There is urgent, growing necessity for better recognition and community-based management of behavioral health needs. Today, rural areas face a dearth of trained behavioral health specialists, leaving frontline treating clinicians often in hospital emergency departments to treat mental health issues. Emergency room (ER) providers find themselves both largely responsible and unequipped—neither trained nor adequately supported—to address the increasingly complex array of serious, persistent symptoms and mental health concerns among their patients. As a result, patients and families struggle as critical needs go under-recognized and significantly unmet.
The cost of insufficient behavioral health care is profound. Patients may experience unnecessary and prolonged suffering, and their families report negative effects on health, employment, and financial security. At the community level, escalating costs associated with healthcare for patients with behavioral disorders, and other serious illnesses are unsustainable. Specialty care approaches, have been shown to improve quality of life and decrease costs associated with care giving. And indeed, increasingly, high-quality behavioral health care in the community is becoming the expectation.
"In order to improve the quality of behavioral health care in rural hospitals, a multifaceted approach is required"
Birth of Telemedicine
The evolution of telehealth technology is paving the way to increase the reach of behavioral health care to millions of Americans, who previously did not have access to these services. In 1959, the Nebraska Psychiatric Institute introduced the concept of telemedicine when they initiated the first synchronous audio and video transmission to provide psychiatric consultation and therapy to patients at a small rural hospital 112 miles away. Fast forward 60 years, and it is now estimated that over 75 percent of U.S. hospitals connect their patients with consulting providers at a distance through the use of telemedicine.
Behavioral Health Integration
In order to improve the quality of behavioral health care in rural hospitals, a multifaceted approach is required. It is important not only to provide frontline treating clinicians with skills and knowledge to treat complex patients with mental illness, but also to enhance collaboration between rural hospitals and community-based resources, and increase access to behavioral health specialists in underserved regions. The University of Rochester Medical Center (URMC) located in New York State has developed the PAO Telepsychiatry Program, a novel behavioral health integration approach that leverages telehealth technologies to tackle all three aspects of this ever growing problem. This program was launched in January 2017 as a pilot serving three rural hospitals, each located over 70 miles away from the academic medical center.
Making telehealth technologies work in a rural hospital is not as simple as setting up and turning on a webcam to evaluate patients. Successful programs require strategic planning to support smooth integration into established clinical workflows, and adoption of the technology by the hospital medical teams. The foundation of our Telepsychiatry Program was the establishment of the Psychiatric Assessment Officer (PAO) role, an onsite licensed nurse or social worker, who functions within the established clinical workflows, has daily interaction with the hospital medical staff, and is familiar with the surrounding resources in the community. The PAO serves as the gatekeeper to the Telepsychiatry Program by ensuring that presenting patient’s behavioral health symptoms are addressed in a timely manner within the ER. In addition the PAO coordinates referrals to local community resources and assures that patients who are admitted meet admission criteria.
When the PAO feels that he or she needs more expert guidance regarding the disposition of a patient, a quick telephone call witha URMC Tele psychiatry provider allows for a case review, and if needed, a video consultation. The telepsychiatry platform uses real time, cloud-based, video telecommunications installed on a mobile tablet to conduct the consultation. The goal of the Telepsychiatry consultation is to be able to evaluate more complicated patients in their own communities and refer patients to local resources within those communities. In the past, without telepsychiatry support, all of these patient cases were transferred hours away to the academic medical center for further evaluation only to be discharged after a lengthy wait, back to their rural community without adequate outpatient referrals.
Job satisfaction is closely linked to retention and given the shortage of behavioral health professionals in rural areas, helping to support and retain staff once they are hired is also imperative for sustainable success. The last component of our Telepsychiatry model is ongoing support and mentorship provided to the PAOs. To improve job satisfaction and decrease social isolation, our Telepsychiatry Medical Director conducts weekly telementoring huddles, which serve as a platform for all of the PAOs to learn from each other, collaborate, and feel connected to a larger behavioral health team. It is the goal that overtime this platform will entice new behavioral health professionals to practice within these rural communities, where feeling isolated is a major barrier to retention and recruitment.
Since the launch of our PAO Telepsychiatry program, there has been over a 75 percent reduction in out of community transfers of patients presenting to the rural hospitals with behavioral health comorbidities. Each hospital has had significant reductions in potentially avoidable ER presentations, and hospital readmissions. Hospital medical staff report improved professional work life satisfaction due to improved patient flow and ER throughput. Integration of behavioral health into rural hospitals has bolstered relationships with community partners fulfilling the unmet needs of those previously seeking behavioral health care in the ER. We are now starting to see upstream benefits of patients receiving the right care, in the right place, and at the right time, instead of going to the rural hospital for this care by default.
From Nebraska to New York, the adoption of telebehavioral health is rapidly gaining popularity across the United States. It is unrealistic to expect the behavioral health workforce will double in size overnight, and more hospitals will need to rely on telehealth solutions to meet the needs of the communities they serve. As fee-for-service continues to be replaced by value-based reimbursement mechanisms, our program is a great example of how telehealth technologies can increase access to care and improve quality of care to a high cost patient population.