Qualitative Assessment of Telepsychiatry in Ketchikan and Metlakatla FINAL REPORT
November 2003
This project was funded by
Alaska Science and Technology Foundation and Alaska Telehealth Advisory Council ACKNOWLEDGMENTS
Alaska Telehealth Advisory Council
Commissioner Joel Gilbertson, Dept. of Health & Social Services, ATAC Co-Chair Paul Sherry, CEO, Alaska Native Tribal Health Consortium, ATAC Co-Chair Jeff Tyson, Vice-President, Strategic Planning, Alaska Communications System Al Parrish, Vice-President, Providence Health Care System, Chief Executive of Alaska Region, Providence Health System in Alaska Ron Duncan, CEO, GCI Mike Felix, CEO/President, AT&T Alascom Dee Hutchison, ANMC Administrator, Alaska Native Tribal Health Consortium Jeff Jessee, Executive Director, Alaska Mental Health Trust Everette Anderson, Administrative Office Manager, TelAlaska, Inc. Marilyn Kasmar, Executive Director, Alaska Primary Care Association Edward H. Lamb, CEO/President, Alaska Regional Hospital Jerome List, MD, Past President, Alaska State Medical Association Mike Powers, CEO, Fairbanks Memorial Hospital Karen Perdue, Vice-President, Health Affairs, University of Alaska Alex Spector, Director, Department of Veterans Affairs Commissioner Nanette Thompson, Regulatory Commission of Alaska Eric Wall, MD, Medical Director, Premera Blue Cross Diane Toebe, RN, PhD, Alaska Nurses Association (Rep.) Tom S. Nighswander, MD, Alaska Native Tribal Health Consortium, ATAC Facilitator
Alaska Science and Technology Foundation
James Kenworthy, former Executive Director James Palin, Grants Administrator
Alaska Center for Rural Health, UAA - Project Team
Beth Landon, Director Mariko Selle, Research Associate Janice Troyer, Research Associate Kathy Graves, Research Associate Claudia Lampman, Associate Professor of Psychology, University of Alaska Anchorage, Interim Principle Investigator
Acknowledgments i EXECUTIVE SUMMARY
The core purpose of this project was to evaluate telepsychiatry demonstration projects toward the thoughtful proliferation of telepsychiatry in Alaska.
Telepsychiatry, the delivery of psychiatric consultations via remote videoconferencing technology, is consistently recognized as a possible means to improve access to psychiatry in remote locations. Given Alaska’s geography, and the dearth of psychiatrists outside of the state’s three largest communities, Alaska Telehealth Advisory Council (ATAC) sought to determine if telepsychiatry would benefit Alaskans in remote communities.
Ketchikan’s Gateway Center for Human Services conducted a demonstration telepsychiatry project. The goal of their pilot telepsychiatry program was to serve the child and adolescent psychiatric needs of Ketchikan and the remote island community of Metlakatla. To this end, they contracted with a remote provider at Bartlett Regional Hospital in Juneau.
The majority of the data collected in evaluating this project came from three site visits each to Ketchikan and Metlakatla to document the status of their child and adolescent telepsychiatry demonstration project. ACRH researchers conducted key informant interviews with staff members involved in the administration of telepsychiatry, as well as with parents of child/adolescent patients. All interviewees were adults; children were not interviewed in keeping with Institutional Review Board standard protocols.
As a secondary means of data collection, the participating telepsychiatrist completed a survey after each clinical telepsychiatric visit.
General Findings
A. Biggest Benefit Is Access To Care. Access to a provider was seen as the biggest benefit of telepsychiatry in all waves for both sites. Because Ketchikan already enjoyed regular access to psychiatric services, they perceived telepsychiatry as a ‘back up’ option.
B. Greater Need in Metlakatla. Throughout the evaluation period, Metlakatla staff and consumers articulated that telepsychiatry addressed unresolved mental health issues in the community, which desperately needed attention. In all three waves, Ketchikan staff emphasized that telepsychiatry was more important for Metlakatla. Ketchikan staff was accustomed to regular psychiatric care provided by the itinerating psychiatrist, which they regarded as excellent.
C. Perception of Quality of Care Generally Positive. Metlakatla staff and users valued the quality of care delivered by telepsychiatry. Ketchikan staff had more doubts
Executive Summary ii about the quality of care, emphasizing that telepsychiatry was not as good as face-to- face consultations. The telepsychiatrist also reported that the overall quality of service was compromised in comparison to in-person consults.
D. Increased Access Changes Perceptions Over Time. Initial reactions to telepsychiatry were overwhelmingly positive. Over the year-long evaluation period, however, some Metlakatla parents grew frustrated with the negative side effects of medications and having their children potentially stigmatized by mental illness. Some articulated doubt that a person from the ‘outside’ could truly understand the difficulties of their small island community. These changes in attitudes reflect the reality of increased access to care and are a natural outcome of bringing new mental health services into an environment where services were previously unavailable.
E. Anonymity Still a Benefit. Despite the reservations mentioned above, Metlakatla staff and users reported that telepsychiatry offered an appropriate distance between the patient and the provider. In a small community, not only is it difficult to maintain confidentiality, but some users were simply more comfortable sharing highly sensitive information with someone they would not run into at the local store.
F. Staff Recognize Potential for Organizational Cost Savings. Cost Not Biggest Benefit for Patients. Executive staff believed that telepsychiatry had the potential to reduce the cost of service delivery, if used in place of in-person visits. However, definitive conclusions of telepsychiatry’s cost advantage would require an in-depth cost- benefit analysis not possible in this project.
