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Service Delivery Innovation Profile

Videoconferencing Enhances Access to Psychiatric Care for Children and Adults With Mental Illness in Rural Settings


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Snapshot

Summary

Psychiatric fellows and residents at the University of Virginia Health System in Charlottesville use videoconferencing to serve children and adult patients with mental illness who live in rural parts of the State. Children gain access to this care by visiting any of three local mental health centers (known as community service boards), whereas adults do so at local primary care and geriatric clinics. To facilitate the provision of care, the health system's Center for Telehealth offers technical support and other tools and services to participating mental health centers and clinics. The program has enabled thousands of patients with mental illness to receive psychiatric care who otherwise likely would not have had access to such care, and has generated high levels of satisfaction among parents and adult participants.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of videoconference sessions held with adults and children, along with results from a 21-question survey of parents that used a 5-point Likert-type scale and a survey of adults that used a 4-point scale.
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Developing Organizations

University of Virginia Health System
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Date First Implemented

2006
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Patient Population

The videoconferencing programs primarily serve low-income patients in rural parts of southern and southwestern Virginia. Many of the adult patients and parents of children served by the program are unemployed or have low levels of educational achievement.Vulnerable Populations > Children; Frail elderly; Mentally ill; Rural populationsend pp

Problem Addressed

Mental illness is common among children and adults, but many of those who experience it face difficulties in accessing psychiatric care, particularly low-income individuals and those living in rural areas. Left untreated, mental health disorders frequently have a serious, long-lasting, negative impact on a person's life.
  • High prevalence of mental disorders: According to the National Institute of Mental Health, 1 in 4 American adults experiences a mental illness or substance-related disorder each year, and approximately 10 percent experience severe, chronic, or debilitating conditions, including schizophrenia, bipolar disorder, depression, anxiety, and drug addiction.1 Many children are also affected by mental illness, with roughly 20 percent of those between the ages of 9 and 17 years being impaired to some degree by a mental disorder, including anxiety, disruptive mood, and substance abuse disorders.2
  • Difficulties accessing psychiatric care, especially in rural areas: Psychiatrists can play a key role in treating mental health disorders by making accurate diagnoses and providing psychotherapy and other therapies, including medications. However, many adults and children lack access to a psychiatrist, particularly low-income individuals and those living in rural areas.3 In rural southern and southwestern Virginia, for example, those in need of psychiatric care generally must drive hundreds of miles to see a psychiatrist, resulting in missed work and school time.
  • Long-lasting negative impact: Untreated mental health disorders can have severe negative consequences that often last a lifetime, including increased risk of strained relationships, drug abuse, violence, missed school and work, and suicide.1,4

What They Did

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Description of the Innovative Activity

Psychiatric fellows and residents at the University of Virginia Health System in Charlottesville serve children and adult patients in rural parts of the State via videoconferencing. Children gain access to such care by visiting any of three local mental health centers [known as community service boards (CSBs)], whereas adults do so at local primary care and geriatric clinics. To facilitate the provision of care, the health system's Center for Telehealth offers technical support and other tools and services to participating CSBs and clinics. Key program elements are described in more detail below:
  • Treatment of children through local CSBs: Children typically get referred to the program by their pediatrician or a mental health counselor, or after a parent requests an appointment. Those referred come to any of three CSBs in the area that have contracted with the health system to offer access to psychiatric care via a videoconference link to an outpatient clinic in Charlottesville. Working out of two dedicated offices at the Charlottesville clinic, six child psychiatry fellows who are completing their studies at the University of Virginia (UVA) School of Medicine provide most of the care, under the supervision of three faculty psychiatrists. Each fellow typically works dedicated shifts of 3 to 4 hours twice each week, collectively offering services for 43 hours a week. In addition, one fellow is on call at all times for emergency consultations by telephone. Treatment begins with an initial 90-minute evaluation, followed by monthly 30-minute followup visits for as long as needed. Fellows treat a variety of common mental disorders, including depression, anxiety disorders, substance abuse, attention deficit hyperactivity disorder, and learning disabilities. Treatment consists primarily of medication, with the psychiatry fellow determining which drug(s) to prescribe and then monitoring the effectiveness of the medication(s) over time.
  • Consultations for adults at local primary care and geriatric clinics: Adults with mental illness typically get referred to the program by primary care physicians (PCPs) who have been unable to help the patients on their own. These adults access videoconference-based psychiatric care at any of 20 primary care clinics and 2 geriatric clinics in the area. Working Wednesday and Friday afternoons out of 4 dedicated offices at the Charlottesville clinic, 10 fourth-year adult psychiatry residents from the UVA School of Medicine provide most of the care, under the supervision of a faculty psychiatrist. Residents usually meet with patients two or three times—an initial consultation lasting 90 minutes to 2 hours and 1 or 2 30-minute followup sessions. As much as possible, residents are assigned to one specific primary care clinic, to foster familiarity and trust among patients. Commonly treated conditions include depression, posttraumatic stress disorder, substance abuse, and bipolar disease. The residents primarily play the role of consultant to the patient's PCP—after learning about the patient's background and medical history and completing the sessions, the resident sends treatment recommendations via fax to the PCP, who provides or arranges for the treatment, including prescribing medications.
  • Support services and tools to facilitate care: The health system's Center for Telehealth coordinates both programs and offers various services and tools to support the Charlottesville clinic and the participating CSBs and clinics in rural areas, including the following:
    • Initial installation and ongoing technical support: Center staff work with the CSBs and primary care and geriatric clinics to install the needed videoconferencing technology. Center technicians are available on an ongoing basis to address any problems with audio or visual connections.
    • Standardized contracts and forms: All CSBs and primary care offices operate under the same contract and use standardized forms for patients who participate in the videoconferencing program, including consent and medical history forms.
    • Access to archiving and communication system: The center uses a picture archiving and communications system (PACS) to facilitate the storing and sharing of medical records by psychiatrists.

