Telepsychiatry: Enhancing Access to Mental Health Care · 2020-03-31 · PsychU Virtual Forum Rules of Engagement: Otsuka Pharmaceutical Development and Commercialization, Inc

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Telepsychiatry:Enhancing Access to Mental Health Care

Meera Narasimhan, MDAssociate Provost for Health Sciences, University of South Carolina, Columbia, SC

Professor and ChairDepartment of Neuropsychiatry and Behavioral Sciences,

University of South Carolina School of Medicine, Columbia, SC

Jonathan EvansChief Executive Officer

Safe Harbor Behavioral Health and InnovaTel Telepsychiatry, LLC., Erie, PA

August 2016 MRC2.CORP.D.00144

Otsuka Pharmaceutical Development & Commercialization, Inc. Lundbeck, LLC.

© PsychU. All rights reserved.


Jonathan EvansPosition: Mr. Evans is the Founder, President, and CEO of both InnovaTelTelepsychiatry, a private telepsychiatry provider servicing community based clinics, and Safe Harbor Behavioral Health, a public behavioral health clinic in Erie, PA.

Education: Mr. Evans earned his BA degree in Psychology and MA degree in Clinical Psychology from Edinboro University of Pennsylvania.

Meera Narasimhan, MD

Position: Dr. Narasimhan serves as the Associate Provost for Health Sciences at the University of South Carolina, as well as the Professor and Chair in the Department of Neuropsychiatry and Behavioral Sciences at the University of South Carolina School of Medicine.

Education: Dr. Narasimhan completed her residency in psychiatry and a neuroscience fellowship at Yale University, and she attended medical school at Gandhi Medical College in Bhopal, India.

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Commercialization, Inc. and Lundbeck, LLC. The speakers are compensated contractors of

Otsuka Pharmaceutical Development & Commercialization, Inc.



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• Discuss current barriers in mental health care and the goals of telepsychiatry

• Consider the potential benefits of telepsychiatry• Discuss settings and patient populations for

which telepsychiatry may be appropriate/useful• Review factors for consideration when

implementing telepsychiatry

Objectives

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What barrier in mental health care do you feel to be most relevant in your clinical experience?

A. Cost of therapy/insurance coverageB. Time constraintsC. StigmasD. Patients who have difficulty visiting the officeE. Access to available care

Polling Question

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• There are many barriers to accessing optimal mental health care1,2

• One goal of telepsychiatry is to reduce disparities in patient access to mental health care3

• Telepsychiatry may be feasible for patients diagnosed with serious mental illness (SMI), and may potentially offer multiple benefits4-6

– Patient appropriateness should be determined based on the professional’s assessment of the patient’s ability to arrange a suitable setting for videoconferencing services and cooperativeness regarding managing safety issues7

• State-specific regulations and other challenges must be considered and addressed for implementation of telepsychiatry8,9

Telepsychiatry – Overview

1. Thomas KC, et al. Psychiatr Serv. 2009;60:1323‐1328.2. Mohr DC, et al. Ann Behav Med. 2006;32:254-258.3. Grady B, et al. Telemed J E Health. 2011;17:131-148.4. Preschl B, et al. BMC Psychiatry. 2011;11:189.5. Sheeran T, et al. Telemed J E Health. 2011;17:620-626.

6. Rotondi AJ, et al. Rehabil Psychol. 2005;50:325-336.7. Turvey C, et al. Telemed J E Health. 2013;19:722-730.8. APA Council on Psychiatry & Law. 2014;1-18.9. American Psychological Association.

http://www.apa.org/practice/guidelines/telepsychology.aspx. Accessed September 30, 2015.

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TRANSPORTATION DIFFICULTIES2

$ COST OF THERAPY2

There Are Many Barriers to Access to Optimal Mental Health Care in the United States

1. Thomas KC, et al. Psychiatr Serv. 2009;60:1323‐1328.2. Mohr DC, et al. Ann Behav Med. 2006;32:254-258.3. Bauer AM, et al. Med Care. 2010;48:1097-1104.

A

TIME CONSTRAINTS2

CONCERNS ABOUT WHAT OTHERS WOULD THINK2

LIMITED ENGLISH PROFICIENCY3

SHORTAGE OF MENTAL HEALTH PROFESSIONALS1

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Digital Technology Is Poised to Become the Fourth Wave of Evolution in Mental Health Care

1. Gleitman H, et al. Psychology. 8th ed. W. W. Norton & Company. 2011:591-633.2. Ahuja N. A Short Textbook of Psychiatry. 7th ed. Jaypee Brothers Medical Publishers (P)

Ltd. 2011:172-198.3. Spring B. J Clin Psychol. 2007;63:611-631.