Though patients who traveled to received psychiatric care incurred some out-of-pocket expenses such as meal costs and cab fares, larger expenses such as airfare and cost of psychiatric services were covered by insurance. Therefore, there was minimal cost saving for patients using telepsychiatric services.
G. Telepsychiatry Delivery Takes Longer than In-person. The psychiatrist and other staff reported that telepsychiatry took longer than in-person visits, as even the slightest equipment lag time could make it difficult to conduct patient consults and gather information. Additionally, delays in local staff registering patients, sending patient vital data and transcriptions slowed the delivery process. These findings, however, conflict with the findings from current literature, which describes telepsychiatry as a faster delivery model than in-person consultations. The literature does not currently include studies of telepsychiatry conducted across cultures.
H. Telepsychiatry has Potential for Excellent Care. Executive staff talked positively about telepsychiatry’s potential for expansion of mental health services in remote areas. Patients also expressed interest in expanded services.
Executive Summary iii Recommendations
Despite positive patient and staff response, the demonstration project ended in July 2003, and executive staff did not renew the telepsychiatry contract. As other communities consider telepsychiatry as a means for expanding local mental health services, equipment costs and logistics represent a small portion of the challenge. The following recommendations are based on the lessons learned from this project. When all of these factors are thoughtfully considered, telepsychiatry can be a valuable and viable local service.
A. Financial The telepsychiatry contract for this demonstration project was based on flat hours, not volume of services rendered. As a result, Gateway had to absorb the cost of patient cancellations and inadequate flow of patients. Additionally, Gateway was not able to bill Medicaid in an efficient manner. This stemmed from training deficiencies in Metlakatla, where local staff did not systematically register patients and were unable to quickly produce intake assessments,. The combination of these financial factors inflated the cost of providing services to patients and compromised sustainability.
• To be financially sustainable, the telepsychiatry contract should be based on volume of clients served • Staff should be trained for all tasks related to reimbursement and corresponding procedures should be in place
B. Training The project underestimated Metlakatla’s supervision and training needs by employing Gateway’s standard training procedure – a brief training period followed by monitoring from a distance. Operating a psychiatric services center was a completely new experience for Metlakatla staff, and they needed continuous training on how to register patients, conduct intake assessments, collect patient vitals and assure patient compliance. Executive staff reported that this project may have worked better if it had taken place in the local health clinic, where staff were already familiar with such protocols.
• Training standard should be continuous • For clinics with limited infrastructure, a hub facility must provide continuous training and oversight
C. Standardization of procedures Certain functions that are consistently necessary in administering telepsychiatry should be standardized. Though the absence of some of these procedures did not lead to the demise of the telepsychiatry project, their presence may have helped strengthen its overall effectiveness.
• New staff must be trained to use the videoconferencing equipment prior to sessions
Executive Summary iv • New patients should receive an orientation on what to expect during a telepsychiatry consultation • Procedures related to clinical work should be in place. With new prescriptions or changes in medication, certain clinical work, especially vitals and blood draws, must be done prior to the psychiatric consultation. • Local staff should systematically communicate information on prescribed medication with patients, including possible side effects and why it is important to have this information
C. Local Control Though Metlakatla was an important participant in this project, the staff did not have an active voice in the implementation, nor the discontinuation, of telepsychiatry. The news that the telepsychiatric contract had not been renewed came to them as a surprise and disappointment, as they had become accustomed to having the resource. On the other hand, Ketchikan staff chose to continue face-to-face consultations over telepsychiatry because they had established relationships with their existing itinerant providers.
• Local members should be called to the table for decisions that affect the community and residents • Staff must be involved early in program planning and discussions related to implementation • Staff should be involved in selecting the consulting psychiatrists
Executive Summary v
Table of Contents EXECUTIVE SUMMARY ...... II TABLE OF CONTENTS...... VI I. BACKGROUND/INTRODUCTION...... 1 II. OVERVIEW OF THE LITERATURE ...... 4 III. METHODOLOGY...... 6 IV. ANALYSIS AND FINDINGS...... 9 A. CONSULTING TELEPSYCHIATRIC SURVEYS ...... 9 B. SUMMARY OF FINDINGS FROM SITE VISITS ...... 17 C. SUMMARY OF FINDINGS FROM POST-PROJECT INTERVIEWS ...... 23 V. DISCUSSION AND RECOMMENDATIONS ...... 26 VI. CONCLUSION...... 30 APPENDIX A ...... 31 APPENDIX B ...... 61 APPENDIX C ...... 84 APPENDIX D ...... 105 APPENDIX E ...... 112
Table of Contents
I. BACKGROUND/INTRODUCTION
A. Research Purpose Telepsychiatry, the delivery of psychiatric consultations via remote videoconferencing technology, is consistently recognized as a possible means to improve access to psychiatry in remote locations. Given Alaska’s geography, and the dearth of psychiatrists outside of the state’s three largest communities, the Alaska Telehealth Advisory Council (ATAC) sought to determine if telepsychiatry would benefit Alaskans in remote communities.
The core purpose of this project was to evaluate the demonstration projects toward the thoughtful proliferation of telepsychiatry in Alaska.
This was a process and outcome evaluation, not a comparative study. The findings are solely attributed to participant experiences with telepsychiatric consultations. A control study of in-person consultations was not employed; all comparisons made with in- person consults reflects study participants’ subjective opinions.
