Telemental Health Blog Series, Part 1 of 3: An Overview of Elements of Telemental Health in Crisis Settings

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A note from the Blog manager: 

The following post is the first in a three-part series on telemental health. This post will give an overview of the elements of emergency telemental health. Future posts will include results from a brief survey on telemental health in Virginia's Community Services Boards conducted by the ILPPP in 2016 and an in-depth look at emergency telemental health programs across the country with a spotlight on interviews with telemental health experts from the University of Virginia. 

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University of Virginia Institute of Law, Psychiatry, and Public Policy

KM Faris and AA Allen
February, 2018

Background and methodology

TMH in Emergency Settings: “Smart Practices” for Community Services Boards Learned from the Field

TMH in Emergency Settings: “Smart Practices” for Community Services Boards Learned from the Field

jchc Report: Options for Increasing the Use of Telemental Health in the Commonwealth - Interim Report

jchc Report: Options for Increasing the Use of Telemental Health in the Commonwealth - Interim Report

The following research was conducted to support “SJ-47” – the Joint Subcommittee to Study Mental Health Services in the Commonwealth in the 21st Century, specifically, the work of the Emergency Services Expert Advisory Panel. Telemental health[*] has been frequently discussed by the panel as a way to enhance emergency services. Researchers from the ILPPP have been looking closely at existing emergency telemental health practices and their current and potential use in emergency departments and other emergency settings. Note that the ILPPP has also published an in-depth report on the use of telemental health in emergency settings by Community Services Boards (CSBs) statewide, which can be found at https://uvamentalhealthpolicy.org/s/TPinES_SmartPractices_FINAL.pdf. Another report for a related subgroup of SJ-47, the Telemental Health Workgroup, was published in November 2017 by the Joint Commission on Health Care, which can be found at http://jchc.virginia.gov/CompleteTelemental%20Health%20RD509-%20Interim%20Report%20.pdf . This “interim” report describes findings and recommendations for the Telemental Health Workgroup (a sub-group of SJ-47). The final report which will investigate additional options for telemental health in Virginia will be submitted by November 2018.

This post does not make recommendations regarding what emergency telemental health and telepsychiatry programs Virginia should pursue, but rather exists in order to educate policymakers regarding the array of programs that exist, including considerations that must be made when adopting any such program.

ILPPP staff gathered information through literature reviews, interviews, and surveys. As part of a separate report[†] on telemental health in emergency settings at CSBs, researchers interviewed CSBs and two CSB telemental health partners (two local hospitals) on their current practices. Literature reviews were conducted on current trends in emergency telemental health and specific programs to provide a wider view of telemental health in the U.S.

Goals of emergency telemental health

Emergency telepsychiatry has been described as “psychiatric care delivered over live interactive videoconferencing to assess and treat patients experiencing potential imminent dangerousness to themselves (suicidal or grossly disturbed behavior) or dangerousness to others (homicidal or other violent behaviors).”(7) This can also describe emergency “telemental health” services, a term that encompasses all emergency mental health services provided via videoconference. Telemental health in acute or emergency situations has become more common in recent years and addresses an important need for many individuals and health providers. Telemental health has been shown to be safe and effective for emergency assessments. A 2014 study found that there were no differences between face-to-face and telemental health assessments in disposition determination and the two were similar on measures of suicidality, dangerousness, and diagnostic category.(6)

Many patients lack access (due to geography or excessive wait times) to necessary mental health care. In emergency situations, many hospital emergency departments are not prepared to address the needs of psychiatric patients which can lead to lengthy patient wait times and improper diagnosis.(11) Through telemental health, emergency department providers can connect with psychiatrists or other mental health professionals for treatment, consultation, and/or evaluation services in a timely manner. This can have significant impact on patient length of stay or the need for inpatient admission.(11) While emergency telemental health is used for treatment in some cases, the most common use appears to be consultation or evaluation services. The setting for emergency telemental health is typically a structured one such as hospital emergency departments and specialized mental health centers. A small portion may occur in the patient’s home if the patient is already engaged in telemental health service from their home during which the patient experiences a mental health crisis.(8,10)

