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Service Delivery Innovation Profile

Statewide Partnership Provides Mental Health Assessments via Telemedicine to Patients in Rural Emergency Departments, Reducing Wait Times, Hospitalizations, and Costs


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Snapshot

Summary

The South Carolina Department of Mental Health partnered with the University of South Carolina School of Medicine and 18 predominantly rural hospitals from the South Carolina Hospital Association to establish the statewide telepsychiatry initiative. This public–private–academic partnership makes psychiatrists available via teleconference 16 hours a day, 7 days a week, to assess and treat patients with mental health issues at hospital emergency departments. Clinicians call the psychiatrist on duty whenever they have a patient who needs a mental health assessment and provide relevant medical records and details. Through a secure video link, the psychiatrist assesses the patient and makes recommendations about needed treatment and followup, including referrals to community-based resources. The program has reduced emergency department wait times, inpatient admissions, and costs; increased attendance at followup outpatient appointments; and generated high levels of satisfaction among patients and clinicians.

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of wait times, inpatient admission rates, costs, and attendance at followup appointments between emergency department patients at hospitals offering the program and similar patients seen at hospitals that do not. Additional evidence includes post-implementation surveys that gauge the satisfaction of patients and clinicians with the program.
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Developing Organizations

South Carolina Department of Mental Health
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Date First Implemented

2009
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Patient Population

Vulnerable Populations > Mentally ill; Rural populationsend pp

Problem Addressed

Emergency departments (EDs) in rural areas often do not have a psychiatrist immediately available to assess and treat patients experiencing mental health crises. As a result, these patients generally face long waits and in some cases end up being admitted to the hospital while they await a consult. In addition, tending to these patients while they wait impedes the ability of ED clinicians to handle general medical emergencies, thus exacerbating ED overcrowding problems.
  • Lack of onsite psychiatrists: Because of a nationwide shortage of psychiatrists and reductions in State funding available for mental health services, hospitals in rural areas often do not have a psychiatrist onsite to assess and treat patients in the ED or only have one available during traditional business hours.1 One survey of critical access hospital EDs found that 43 percent operate in communities with no mental health services available and just 2 percent have inpatient psychiatric services available.2 South Carolina suffers from a shortage of psychiatrists, with only 10 to 12 available per 100,000 residents, well below the national average.
  • Long waits: The lack of available psychiatrists means that ED patients with mental health issues often wait hours or even days for a mental health assessment. Hospitals without a psychiatrist available must arrange for one to drive in to see the patient, which can take several days. In hospitals with a psychiatrist available during traditional business hours, patients coming to the ED over the weekend must wait until Monday morning for an appointment. Prior to implementation of this program, patients coming to South Carolina EDs typically had to wait 48 to 72 hours to see a psychiatrist. These long waits can be stressful for patients and cause their condition to deteriorate.1,3
  • Many (costly) inpatient admissions: EDs often admit patients when waiting times to see a psychiatrist reach a day or longer. Prior to implementation of this program, 18 percent of patients in South Carolina EDs who required psychiatric care ended up being admitted to the hospital, at an average cost of $2,000 to $2,500 per day.4
  • ED overcrowding: ED staff spend significant time tending to patients with mental health problems who are waiting to see a psychiatrist. This time takes away from their ability to care for patients with other types of medical emergencies, contributing to ED overcrowding and longer overall wait times.3

What They Did

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Description of the Innovative Activity