B. Overview of the Project Evolution During the summer of 2000, ATAC funded two demonstration projects and provided seed money toward an evaluation of those projects. The Alaska Science and Technology Foundation (ASTF) provided the majority of funding for the evaluation component. Since the beginning, this project was a moving target, with various demonstration sites starting and ceasing operations at varying points in time. The table below describes the chronology of events related to this effort.
ATAC provided funding for telepsychiatry demonstration projects
ASTF provided funding for evaluation activities
Summer 2000 Three sites plan to participate in evaluation • City of Ketchikan Gateway Center for Human Services (Gateway) • Eastern Aleutian Tribes (EAT) • Maniilaq Association All three demonstration sites cease project • Gateway – Funding issues February 2001 • EAT – Could not establish line connection • Maniilaq – Staffing and facility issues Gateway and EAT resolve respective issues and February 2002 resume telepsychiatry demonstration
Background/Introduction 1
ACRH recommences evaluation to review access, April 2002 quality and cost, identifying benefits and drawbacks to the service delivery method
January 2003 EAT withdraws from evaluation project
Gateway completes a year of child and adolescent Summer 2002 – Summer 2003 telepsychiatric activities, with full participation in evaluation
July 2003 Gateway telepsychiatry project ceases operation
At the start of this project, three sites – City of Ketchikan Gateway Center for Human Services (Gateway), Eastern Aleutian Tribes (EAT) and the Maniilaq Association – planned to participate in telepsychiatry and corresponding evaluation. EAT and Gateway already received “itinerant” psychiatry services, in which a psychiatrist traveled regularly to their communities to provide in-person services. However, the frequency and duration of those visits was determined by the availability of funding and weather. In theory, a more cost-effective and less weather-dependent delivery modality would improve access to care for psychiatric patients. Though the Maniilaq Association was not funded through ATAC at this time, they had installed T1 lines on their own and planned to conduct telepsychiatry.
The EAT project ceased in December 2000, because it was not possible to consistently secure a videophone connection. Maniilaq also ceased participation around this time, due to patient confidentiality concerns in their village clinics and the absence of village counselors. Soon after, Gateway determined that they did not have sufficient funds to proceed. By February 2001, the telepsychiatric demonstration projects were entirely inactive.
Within the next year, Gateway successfully secured and installed lines for conducting child and adolescent telepsychiatry in Ketchikan and Metlakatla and contracted for telepsychiatry through Bartlett Hospital in Juneau. This new modality was expected to augment and potentially replace in-person visits in Ketchikan. Metlakatla had never received itinerant psychiatric services; this would be an entirely new service for the community. In April 2002, an EAT social worker in King Cove established a telepsychiatric consultation between her community and a psychiatrist in Anchorage. Unfortunately, due to a clinic move and technical limitations, only two telepsychiatric consultations occurred between April 2002 and January 2003 in the EAT region.
With heavy input from Gateway and their consulting telepsychiatrist, ACRH revised and recommenced the evaluation of Gateway’s telepsychiatry project in the late spring of 2002. In its new form, the study would evaluate the access, quality and cost of
Background/Introduction 2
telepsychiatry, identifying the benefits and drawbacks to the service delivery method. This evaluation could be used by other communities in determining how to – and how not to – implement telepsychiatry.
On July 30, 2003, after a full year of activity and corresponding evaluations, the Gateway telepsychiatry project ceased operations. An analysis of causal factors is included in this report.
In Sept 2003, ACRH learned that EAT had conducted several telepsychiatric consultations over the past nine months. Due to learning of this development late in the project, an evaluation of EAT’s most recent telepsychiatry experiences was not possible.
Background/Introduction 3
II. OVERVIEW OF THE LITERATURE
Telepsychiatry offers hope for an affordable means of providing psychiatric services reliably to remote populations. A cursory review of recent literature provides a contextual background for this project.
A. Cost The primary argument in favor of telepsychiatry is cost savings. However, cost analyses are noticeably absent in the literature. ACRH searched the literature and found one published literature reviewi with only one study that included cost-effectivenessii. The comparison study in rural Queensland, Australia demonstrated cost savings from reduced travel. However, the study neglected to include costs for the maintenance and upgrading of equipment.
In fairness, the delivery of health care in rural and remote Alaska is expensive relative to other communities in Alaska and the “lower 48.” If a new delivery method can improve access or quality without increasing the overall cost, it is still a net gain for all parties.
B. Quality In the literature cited above, only two clinical outcome studies were identified. In the first, Brown and associatesiii found similar outcome results on the Profile of Mood States and other relevant measures. In the second, Zayloriv retrospectively compared Global Assessment of Functioning (GAF) scores for 49 patients who were treated by telepsychiatry and same-room sessions for at least six months. No differences were found in the percentage change in GAF scores from initial visit to six-month visit between the two groups, suggesting clinical efficacy. Furthermore, the patients treated by telepsychiatry had greater attendance rates and required dramatically shorter sessions compared with those in the same-room group.
In the same literature review, several studies furnished evidence of the reliability of psychiatric evaluations conducted by telepsychiatry. Baigent and colleaguesv found equally reliable diagnoses between remote and same-room psychiatric consultations for 63 randomly assigned subjects. Ruskin and associatesvi examined interrater reliability of psychiatric diagnoses made by telepsychiatry and same-room settings of 30 psychiatric inpatients. The resulting reliability coefficients were nearly identical for both groups.
