20, 2013. Wait times reported in this report are more than those reported in the one- month study conducted in November 2010. This report found that during fiscal year 2009–10, 135,536 people were treated in hospital emergency departments across the state for a mental health crisis. More than 20 percent were transferred to a community psychiatric hospital bed. Only 239, or 2.7 percent, were sent to a state psychiatric hospital. The average length of stay in emergency departments for those that were transferred to a community hospital was 14 hours and 7 minutes. The average length of stay for those that were transferred to a state psychiatric hospital was 26 hours and 38 minutes — more than 12 hours longer. N.C. Department of Health and Human Services, Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, “Report on the Provision of Behavioral Health Crisis Services by Hospital Emergency Departments,” Raleigh, NC, March 1, 2011, pp. 3–5.
  3.  A pilot program in western North Carolina uses sitters in- stead of law enforcement for high acuity patients. The cost in fiscal year 2011 was $503,494 rising to $642,498 in FY 2012 and $671,168 projected for FY 2013. Mission Health Hospital, “North Carolina’s Mental Healthcare Crisis and the Resulting Challenges Facing Mission Hospital,” July 2013, p. 10.
  4. See also N.C. Department of Health and Human Services, “Statewide Telepsychiatry Program Plan,” Raleigh, NC, August 15, 2013, pp. 9, 11. On the Internet at http://governor.nc.gov/sites/default/files/TelepsychiatryProgramPlan.pdf, accessed on August 21, 2013.
  5.  Ibid., pp. 10–11. For more information on program out- comes, see Sheila Davies, Telepsychiatry Program Director, Albemarle Hospital Foundation, “A Hospital Driven Telepsychiatry Initiative to Improve Patient Care and Reduce Costs,” North Carolina Medical Journal, Vol. 73, No. 3, May/June 2012, p. 228.
  6.  On the Internet at http://www.state.sc.us/dmh/telepsychiatry/, accessed on September 19, 2013.
  7. Store-and-forward technology involves clinical information (for example, data, image, sound, or video) that is created, stored, then forwarded to another provider for clinical evaluation using email, for example. On the Internet at http://www.telehealth.va.gov/sft/, accessed September 20, 2013.
  8. Henry Smith and Roland A. Allison, Telemental Health: Delivering Mental Health Care at a Distance: A Summary Report, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, Washington, DC, 1998, p. 29.
  9.  On the Internet at http://www.psychiatry.org/practice/professional-interests/underserved-communities/telepsychiatry, accessed on August 23, 2013.
  10.  On the Internet at http://www.hrsa.gov/ruralhealth/about/ telehealth/, accessed on August 23, 2013.
  11. On the Internet at http://hpsafisa.gov/HPSASearch.aspx, data as of August 22, 2013. See also N.C. Department of Health and Human Services, “Fact Sheet: Using Technology to Take on NC’s Toughest Mental Health Challenges.” On the Internet at http://governor.nc.gov/sites/default/files/Telepsych%20Fact%20 Sheet.pdf, accessed on August 21, 2013.
  12.  Smith and Allison, note 8 above, p. 22.
  13. On the Internet at http://www.psychiatry.org/practice/ professional-interests/underserved-communities/telepsychiatry, accessed on August 23, 2013.
  14. Ibid.
  15.  Sy Saeed, MD, et al., “Telepsychiatry: Overcoming barriers to implementation,” Current Psychiatry, Vol. 11, No. 12, December 2012, p. 29.
  16.  Lee Ann Blackmon, H. Otto Kaak, and John Ranseen, Consumer Satisfaction With Telemedicine Child Psychiatry Consultation in Rural Kentucky, Psychiatric Services, Arlington, VA, November 1997, Vol. 48, No. 11, pp. 1464–66.
  17.  William D. Leach, “If You Bill It, They Will Come: A literature review on clinical outcomes, cost-effectiveness, and reimbursement for telemedicine,” California Telemedicine and eHealth Center, Sacramento, CA, January 2009, pp. 3–6.
  18.  John C. Fortney, Jeffrey M. Pyne, Mark J. Edlund, David Williams, Dean E. Robinson, Dinesh Mittal, and Kathy Henderson, “A Randomized Trial of Telemedicine-based Collaborative Care for Depression,” Journal of General Internal Medicine, Washington, DC, 2007, p. 1090.
  19.  Leach, note 17 above, p. 8.
  20. Ibid.
  21. Ibid.
  22. Ibid., p. 9.
  23. Statewide Telepsychiatry Program Plan, note 4 above, p. 14.
  24.  Leach, note 17 above, p. 9.
  25.  Ibid.
  26. John Sargent, MD, and Meredith Sargent, Ph.D., on the Internet at http://www.aacap.org/aacap/Medical_Students_and_Residents/Mentorship_Matters/DevelopMentor/Telepsychiatry.aspx, accessed on September 19, 2013.
  27. Legislative Fiscal Note for House Bill 580 (First Edition), May 24, 2013, p. 2.
  28.  David Brantley et al., Innovation, Investment and Demand in Telehealth, U.S. Department of Commerce Office of Technology Policy, February 2004, p. 73.
  29. Sy Saeed, MD, et al., note 15 above.
  30. Ibid., p. 30, citing a resource document on telepsychiatry via videoconferencing of the American Psychiatric Association that is not available online anymore.
  31.  Brantley et al., note 28 above, p. 74.
  32.  Saeed et al., note 15 above, p. 29.
  33.  On the Internet at http://www.securetelehealth.com/medicaid-reimbursement.html, accessed on August 21, 2013.
  34. N.C. Session Law 2013–360, Senate Bill 402 §12A.2B(a), p. 149.
  35. Statewide Telepsychiatry Program Plan, note 4 above, p. 7.
  36. Ibid., p. 23. The N.C. Telepsychiatry Work Group led to the creation of the North Carolina Telepsychiatry Program Advisory Group. See Table 3.
  37.  Ibid., p. 11.
  38.  Emails from Sheila Davies, former telepsychiatry project director of the Albemarle Hospital Foundation, on Oct. 29, 2013 and May 28, 2014.
  39.  Email from Phil Donahue, former vice president of the Albemarle Hospital Foundation, on Oct. 30, 2013.
  40. Annual Report, Albemarle Hospital Foundation, 2012, p. 4. On the Internet at http://www.albemarlehealth.org/wp-content/uploads/2013/04/AHFoundationAnnual201212.pdf, accessed on August 23, 2013.
  41. Statewide Telepsychiatry Program Plan, note 4 above, p. 15.
  42.  Letter from Sen. Phil Berger, President Pro Tempore of the N.C. Senate, and Rep. Thom Tillis, Speaker of the N.C. House of Representatives, to Sen. Tom Apodaca and Rep. Tim Moore, Co-Chairs of the 2013–14 Legislative Research Commission, on October 29, 2013.
  43. On the Internet at http://www.americantelemed.org/resources/telemedicine-practice-guidelines/telemedicine-practice-guidelines/practice-guidelines-for-video-based-online-mental-health-services, accessed on August 23, 2013.

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