'Telepsych' program is a hit with patients, ED

Provider plans to begin outsourcing the service

While telemedicine has proven successful in several ED settings, some observers have long been skeptical that it could be applied to behavioral health. However, a program developed at the Princeton (NJ) HealthCare System has proven so successful that plans have been unveiled to offer it to other interested facilities.

"The program speaks for itself; wait times have been dramatically reduced," says Ken Tedesco, MA, director of external programs for Princeton House Behavioral Health, the behavioral health unit of Princeton HealthCare. Tedesco oversees the process. In the past, if patients arrived at the ED in the evening and there was no staff psychiatrist to see them, they could have waited until the morning to be seen, Tedesco says. Now, he says, the typical wait time is two or three hours.

Tedesco describes "wait time" as the time that it takes to move the patient through the ED, not the time that the patient waits before being seen or to see a psychiatrist. "So, while they 'wait,' they are also getting a nursing assessment, a crisis specialist assessment, and being seen by a medical doctor," he explains.

Kevin Sopko, MA, director of admissions at Princeton House Behavioral Health, says, "Being attended to quickly gives them something tangible, and that helps because during wait times there can be an elevation of anxiety for these patients." Sopko is responsible for the crisis clinicians in the ED of University Medical Center at Princeton.

When considering the program, there was some fear that patients would resent the fact that the process was being sped up, Sopko says. "But they actually prefer that; they want be seen as quickly as possible," he says. Once they become familiar with the technology, they like the fact that they can see the psychiatrist on the screen, Sopko says.

The process, which was introduced in mid-2007, is often set in motion during triage. "The patient may say something to the triage nurse that gets them designated as a patient with a safety risk. They may be suicidal, homicidal, or self-mutilative," Sopko explains. "They go through ED clearance, are examined by an ED doctor, and then our crisis clinicians will be called to the ED." The "crisis clinicians" are counselors or social workers — masters-prepared individuals with degrees in the psychological field, he says. There are at least two of them on any given shift, says Sopko.

"After they interview the patient, they'll speak to the psychiatrist on call as well as the ED physician to keep them in the loop," he says. If a higher level of care is recommended by the crisis clinician — perhaps they had recommended admission but the patient refuses — the crisis clinician might call the psychiatrist to perform telepsychiatry. This process also can be used for commitment.

In addition, Sopko notes, the telepsychiatrist also might be called if a patient is otherwise ready for discharge but there are psychiatric concerns. Perhaps the patient might have been deemed unsafe prior to presenting to the ED.

Participation in the program is completely voluntary, Sopko emphasizes. "Written consent is required, and the clinician is with the patient the whole time to assist them with the device and to answer any questions," he explains.

Another concern that has proven unfounded was that the patients would perceive a physician speaking from a remote location to be cold and unsympathetic. "But it seems to have worked better than anticipated; the patients have connected with the psychiatrists," Sopko says. The staff "has been quite in favor of it being used," he adds.

Flexibility is hallmark of telepsych program

A successful telepsychiatry program at the Princeton (NJ) HealthCare System owes part of its success to its flexibility, says Ken Tedesco, MSW, director of external programs for Princeton House Behavioral Health, the behavioral health unit of Princeton HealthCare. Tedesco oversees the process.

For example, there are no rigid rules concerning the configuration of equipment, he says. "The nice thing about equipment is that it has become so high tech and readily available. For setup, all you require is a viewing screen and a link to the Internet," says Tedesco. So, for example, the ED user can employ a computer or a 42-inch, flat-panel TV screen, along with a webcam. "One of the more interesting things we're looking at that would be real helpful around the state is putting a smaller version on a little cart on wheels so you can bring it bedside and further speed up the psychiatric screening process," says Tedesco.

Princeton has just launched a service for facilities outside the system. Here, staffing flexibility, which already has benefitted the system, can come in handy.

"The psychiatrists are the staff of the Princeton Healthcare System," Tedesco explains. "We engage our psychiatrists with the staff of the host facility to assess the patient and move the process along as quickly as possible in the best possible way." There are designated Princeton staff members for telepsychiatry, he adds, "and we may have additional people who float."

If there is a contract with other facilities, he adds, additional psychiatrists might be designated. "We can manage the process in two different ways," Tedesco explains. "We have a Princeton House unit through which the psychiatrist can remotely access the facility, but if they are unable to be there, we have a physician available who can connect remotely from a home office."

Sources

For more information on telepsychiatry, contact:

  • Kevin Sopko, MA, Director of Admissions, Princeton House Behavioral Health, Princeton, NJ. Phone: (609) 497-4000.
  • Ken Tedesco, MSW, Director of External Programs, Princeton House Behavioral Health. Phone: (609) 712-0731.

Clinical Tip

Explaining process keeps patients calm

While there were some concerns that a telepsych program would cause anxiety among the patients, that has not been the case with a program developed by Princeton (NJ) HealthCare System and its behavioral health unit, Princeton House Behavioral Health. Additionally, it shouldn't be a concern with any such program, says Ken Tedesco, MSW, director of external programs for Princeton House Behavioral Health.

"We have not seen any agitation from patients and only use the system for patients who consent to its use it," he notes. "When we explain the system, the patients are generally calm; but if medication interventions are needed to ease the patient, they are administered by the ED's RNs."