C. Access Telemental health projects have increased the services to rural and remote regions of the United States. Rothchildvii stated that access to care is the most compelling reason to use telemedicine. This technology has allowed many rural and remote patients to obtain mental health care who would have otherwise gone without servicesviii. In many cases, it is cost prohibitive and inconvenient for rural patients to leave their homes to travel to a location where mental health services are provided. “Telepsychiatry offers hope for affordably solving long-standing workforce problems in providing services to populations in remote regions or to other isolated groups”ix. Overall, findings suggest
Overview of the Literature 4
that telecommunication technologies provide a sufficient and satisfactory alternative to face-to-face delivery of psychiatric services to populations living in remote or isolated regionsx.
D. Human Factors In 1996, two experienced telemedicine researchers argued that “most failures of telemedicine programs are associated with the human aspects of implementing telemedicine”xi. Concurrently, policy-makers from the Federal Office of Rural Health Policy, the National Library of Medicine and other agencies sponsored workshops and conferences on the opportunities and barriers facing telemedicine. Participants of these venues concluded that more research was needed to determine how patients and health professionals respond to telemedicine. Participants also felt that telemedicine implementation should begin with identification of the needs and preferences of consumers and providers; research should be user-driven rather than technology- driven. They also identified factors that may slow acceptance and adoption of telemedicine, including lack of documented benefits for clinicians; difficulty incorporating telemedicine into existing practice; problems related to equipment; concerns about professional image; inadequate assessment of needs and preferences; lack of societal readiness; and health care restructuringxii.
One popular framework for understanding factors influencing the uptake of telehealth is the diffusion of innovationxiii xiv. According to Rogers, organizational structures and cultures will affect health professionals’ perceptions of telehealth. Two examples from the literature bear mention. The first is a case study of the successful Networking North Queensland two-year telehealth project. Researchers found that consideration of local issues – local needs and existing resources – was vital to the achievements of the projectxv. The second is a review of a four phase telepsychiatry program in southern Michiganxvi. Two phases proved successful, one phase failed in its initial goal but succeeded with a redefined goal, and one phase (in a correctional facility) failed completely. A key factor in the success of one phase was that several providers could see the advantages of using the system in their practices. There were two determining factors in the failed endeavor: a) the subcontracted agency for in-person care was profitably and firmly established in providing onsite behavioral health management to inmates at the jail; and b) there was a lack of coordination and communication between administrative and provider staff.
Clearly, the needs and motivations of the users, providers and clients must be carefully considered when planning a telehealth program.
Overview of the Literature 5
III. METHODOLOGY
A. Project Scope By implementing telepsychiatry, the small community of Metlakatla would have consistent access to a psychiatrist for children and adolescents for the first time. Metlakatla patients would become clients of Ketchikan’s Gateway Center for Human Services and receive services from a psychiatrist in Juneau, while receiving staff support and training via their connection to Gateway.
Though children and adolescents in Ketchikan already benefited from monthly psychiatric services provided by itinerant providers from Seattle, telepsychiatry with a physician in Juneau would supplement these regular visits for greater continuity and access to care. Some Ketchikan patients would receive care completely via telepsychiatry, which could be a significant cost savings for Gateway.
The majority of the data collected in evaluating this project came from three site visits each to Ketchikan and Metlakatla wherein researchers documented the status of the child and adolescent telepsychiatry demonstration project. A qualitative format enables content-rich responses not possible in a survey format. ACRH researchers conducted key informant interviews with staff members involved in the administration of telepsychiatry, as well as with parents of child/adolescent patients. All interviewees were adults; children were not interviewed in keeping with Institutional Review Board standard protocols.
As a secondary means of data collection, the participating telepsychiatrist filled out a survey after each clinical telepsychiatric visit.
The details of each format are discussed in more detail below.
B. Site Visits ACRH conducted site visits to Ketchikan and Metlakatla in August 2002, February 2003 and July 2003.
For all three site visits, staff in Metlakatla selected and scheduled the ACRH interviews with the parents of children who had used telepsychiatry services since the previous site visit. Ketchikan staff was able to arrange for ACRH staff to speak with a parent and guardian of an adolescent patient during the first visit, but not for the subsequent trips. During the course of the evaluation period, ACRH interviewed the outgoing and incoming Center Directors, the participating psychiatrist, mental health clinicians, case managers and a program coordinator. In addition, ACRH conducted interviews with two mental health clinicians from separate community organizations who had used the telepsychiatry system.
Methodology 6
C. Key Informant Interview Instrument Working with the Center Director and the telepsychiatrist, ACRH staff developed the key informant interview instruments to capture qualitative participant experiences. Questions related to access, quality and cost of care. Two versions were created; one for interviewing parents of users and the other for staff involved in the administration of telepsychiatry.
Parents and guardians of children using telepsychiatry were asked the following: • Overall patient experience with telepsychiatry • What patients liked best and least about telepsychiatry • General perceptions about telepsychiatry equipment • Perceived quality differences between telepsychiatry and in-person consultations • Role of telepsychiatry in patient-physician relationship • Cost implications of participation • Suggestions for improvement
Ketchikan and Metlakatla staff were asked the following: • Overall staff experience with telepsychiatry • What staff believed was and was not working for telepsychiatry • How telepsychiatry had changed their jobs • How telepsychiatry had changed the quality of care for their patients • Greatest benefits and drawbacks of telepsychiatry
D. Survey Instrument for Consulting Telepsychiatrist The instrument was developed from existing surveys used by the University of Washington for their telemedicine project. Alaskan mental health clinicians and others involved in this project evolved the questions for this Alaskan telepsychiatry demonstration project.
