North Carolina and Texas devise regional solutions to mental health care emergencies
Telepsychiatry would seem to have a lot to offer busy EDs that see a significant number of mental health patients but lack the in-house psychiatric resources to meet these patients’ needs. In fact, the allure of telepsychiatry is such that some regions have moved quickly to leverage the approach, particularly in rural areas where access to psychiatric expertise is limited. North Carolina is a case in point: In the summer of 2013, state legislators established the North Carolina Statewide Telepsychiatry Program (NC-STeP), appropriating $2 million per year to operate the program, with an initial focus on giving EDs across the state remote access to psychiatric expertise.
The state was not starting from scratch on this initiative. The Elizabeth City, NC-based Albemarle Hospital Foundation had already demonstrated success from this approach, providing telepsychiatry services to 18 hospitals in 29 counties, with some impressive outcomes in terms of substantially reduced lengths-of-stay (LOS) in the ED for patients awaiting discharge to inpatient treatment, and a drastically reduced need for involuntary commitments.
While the Albemarle Hospital Foundation program served as a starting point for NC-STeP, the new program, which is administered by East Carolina University’s (ECU) Center for Telepsychiatry and e-Behavioral Health in Greenville, NC, has grown even faster than anticipated, according to Sheila Davies, PhD, the coordinator of NC-STeP and the president and CEO of MedAccess Partners, a telemedicine consulting firm in Kill Devil Hills, NC. (Also see: Carolinas HealthCare system gets jump on potential for telepsychiatry, p. 18.)
“We are now at 53 hospitals participating, meaning they have the equipment in their facilities; of those 53 hospitals, 39 hospitals are actually live. The others have the equipment and their personnel have been trained; we are just waiting on the credentialing of the providers, so [these hospitals] will be going live within the next couple of months,” says Davies. “Beyond that, we have another 38 hospitals that are on the list in various discussions or phases of implementation. Some are reviewing contracts and some are just beginning their credentialing phases, so that takes us up to about 91 hospitals that are engaging [or are] looking at engaging in NC-STeP.”
Further, even though the statewide network is still in the early stages, the program’s return-on-investment (ROI) thus far is impressive indeed. “You’ve got a $2 million program saving about $7 million,” explains Sy Saeed, MD, the director of both NC-STeP and ECU’s Center for Telepsychiatry and e-Behavioral Health. “The 30,000-foot view of this is that in the first 11 months of this program, there were about 7,000 encounters, and we cut the average LOS for patients by about half.”
Saeed adds that much of the savings stem from the fact that as a result of the telepsychiatric consults, about one-quarter of the patients who present to the ED with involuntary commitment orders (IVC) get those orders overturned.
Prepare for hurdles
While the statewide telepsychiatry effort has delivered multiple benefits, other hospitals or regions that are interested in pursuing a similar strategy should be prepared to tackle numerous obstacles along the way, observes Davies. For instance, she notes that the credentialing of mental health providers at all the participating hospitals has been particularly challenging.
“Every provider that participates has to be credentialed at every single hospital … and that is a huge investment of resources from the processing of the paperwork to verifying the credentials,” she explains. “The other thing that exponentially grows as a challenge is that one of the components of credentialing a provider is verifying hospital affiliation, so if we continue to build the network, and we may have one [mental health] provider hub serving 25 hospitals, and then another one comes on as a 26th hospital — now [we] are having to verify their affiliation with the other 25 hospitals.”
Davies says that administrators are overcoming this challenge just by persistence and diligence, but it is very time-consuming. “A lot of work goes into this on the provider side and the hospital side,” she adds.
Hospitals or health systems interested in developing this type of program should also be prepared to work through significant technological or information technology-related problems, although these won’t necessarily be related to hardware.
“We’ve really got the equipment that we are putting in each of the hospitals and each of the provider’s [offices] right down to a well-oiled machine,” says Davies. “We know exactly what needs to go in each of these facilities and it works really well, but you do need to navigate firewall issues with each of these, and that can be quite taxing.”
Further, with participating hospitals and mental health providers all using an array of electronic medical records (EMR), the push and pull of patient information to and from the various provider sites can be difficult, and it is still a work in progress at NC-STeP. Administrators are developing a web portal so that there will eventually be a single port of entry that both emergency providers and mental health providers can use to arrange psychiatric consults and exchange information about patients.
“Developing this portal has been the single most expensive part [of the program],” notes Saeed. “From the $2 million funding [from the state], roughly 40% has gone toward [the portal]. It is an enormous, monumental task, and extremely time-consuming to work out all the details.”
While the financial savings from NC-STeP are attractive, funding the program is still a struggle because a large percentage of the patients receiving telepsychiatric services lack insurance of any kind, and another sizable percentage are on Medicaid. “What I told legislators is that if you are running a business and 40% of the patients who bought your product don’t pay you a dime, and another 40% pay you below cost, how do you survive? And the answer is, you don’t. That is a big issue,” says Saeed.
