Telemental Health Blog Series, Part 3 of 3: Spotlight on UVA’s Telepsychiatry Programs

A note from the blog manager:

Telepsychiatry and telemental health continue to be of importance to policymakers, as seen in the recently adopted Virginia State Budget, which includes for funds for general expansion of telepsychiatry within DBHDS, as well as funds for the development of the Appalachian Telemental Health Initiative. The following post is the third in a three-part series on telemental health in Virginia (click here for the first installment and click here for the second installment).

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Kathy Faris, B.A.
ILPPP Research Assistant
MPH Candidate, Class of 2019

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UVA Psychiatry Department Interviews

In November of 2016, the ILPPP interviewed Dr. Larry Merkel and Dr. Zack Dameron of the UVA Department of Psychiatry and Neurobehavioral Sciences. This post summarizes the insights of Dr. Merkel and Dr. Dameron into the state of emergency telepsychiatry in Virginia, specifically in relation to the UVA medical network.

Dr. Larry Merkel – an associate professor of psychiatric medicine at the UVA Department of Psychiatry and Neurobehavioral Sciences

 Dr. Zack Dameron - an associate professor of psychiatric medicine at the UVA Department of Psychiatry and Neurobehavioral Sciences

UVA State Contracts and Payment Structures

At the time of the interview, UVA provided adult telepsychiatry services to Chesapeake Community Services Board (CSB), Federally Qualified Health Centers (FQHCs) in southwest Virginia, as well as child telepsychiatry services throughout the state. When speaking about CSB partnerships, Dr. Merkel said that sharing contracts is a possibility for CSBs, which may reduce concern about no-shows as this opens up the option to use timeslot sharing between CSBs. If this was the case, when a client did not attend an appointment at one of them, the other could use that timeslot. Mt. Rogers CSB and Southside CSB are currently in this type of shared contractual arrangement and they share psychiatry hours. All of these are contractual agreements; however, UVA does provide some fee-for-service work in southwest Virginia which is funded through an Anthem grant. This fee-for-service work is provided by assigning one resident to 3 or 4 clinics, creating a network.

Dr. Merkel spoke further on payment models by noting that in fee-for-service models, the patient site can bill Medicaid for facility fees but not the service. In contractual models, the patient site can bill for both facility fees and services provided. He suggests that contractual models incentivize a low no-show rate. This is because a contractual agreement, the time slot is already paid for on a monthly basis even if the patient does not show. This may encourage the patient site to be more vigilant in insuring that the patient attends the appointment. The provider also benefits from this model because they still receive payment for the time slot, even if the patient does not show up (unlike in the fee-for-service model). Dr. Merkel indicated that UVA has had problems with no-shows in the past when using the fee-for-service model. Dr. Merkel suggested that the employment of behavioral health managers may reduce the no-show rate for telepsychiatry services via a collaborative health model. (1) He further added that studies support this claim about the collaborative model when compared against the consultation model. Dr. Dameron adds that hiring behavioral health managers in Charlottesville is challenging due to competition with salaries for social workers providing outpatient therapy in the community. Another thing mentioned by Dr. Merkel that has helped UVA reduce the no-show rate is hiring a person specifically tasked with telepsychiatry scheduling at the Telemedicine Department. She is in frequent contact with the sites, reminding them and the patients of their appointments.

When asked about the potential for using telepsychiatry technology to improve the efficiency of the emergency evaluation process (2) for CSBs, Dr. Dameron reported that he thought utilizing telepsychiatry for prescreening would likely be met with resistance from emergency departments stemming from the lengthy time required for telepsychiatry. He pointed out that telepsychiatry would add up two hours to the emergency department workload. He conceded, however, that it might be beneficial in rural areas.

Details about implementing UVA’s telepsychiatry programs

UVA providers of telepsychiatry are primarily psychiatric residents with each one assigned a single region or network for their one year residency. Dr. Merkel compared UVA to private telepsychiatry providers concluding that there seems to be more dissatisfaction with private providers due mainly to inconsistency in psychiatrists. He further added that UVA’s model has the advantage of keeping one consistent provider assigned to a location for at least a year. However, at the time of the interview, UVA was at capacity for providing psychiatric services but looking to hire more providers. Dr. Dameron noted that critics of the physicians at UVA may believe capacity is stymied since they are not working nights and weekends but should be doing so to meet demand. However, these critics may not realize that nights and weekends are when physicians complete electronic recordkeeping.