The South Carolina Department of Mental Health partnered with the University of South Carolina School of Medicine and 18 predominantly rural hospitals from the South Carolina Hospital Association to establish the statewide telepsychiatry initiative. This public–private–academic partnership makes psychiatrists available via teleconference 16 hours a day, 7 days a week to assess and treat patients with mental health issues at hospital EDs. ED-based clinicians call the psychiatrist on duty whenever they have a patient who needs a mental health assessment and provide relevant medical records and details. Through a secure video link, the psychiatrist assesses the patient and makes recommendations about needed treatment, including referrals to community-based resources that can help. A detailed description follows:
  • Program coordination and oversight: The partnership includes the South Carolina Department of Mental Health (the lead agency), the University of South Carolina School of Medicine, and representatives of the 18 participating hospitals. Representatives of these organizations coordinate and oversee the program. (The Planning and Development Process section provides more information.)
  • 7-days-a-week, 16-hours-a-day availability: Psychiatrists employed by the State work 8-hour shifts at four urban hospitals (in Charleston, Columbia, Aiken, or Anderson/Greenville). Through this schedule, at least one telepsychiatrist is available every day from 8 a.m. to midnight.
  • Communication and transfer of information to psychiatrist: ED physicians in participating hospitals call the psychiatrist on duty whenever a patient appears to need a mental health assessment. On average, such requests come in roughly 12 times a day. Common reasons for contacting the psychiatrist include evidence or history of mood disorders, psychoses, and/or drug-related mental health problems. After briefing the psychiatrist, the ED physician forwards relevant medical records (e.g., medical history, laboratory results, other findings) though a secure statewide electronic medical record (EMR) system.
  • Assessment via telemedicine: A nurse brings the patient to a quiet room in or near the ED that has been dedicated to telepsychiatry consultations. The nurse explains the purpose of the session and how the videoconference will work. The equipment displays a high-definition image on a 26-inch screen with zoom-in capabilities so the psychiatrist can carefully observe the patient. Once the telepsychiatrist and the patient have been introduced via the video link, the nurse usually leaves the room. The assessment process typically takes 30 to 60 minutes. As with a face-to-face ED consultation, the telepsychiatrist's role is to calm the patient if necessary, make a diagnosis, and determine the recommended course of treatment.
  • Recommendations to ED-based physician: Shortly after the consultation, the psychiatrist discusses the case via the telepsychiatry video link and/or by phone with the ED physician, communicating his or her treatment recommendations, such as hospitalization, outpatient care through a community mental health center (the most common option), or care from the patient's primary care doctor. Because the psychiatrist is familiar with available community-based mental health services, recommendations typically emphasize use of these resources as a way to avoid hospitalization and improve the patient's quality of life. The psychiatrist may also recommend medications to the ED physician. After the conversation, the psychiatrist transmits a signed consultation recommendation to the physician via the EMR; ED staff reference this document for treatment, discharge planning, and billing purposes. In cases where a referral has been made to a community mental health center, the recommendation is also sent via the EMR to the center, along with the patient's medical record.
  • Discussion with patient and family members prior to ED discharge: Prior to the patient's discharge, the ED physician and/or psychiatrist go over the followup treatment plan with the patient. If family members participate in the patient's care, this clinician talks with them by phone or in person to discuss what they can do to help, such as encouraging the patient to go to self-help group meetings, supervising medications, monitoring symptoms, and making the home a weapons-free environment.

Context of the Innovation

The South Carolina Department of Mental Health, which serves approximately 100,000 citizens with mental illnesses, provides outpatient services through a network of 17 community mental health centers and numerous clinics. It also operates four hospitals, one community nursing care center, and three veterans' nursing homes.

The impetus for this program began in the 1990s, a decade that saw a marked decline in the number of long-term facilities in South Carolina that housed and treated people with mental illness. Closure of these facilities led to a significant increase in the number of patients with mental health problems seeking medical care at EDs. The vast majority of these EDs—including nearly all those in rural areas—did not have psychiatrists available to assess these patients. This shortage led to multiple problems for EDs, including long wait times, associated increases in inpatient admissions, operating inefficiencies, and a severe financial burden. Concerned about these problems, State health department leaders partnered in 2008 with the South Carolina Hospital Association (a private, not-for-profit membership of roughly 100 hospitals), the University of South Carolina School of Medicine in Columbia, and other parties interested in better and more efficient ED care to patients with mental health problems.

Did It Work?