Funding would be greatly improved if North Carolina expanded Medicaid under provisions in the Affordable Care Act, but since the state has not moved on that initiative, Saeed is seeking additional funds from the entities that are actually saving money from the program. “For example, for Medicaid, this is going to save about $1.8 million just from overturned IVC orders; for Medicare, the savings are about $1.3 million; for third-party payers, the savings are also about $1.3 million,” explains Saeed. “Funding of this program ought to come from those people who actually reap the benefits of this … so that is our strategy for now.”
Think beyond ED focus
The program has received financial help from the Duke Endowment, which has provided $1.4 million to NC-STeP, but demand is such that administrators are having to do more with less. “The state funds were to help us onboard up to 59 general hospitals, and right now the Duke Endowment funding is to give us the ability to bring on 17 more hospitals, but we are already past that threshold,” observes Davies. “That [demonstrates] how well this has been embraced by hospitals — the need for this program and the demand for it.”
Beyond ROI, Saeed is anticipating additional benefits from the program in terms of better treatments and outcomes. “As physicians, we need to narrow the gap between science and practice. That [involves] standardizing treatment so that the majority of people are provided treatment that is consistent with the best evidence out there,” he explains. “Telepsychiatry offers a great opportunity. If you have a program that is up and running in 50 EDs, there is your opportunity.”
Further, as development of the network continues, the focus will expand beyond decompressing EDs that see large numbers of mental health patients. The goal must be improved patient care for this group of patients, whose mental health needs are not served in the ED, which is designed as a site for medical and trauma emergencies. “One of the things I have said all along … is that if we build a program with the sole purpose being to get people out of the ED, we will be building the wrong program,” says Saeed. “We live in certain times when psychiatric treatment has never been more effective, and we owe it to our citizens and population to provide them with these effective treatments that indeed lead to recovery.”
Consequently, the program’s ultimate aim is to provide mental health care to people in community settings so that they are less likely to show up in the ED in the first place; that means taking the savings from the program and reinvesting them in community-based care, observes Saeed. “Overall, the focus is population-based care in community-based settings and not just the ED,” he says.
Consider centers for mental health emergencies
The state of Texas is also leveraging telepsychiatry to meet the demand for emergency mental health care, but it is taking a different tack in that the idea from the start has been to enable people with mental health emergencies to bypass the ED altogether. “It takes all of the models of emergency care that have been developed over the years, and then takes them a step further,” explains Avrim Fishkind, MD, president and chief medical officer of JSA Health Telepsychiatry based in Houston, TX. “Most models are about how to get people out of the ED more quickly. Our model is how do you keep people from ever getting there in the first place.”
Fishkind explains that the model was developed as part of a collaborative effort that the state initiated in 2005. He was tapped to chair a committee to redesign psychiatric emergency services for the state, and the model evolved from that process.
At the heart of the approach are free-standing mental health emergency centers (MHEC) which are equipped with a psychiatric emergency service or receiving area for both voluntary and involuntary patients; an extended observation unit, which usually includes six beds and is capable of housing both voluntary and involuntary patients; and a crisis unit that typically includes 16 beds, explains Fishkind. Also included in the MHEC model are mobile crisis teams.
“The reason [the model] was designed this way is that most emergency models are in big, urban cities, so there is a big hospital, and it can afford to have a big psychiatric emergency service,” observes Fishkind. “But many mental health emergencies are occurring everywhere around the country — in rural locations, suburban locations, virtually everywhere including jails and schools and all kinds of different places.”
With the dearth of psychiatrists in rural locations, the MHECs are staffed via telemedicine around the clock. When a patient is brought in by the police or voluntarily, MHEC staff will put a call in to one of the remote psychiatrist providers, explains Fishkind. Most telemedicine encounters can be arranged in 15 to 20 minutes on average, he says.
“The psychiatrist is on a 42-inch, high-definition TV interviewing the patient in crisis, sometimes from as far away as Israel or Spain, or sometimes locally from Texas,” says Fishkind. “Our psychiatrists literally span the globe and have Texas licenses.”
A remote psychiatrist also makes rounds at the MHECs three times a day, seeing patients on the crisis residential unit, the extended observation unit, and patients who are brought in by the mobile crisis teams, explains Fishkind.
Establish criteria for first responders
There are multiple dispositions available to the providers, explains Fishkind. “When we see patients we can send them home, we can put them in the extended observation unit, we can put them in the crisis residential unit, we can send them home with the mobile crisis unit following them, or we can admit them to the hospital,” he says. “We have this entire range of wrap-around [services] available after we see the patients in the MHECs.”