Dr. Dameron acknowledged that the UVA residents who provide telepsychiatry services may not like it due to the additional time it takes to set up the equipment and communicate between the resident and patient site. He estimated that at some sites, what should take 1 hour in-person would take 3 to 4 hours over telepsychiatry. However, he also noted that some residents have more positive experiences and go into 100% telepsychiatry practices. Dr. Dameron provides about 4 hours of telepsychiatry services per week and finds it particularly rewarding to impact populations that have otherwise limited access to care. He also spoke about political pressure to expand into the western part of the state to provide telepsychiatry services. However, there is no capacity to bring on more work and the UVA residents are vehemently opposed to expanding into this area as they would view the expansion as motivated by profit only. The residents also find the electronic medical records (EMRs) to be cumbersome and time-consuming due, in part, to their poor design. Indeed, a “Time in Motion” study (3) indicated that for each 1 hour with a patient, physicians spend 2 hours with tech. Dr. Dameron expressed concern that the residents may leave this area for more affluent ones where they would receive “cash” for services and have less required use of EMRs (e.g., small, private practices). EMR systems may further complicate matters when granting access to lab results in telepsychiatry as the patient and provider site need to trust one another and have compatible EMR systems or information sharing agreements. For example, UVA and Sentara Martha Jefferson Hospital (MJH) both use EPIC but they are not the same system and are not compatible with one another without additional training. Dr. Dameron said that both engagement at an upper level (not just IT level) as well as communication between EMRs was necessary for this type of information sharing to work.

Dr. Dameron spoke at length about another UVA emergency telepsychiatry contract with MJH. The original contract addressed two problems: lack of psychiatric resources at MJH and overcrowding in the UVA emergency room. MJH was closing its original hospital which housed 20 of UVA’s psychiatric beds and UVA provided psychiatric consultation to MJH hospital and emergency room. Since UVA was no longer on site, telemedicine consultation allowed UVA psychiatry to continue to provide services and avoided having to send psychiatric patients to UVA’s overcrowded emergency room. Cost projections for the contract are based on historical precedent for number of consultations UVA made per month with value assigned to each consult. The monthly fee is then estimated from these numbers. The workload for UVA psychiatrists did not increase when this contract began as they were already providing services, it only increased payment (fee was charged regardless of insurance status). This type of contract, however, is only feasible in settings where residents are available 24/7. Dr. Merkel mentioned that it is a possibility for Region 10 CSB (the Charlottesville area’s CSB) to link with MJH in order to do emergency evaluations. Also, Dr. Merkel noted that despite their successful program, there are still several challenges with the MJH arrangement. The main issues seem to be transporting labs and other ancillary communications to UVA.

Dr. Dameron spoke about workforce issues in the field of psychiatry and telepsychiatry specifically. He first noted that training mid-level providers, such as nurse practitioners, is much faster than training physicians. However, there is a difference in expertise and experience between the two. He also pointed out that the differential in salaries is so narrow that there would be limited savings. There are also other considerations beyond cost for nurse practitioners at UVA because nurse practitioners cannot meet the teaching mission to UVA medical residents. For private facilities, substituting psychiatric nurse practitioners for physicians in emergency consults may partially reduce expenses due to increased discrepancies in salaries between the two groups. He indicated that psychiatric nurse practitioner’s may not be able to make inpatient admission determinations in psychiatric consultations, with inpatient psychiatric units being the most restrictive in terms of requiring a psychiatrist in order to admit patients. Physicians may be resistant to giving them this authority but he suggested that the initial decision could be made by the psychiatric nurse practitioner and a physician would be required to confirm the decision.