4. APA Presidential Task Force on Evidence-Based Practice. Am Psychol. 2006;61:271-285.5. Kumar S, et al. Am J Prev Med. 2013;45:228-236.6. Mohr DC, et al. Gen Hosp Psychiatry. 2013;35:332-338.7. Lehman AF, et al. Am J Psychiatry. 2004;161:1-184.

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Suboptimal treatment response remains an ongoing concern7

1890sPsychoanalysis1

1952Psychopharmacology2

1980s-’90sEvidence-based practice in

mental health care3,4

2015Digital psychiatry5,6

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Provision of health services over distance through the use of electronic information and telecommunications technologies1,2

• Examples of applications include patient consultations, liaisons with emergency personnel, telesurgery1

• In addition to patient care, these varied technologies may have a multiplicity of current and possible uses in professional education, research, public health, and administration1

Provision of mental health services from a distance3

• May include two-way, interactive videoconferencing or other technologies such as virtual reality, electronic mail, remote monitoring devices, chat rooms, and web-based clients4

• May be used for mental health assessment, treatment, education, monitoring and collaboration3

Telepsychiatry, a Form of Telemedicine, May Help Improve Access to Mental Health Care

1. Field MJ. Telemedicine: A Guide to Assessing Telecommunications for Health Care. 2011. 2. Fong B, et al. Telemedicine Technologies: Information Technologies in Telemedicine and Telehealth. 2011:1-14. 3. Grady B, et al. Telemed J E Health. 2011;17:131-148.4. Yellowlees P, et al. Telemed J E Health. 2010;16:1074-1089.

TELEMEDICINE TELEPSYCHIATRY (OR TELEMENTAL HEALTH)

Goal: to eliminate disparities in patient

access to quality, evidence-based, and emerging health care

diagnostics and treatments3

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Telepsychiatry May Be Associated With Several Potential Benefits

1. Backhaus A, et al. Psychol Serv. 2012;9:111-131.2. Jenkins-Guarnieri MA, et al. Telemed J E Health. 2015;21:652-660.3. APA Council on Psychiatry & Law. 2014;1-18.4. Mohr DC, et al. JAMA. 2012;307:2278-2285.5. Leigh H, et al. J Telemed Telecare. 2009;15:286-289.

Potential Benefits of

Telepsychiatry • Comparable levels of patient satisfaction1,2

• Feasible to deliver various types of psychotherapy1

• Decreased costs in terms of time and travel expenses1

• Increased access to care3

• Improved retention4,5

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• Major depressive disorder– May be acceptable1

– May be associated with a high level of patient satisfaction1

– May facilitate a strong working alliance comparable to that formed in face-to-face settings2

– May be feasible for use in elderly, homebound depressed patients3

• Schizophrenia– May be used to interview and

assess patients4

– May be acceptable4

– May increase patients’ ease of expression4

– May improve perceptions of social support5

Telepsychiatry May Be Feasible and Offer Potential Advantages for Patients Diagnosed With SMI

1. Chong J, Moreno F. Telemed J E Health. 2012;18:297-304.2. Preschl B, et al. BMC Psychiatry. 2011;11:189.3. Sheeran T, et al. Telemed J E Health. 2011;17:620-626.

4. Chae YM, et al. J Telemed Telecare. 2000;6:83-90.5. Rotondi AJ, et al. Rehabil Psychol. 2005;50:325-336.

Studies have shown that telepsychiatry may offer advantages when used in the management of patients diagnosed with SMI:

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*Treatment consisted of antidepressant medication management, psychoeducation, and brief supportive counseling

1. Ruskin PE, et al. Am J Psychiatry. 2004;161:1471-1476.

• In a randomized, controlled trial of veterans referred for outpatient treatment* (N=119; 105 men and 14 women), management of depression using telepsychiatry was comparable to in-person management, in terms of– Significant improvement in

symptoms – Study drop-out rates– Medication adherence– Patient satisfaction– Treatment costs

In a Study of Veterans, Remote Treatment* of Depression With Telepsychiatry Was Comparable to In-Person Treatment

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DISCUSSION



For which patient population would you be most inclined to utilize telepsychiatry?

A. Patients in emergency mental health care situations

B. Patients who live in rural settingsC. Patients who are veteransD. Patients in correctional facilitiesE. Patients in primary care settings

Polling Question

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RURAL SETTINGS VETERANS CORRECTIONALFACILITIES

• May reduce travel for patients and providers1

• May help decrease stigma2

• May support continuity of care3

• May enhance therapeutic alliance4

• May help reduce hospital admissions5

• May facilitate group therapy6

• May help address provider shortage7

• May allow for evaluation and consultation without compromising public safety7

Telepsychiatry May Help Extend the Reach and Facilitate the Delivery of Psychiatric Care

1. Horn BP, et al. J Telemed Telecare. 2016;22:47-55.2. Chakrabarti S. World J Psychiatry. 2015;5:286-304.3. García-Lizana F, et al. Prim Care Companion J Clin Psychiatry. 2010;12:e1-e5.4. Morland LA, et al. J Clin Psychiatry. 2010;71:855-863.5. Godleski L, et al. Psychiatr Serv. 2012;63:383-385.

