ED telemedicine extends to mental health care
Telemed helps with mental health patients
Like many hospitals around the country, Mercy San Juan Medical Center in Carmichael, CA, has seen a steady increase in patients presenting to the ED with mental health problems. Officials attribute the problem to dwindling resources for mental health care and, in particular, the closing of an inpatient psychiatric unit in the region in 2009. Many of the patients who previously would have been stabilized in the inpatient unit are now showing up in the ED.
Until recently, these mental health patients would often sit and wait in the ED for as long as a week, in some cases, to receive definitive care. However, taking a page from the hospital’s neurology department, which leverages telemedicine to bring expert guidance from a neurologist’s home directly into the ED, many of these mental health patients are now being quickly linked to a psychiatrist who beams in from a remote location to speak with the patient and, when needed, to advise emergency providers on appropriate treatment. The technology required for the remote sessions is contained on robots that can move from room to room in the ED.
Thus far, the approach has been well received by patients, and providers welcome the expert input when they have patients with mental health problems. "We get to have physician-to-physician conversations immediately [after the patient encounter]," explains Seth Thomas, MD, FACEP, medical director of the ED. "I don’t remember ever having that available to me at any other facility I have ever worked, so it is truly remarkable and it makes us feel a lot better about the care we are providing."
Consider patient, ED needs
The ED at Mercy San Juan Medical Center sees about 73,000 patients per year, but it has been significantly impacted in recent years by an influx of patients requiring mental health care. "Our ED, at any given moment, could have 10 to 15 or more mental health patients on a hold in our department, and we saw no other way to give them definitive care except to wait," says Thomas. "We said that is unacceptable and we need to look at other ways of evaluating these patients and potentially starting treatment on them while they are in the department. We felt it was cruel and unusual to keep them in the department [for such long periods of time]."
With the technological capabilities already in place to carry out telemedicine visits, it made sense to apply the approach to psychiatry, given the needs of both patients and the ED. "This is a county that is extraordinarily impacted by the volume of mental health patients and the lack of resources," says Thomas. Consequently, in October 2013, the ED began using what Thomas refers to as tele-mental health as an evaluation tool.
The hospital’s partner in this approach is Aligned TeleHealth, an Agoura, CA-based company that specializes in linking hospitals and EDs to psychiatrists who are available on a 24/7 basis. The Dignity Health Telemedicine Network contracts with Aligned TeleHealth to make the psychiatrists available to Mercy San Juan Medical Center, which is one of the hospitals under the San Francisco-based Dignity Health umbrella.
Decide how to use the approach
The ED primarily uses tele-mental health with two groups of patients, explains Thomas. The biggest group is comprised of patients who present to the ED with a mental health complaint for which the physicians themselves don’t feel comfortable initiating treatment without having the patient evaluated by a psychiatrist. Further, these patients may not meet the criteria for an inpatient stay.
For instance, Thomas explains that patients who come in saying they feel anxious or depressed, but are not suicidal, are the type of patients who stand to benefit from a tele-mental health visit because they can get started on a treatment and then pursue outpatient follow-up.
The second group targeted for tele-mental health visits includes patients who have been in the ED for an extended period of time, and it is clear that they will not be transported to an inpatient psychiatric facility any time soon, says Thomas. "We want to start treatment on them, so we will look to the [remote] psychiatrists to give us advice on what to start, and to do a formal consultation," he says. "They can then also do follow-up consultations [while the patients are still in the ED] to assess if the treatment is working, and whether the patients still meet the criteria for inpatient psychiatric consultation."
After a day or two of treatment, some of the patients improve to the point at which they can be released, adds Thomas. "That is a huge benefit to this. We are really reserving inpatient beds for those who really need them, as opposed to those who could be managed as well, if not better, in their home environment with outpatient visits to a psychiatrist or counselor," he says. "We are initiating care much sooner based on [the remote psychiatrist’s] recommendations."
The need for psychiatric input has increased, in part, because more and more patients are being placed on involuntary holds, explains Pei-Huey Nie, MD, the regional medical director at Aligned TeleHealth. "Since the 1960s, with the whole deinstitutionalization of psychiatric patients and psychiatric facilities being closed, a lot of patients with chronic mental illness have been becoming homeless, put in jail, or they have come to the ED," says Nie. "I have been told that a major part of a hospital’s budget is just holding these patients while they wait for a psychiatric bed, and that is extremely costly to the ED."
Nie adds that involuntary holds are often placed on patients by police officers. "Police do their best, but they are not mental health providers, so what happens is emergency physicians will ask us to weigh in," she says. "By state law [in California], a physician appointed by the hospital can discontinue these holds."