Program structure and linkages

Networks/Health Systems

The structure of programs for telemental health in emergency settings has been largely neglected in literature and studies of telemedicine. The available literature indicates that emergency telemental health networks are largely structured as hub-and-spoke sites centered around the patient site (e.g., emergency department) of a local hospital or specialized facility with a telemental health program through which the patient receives consultation services, usually via videoconferencing, from a psychiatrist or other licensed mental health professional located at the “hub” site (e.g., a large, in-network hospital).(10) The telemental health services may be provided by a health facility in the same network as the spoke sites or the services may be procured through a membership with an external network of providers through a formal arrangement. A telemental health network may provide the added benefit of administrative support for spoke sites.(2)

Free-standing sites

While the telemental health network structure seems to be the most popular for emergency telemental health, there are also free-standing psychiatric facilities that do not belong to larger health networks. These sites work with private companies which provide telemental health services directly to facilities on a monthly or appointment-based fee schedule rather than through a network membership.(1,10) In fee-for-service models for the provision of telemental health, the telemental health professional bills the third-party payers (e.g. Medicaid, private insurance) per appointment. In the contractual model, telemental health professionals are paid a negotiated fee or wage for specified periods of time when they are on-call and the patient site bills third-party payers for telemental health services.(3) Contracting for these services must be arranged with the providers of telemental health services, including any necessary administrative services.(2)

State or Regional Public Networks

States or regions looking to address mental health needs of their communities may be interested in providing telemental health services to a network of community-based agencies. The South Carolina Department of Mental Health has such a program where the state telemental health providers connect to emergency facilities around the state for consultation.(4) The network provides telemental health to Medicaid populations via the pool of psychiatrists and other mental health professionals employed by the state. The capitated payments for services provide enough revenue to employ providers for this population without concerns about patient location.(2)

Primary Responsibility for the Patient

The determination of which party assumes the primary responsibility for the patient is complex and should be established prior to implementing telemental health services.  Many factors can affect which party holds primary responsibility such as the type of patient site and even the time of day. If, for example, the patient site is a specialized mental health crisis center, the relationship between the patient site providers and the telemental health providers will typically be a collaborative one. In freestanding clinics or hospitals with no psychiatric/mental health crisis team, the telemental health providers will assume primary responsibility for patient mental health decisions. Another issue to consider in responsibility is the time of day in which the evaluation takes place. After hours, there may be fewer on-site mental health resources or staff available and thus, the telemental health providers hold primary responsibility.(7)

If the telemental health provider is a psychiatrist (telepsychiatrist), they may partner with patient site prescribers who will write the prescription recommended for the patient. Alternatively, the telepsychiatrist may write the prescription and email or fax it to the patient site.(3)

Funding and Costs

In recent years, the costs for implementing telemental health have been dropping due to the lower cost of purchasing equipment. However, purchasing equipment is still an initial investment estimated at roughly $7,000 per site.(10) Depending on existing internet infrastructure, facilities may also need to invest in increased bandwidth in order to provide continuous encrypted videoconferencing. Another financial concern involved in implementing a telemental health program is the cost associated with paying for telemental health services in addition to the staff member(s) who facilitates the telemental health appointment. Although there may be an initial increase in overall costs, telemental health in emergency situations often reduces the patient wait time, especially in rural situations.(9) Calculating the relative cost of telemental health in emergency situations is therefore fairly complex and may lead to a reduction in overall costs incurred by patient boarding[‡] or transport in the long term.