The in-person staff at the MHECs include nurses, social workers, and psychiatric techs, and the centers are equipped to handle most of the tasks involved with getting the patients medically cleared so that they don’t have to visit an ED first, explains Fishkind. “We do our own EKGs, blood draws, and all the basic medical components that need to get done,” he says.
“About 2% of the patients who reach us who haven’t gone to the ED first are found to have some medical condition that warrants them going to a medical ED and they are sent, but the EDs that were previously overcrowded and going on diversion due to the number of mental health patients backing up the ED don’t have any problem taking a few cases occasionally who need a better medical workup or medical treatment,” says Fishkind. “We take a far larger number of these patients, preventing them from ever getting to the ED … so we have a great relationship with all of the area EDs.”
A set of criteria has been established so that first responders can determine when it is safe to take a patient directly to an MHEC rather than a medical ED, explains Fishkind. “Psychiatry has this reputation of being very, very conservative about medical issues, and so many psychiatric hospitals won’t even accept a patient unless they have had their blood drawn in an ED no matter what the circumstance,” he says. “We don’t have that rule.” This program element would save millions if applied on a wider base. Across the country, most mental health patients have extensive and unnecessary medical diagnostic testing done before the mental health consultants will even listen to the need for an evaluation.
Make the case with data
Funding for the MHECs comes from multiple sources. First, communities can apply for state funding to establish MHECs, but local stakeholders need to be willing to provide ongoing support as well, explains Fishkind. “Wherever these centers are built we ask the local EDs to help pay a certain amount of money every year to help defray the cost of running the MHECs,” he says.
Such requests are not as difficult as one would expect once hospitals analyze all of the unreimbursed care that they are providing to psychiatric patients who sit in their EDs for an average of two and a half days, observes Fishkind. “If you ask a hospital to pitch in some money for an MHEC where the costs are one-twentieth of what they are spending [on these patients] per year, it is not real hard to get them to provide some funds,” he says.
The savings come, in part, from the fact that the MHECs only pay for psychiatrists for the times they are engaged. “If you wanted to keep one psychiatrist on board around the clock 365 days of the year, you would pay easily two-and-a-half times as much for psychiatric time if you could even find [a psychiatrist to do it] as you would when you are just paying for the psychiatrists when they are needed for the emergency cases as they come in, and when they make rounds every day,” observes Fishkind.
Other sources of funding include local governmental authorities that are often willing to kick in money to prevent regional jails from filling up with patients who have mental health diagnoses, notes Fishkind. “The average cost of an episode of care in an MHEC is about one-fifth the cost of being jailed or going into an inpatient psychiatric unit,” he explains. “So everyone not only gets a social win and a clinical win, but a financial win as well.”
Fishkind acknowledges that people tend to be surprised to hear that this type of model is succeeding in Texas because the state is always near the bottom in per capita spending on mental health. “However, we also have an incredible R&D [research and development] community here that comes up with all kinds of amazing things to do, and this wasn’t hard because every step of the way the people who led it did careful assessments of the [potential] costs savings,” he explains.
Get constituents together
Currently, there are nine MHECs in operation in Texas with several more in the planning stages, says Fishkind. “We are starting to get calls from other states and internationally about the model because it is the first time in history when you can really staff psychiatric emergency services outside of major urban centers,” he says. “I am frequently called to consult in communities that want to do this.”
Fishkind cautions that there are often obstacles to implementing this type of approach. “The key for EDs to realize is that whatever plan they want to put in place … there is going to be a need to call together all of the constituents,” he says. “These would include advocacy groups, the local mental health authority, the local psychiatric hospitals, the local jails, local judges, and the local commissioner’s courts or whatever body actually governs that particular area.”
What’s difficult about this process is that these entities have often been at odds in recent years as different stakeholders placed blame for why psychiatric patients were filling up area EDs, observes Fishkind. “It is not beyond the EDs to be the good guys in the whole thing and call a process together with all of the relevant stakeholders to get started on how to find a solution,” he says. “We do find EDs occasionally who have just said enough is enough. They find a champion within their hospital to start this process of bringing in all the stakeholders, looking at models that work, and go from there.”
Sheila Davie, PhD, Coordinator, North Carolina Statewide Telepsychiatry Program, and President/CEO, MedAccess Partners, Kill Devil Hills, NC. E-mail email@example.com.
Avrim Fishkind, MD, President and Chief Medical Officer, JSA Health Telepsychiatry, Houston, TX. E-mail: firstname.lastname@example.org.
Sy Saeed, MD, MS, Director, North Carolina Statewide Telepsychiatry Program, and Director, East Carolina University Center for Telepsychiatry and e-Behavioral Health, Greenville, NC. E-mail: email@example.com.
Brad Watling, MD, FACEP, FAAEM, System Medical Director, Carolinas Medical Center, Charlotte, NC. E-mail: firstname.lastname@example.org.