A primary care physician recently referred a patient with a history of mental illness to the emergency department (ED) of Mercy Medical Center Roseburg, a community hospital in Oregon. The physician requested that the patient be considered for psychiatric hospitalization and communicated concern for imminent danger.
The patient arrived at the crowded ED on a Friday night. Her initial examination showed no worrying signs or symptoms. Her mood was appropriate, and she interacted well with ED staff. However, because of her primary care doctor’s concerns, the emergency physician did not feel confident discharging her without first ordering a comprehensive psychiatric evaluation.
But there was a problem: the ED had no psychiatric coverage on weekends. “Without on-demand specialty care, this patient would have been placed on a hold and waited [in the ED] until Monday,” said Herb Harman, MD, Vituity’s Associate Director of Telepsychiatry.
Fortunately, this ED had recently launched an on-demand telepsychiatry program to provide 24-7 access to an emergency psychiatrist. Let’s take a look at the benefits of this approach and some best practices for implementation.
ED visits involving mental health and substance abuse complaints increased by 44 percent between 2006 and 2014. During the same time period, the number of patients presenting to EDs with suicidal ideation rose 414 percent.
Unfortunately, many EDs struggle to meet this growing demand for care. A 2016 ACEP survey found that just 17 percent of emergency physicians had access to an on-call psychiatrist. And 11 percent of respondents had no one to consult on mental health and substance abuse cases.
With appropriate care, most psychiatric emergencies stabilize in less than 24 hours. However, patients who present to the ED with psychiatric complaints are 3 to 4 times more likely to be admitted to an inpatient facility compared to those with purely physical complaints.
A number of factors drive the high rate of psychiatric admissions, including lack of access to psychiatric consults in the ED. Moreover, a decision to admit sometimes creates more problems than it solves.
Inpatient psychiatric facilities are in short supply in many parts of the country. As a result, patients awaiting admission are held in the ED for an average of seven to 34 hours waiting for bed placement, in some cases being transferred hours away.
This practice of holding patients, which is also known as boarding, has significant costs for hospitals. A study at one academic center estimated that each boarded patient cost the ED $1,198 in reimbursement losses. When researchers factored in opportunity costs, this figure rose to $2,264.
The plight of psychiatric ED patients has sparked a wave of advocacy and innovation. Experts like Scott Zeller, MD, Vituity’s Vice President of Acute Psychiatry and pioneer of the Alameda Model of psychiatric emergency care, have called for a shift toward early intervention and treatment for ED patients.
“If you go to the ED with an asthma attack, they’re going to give you the treatment you need and send you home,” Zeller told Hospital Peer Review in a recent interview. “We should be treating people [with psychiatric complaints] in the ED and resolving their problems in the emergency setting, just like any other emergency.”
In addition to being the right thing to do for patients, early intervention in the ED benefits hospitals. Stabilizing and treating a patient in psychiatric crisis is often faster than arranging an admission, and in many cases, the patient can be discharged home. Reducing ED length of stay for psychiatric patients saves money, improves patient flow, and boosts the department’s capacity to care for all emergencies.
In order to improve care quality and minimize boarding of psychiatric patients, more and more hospitals are turning to telepsychiatry. To see one example, let’s return to the case in the introduction.
When the emergency physician decided the patient needed a psychiatric assessment, he initiated a telepsychiatry consult. Within minutes, a board-certified psychiatrist responded through the secure video-conferencing platform.
The psychiatrist spoke with the patient face-to-face virtually to establish rapport and conducted a thorough, comprehensive, and detailed evaluation. The results confirmed the ED team’s impression that discharge with follow-up at an outpatient facility was the appropriate level of care.
“In this common case where a patient may have stayed in the ED three to four days, she was instead discharged in under two hours,” Harman says.
In addition to the ED, telepsychiatrists can also support inpatient psychiatry, EmPath (crisis stabilization) units, hospital medicine, and outpatient services.
The same telepsychiatry panel can serve a single hospital or a network of hospitals. Health systems with inpatient psychiatry programs sometimes use telepsychiatry to establish themselves as regional hubs for mental health and substance abuse care. As such, they consult with providers at local community hospitals to ensure that only appropriate cases are transferred and admitted. This provides a valuable service to the community while allowing the hospital to grow its business.
The first step in getting started with telepsychiatry is usually to create buy-in with administrators, physicians, and staff for the idea. The following are some common myths and objections that champions may need to address:
Can psychiatrists possibly provide the same standard of care via video conferencing that they can in person? The evidence strongly suggests they can. In a study involving rural patients, diagnostic accuracy via telepsychiatry was within 1–2 percent of in-person assessment. What’s more, accuracy is expected to improve as technology advances.
Other studies have found that telepsychiatry patients have similar treatment outcomes to those seen in person. This finding holds true across a wide range of populations, including children, adolescents, nursing home residents, college students, immigrants, veterans, and incarcerated individuals.
For some populations, telepsychiatry can reduce the cost of care by 40 to 70 percent. However, reimbursement varies widely by state, setting, and patients served. There is still a long way to go on this front, but progress is being made at the Federal CMS level and state Medicaid level, and commercial payers are slowly coming on board.
At present, Medicare, Medicaid, and many third-party payers only reimburse under certain circumstances. We recommend researching your state’s parity laws and strategizing with your payer contracting team. For example, Medicare will pay for crisis services delivered by telepsychiatry if the facility is rurally designated.
Anecdotal evidence suggests that even where reimbursement is zero, telepsychiatry can still save hospitals money in the long run. When factoring in the cost of the program, administrators should also consider:
After set-up fees, most telepsychiatry services charge by the consultation. So even where psychiatric coverage is available, on-demand telepsychiatry may still be a more cost-effective option. This is especially true for lower-volume EDs that don’t treat enough psychiatric cases to justify the cost of a dedicated, local call panel.
Research suggests patients don’t mind telepsychiatry — and may even prefer it to an in-person consultation. Even if patients have hesitations around using telehealth technology, they should certainly appreciate the rapid response to meet their care needs in the ED versus waiting hours or days to see a psychiatrist.
Once you’ve gained buy-in for the program, consider involving community partners. Public health programs, local care networks, and private mental health charities may be willing to contribute financial and human resources to your efforts.
When choosing a telepsychiatry provider, look for one that provides a panel of psychiatrists with expertise and experience to treat acute psychiatric patients. To realize the full value of this type of service, having a physician partner with the confidence to treat and disposition emergency psychiatric patients will ensure qualitative and quantitative returns on your investment.