Traversing the 114 Mile Gap at the Speed of Light A D A M B I U C K I A N S , M D E R I N G L E N N , L S W
Who We Are Adam Biuckians, MD Community Services Group, Medical Director Board Certified Child and Adolescent Psychiatrist Erin Glenn, LSW TrueNorth Wellness Services, Fulton County Outpatient Clinical Supervisor
History of Communication Figure 1: Timeline of communication tools, 2014 update. Ref: Khourdajie, A. (2008), Marketing for the Wireless World. Individual Term Paper, MARK1051, University of Greenwich, UK.https://commons.wikimedia.org/w/index.php?curid=31202496
History of Communication in Psychiatry Old School Face to Face Telephone Snail Mail Facsimile New School Email Instant/Text Messages Patient Portal Virtual Visits (telepsychiatry) Apps (ie MyStrength)
Brief History of Telepsychiatry Nebraska Psychiatric Institute 1959 Debut of audio and video transmissions in psychiatric setting Starting with teaching medical students at Medical College of Nebraska, but evolved into providing consultation, diagnostic assessment, and even group psychotherapy (American Psychiatric Association (APA)) NIMH 1968 Funded the first microwave relay to facilitate a direct consultation to a patient’s remote location Occurred between Dartmouth Department of Psychiatry and a rural hospital (Solow, C.; Weiss, RJ.; Bergen, BJ., 1971)
Brief History of Telepsychiatry Massachusetts General Hospital 1973 Use of closed circuit television for psychiatrists to see patients at a nearby airport Reportedly the term “ telepsychiatry ” came from this project Also introduced the use of remote control cameras to pan, zoom, and tilt (APA) From mid- 70’s onward Slow growth, but gradually increasing acceptance and overcoming of various obstacles/barriers Ongoing, and often dramatic, improvements in technology help to facilitate growing acceptance (APA)
Brief History of Telepsychiatry 2000 Onward More rapid growth Larger institutional programs utilizing more frequently VA Health Maintenance Organizations Academic Centers Smaller clinics and hospitals begin utilizing as well Individual practitioners direct to patients’ homes with the explosion of the internet and patients’ increasing familiarity and comfort with web-based videoconferencing Telepsychiatry companies begin offering services to clinics/hospitals unable to sufficiently staff for their communities’ needs (APA)
What is Telepsychiatry? Form of videoconferencing Uses video cameras and microphones Able to connect psychiatrists to patients in otherwise remote and/or underserved locations Direct services provided include diagnostic assessment, ongoing medication management, individual and group therapy Indirect services provided include consultation and collaboration between professionals One of the most effective ways to increase access to psychiatric care
The Goal Navigating the obstacle course of accessing care
The Goal
Our Community Fulton County, Pennsylvania – By Numbers Total Population: 14,747 (US Census Bureau – American Community Survey 2010-2014) 15.7 % of population eligible for Medical Assistance (PA Department of Health, Bureau of Health Statistics & Research 2014) 56/67 ranking among PA counties for Health Factors (County Health Rankings 2015, Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute) Measured considering Health Behaviors, Clinical Care, Social and Economic Factors, and Physical Environment
Our Community Fulton County, Pennsylvania – By People Largest Employer: JLG Industries, Inc. (Center for Workforce Information & Analysis 4 th Quarter 2014 Initial Data) Fun Fact: Only county left in PA with more cows than people! Figure 2: 400S Telescopic Boom Lift, JLG.com
Our Community Fulton County, Pennsylvania – By Location 112,201 Acres Farmland (2012 US Census of Agriculture) Surrounded by three mountains
Our History Statewide, there is a significant shortage of Psychiatrists, specifically Child and Adolescent Psychiatrists. Prior to TrueNorth Wellness opening in Fulton County, there was 1 psychiatrist, 1 day per month, to entire population. American Academy of Child & Adolescent Psychiatry
Our History Population Health estimates that there should be a ratio of 10,000 citizens to 1 full time psychiatrist. Most individuals sought medication management through Primary Care. Two major PCPs in area. Overwhelmed by having to provide mental health care on top of physical health care.
Our History Prior to True North Wellness Services, distance to services: Chambersburg, PA – Approximately 25 miles, 35-40 minutes Hagerstown, MD – Approximately 30 miles, 45 minutes Harrisburg, PA – Approximately 75 miles, 1 hour 20 minutes
Our History The joining of Brilliant Minds Susan Blue, Mary McGrath, James Martin, Gary Minnier An established relationship between CSG and TrueNorth Wellness
Our History Began Child and Adolescent Psychiatry June 2013 Every other Tuesday 110 Services in Year 1 Began Adult Psychiatry January 2014 Every other Thursday 155 Services in Year 1
The Model Synchronous Directly interacting with the consumers and providing treatment Asynchronous Consultation provided to another provider, regarding a consumer
The Model Agency partnership Contracted telehealth provider InSight InnovaTel Web based platforms Secure Telehealth
Our Process Referral made for psychiatry Majority made by area Primary Care Physicians Referrals made to Centralized Intake Department Same process for seeing on site physician 6 years old and up, scheduled 5 years old and younger, clinical supervisor consulted Looking for other supports and services being tried prior to psychiatry Appointments scheduled with nurse and psychiatrist
Our Process Nursing Visit Weight (each visit) Blood Pressure (each visit) Medical History (first visit) Assess (each visit) Safety, medication compliance, side effects, etc.
Our Process Psychiatric evaluation/medication management Can request additional observation by nurse for anything unable to determine (i.e. gait) Can zoom in and out, without the client being aware Prescriptions printed to front office IMs sent for any questions, concerns, assistance
Our Process Nurse and Physician communicate throughout session Nurse can follow up on lab work requests, additional information gathering Nurse and/or front office assist in completion of releases for additional providers or supports
The Challenges and Solutions I need to talk to you! This challenge really is based more on timing than providing services via teleconferencing Once every other week is not always enough time Let’s talk! First half hour of each day is scheduled for physician, nurse, and therapists Conference calls scheduled for “off weeks” Nurse is able to email for any emergent concerns On site meetings, alternating locations, 2 times per year
The Challenges and Solutions I need a day off! Having physicians working with multiple agencies makes meeting sufficient psychiatric coverage more complex We can make that work! We found that we had to be flexible on each side Offer other days to replace days off Utilize on site physicians when necessary
The Challenges and Solutions Who can help?! Not living in the community in which you work can make learning about that community more difficult It is often a challenge to locate needed resources, especially when assumed Fulton County does not have them We’ve got this! Created a resource list for physicians to have on hand
The Challenges and Solutions Where did they come from? Often very little information when a client is referred Telehealth physicians are not linked to local providers I found them! We have learned to utilize our nurse as a detective We are working to determine better ways to access information prior to appointments We have taken telehealth providers to local agencies in order to facilitate linkages
The Challenges and Solutions Can you hear me now? Technology is not always reliable What happens when there is a disconnect? I copy you loud and clear! “Tech guys” for each agency worked on developing the system and are aware of the importance of smooth operating We do have “back up plans”
The Challenges and Solutions Technology failure back up plans Turn it off and turn it back on Call the “tech guys” Urgent matters addressed via telephone in interim Offer a different location CSG and TrueNorth Wellness both have the ability to use telepsych equipment from other locations Our adult provider one time even drove to Fulton County!
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