What is telePsychiatry?

TelePsychiatry is the diagnosis and treatment of mental health patients by a remote clinician using telecommunications technology like videoconferencing. It makes it possible for a psychiatrist and patient to be in separate rooms, cities, states, or even countries and still be connected face-to-face.

When a patient with mental health or substance abuse issue arrives at the ED, they are triaged similar to any other illness. Once any medical issues are established or eliminated, the patient is typically isolated and monitored closely. Hospitals request a telePsychiatry consult, and the patient is seen by the remote psychiatrist. Treatment options are discussed with the patient, patient’s family, and onsite staff.

How does telePsychiatry work in a hospital?

The use cases for telePsychiatry are well-established in hospitals: 

  • In the emergency room, remote specialists can “beam in” to consult with the patient and onsite staff for patients with mental health or substance abuse issues. 
  • TelePsychiatry can be used with admitted patients, as well, when mental status changes occur due to anxiety or stress

Why is the use of telePsychiatry growing?

It is estimated that 18% of adults in the United States currently struggle with mental, behavioral, or emotional disorder.  Mental health and substance use disorders are now the leading cause of disease burden in the US.

Right now, the CDC estimates that 10%5 of all ED patients present with a psychiatric illness. But that only tells part of the story. Two recent studies demonstrated that 45% of adults and 40% of pediatric patients who present in the ED with non-psychiatric complaints have an undiagnosed mental illness.

Even though the demand for mental health services has steadily increased, access to care has declined.  

  • 77% of US counties face a serious shortage of psychiatrists  
  • Swamped psychiatry practices have long waits for appointments. In some states, the average wait is 25 days for an initial visit, and approximately 20% of psychiatrists are not accepting new patients. 
  • And the shortage is expected to increase: more than 60% of practicing psychiatrists are over the age of 55. For most hospitals, that means they no longer have to take calls. There is also an upcoming wave of retirements. 

Because the demand for mental health resources outstrips the supply, many hospitals have turned to telePsychiatry to help manage this vulnerable and challenging patient population.

How do mental health and substance abuse patients impact the Emergency Department?

Medical emergency departments are not designed to handle large volumes of mentally ill patients. ED physicians are understandably uncomfortable determining the plan of care in a silo as the vast majority have not received in-depth behavioral health training.  There are several ways an Emergency Department can be impacted:

ED Overcrowding: 

  • Increased average length of stay—for ALL patients 
  • Patients leaving without being seen (LWBS) 
  • In extreme cases, hospitals may be forced to go on divert (prolonged transfer times negatively impact quality of care) 

 Quality: 

  • According to the Joint Commission, 50% of sentinel events causing serious injury or death occur in the ED—and 1/3 are directly related to crowding 
  • Increased mortality rate—crowding increases the hazard ratio for death to approximately 1.3  
  • Medical liability: the frequency of medical liability lawsuits filed against ED physicians increases by a factor of 5 if it takes longer than 30 minutes for the patient to be seen

 Financial Impact: 

  • Lost revenue because non-mental health patients leave without being seen
  • Reimbursements for mental health patients are 40% less than other patients
  • Violent or suicidal patients must be monitored at all times; this increases costs for sitters and security 
  • Some hospitals are boarding mental health patients in the ICU—one of the most expensive settings of care

Staff Impact:

  • Staff turnover and burnout because of frustration with limited psychiatric resources or risk of violence and verbal abuse
    • 75% of ED physicians experience acts of violence or verbal abuse at least once per year
    • 25% of ED nurses see over 20 episodes of physical violence over 3 years
  • Reduction in patient satisfaction 

What is boarding?

Boarding is the term used to describe the wait time a mental health patient experience after diagnosis but before inpatient treatment. On average, mental health patients can wait 8 to 34 hours for an inpatient bed. Just about every hospital or ED physician can tell you stories about much longer waits—100s of hours, even days. According to a recent poll, 70% of emergency physicians reported psychiatry patients being boarded in the ED on their last shift.

An inpatient bed is not a certainty, however. Inpatient psychiatric services have declined sharply, making post-discharge placement a very real challenge. 

  • There has been a 77.4% reduction in inpatient psychiatric capacity nationwide 
  • And $5 Billion in additional state funding cuts between 2009-2012 

How can emergency departments decrease suicides?

Suicide is currently the 10th leading cause of death in the US and suicide rates have risen sharply over the years―increasing by more than 30% in most states. Because so many mental health patients present to the ED, we have a unique chance to screen these patients for suicide risk.

The Joint Commission reviewed its National Patient Safety Goal for suicide prevention, adjusting the requirements (NPSG 15.1.1) as of July 1, 2019. All hospitals participating in the Hospital Accreditation Program are now required to screen patients for suicidal ideation and conduct a risk assessment. Those patients identified and documented as moderate- or high-risk require a plan—mitigating the risk of suicide.

With telePsychiatry, these assessments could be done by a remote provider, freeing up clinicians and other staff for other patients.

What are the benefits of telePsychiatry?

TelePsychiatry provides a host of benefits for both providers and patients, including:

  • Access to specialists not otherwise locally available
  • Reduced wait time during a mental health crisis
  • More efficient patient treatment workflow, allowing providers and hospitals to see more patients
  • Increased provider and hospital revenue
  • Reduced provider and hospital costs
  • Reduced time to diagnosis and treatment
  • Rapid communication between members of the medical team and patient
  • Reduced physician and nurse burnout
  • Helping patients get better, faster

Conclusion

TelePsychiatry is an efficient use of scarce mental health resources. With an increase in the number of patients visiting the emergency room with mental health and substance abuse issues, telePsychiatry can help decrease wait times for all patients. Reimbursement for mental health patients is substantially lower than for other patients. By using telePsychiatry, hospitals can free up ED staff to see other, higher reimbursement patients faster.

Additional Resources on telePsychiatry

7 questions to answer before implementing telePsychiatry

How telePsychiatry Decreased ED Crowding

How telePsychiatry Decreases ED Overcrowding at CaroMont Regional

Sandra Bland Act Means Telemedicine is Coming to Texas Jails

Sandra Bland Act: Telemedicine is Coming to Texas Jails

Using telePsychiatry to treat substance abuse

Using telePsychiatry to Treat Substance Abuse

From Failure to Future: The Ryan Leaf Story on Addiction Recovery

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