At the conclusion of each telepsychiatric visit between 12/23/02 and 6/10/03, the telepsychiatrist completed a survey evaluating the quality of the distance-delivered patient encounter. The survey form included approximately 13 questions; some questions consisted of multiple parts.
Survey content included questions regarding medication management, disposition of the consult, effectiveness of the consultation and comparisons with telephonic and face-to-face encounters. It also indicated if the patient missed the scheduled appointment.
A total of 31 patient surveys were returned; 22 of them were completed in full, while 9 were indicated to be “no shows.” Surveys were entered into SPSS and compiled into data tables as shown in Section IV.
Methodology 7
E. Post-project Interviews The telepsychiatry contract ended on July 30th, 2003 and was not renewed. In early September, the ACRH research team conducted phone and in-person interviews with key project stakeholders to determine the causal factors for the project termination. Rather than employing the use of formal interview instruments, interviewees were simply asked one question, “what happened?” When necessary, additional probes for clarity were employed.
Methodology 8
IV. ANALYSIS AND FINDINGS
A. Consulting Telepsychiatric Surveys At the conclusion of each telepsychiatry consult, the telepsychiatrist completed a questionnaire that captured his opinions about the session. One psychiatrist completed all the surveys in this study. Findings reflect his experiences and cannot be generalized to other psychiatrists.
Total Patient Number and Total Completed Consults There were a total of 31 surveys returned during the evaluation period. Of these, nine were indicated as “no shows,” for a total of 22 completed consults. There were a total of thirteen patients reviewed in this assessment, with approximately half seen multiple times over the course of the evaluation period.
Q1: Category of visit
Q1a. New Patient Frequency Percent (%) New patient 5 16% Not new patient 22 71% Not indicated 4 13% Total 31 100%
Of the 22 total cases documented in surveys, five were new patients.
Q1b. History Obtained History Full Partial status not Client no history history Total determined/ show obtained obtained not required New patient 0 5 0 0 5
Not new patient 0 9 5 8 22 Patient status 0 2 1 1 4 undetermined
Total 16 6 9 31
Partial histories, not full histories, were obtained for the five new patient cases in this study. Partial histories were also obtained for a majority of the previously established patients.
Analysis and Findings: Consulting Telepsychiatric Surveys 9
Q1c. Medication Management Frequency Percent (%) Complex 1 4% Moderately complex 15 65% Routine 7 30% Total 23 100%
Medication management for these patients was primarily found to be “moderately complex,” with a few categorized as “routine.” Only one case was found to be “complex.”
Q1d. Case Consultation with Local Provider Frequency Percent (%) Complex 6 27% Moderately complex 13 59% Routine 3 14% Total 22 100%
The psychiatrist was asked to rate the complexity of the case consultation with the local provider. It was found to be either “complex” or “moderately complex.” Only three cases were found to be “routine.”
Q2: Did the diagnosis change as a result of this visit? Frequency Percent (%) Yes 5 23% No 17 77% Total 22 100%
The psychiatrist changed patients’ diagnoses in five cases, as a result of the telepsychiatry visit. The following table outlines each of the five changes.
Analysis and Findings: Consulting Telepsychiatric Surveys 10
Q 2a. If applicable: How did the diagnosis change as a result of the visit?
Diagnosis Before Diagnosis After Cannabis and nicotine Case 1 Adjustment D/O dependence added
Case 2 ADHD ADHD, bipolar d/o, conduct d/o Major depression, single Case 3 episode Major depression, recurrent
Case 4 Sexual abuse PTSD
Case 5 Adjustment D/O Depression
Q3: To what extent did the consult change the treatment plan? Frequency Percent (%) Change medication only 8 36% Change behavioral treatment plan only 4 18% Change both med and treatment plan 8 36% Not applicable 2 9% Total 22 100%
In the majority of the telepsychiatry cases, there was a change in the patient’s medication plan. In approximately half the cases, there was a change in the behavioral treatment plan.
Q4: Rate the importance of this visit occurring in a tight timeline. Frequency Percent (%) Very important 12 58% Somewhat important 10 42% Non-urgent 0 0% Total 22 100% This mean is based on a three-point scale, not a 5-point scale.
In most cases, it was very important that the telepsychiatric visit occur quickly.
Analysis and Findings: Consulting Telepsychiatric Surveys 11
Q5: How beneficial to the patient’s care was having the local provider present during the session? Frequency Percent (%) Very beneficial (5) 19 86% Somewhat beneficial (4) 2 9% Somewhat detrimental (2) 0 0% Very detrimental (1) 0 0% Not present 1 5% Mean: 4.90 Total 22 100%
In almost every case, the psychiatrist found it very beneficial for the local provider to be present during the session.
Q6: What was the disposition of this consult? Frequency Percent (%) No treatment or follow up necessary 1 4% Continue treatment with local provider 0 0% Scheduled patient for another telehealth visit 19 76% Scheduled patient for another in person visit 4 16% Referral for non-local service provider 2 8% Other 1 4% Percentages do not add to 100, because more than one answer could be selected. Also, three responses were for ‘no show’ patients.
In most cases, another telehealth visit was scheduled. Scheduling rationale is outlined below.
Q6a: If applicable: Why was the patient scheduled for another telehealth visit? Frequency Percent (%) Complete/continue the evaluation 5 27% Medication management 14 73% Total 19 100%
In most cases, appointments for additional telepsychiatry consultations were for medication management. In five cases, they were to complete or continue with the evaluation.