Emergency Psychiatric Consultations in the UVA system

Both Dr. Dameron and Dr. Merkel shared information about the emergency psychiatric consultation process and its barriers. Dr. Dameron noted that during an emergency consultation, the main focal areas are suicidal ideation, homicidal ideation, or altered mental states. He noted that altered mental states are the most difficult to parse as clinical expertise is necessary to rule out medical explanations, particularly delirium. Dr. Merkel added that UVA will not prescribe medication in emergency consultations except in very rare cases. If prescriptions are provided, they are very limited (for both telepsychiatry and in-person) as prescribing can be problematic due to potential for abuse by drug-seeking individuals who come to the emergency department. Dr. Merkel also noted that following up with the same provider seen during an emergency service is possible, however, it is more feasible within a network such as the one in southwest Virginia (see UVA State Contracts and Payment Structures section). Finally, Dr. Merkel mentioned that in-home evaluations are being done for non-psychiatric reasons by Program of Assertive Community Treatment (PACT) (4) teams therefore it may be possible to explore emergency telepsychiatry services via this route.

Both spoke about the new emergency department facility being built at UVA and how this may impact emergency psychiatric services. The goal is to have 8 psychiatric holding beds in a quiet, safe area of the facility. However, staffing has not yet been arranged for these beds as the planning is in early stages. These beds would hold patients for up to 23 hours and may provide an alternative to quickly making a disposition and putting patients under a Temporary Detention Order (TDO) (5) to a state hospital. Dr. Dameron suggests the beds may allow physicians to intervene with medication sooner or influence the emergency department’s willingness to extend the time the patient is there for medication to take effect. He pointed out that this may not have the same effect if the patient is currently under an Emergency Custody Order (ECO)[6]. Dr. Dameron also spoke about the psychiatric holding facilities in North Carolina in relation to the effectiveness of this strategy. He noted that these NC units could be seen as a success or a failure but seemed to think they were harmful. He added to this by saying that psychiatric patients would end up leaving these locations without treatment due to the long wait times. The facilities themselves were not treatment sites and merely served as a facility to alleviate emergency department pressure. He concluded by saying that patients in these 23-hour type beds should receive services and should not be kept in an environment where their condition may worsen.

 References

1. According to the American Psychiatric Association, the Collaborative Care Model is a well-researched model aimed at integrating behavioral health and general medical services (shown to improve patient outcomes, save money, and reduce stigma related to mental health). https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/get-trained/about-collaborative-care

2. See the ILPPP report“Telemental Health in Emergency Settings: ‘Smart Practices’ for Community Services Boards Learned from the Field” at https://uvamentalhealthpolicy.org/s/TPinES_SmartPractices_FINAL.pdf for more information about this topic.

3. Sinsky C, Colligan L, Li L, Prgomet M, Reynolds S, Goeders L, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med. 2016;165:753–760. doi: 10.7326/M16-0961

4. Assertive community treatment is, “a team-based treatment model that provides multidisciplinary, flexible treatment and support to people with mental illness 24/7… ACT team members help the person address every aspect of their life, whether it be medication, therapy, social support, employment or housing.” (https://www.nami.org/Learn-More/Treatment/Psychosocial-Treatments)

5. A TDO is “a legal document requiring an individual to receive immediate hospitalization for further evaluation and stabilization, on an involuntary basis, until a commitment hearing can be arranged to determine their future treatment needs.” For more information, see the NAMI Virginia Guide to Psychiatric Crisis and Civil Commitment Process in Virginia at https://namivirginia.org/wp-content/uploads/sites/127/2016/03/GuidetoPsychiatricCrisisandCivilCommitmentProcessforWebsite-justlawscriteria2016.pdf.

6. An ECO is, “a legal order by the court authorizing the law enforcement agency to take a person into custody for a mental health evaluation performed by a qualified mental health clinician through the local CSB/BHA.” Based on her own observations or the reports of others, a law enforcement officer may also take an individual into “orderless emergency custody” and transport the individual for an evaluation if she has probable cause to believe that individual meets commitment criteria. More information about Virginia’s civil commitment laws may be found at http://dls.virginia.gov/GROUPS/MHS/CivilCommitmentLaws.pdf.