As administrators of a general hospital with no specialized psychiatric unit, leaders at Chester County Hospital in eastern Pennsylvania had become accustomed to a waiting game for psychiatric consultation when a patient with clear mental health needs presented in their emergency department. As is the case at a growing number of general hospitals around the country, telepsychiatry is providing these leaders with an alternative to what can become a crisis in emergency operations — as well as for patients in need.
In partnership with national telepsychiatry company InSight Telepsychiatry, LLC, Chester County Hospital is now using video technology to enable it to receive expert consultation on cases, usually within an hour of making initial contact.
This reduces wait times for services and creates more effective referral to specialty mental health treatment services in the community, while in other cases it simply might offer a more rapid and expert confirmation that a patient with mental health needs can be safely discharged.
“In the emergency department, the availability of specialty services is always difficult,” Betty Brennan, Chester County Hospital’s director of emergency services, told MHW.
“We were finding that the availability of psychiatrists was increasingly more difficult, because of their professional load in their offices. The immediacy that we needed just wasn’t there.”
The hospital’s phone calls to other facilities to see how they were handling the issue of delays in mental health patient transfer or discharge led the organization to InSight in 2011.
Brennan said the high quality of communication between patient and remote provider via video gives her confidence that the sessions between patient and psychiatrist virtually duplicate the more common face-to-face experience. “You almost forget in today’s world that you’re talking on videoconference,” Brennan said of the telepsychiatry experience.
The hospital launched its work with telepsychiatry for evening and overnight hours but has since expanded the program in order to maintain round-the-clock coverage.
In a typical scenario, a patient might present with suicidal ideation and be seen immediately by an emergency physician on the hospital staff. Once an initial level-of-care evaluation takes place in the ER setting, the hospital will contact In- Sight’s Access Center and transmit a patient history.
Brennan said InSight provides a number of psychiatrists for the telepsychiatry services, and the hospital has been able to develop a rapport with these individuals over the course of the project. (The psychiatrists are required to be credentialed at the hospital facility with which they are working.)
Often the hospital staff physician will speak with the psychiatrist before the specialist conducts the patient interview. For the video interviews, the hospital uses several secure rooms that are located a fair distance from any hospital exits. A hospital employee, such as a nurse or a member of the security team, is required to be present while the patient is being assessed via video.
The interviews are highly detailed and usually last anywhere from 20 to 45 minutes, Brennan said.
The high-definition videoconferencing equipment helps to establish a process that very closely approximates what occurs in a face-to-face interview, she said.
“We’ve never had a patient refuse,” Brennan said, as the message to them becomes one of facilitating necessary services in the quickest manner possible. “The physicians are very skilled, and the patients like that it’s private.”
A written consult from the psychiatrist is faxed to the hospital upon completion of the specialist’s interview and evaluation. “We’re not waiting for a psychiatrist to come in when his office hours are over,” Brennan said.
Often it is the case that the psychiatrist’s consultation offers a rapid confirmation of a course of action that was already apparent to the hospital staff, from a referral to a specialty behavioral health facility in the community to a discharge without extensive follow-up.
Brennan added that having this service available not only helps establish more effective linkages with mental health providers outside the hospital for followup care, but also speaks to a more humane way of addressing patient needs.
“There is an increased focus now on the rights of the mental health patient, and on getting them to the right facility,” she said.
Brennan believes the telepsychiatry option can work equally well for adult and adolescent patients. The secretary of the Delaware Department of Health recently said that telepsychiatry could assist in reaching underserved young people in a state that this year has seen a significant number of teen suicides related to unaddressed mental health needs.
Brennan said the telepsychiatry experience at Chester County Hospital has proven so effective that the hospital has begun to extend telehealth into other operations. It is now using similar technology for evaluations of stroke patients, she said.
Other hospitals across the country that are working with InSight technology have reported similar improvements in wait times and overall emergency operations as a result of telepsychiatry’s availability.
“On occasion, patients are taken to the hospital under the Baker Act for a behavioral issue when they’re actually under the influence of drugs or alcohol,” said Eddie Carie, behavioral health case manager at South Florida Baptist Hospital in Tampa.
“These patients used to wait days for a psychiatrist’s evaluation. Now, we’re able to have a psychiatrist evaluate the patient and make a decision within hours.”