Analysis and Findings: Consulting Telepsychiatric Surveys 12
Q6b: If applicable: Why was the patient scheduled for an in-person visit? Frequency Percent (%) Routine visit/routine site visit 4 100% Total 4 100%
All four cases scheduled for in-person visits were for routine site visit consults.
Q6c: If applicable: Where was the person referred for non-local service? Frequency Percent (%) Hospitalization in Anchorage (API) 2 100% Total 2 100%
Those referred to a non-local service provider were transferred to an Anchorage psychiatric hospital.
Q6d: If applicable, specify “other” disposition of the consult. Frequency Percent (%) Follow up rash or side effects with local MD 1 100% Total 1 100%
Q 7: How satisfied were you with this consultation? Frequency Percent (%) Very satisfied (5) 3 14% Somewhat satisfied (4) 10 45% Somewhat dissatisfied (2) 4 18% Very dissatisfied (1) 5 23% Mean: 3.09 Total 22 100%
In most cases, the psychiatrist reported to be at least “somewhat” satisfied with the consultation. In nine out of 22 cases, however, the psychiatrist was “somewhat” or “very” dissatisfied.
Analysis and Findings: Consulting Telepsychiatric Surveys 13
Q 8: Rate the effectiveness of this consultation. Frequency Percent (%) Very good (5) 1 5% Good (4) 8 36% Average (3) 7 32% Poor (2) 3 14% Very Poor (1) 3 14% Mean: 3.05 Total 22 100%
The consultation was found to be at least “average” for effectiveness in most cases. The psychiatrist categorized six of the 22 cases to be “poor” or “very poor.”
Q9: How did the technology affect your rapport with the patient compared to a face-to-face visit? Frequency Percent (%) Much better (5) 0 0% Better (4) 0 0% About the same (3) 3 14% Worse (2) 16 73% Much worse (1) 3 14% Mean: 2.00 Total 22 100%
In most cases, telepsychiatry resulted in a “worse” rapport with the patient when compared to a face-to-face visit.
Q 10: Rate how adequately you were able to assess the patient’s condition with this telemedicine technology. Frequency Percent (%) Very adequately (5) 1 5% Somewhat adequately (4) 14 64% Somewhat inadequately (2) 6 27% Very inadequately (1) 1 5% Mean: 2.91 Total 22 100%
In the majority of cases, the psychiatrist felt he was able to at least “somewhat” adequately assess the patient’s condition using the telepsychiatry equipment. In seven cases, he felt his ability to assess patient condition to be at least “somewhat” inadequate.
Analysis and Findings: Consulting Telepsychiatric Surveys 14
Q11: Rate the following aspects of this visit. Very Good Average Poor Very Good Poor Mean (5) (4) (3) (2) (1) Total Local staff’s effectiveness providing technical/logistical 5 11 2 2 2 22 support 3.68 23% 50% 9% 9% 9% 100%
4 8 9 0 1 22 Quality of telehealth images 3.64 18% 36% 41% 0% 5% 100%
2 5 8 6 1 22 Quality of telehealth sound 3.05 9% 23% 36% 27% 5% 100%
3 9 10 0 0 22 Adequacy of privacy 3.68 14% 41% 45% 0% 0% 100%
Cooperation received from the 2 8 9 1 2 22 local provider 3.32 9% 36% 41% 5% 9% 100%
Timely performance of the 3 9 8 1 1 22 equipment/time to get set up 3.55 14% 41% 36% 5% 5% 100%
Your sense of patient’s 1 4 5 8 4 22 engagement 2.55 5% 18% 23% 36% 18% 100%
0 5 11 4 2 22 Overall quality of clinical encounter 2.86 0% 23% 50% 18% 9% 100%
In most cases, the psychiatrist found it effective to have the local staff providing technical and logistical support.
In most cases, the quality of the equipment images and sound was good. There appeared to be several instances where the sound quality was not as good.
The psychiatrist evaluated privacy to be “very good,” “good,” or “average” in every case.
In most cases, the cooperation received from the local provider was at least “average.” In ten cases, it was “good” or “very good.” It is apparent that the psychiatrist valued the attendance of the local provider during telepsychiatry sessions.
In most cases, the equipment and set up timeliness was at least “average”, with nine cases being “good.”
The psychiatrist evaluated his sense of patients’ engagement to be ‘poor’ or ‘very poor’ in over half the cases. He noted that his assessment of poor “patient engagement” could be due to cultural differences in addition to other factors. See page 19 for more information.
The psychiatrist rated the quality of the clinical encounter “average” most of the time.
Analysis and Findings: Consulting Telepsychiatric Surveys 15
Q 12: Was this telehealth consult better or worse in terms of care the patient received when compared to a telephone-only remote consultation? Q 13: To what extent has the telepsychiatry equipment resulted in delivering better or worse care to this patient than in-person visits alone? About Much the Much Mean better Better same Worse worse Total
Q12: Compared to telephone 2 20 0 0 0 22 only remote consultation 4.09 9% 91% 0% 0% 0% 100%
Q13: Compared to in-person 0 1 1 17 3 19 visits alone 2.05 0% 5% 5% 77% 14% 100%
In general, telepsychiatric consultations were found to be “better” than telephone only consultations. However, when compared to in-person visits, they were found to be “worse” most of the time.