With expert guidance from the remote psychiatrists, emergency physicians can not only initiate appropriate treatment, but also direct patients to appropriate care more expeditiously, says Nie. "The ED physicians can ask us at any time to [evaluate] a patient and see if we really need to maintain the involuntary hold and wait for an inpatient hospital bed," she says. "Emergency physicians like to have the backing of a psychiatrist, so we will beam in, we will assess the situation, someone will read the hold’ to us, and then we will advise that yes, we think the patient should be hospitalized, or no, this patient does not meet the criteria, which suggests follow-up in a clinic or [a disposition of that nature]."
Establish a comfort level
While the hospital has not yet tabulated specific results from the intervention, Thomas believes that the length-of-stay (LOS) for patients who undergo tele-mental health evaluations and are released has decreased. "Every time I have used tele-mental health I know the LOS of those patients, particularly if they are discharged, is much improved," he says.
Unfortunately, since Mercy San Juan Medical Center began offering the tele-mental health visits, the number of mental health patients presenting to the ED for care has continued to increase. "I don’t know if that is because we are offering the service or if it is related to county-wide issues and resources becoming scarcer, but I suspect it is the latter," says Thomas.
However, Thomas says the ED is providing better care with treatment for mental health patients being initiated earlier and earlier. "Probably the biggest benefit of all of this is that we are allowing individuals who may not have mental health disorders or complaints to receive treatment more quickly," he says. "We are really trying to better utilize our resources here."
At first, Thomas acknowledges that there was some pushback to the intervention from nurses who were concerned that a mental evaluation via a remote psychiatrist would not be effective, especially in cases in which a patient was psychotic, but he says such concerns have mostly gone by the wayside as both clinicians and patients have gotten comfortable with the technology. "Patients interact with [the computer screen] as well, if not better than an in-person individual," says Thomas. "I have not yet had a patient who refuses to talk to the robot. It is actually very personal, and there is a phone handset on it for privacy so [others] cannot hear any of the conversation at all."
Nie acknowledges that she has encountered a handful of patients who do not respond well to communicating via video screen. "In these cases, I invite them to use the telephone and I think that makes people feel a little bit more comfortable," she says. "Usually the people who are uncomfortable are older in age or paranoid, but there are some good stories too. Pediatric patients — patients as young as 8 — I have found do extremely well with it."
Nie stresses that both the provider and the patient need to be comfortable communicating remotely for the visits to be successful. "If the provider, like myself, is comfortable interacting in this way, that will translate across the screen, and if the patient is comfortable engaging in this way, and willing to open up to someone on the screen, it can work perfectly. It is really just a matter of getting both parties interested and comfortable with it."
Look at costs, benefits
Thomas believes a tele-mental health solution could fit many EDs that are struggling with an influx of patients with mental health needs, but there are many factors to consider. "Look at your needs first and determine if this is an area where you feel you are struggling to care for these patients," he says. "What is your LOS and what is your volume?"
Administrators should also look at what resources they already have available to them, adds Thomas. "Do you have psychiatrists on the medical staff? Do you have social workers or trained mental health workers who can assess these patients and help you with your needs?" he says. "If you feel as though those internal resources are not enough, then this could be a definite possibility."
However, organizations also need to take a close look at whether this type of intervention is going to be a cost-saving measure or not. "By initiating the tele-mental health coverage, we are finding that the cost has actually decreased," says Thomas. "We have mental health workers who come from the county to assess patients, but the cost of those individuals is relatively high compared to tele-mental health consultations by psychiatrists, so that is one benefit. But we also find that when we decrease the LOS of these individuals, we are opening up resources and utilizing nurses and security guards for other purposes."
When calculating costs, be sure to consider what the expenditures associated with boarding mental health patients in your department are, and whether such practices are preventing other patients from coming into the ED, says Thomas. Also, consider what providers in your region offer tele-mental health, what credentialing would be involved, and what the technology requirements would be, he says.
Mercy San Juan Medical Center is part of Dignity Health’s telehealth network, so there was already an infrastructure in place to manage the tele-mental health visits, but the technical hurdles for some organizations could be much higher.
Nie adds that ED administrators who are considering the use of tele-mental health should identify a private space they can use for the patient-psychiatrist encounters. "Emergency departments can be very tight on space, but if this is something administrators are considering, a dedicated corner or room would be very helpful logistically," she says. "There should be privacy."
The approach has worked well enough at Mercy San Juan Medical Center that Thomas is interested in further ramping up the use of tele-mental health in the ED. "Right now, 25%-30% of our mental health patients are being touched by the tele-mental health psychiatrists," he says. "Maybe we need to look at [using tele-mental health with] 50% or 75% of those patients, and potentially doing regular rounds."
For instance, once a day, or perhaps on days when the ED is particularly impacted by mental health patients, Thomas envisions going through all of the mental health patients with the remote psychiatrists to evaluate whether there are opportunities to discharge some of the patients, or perhaps alter treatment or arrange follow-up. "I think the psychiatrists would be very receptive to that, and I would be interested in seeing how that could help us in the long run," says Thomas. "That might be our next big step."