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Results

The program has reduced ED wait times, inpatient admissions, and costs; increased attendance at followup outpatient appointments; and generated high levels of satisfaction among patients and clinicians.
  • Shorter ED wait times: From March 2009 through the end of 2012, the average waiting time for patients with mental health problems at the 18 participating EDs fell by roughly 50 percent.
  • Fewer hospitalizations: During the same timeframe, 11 percent of ED patients assessed by a psychiatrist were hospitalized, half of the 22-percent admission rate among similarly cared-for patients in South Carolina EDs not offering this program
  • Cost savings: Telepsychiatry consultations save an estimated $1,400 per mental health patient per year, due primarily to the reductions in hospital admissions.
  • Greater attendance at followup appointments: About 46 percent of patients served by the program attended an outpatient followup appointment within 30 days of the initial ED visit, well above the 16-percent attendance rate among similar ED patients cared for in South Carolina hospitals not offering the program. Similarly, 54 percent of patients served by the program attended a followup appointment within 90 days, versus 20 percent among ED patients in hospitals not offering the program.
  • High satisfaction among patients and staff: More than 80 percent of patients served by the program reported being satisfied with the process and services received. In addition, 84 percent of ED physicians and staff believe the program has improved patient care; 91 percent report being satisfied with program-related procedures; and 84 percent express satisfaction with the technology used.

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of wait times, inpatient admission rates, costs, and attendance at followup appointments between emergency department patients at hospitals offering the program and similar patients seen at hospitals that do not. Additional evidence includes post-implementation surveys that gauge the satisfaction of patients and clinicians with the program.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Decision to focus on telepsychiatry: The increasing popularity of telemedicine and its potential to bring services to underserved geographic areas made telepsychiatry a logical initial target for these discussions. After reviewing the use of telemedicine in South Carolina and other States, the partners collectively decided to create and implement a telepsychiatry program in hospital EDs.
  • Securing of funding for demonstration project: In 2007, program leaders contacted the Duke Endowment (a nonprofit foundation that supports innovative health care programs) about funding a demonstration project. In 2008, the Duke Endowment agreed to provide a $3.7 million, 3-year grant for this purpose.
  • Project planning: Four hospitals agreed to participate in the demonstration project, which launched in March 2009. In advance of this date, the partners and participating hospitals worked together to hire and train six psychiatrists, install and test the video equipment in EDs, and set up an EMR system linking the psychiatrists with the EDs.
  • Program expansion: After the demonstration project went smoothly, program leaders decided in June 2009 to expand the program to three additional sites and have continued to add more sites gradually since that time. From March 2009 through October 2013, more than 17,000 telepsychiatry ED consults have taken place. As of October 2013, 18 hospitals participate, with plans to add 6 more in 2014.
  • Standardization of training: As the initiative expanded, program leaders standardized the training process for psychiatrists and ED staff, as outlined below:
    • Psychiatrist training: Participating psychiatrists complete 6 hours of clinical training by viewing videos prepared by University of South Carolina School of Medicine faculty. Supplemented with handouts, the videos cover child and adolescent psychiatry, adult psychiatry, geriatric psychiatry, addiction psychiatry, risk assessment, and legal issues. Newly hired psychiatrists also undergo peer review every 2 weeks during their first 3 months of employment. In addition, during this initial 3-month period, the supervising psychiatrist meets with other hospital physicians to review and discuss consultations performed by newly hired psychiatrists.
    • ED staff training: ED staff in participating hospitals watch a video that explains the videoconferencing system and reviews the goals of the program and the training and credentials of the participating psychiatrists. A member of the project leadership team visits each participating ED to discuss questions or concerns that staff might have about the program.
  • Ongoing meetings to resolve problems, plan expansion: Representatives of the partnering organizations and the participating hospitals meet on a quarterly basis to share program-related experiences, resolve any issues or problems that arise, and discuss and plan for expansion to other EDs. Typically hospital administrators, providers, researchers, and information technology staff come to these meetings; representatives of nonparticipating hospitals are also welcome to attend to learn more about the program.