Q14: Rate your ability to assess mental status with the telepsychiatry equipment. Very Impossible to Mean* Good Fair Poor Total determine N/A 0 13 3 16 1 2 Language skills* 2.32 0% 81% 19% 100% 0 18 1 19 Tics 2.09 0% 95% 5% 100% - - 1 16 2 19 Activity level 2.05 5% 84% 11% 100% - - Relationship to 0 7 10 17 1 1 parent/guardian* 1.86 0% 41% 59% 100% 0 10 8 18 1 Thought process* 1.64 0% 56% 45% 100% - 0 9 9 18 1 Relatedness, in general* 1.59 0% 50% 50% 100% - 0 11 8 19 Affect* 1.55 0% 58% 42% 100% - - 0 11 8 19 Mood* 1.55 0% 58% 42% 100% - - Ability to express own 0 8 10 18 1 concerns* 1.55 0% 45% 56% 100% - 0 10 9 19 Anxiety Level* 1.50 0% 53% 47% 100% - - 19 EPS - - - - - 19 Tardive Dyskinesia - - - - - “Very good” was explained to be “same as in person” Means are based on a three-point scale, not a 5-point scale.
It is clear from these results that the psychiatrist found it more difficult to assess mental status through telepsychiatry than in-person visits.
Analysis and Findings: Consulting Telepsychiatric Surveys 16
*The psychiatrist noted for language skills, to parent/guardian, thought process, relatedness, affect, mood, ability to express own concerns, anxiety level, relationship:
“Assessing these features in Alaska Natives is difficult even person to person sometimes, as they can be very stoic appearing and not forthcoming with their feelings/affect. Especially true in Metlakatla, and especially when there is a history of abuse by someone in the house.”
B. Summary of Findings from Site Visits
1. OVERALL PERCEPTION AND ATTITUDES
Metlakatla social services office staff and parents were very positive about having and using telepsychiatry in their community throughout the evaluation period.
Ketchikan staff initially spoke positively about telepsychiatry. However, in subsequent interviews, they became increasingly convinced that telepsychiatry was not well suited for their local patients.
2. ACCESS TO CARE ISSUES
a) Biggest Benefit is Access to Care. Access to a provider was seen as the biggest benefit of telepsychiatry in all waves for both sites. Immediate, speedy access was especially noted. Metlakatla parents and staff also recognized that it was convenient and comfortable to receive care in their own community.
“I think that she would be severely lacking right now if we had to keep ferrying her up to a doctor for him to monitor.” (Metlakatla Parent, Wave 1)
Because Ketchikan had more access to psychiatric services than Metlakatla, Ketchikan staff perceived telepsychiatry to be an effective ‘back up’ option, not a substitute for face-to-face care. Ketchikan staff was accustomed to regular psychiatric care provided in the community by itinerating psychiatrists, which they regarded as excellent. Telepsychiatry was not as important to them.
“I mean it is nice to have the option, it is nice that it is available, if need be.” (Ketchikan Staff, Wave 2)
“We have very good child psychiatrists already that come up…They are very good and people really like them. So they really prefer to use them.” (Ketchikan Staff, Wave 2) b) Greater Need in Metlakatla. In Metlakatla, it was recognized throughout the evaluation period that this was a service that was greatly needed. In all three waves, Metlakatla participants emphasized that telepsychiatry had impacted lives enormously.
Analysis and Findings: Consulting Telepsychiatric Surveys 17
“I think we really need it here in this community.” (Metlakatla Parent, Wave 1)
“If they didn’t have this, either I would give up [my son] or we would all move.” (Metlakatla Parent, Wave 1)
“It saves lives. There’s no question in my mind. I can think of about three right now that probably would not be here if it had not been for [the telepsychiatrist] and telepsychiatry and the ability to move quickly.” (Metlakatla Staff, Wave 3)
In all three waves, Ketchikan staff emphasized that telepsychiatry was important for Metlakatla, but it was not well suited for them.
“It has been at times helpful in terms of being able to oversee some stuff that goes on in Metlakatla.” (Ketchikan Staff, Wave 2)
3. QUALITY OF CARE ISSUES
a) Ketchikan Skeptical While Metlakatla Optimistic. Ketchikan staff had more doubts about the quality of care delivered via telepsychiatry than Metlakatla, emphasizing that telepsychiatry was not as good as face-to-face consultations. Again, Ketchikan had psychiatrists regularly visiting their facility, so they could readily compare telepsychiatry with in-person visits. Ketchikan staff also pointed out the difficulties building rapport and reading body language with videoconferencing when compared to in person consultations.
Conversely, Metlakatla parents and staff recognized that telepsychiatry addressed unresolved mental health issues in the community. Compared to the past when the community did not have psychiatric care, the very presence of the service was an improvement in itself. Consequently, Metlakatla had a very positive perspective of the quality of care delivered.
“Frankly, I don’t think it does provide better psychiatry, just better access…” (Ketchikan Staff, Wave 1)
“It was like night and day compared to functioning without it. We’re functioning, don’t get me wrong, but it was such a wonderful tool.” (Metlakatla Staff, Wave 3)
b) Brings Needed Expertise to Metlakatla. In every wave, parents and staff in Metlakatla discussed the positive outcome of having professional expertise brought to the community.
“It gives us more eyes, more expertise in dealing with mental health issues.” (Metlakatla Staff, Wave 1)
Analysis and Findings: Summary of Findings from Site Visits 18
d) Increased Access Changes Perceptions Over Time. Metlakatla staff and parents strongly believed that telepsychiatry delivered good quality of care, particularly in the first wave. Staff enthusiasm was consistent throughout the evaluation period. In contrast, parents were more apt to express concern about their children potentially being stigmatized by mental illness over the next several months. Similarly, parents and Metlakatla staff were initially enthusiastic about new access to pharmacological treatment, but in subsequent waves the parents began to have reservations about the negative side effects of medications. The same applied for enthusiasm for the telepsychiatrist. In the first wave, parents were highly positive about the psychiatrist. They felt their children were quite comfortable receiving services from him and had nothing but positive feedback regarding how culturally sensitive he was. In the last visit, parents were more likely to express doubts that a person from the ‘outside’ could truly understand the difficulties they had in their small community.