6. Greene CJ, et al. J Consult Clin Psychol. 2010;78:746-750.7. American Psychiatric Association. Work Group to Revise the APA Guidelines on

Psychiatric Services in Correctional Facilities. Psychiatric Services in Correctional Facilities. Arlington, VA: American Psychiatric Publishing; 2016.

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1. US Department of Health and Human Services. Mental Heatlh: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. USDHHS, 2001.2. Ye J, et al. Telemed J E Health. 2012;18:797-802. 3. Jang Y, et al. Gerontologist. 2014;54:290-296.4. Chong J, Moreno F. Telemed J E Health. 2012;18:297-304.5. Mucic D. J Telemed Telecare. 2010;16:237-242.

Telepsychiatry May Help Extend Care to Populations Who Face Language Barriers

• Telepsychiatry has been explored in populations that face language and/or cultural barriers2-5

• Patient-reported benefits of telepsychiatry reported in 4 studies included– Convenience and easy access2

– Comfort, security, and confidentiality2

– Decreases in language and cultural barriers2,5

– Access to treatment in native language without needing to travel5

– Facilitation of therapeutic relationship3,4

“Race, ethnicity, culture, language, geographic region, and other social factors affect the perception, availability, utilization, and potentially, the outcomes of mental health services.”

US Public Health Service, Mental Health: Culture, Race, and Ethnicity1

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1. Seidel RW, et al. J Telemed Telecare. 2014;20:59-62.2. Narasimhan M, et al. Psychiatr Serv. 2015;66:1167-1172.

• May be used to assess psychiatric patients in the emergency department (ED)1

– In a study of patients presenting to the ED (N=73), telepsychiatricand face-to-face assessments showed agreement in disposition recommendation and diagnosis

• In a retrospective analysis of a state-wide, ED-based telepsychiatry program (N=14,522), compared to a matched control group, recipients of telepsychiatry2: – were less likely to be admitted – were likely to have a shorter length of stay, if admitted– were more likely to receive 30-day and 90-day outpatient follow-up– had lower total health care charges in 30-day follow-up period

Telepsychiatry May Play a Role inEmergency Mental Health Care

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1. American Psychiatric Association. Work Group to Revise the APA Guidelines on Psychiatric Services in Correctional Facilities. Psychiatric Services in Correctional Facilities. Arlington, VA: American Psychiatric Publishing; 2016.

• Multiple individual and institutional factors may complicate the provision of psychiatric services to individuals in correctional facilities1

• The Work Group to Revise the APA Guidelines on Psychiatric Services in Correctional Facilities (2016) indicates that telepsychiatry may be well-suited for use in correctional facilities as a supplement to on-site services1

– Prisons and jails are often located in rural communities with limited access to psychiatric services

– Use of telepsychiatry avoids the need to transport inmates to an off-site location for psychiatric consultation, which enhances the safety of the community

– Telepsychiatry may also allow for the observation of patients during an after-hours crisis or for monitoring of suspected medication side effects

Telepsychiatry May Be Acceptable for Use in Correctional Facilities

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1. Rabinowitz T, et al. Telemed J E Health. 2010;16:34-40. 2. Spaulding R, et al. Telemed J E Health. 2010;16:867-871. 3. Morland L, et al. Telemed J E Health. 2013;19:754-759.

4. Horn BP, et al. J Telemed Telecare. 2016;22:47-55.5. Pyne JM, et al. Arch Gen Psychiatry. 2010;67:812-821.6. Chakrabarti S. World J Psychiatry. 2015;5:286-304.

• Geriatric: Data analysis on the use of telepsychiatry among rural nursing home residents (N=106) over 278 encounters suggests that it could potentially result in cost savings in the following areas1:

– provider travel time, direct travel costs (eg, gasoline), patient transport, and related personnel costs

• Pediatric: Use of telepsychiatry among rural pediatric patients (N=132) over 257 consultations suggested substantial cost savings to patients and families2

• Veteran: Use of telepsychiatry among rural combat veterans (n=74) resulted in significant provider-level cost reductions, relative to in-person services3

• Native American: Use of telepsychiatry among rural Native American patients (762 total visits) resulted in savings on both provider and patient travel, relative to in-person services4

• In some cases, the costs of telepsychiatry may exceed the threshold for adoption5; the quality of the existing literature on cost-effectiveness varies6

Cost Savings of Telepsychiatry Have Been Evaluated in Various Rural Settings

“Break-even point” analyses suggest that telepsychiatry may result in cost savings when travel distances exceed about 30 km (19 miles)6

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Telepsychiatry May Potentially Offer Benefits to All Stakeholders in Mental Health Care Service and Delivery

1. APA Council on Psychiatry & Law. 2014;1-18.2. Backhaus A, et al. Psychol Serv. 2012;9:111-131.3. Jenkins-Guarnieri MA, et al. Telemed J E Health. 2015;21:652-660.