Resources Used and Skills Needed

  • Staffing: Six full-time psychiatrists and one part-time psychiatrist staff the program, under the supervision of a lead psychiatrist. The program also has a director, coordinator, fiscal technician, programmer, and two information resource consultants. Two faculty members from Emory University and the University of Pennsylvania and one staff person from the South Carolina Office of Research and Statistics also provide support to the program.
  • Costs: Hard data on the program's total annual cost are not available. Major program expenses consist of staff salaries and the upfront and ongoing expenses associated with the videoconferencing and EMR technologies.
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Funding Sources

National Institutes of Health; National Institute of Mental Health; Duke Endowment; South Carolina Department of Health and Human Services
As of the end of 2012, the Duke Endowment had provided more than $7.25 million in support of the program. Additional funding has come from the South Carolina Department of Health and Human Services, the National Institute of Mental Health (NIMH), and the National Institutes of Health (NIH). NIMH and NIH awarded two grants (one in 2009 and one in 2012) totaling $3.04 million to support evaluation of project outcomes (on quality, economic impact, utilization, and sustainability). In addition to grant funding, user fees and third-party insurance cover some program-related costs; for example, beginning in 2013, BlueCross BlueShield of South Carolina began covering use of telemedicine in mental health.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Form broad partnership: The scope of the founding partnership—which included representatives from State government, academia, and hospitals—proved critical to the success of the program launch. The breadth of the partnership made it possible for program leaders to foresee potential organizational and technological problems and mobilize qualified staff to address them.
  • Hire experienced psychiatrists: Psychiatrists who have been practicing for at least 5 years tend to be most effective with this type of program. This level of experience allows them to develop familiarity and strong relationships with community mental health centers that can effectively treat patients who present to EDs with mental health issues.

Sustaining This Innovation

  • Emphasize followup care: The patient's ED-based interaction with the psychiatrist represents just the first step toward successful treatment. To be successful, the program needs to promote continuity of care by involving family members whenever possible, referring patients to qualified community mental health centers, and closely monitoring attendance at followup appointments.
  • Host regular stakeholder meetings: Ongoing meetings provide a venue for participants to share experiences, discuss lessons learned, and plan program enhancements.

More Information

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Contact the Innovator

Meera Narasimhan, MD, DFAPA
Professor and Chairman
Department of Neuropsychiatry and Behavioral Science
USC School of Medicine
Suite 301, 3555 Harden Street Extension
Columbia, SC 29203
(803) 434-4266
E-mail: meera.narasimhan@uscmed.sc.edu

John Magill
State Director
South Carolina Department of Mental Health
2414 Bull Street
Columbia, SC 29202
(803) 898-8581
E-mail: cam35@scdmh.org

Innovator Disclosures

Dr. Narasimhan and Mr. Magill 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.

References/Related Articles

Silver Award: Statewide telepsychiatry initiative, South Carolina Department of Mental Health and South Carolina School of Medicine, Columbia—a collaborative partnership bring telepsychiatry to South Carolina emergency departments. Psychiatric Services. November 2011. 62:11. Available at: http://ps.psychiatryonline.org/article.aspx?articleID=179992.

Otto, M.A. ED telepsychiatry cuts admissions, saves money. ACEP News. July 2011. Available at: http://www.acep.org/Content.aspx?id=80804.

Footnotes

1 Khazan O. Psychiatric patients wait in ERs for days and weeks as inpatient beds are scaled back. Washington Post. January 22, 2013. Available at http://articles.washingtonpost.com/2013-01-22/local/36482113_1_psychiatric-patients-acute-care-beds-mental-health.
2 Hartley D, Ziller EC, Loux SL, et al. Use of critical access hospital emergency rooms by patients with mental health symptoms. J Rural Health. 2007;23(2):108-15. [PubMed]
3 Brauser D. Psychiatric patients often warehoused in emergency departments for a week or more. Reduction in mental health beds prevents timely transfers. Medscape. Jan 24, 2011. Available at http://www.medscape.com/viewarticle/736187.
4 Silver Award: Statewide telepsychiatry initiative, South Carolina Department of Mental Health and South Carolina School of Medicine, Columbia—a collaborative partnership brings telepsychiatry to South Carolina emergency departments. Psychiatric Services. November 2011. 62:11. Available at: http://ps.psychiatryonline.org/article.aspx?articleID=179992.
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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: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.