As mentioned above, billing for telemental health services is dependent upon the arrangement in each location with either the patient site or the telemental health provider billing third-party payers. Medicaid will not reimburse for technology costs for purchase of telemental health equipment but this funding has been acquired internally or via grant funding for many telemental health programs.(10) However, grant funding does not allow for a sustainable program and thus determining the reimbursement policies and procedures for Medicaid and private insurance providers is a necessary part of program planning. While most states have Medicaid programs that will provide some degree of reimbursement for telemental health, policies of private health plans vary more widely. Some telemental health programs have raised concerns that, even if payers will provide reimbursements, they may not be adequate to sustain programs without supplemental funding.(2)  

Emergency telemental health in Virginia

In Virginia, telepsychiatry and other telemental health services are used by the majority of Community Services Boards (CSBs), however, as of September 2016, only 5 are currently using emergency telemental health and of these 5, there are 4 currently using it for prescreening clients. CSBs have a variety of partnership arrangements for telemental health services including different levels of care collaboration as well as billing models (e.g., contractual and fee-for-service models). More in-depth information is needed from stakeholders, specifically, CSBs, telemental health providers, hospital emergency department staff, law enforcement, and community leaders. Particular topics of interest for stakeholder discussions are how telemental health is being used in emergency situations, the different providers of telemental health in Virginia, and the different types of billing and care models used by CSBs across the state.

References

1.     Burke Mental Health Emergency Center. Prepared for 2014 ATA Innovation in Remote Care Award Nominee.Print.

2.     Lambert, David, et al. "Understanding the Business Case for Telemental Health in Rural Communities." The journal of behavioral health services & research 43.3 (2016): 366-79. Web.

3.     Myers, Kathleen, and Carolyn Turvey. Telemental Health: Clinical, Technical, and Administrative Foundations for Evidence-Based Practice. Newnes, 2012. Web.

4.     Narasimhan, Meera, et al. "Impact of a Telepsychiatry Program at Emergency Departments Statewide on the Quality, Utilization, and Costs of Mental Health Services." Psychiatric Services 66.11 (2015): 1167-72. Web.

5.     Nicks, BA, and DM Manthey. "The Impact of Psychiatric Patient Boarding in Emergency Departments." Emergency medicine international 2012 (2012)Web.

6.     Seidel, Richard W., and Mark D. Kilgus. "Agreement between Telepsychiatry Assessment and Face-to-Face Assessment for Emergency Department Psychiatry Patients." Journal of telemedicine and telecare 20.2 (2014): 59-62. Web.

7.     Shore, Jay H., Donald M. Hilty, and Peter Yellowlees. "Emergency Management Guidelines for Telepsychiatry." General hospital psychiatry 29.3 (2007): 199-206. Web.

8.     Shore, Peter, et al. "Meeting Veterans Where they'Re @: A VA Home-Based Telemental Health (HBTMH) Pilot Program." Int J Psychiatry Med 48.1 (2014): 5-17. Web.

9.     Southard, Erik P., Jonathan D. Neufeld, and Stephanie Laws. "Telemental Health Evaluations Enhance Access and Efficiency in a Critical Access Hospital Emergency Department." Telemedicine and e-Health 20.7 (2014): 664-8. Web.

10.  Williams, Mike, MM Pfeffer, and Donald M. Hilty. "Telepsychiatry in the Emergency Department." California HealthCare Foundation (2009)Web.

11.  Yellowlees, Peter, et al. "Emergency Telepsychiatry." Journal of telemedicine and telecare 14.6 (2008): 277-81. Web.

Footnotes

[*] There are many terms used to describe teleconferencing for mental health services such as telemental health or telepsychiatry. In this report, the term “telemental health” will be used to describe all types of telemental health activities including psychiatric (i.e., provided by a psychiatrist) services. 

[†] https://uvamentalhealthpolicy.org/s/TPinES_SmartPractices.pdf

[‡] “Patient boarding” can be defined as “holding a patient in an ED [emergency department] bed while awaiting an inpatient mental health bed” and is a common occurrence in emergency departments.(5)