Context of the Innovation

Affiliated with the UVA School of Medicine, the University of Virginia Health System in Charlottesville, VA, includes a 604-bed hospital, a level I trauma center, and primary and specialty clinics throughout Central Virginia. The health system's Center for Telehealth, which opened in 1994, enables physicians to see patients via videoconference in specialties such as psychiatry, cardiology, gastroenterology, gynecology, infectious disease, neurology, ophthalmology, and pediatrics.

The videoconferencing programs grew out of less formal arrangements that began in the early 2000s when physicians and other health care practitioners in rural areas began asking child and adult psychiatrists at the health system to see some of their patients with mental illness. To meet these requests, these psychiatrists would occasionally use the equipment available through the Center for Telehealth to evaluate and care for patients via videoconference. As the demand for these psychiatrists' services grew, they decided to work with leaders of the health system and the Center for Telehealth to set up more formal programs designed to reach many more patients in rural areas. Aware of the increasingly important role of telemedicine in their field of medicine, psychiatry fellows and residents eagerly volunteered to become part of the program so as to gain experience in this area.

Did It Work?

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Results

The videoconferencing program has enabled thousands of adults and children with mental illness to receive psychiatric care who otherwise likely would not have had access to such services, and has generated high levels of satisfaction among parents of children served by the program and among adult participants.
  • Enhanced access to psychiatric care: From 2007 to 2012, child psychiatry fellows held approximately 12,000 sessions via videoconference with children and adolescents in rural areas of the State. From 2003 to 2012, adult psychiatry residents held approximately 900 sessions with adult patients from these same areas. Without these programs, most of these patients likely would not have received such care.
  • High satisfaction among participants: Surveys of parents whose children participated in the program and adults who participated found high levels of satisfaction.
    • Parents: A 2011 survey of 48 parents found large majorities of parents agreed or strongly agreed with statements such as "my child was comfortable with the videoconferencing format," "I am pleased with the care my child received," "my child received the same level of service through telemedicine as at previous inperson visits with physicians," and "using the telemedicine facility saved me time and/or money versus driving to a more distant inperson visit."
    • Adult participants: In 2010, adult participants were asked to rate on a scale of 1 to 4 answers to several questions. For the questions, "How likely are you to make another appointment?" and "Are you likely to recommend this service to a friend/family member?" the average rating was 3.92. For the question, "How helpful has this appointment been today?" the average rating was 3.64.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of videoconference sessions held with adults and children, along with results from a 21-question survey of parents that used a 5-point Likert-type scale and a survey of adults that used a 4-point scale.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Setting up program to serve children: In 2006, a UVA Health System child psychiatrist initiated a partnership with one CSB in southwestern Virginia to provide videoconferencing services on a regular basis. Over the next 2 years, similar partnerships formed with several other CSBs. In each case, staff from the Center for Telehealth made site visits to install the needed technology and train employees to use it. Faculty psychiatrists who already had experience treating patients via videoconference trained the child psychiatry fellows on how best to provide care through this medium; for example, they taught them the importance of using slightly exaggerated gestures and looking directly at the camera on occasion to approximate eye contact.
  • Setting up program to serve adults: In 2003, a UVA Health System adult psychiatrist began initiating partnerships with several primary care clinics in southwest Virginia to provide videoconferencing on a weekly basis. The service was relatively easy to set up at these sites because the Center had already implemented videoconferencing with many of these clinics in other medical specialties.
  • Expanding programs: Both programs steadily expanded in the ensuing years, as word spread among health care professionals in rural areas that psychiatry services could be obtained via videoconference, and as program leaders promoted the programs through professional organizations and at medical conferences. In 2009, the program expanded to include two geriatric clinics that operate as part of State's Program of All-Inclusive Care of the Elderly (PACE) program.
  • Launching new model for children in crisis: Under a new model initiated in 2013, the program began providing crisis services to children with mental health issues at 10 additional CSBs. Under this initiative, patients having a mental health crisis who come to a CSB receive a prompt videoconference-based evaluation by a psychiatrist, who typically prescribes medication therapy. Once stable, the patient is transferred to the care of a PCP for ongoing monitoring and medication management. The psychiatrist remains available for followup consultations by video or telephone.

