A new telepsychiatry program at Medical City Healthcare allows the North Texas system to address the region’s shortage of psychiatrists through technology.
Contrary to the more commonly discussed telemedicine application, in which the patient is at home, Medical City’s telepsych brings psychiatrists to in-hospital psychiatric patients.
A doctor “beams in” to consult with a patient, as Shannon Winburn-Raitt, Medical City Green Oaks’ director of behavioral health-telepsychiatry, puts it. Nurses move a robot to the patient’s bed, and psychiatrists, who often perform the consults from their own homes, can address suicide attempts, substance abuse or withdrawal, or any other behavioral health issue they’d treat in person.
“Patients can be consulted for pretty much everything that one can see in the outpatient setting,” says Dr. Azim Fatima, medical director of the Medical City Green Oaks telepsychiatry program. “Anxiety problems, depression, you name it, almost everything. We are consulted for an initial diagnosis, or if the patient already has a diagnosis, for the management and adjustment of medication. If they need inpatient psychiatric hospitalization or if they need intensive outpatient services, we recommend that.”
North Texas lags behind when it comes to psychiatric care. Of 16 North Texas counties analyzed in a recent report from the North Texas Community Health Collaborative, seven had no psychiatric beds at all, and most had fewer behavioral health providers than the national average. Nationwide, there are on average about 90 behavioral care providers per 100,000 people. Six North Texas counties fell well below that threshold, however, with 60 or fewer providers per 100,000 people.
Medical City, which treated 28 percent of emergency department visits by behavioral health patients in these counties in 2016, is using telepsych to enhance efficiency and address the shortage. The program fits within its telemedicine program, which started four years ago and has since provided more than 9,000 consultations.
Telepsych specifically targets patients who need both mental and physical treatment. At the hospital, they’re getting the physical help, but they desperately need a comprehensive psychiatric evaluation and diagnosis as well; otherwise they may linger in a hospital bed much longer than necessary.
The service runs from 8 a.m through 4 p.m. on weekdays. Patients see an in-person behavioral health specialist or social worker during off-hours.
Fatima says telepsychiatry helps the patients as well as the doctors by discharging patients more expeditiously. Attending physicians appreciate having a psychiatrist around, even remotely, especially when dealing with an agitated, hostile, or psychotic patient.
“It not only adds comfort to the other physicians, but it also reduces the length of stay,” Fatima says. “If you look at the statistics, psychiatric patients remain in the emergency department three times longer than non-psychiatric patients. When we see the patients and … give appropriate recommendations, that decreases the length of stay and decreases the utilization of medical services for the patient.”
Fatima says using a robot for the examination can even be beneficial so the doctors can get a close examination without getting into the patients’ “personal space.” They can look for tremors or dilated pupils in patients with substance abuse while performing the examination from miles away. The process saves the doctors and the hospital time, maximizing resources.
“This is an added value for our hospitals because there’s such a shortage in psychiatry,” Winburn-Raitt says.
When the program began, Winburn-Raitt says she found psychiatric care providers through a third party. Medical City didn’t have enough internal physicians, so she outsourced to a company that beamed-in doctors from across the country. But Winburn-Raitt found there was no way to monitor their success. Physicians were paid by volume of consults, but no one was measuring the quality of their care. On top of that, it was costly. So Winburn-Raitt cut out the middleman and started using only internal physicians.
“We have processes in place so we can monitor if the consults are timely, and the quality of the consults. The documentation is being sent to the hospital,” she says. “We have that information we can pull at our fingertips at any point of any day. And plus, all of our physicians are in North Texas. I can go to their homes and do training; they can come to the office with us.”
The biggest challenge for telepsychiatry, Winburn-Raitt says, is reimbursement—because insurance companies don’t currently cover telepsych costs.
For now, telepsychiatry is a benefit within Medical City’s facilities, but whether it will expand outside is an open question. Winburn-Raitt says many rural facilities offer no psychiatric care at all, but that telepsych isn’t a panacea: Patients in an emergency room can consult with a doctor, but someone will need to follow up with them after they leave so they don’t end up back in a hospital bed.
“We’re working right now to expand our services, and we’re hoping to pilot about three hospitals in the next couple of months,” she says. “We talked about potentially adding some sort of telemedicine clinic or a teletherapy to those rural areas to be able to follow those patients to make sure they’re stable on their medication or to see if adjustments need to be made. Hopefully we’ll have that rolled out in the next couple months.”