4. Hilty DM, et al. Telemed J E Health. 2013;19:444-454.5. Chakrabarti S. World J Psychiatry. 2015;5:286-304.6. Turvey C, et al. Telemed J E Health. 2013;19:722-730.

• Improved access to care1

• Treatment satisfaction2,3

• Convenience1

• Overcome language and cultural barriers4

• Diagnostic accuracy and reliability4,5

• Non-inferior to in-person treatment6

• Convenience1

• Cost-effective4

• Savings4

– Costs– Travel– Time

PROVIDERS PAYORSPATIENTS

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DISCUSSION



Medicaid and Private Coverage and Reimbursement Policies for Telepsychiatry Vary by State

1. Thomas L, et al. http://www.americantelemed.org/policy/state-policy-resource-center. Accessed February 11, 2016.

Reproduced by permission of American Telemedicine Association from Thomas L, Capistrant G. State telemedicine gaps analysis: coverage and reimbursement. January 2016.

• State policies for telemental health vary in specificity and scope− Map represents state rankings for Medicaid coverage of mental and behavioral health

services provided via telemedicine, based on scope and conditions of payment

Medicaid – Mental/Behavioral Health Services

Highest Grades (12 states and DC)

Other Grades (38 states)

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Several Factors Must Be Considered and Addressed for Successful Telepsychiatry Implementation

1. APA Council on Psychiatry & Law. 2014;1-18.2. American Psychological Association.


3. Turvey C, Coleman M, Dennison O, et al. Telemed J E Health. 2013;19:722-730.

4. Thomas L, et al. http://www.americantelemed.org/policy/state-policy-resource-center. Accessed February 11, 2016.

5. Sucala M, et al. J Med Internet Res. 2012;14:e110.6. García-Lizana F, et al. Prim Care Companion J Clin Psychiatry. 2010;12:e1-e5.7. Chakrabarti S. World J Psychiatry. 2015;5:286-304.

Confidentiality and Security1-3

Data Storage and Other Technical

Issues1,2

Management of Emergent

Situations1-3

Level of Technological Competence1,2

Therapeutic Relationship5

Reimbursement4Licensing and

Other Legal Concerns1,2

Provider Skepticism and Acceptance6,7

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• Telepsychiatry may improve access to mental health care1 and offer multiple benefits (eg, improved retention,2,3 decreased time and travel expenses4)

– Patient appropriateness should be determined based on the professional’s assessment of the patient’s ability to arrange a suitable setting for videoconferencing services and cooperativeness regarding managing safety issues5

• Telepsychiatry may be acceptable for use among patients diagnosed with SMI6 and for assessment of patients in the emergency department7

• Telepsychiatry may also be feasible for use among various underserved patient populations8-11

• Telepsychiatry may offer advantages to all stakeholders in the service and delivery of mental health care, ie, patients, providers, and payors1,4,12,13

• Despite the potential promise, for greater uptake and successful implementation of telepsychiatry, several challenges will need to be effectively addressed1,13,14

1. APA Council on Psychiatry & Law. 2014;1-18.2. Mohr DC, et al. JAMA. 2012;307:2278-2285.3. Leigh H, et al. J Telemed Telecare. 2009;15:286-289.4. Backhaus A, et al. Psychol Serv. 2012;9:111-131.5. Turvey C, et al. Telemed J E Health. 2013;19:722-730.6. Chong J, Moreno F. Telemed J E Health. 2012;18:297-304.7. Seidel RW, et al. J Telemed Telecare. 2014;20:59-62.8. Ye J, et al. Telemed J E Health. 2012;18:797-802.

9. Moreno FA, et al. Psychiatric Services. 2012;63:1213-1217.10. Rabinowitz T, et al. Telemed J E Health. 2010;16:34-40. 11. Morland L, et al. Telemed J E Health. 2013;19:754-759.12. Hilty DM, et al. Telemed J E Health. 2013;19:444-454.13. Chakrabarti S. World J Psychiatry. 2015;5:286-304.14. American Psychological Association.


Summary

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DISCUSSION



QUESTIONS



QUESTIONS



CLOSING

Documents

Telepsychiatry: Enhancing Access to Mental Health Care · 2020-03-31 · PsychU Virtual Forum Rules of Engagement: Otsuka Pharmaceutical Development and Commercialization, Inc