Inspira Health Network, a nonprofit, three-hospital health system serving communities across southern New Jersey, lacked psychiatric providers, resulting in delays in service. Consults have a 24-hour window, which led to bed, intervention and recommendation delays for medical patients.
As a result, it was not unusual for patients to wait longer than 24 hours for psychiatric consults due to a lack of available psychiatrists. Because many patients were accessing services through the emergency department, this protracted wait period created bottlenecks and bed delays. In addition, needed psychiatric interventions and medication therapies were delayed that could help stabilize patient conditions as emergency department staff waited on the direction of specialists with the right expertise.
Inspira Health Network chose to work with the Center for Family Guidance and its sister company, InSight Telepsychiatry, a national service provider that aims to improve access to behavioral healthcare through telehealth technology.
“We opted to use telepsychiatry for psychiatric consultation of medical inpatients to promote efficiency, access and throughput,” said Sarah Seabrook-DeJong, RN, director of psychiatry services at Inspira Health Network. “The expectation was that around-the-clock, real-time access to psychiatric resources would improve patient throughput and speed care delivery processes.”
Patients would receive needed interventions quicker, resulting in better outcomes and higher levels of satisfaction, she explained. The new technology-enabled process would also create workflow efficiencies and lend to less bottleneck in the emergency department, ultimately improving the hospitals’ bottom line, she added.
In addition, around-the-clock access to psychiatric consults would improve provider satisfaction as patients would receive high quality, “whole person” care in a timely manner, said Seabrook DeJong.
“This would allow for 24/7 access to a psychiatrist through a remote video conferencing model, which would promote interventions, recommendations and dispositions to transpire much more quickly and effectively,” she explained.
There are many vendors on the market today offering telemedicine technology, including American Well, Avizia, GlobalMed, MDLive, Novotalk, SnapMD, Teladoc, TeleHealth Services, Tellus and Tyto Care.
Inspira Health provided iPads on mobile carts and a Bluetooth speaker that go directly to a patient’s bedside for a consultation. This new workflow was designed to address inpatient admissions going to the medical floors at two of Inspira’s hospitals. While the system does not currently offer inpatient psychiatric services, some patients require psychiatric consultation prior to leaving the emergency department.
“The telepsychiatry iPad is managed by the nursing supervisor, who deploys the cart when requested,” said Seabrook-de Jong. “The consultation with the patient is monitored by either a medical technician or nurse to ensure patient safety while not affecting confidentiality.”
“By creating a clear, efficient process, modeled after an existing one for teleneurology, staff were educated on the flow and steps to accomplish a consistent experience and expectation for patients.”
Sarah Seabrook-DeJong, RN, Inspira Health Network
The telepsychiatry system is a separate, HIPAA-compliant app with the telepsychiatrists documenting directly into Inspira’s EHR. The telepsychiatry service is integrated with Inspira’s Cerner EHR. InSight’s telepsychiatrists document into Cerner, improving workflow efficiencies and allowing information to be shared in near-real time, she said.
“By creating a clear, efficient process, modeled after an existing one for teleneurology, staff were educated on the flow and steps to accomplish a consistent experience and expectation for patients,” she explained. “Having a designated liaison between Inspira Health Network and InSight telepsychiatry was critical to the success of the innovative technology and new process.”
Inspira Health has seen response times around two hours from request of consult to completion of the assessment. It is able to secure a disposition from a specialist, enabling the hospital attendings to determine treatment care directives, consideration of psychiatric admission, discharge, initiation of effective psychotropics, and more.
“Nearly 100 percent of behavioral health consults are now completed through the telepsychiatry provider,” said Seabrook-de Jong. “Only in rare cases are alternative options employed. For instance, a face-to-face consult was ordered for a deaf patient who used a hearing device. This new technology-enabled approach to care processes has allowed us to substantially reduce wait times and improve throughput.”
Notably, pushback from medical staff has been minimal, she added.
“Hospital physicians appreciate having near-real-time access to psychiatric consult information and the fact that patients receive interventions in a timelier fashion,” she said. “The fact that all staff are agreeable to this change speaks to the initiative’s success.”
This model was so successful in its initial implementations that Inspira Health Network has selected it for their newest hospital, to open in November 2019, as it fits the future needs and use of technology perfectly, she said.