Resources Used and Skills Needed

  • Staffing: As noted, 3 faculty psychiatrists and 6 child psychiatry fellows work on a part-time basis serving children, whereas a faculty psychiatrist and 10 adult psychiatry residents work on a part-time basis to serve adults. Staff from the Center for Telehealth contribute their services to the program as part of their regular duties, working as needed to install and maintain videoconferencing equipment at the Charlottesville clinic and the participating CSBs and clinics in rural areas.
  • Costs: Data on program costs are not available. Upfront costs consist primarily of the videoconferencing equipment, including computers with cameras. Ongoing costs include staff time dedicated to the program and ongoing maintenance of the equipment and secure Internet connections.
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Funding Sources

Anthem Health Plans of Virginia
The State of Virginia and Anthem Health Plans of Virginia have provided significant financial support to the program. For example, in 2003, Anthem awarded a 5-year, $250,000 grant to the Center for Telehealth to help expand the reach of the adult program in rural Virginia, including covering care for indigent patients.end fs

Tools and Other Resources

More information about the UVA Health System's Center for Telehealth is available on the center's Web site at: http://www.healthsystem.virginia.edu/pub/office-of-telemedicine/center-for-telehealth.html.

More information about the videoconferencing programs is available at: http://www.medicine.virginia.edu/clinical/departments/psychiatry/sections/clinical/telepsychiatry
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Adoption Considerations

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Getting Started with This Innovation

  • Do not be intimidated by obstacles: Starting this type of program is not difficult, as the technology has become fairly inexpensive and has progressed to the point that high-quality audio and video are now widely available and glitches usually can be easily corrected when they occur. Children, young adults, medical residents, and fellows tend to embrace this type of program, as they are generally quite familiar with and comfortable using videoconference technology. Most middle-aged and older adults quickly adapt to it as well.
  • Ensure adequate preparation in advance of sessions: Make sure that supporting documents and records are available to those providing psychiatric care well in advance of the session; working from a remote location can make it difficult to obtain this information at the last minute.

Sustaining This Innovation

  • Look for expansion opportunities: Once the program infrastructure is in place, consider recruiting new rural sites to participate (assuming adequate capacity exists to handle additional demand for psychiatric care). As part of this effort, approach the leaders of organizations able to bring on multiple locations at once, such as health plans and public health departments.
  • Standardize as much as possible: Managing the program becomes easier when interactions with participating sites can be standardized through use of common contracts and patient forms.

More Information

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Contact the Innovator

Roger C. Burket, MD, DFAPA, DFAACAP
Chief, Developmental Disorders Section
Director, Child and Family Psychiatry
UVA Department of Psychiatry and Neurobehavioral Sciences
P.O. Box 800793
Charlottesville, VA 22908
(434) 243-6950
E-mail: rcb8n@hscmail.mcc.virginia.edu

R. Lawrence Merkel Jr., MD, PhD
Associate Professor of Psychiatric Medicine and Neurobehavioral Sciences
UVA School of Medicine
P.O. Box 800623
Charlottesville, VA 22908
(434) 243-6950
E-mail: rlm3u@virginia.edu

Innovator Disclosures

Dr. Burket and Dr. Merkel reported having no financial interests or business/professional affiliations relevant to the work described in this profile other than the funders listed in the Funding Sources section.

Footnotes

1 Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-27. [PubMed]
2 U.S. Department of Health and Human Services. Mental health: a report of the Surgeon General. Rockville (MD): U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999.
3 Thomas KC, Ellis AR, Konrad TR, et al. County-level estimates of mental health professional shortage in the United States. Psychiatr Serv. 2009;60(10):1323-8. [PubMed]
4 Manderscheid RW, Berry JT, eds. Mental health, United States, 2004. Rockville (MD): Center for Mental Health Services. Substance Abuse and Mental Health Services Administration; 2006. DHHS Pub No. (SMA)-06-4195. Available at: http://store.samhsa.gov/product/SMA06-4195.
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Original publication: December 04, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: December 04, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.