Telepsychiatry aside, these changes in attitude reflect the reality of increased access to care and the effect of bringing new mental health services into an environment where services were previously unavailable. The following comments exemplify changing perceptions over the three site visits.
“To me, [telepsychiatry] is face-to-face because there is little or no delay…I don’t see any difference really, myself. To me, it seems like exactly the same.” (Metlakatla Parent, Wave 1)
I thought he was really good because he did real good with my son.” (Metlakatla Parent, Wave 1)
“Let the doctor’s sons take all that medication. I don’t want them taking all that stuff.” (Metlakatla Parent, Wave 2)
“It was like [the telepsychiatrist] couldn’t understand what Metlakatla was really like. If you don’t stand up for yourself people will pick on you and it was like he didn’t understand that.” (Metlakatla Parent, Wave 3) c) Anonymity Still a Benefit. Given the difficulties maintaining confidentiality in a small community, telepsychiatry offered appropriate distance between the patient and the provider. Despite concerns that an outsider would not be culturally sensitive, Metlakatla respondents still reported that a remote provider made patients feel more secure in discussing sensitive topics. They would not run into him at the local store or worry that he would contribute to local gossip. Ketchikan respondents, with a population of nearly 8000 (compared to Metlakatla’s 1400), were not as concerned about anonymity.
“I like the fact that I don’t have to look at the person eye-to-eye. He is on a TV. It is a little bit easier to be honest and truthful when you don’t have to look into someone’s eyes and tell them that. It is easier on me to deal with from a distance…[Being in a small community] is twice as hard, because of the fact that
Analysis and Findings: Summary of Findings from Site Visits 19
at a reservation, you can’t keep a secret, you can’t have your own time, space…” (Metlakatla Patient, Wave 1)
“Yeah, I think if you are concerned about confidentiality, if you are talking to someone who is 300 miles away, you don’t worry about having to see them on the street when you walk down the street.” (Ketchikan Staff talking about Metlakatla, Wave 3) e) Difficult Changes to Organizational Culture. Metlakatla staff reported more logistical hurdles with the introduction of this technology. Telepsychiatry demanded tasks and procedures that went beyond their regular routine. It required completing complex and time-consuming paperwork, increased intra-site communication, adjustment of staff roles and occasional equipment problems to resolve. f) Metlakatla Staff Inadequately Trained and Supervised. Supervision and training issues were particularly problematic for Metlakatla staff. The social services office staff had no previous experience coordinating psychiatric services and needed training and oversight. For example, patients were not systematically registered. Local staff had difficulty writing appropriate intake assessments. The executive staff and psychiatrist reported delays in getting lab results and patient vitals. Lack of patient follow-through often held up the entire psychiatric treatment process, and staff were not trained to encourage patient compliance. These problems could be addressed with additional training. It is important to note that Metlakatla’s needs are likely to be typical of remote, Alaskan villages.
Ketchikan staff were already managing a busy center. Because they were not actively using telepsychiatry for their own patients, they were less sensitive to the need for training and support to Metlakatla staff.
4. COST OF CARE ISSUES a) Cost Savings Not Biggest Benefit for Patients. From a patient perspective, cost savings was not the major benefit of telepsychiatry. Though patients incurred some out- of-pocket expenses when traveling to see a provider, such as meal costs and cab fares, larger expenses such as flight and the cost of services were covered by insurance. This was reflected in all three waves of data collection.
“We have so many different ways of insurance, plus a few of social services own things, and I think the cost was pretty much covered.” (Metlakatla Parent, Wave 1)
“When they used to come over from Ketchikan from Gateway…we had to pay $3, so even then we weren’t paying for it.” (Metlakatla Parent, Wave 3)
“If we got weathered in then we had to pay our own way on the ferry.” (Metlakatla Parent, Wave 3)
Analysis and Findings: Summary of Findings from Site Visits 20
b) Staff Recognize Potential for Organizational Cost Savings. Executive staff acknowledged that telepsychiatry had the potential to reduce the cost of service delivery, if used in the place of in-person visits. Equipment costs and line charges are expensive, however, and definitive conclusions of telepsychiatry’s cost advantage would require an in-depth cost-benefit analysis not possible in this project.
1) Costs
Provider Costs: The figures below show Gateway’s actual costs for 1) psychiatric services and 2) telepsychiatric services. Seventeen hours is used because it is the number of working hours for Ketchikan itinerant psychiatrists during a regular 2-day visit.
Figure 1: Itinerant Provider Costs Psychiatrist fee for itinerant provider from UW for 2 working days at, $175/hour $2975.50
Travel cost, round trip Seattle - Ketchikan $455.00
Lodging in Ketchikan, $95/night for 1 night $95.00
TOTAL FOR 17 HOURS OF PATIENT CONSULTS $3525.50
Figure 2: Telepsychiatric Services Costs Psychiatrist fee for telepsychiatrist, at $125/hour for 17 hours of patient consults (same # of hours as itinerant) $2125.00
TOTAL FOR 17 HOURS OF PATIENT CONSULTS $2125.00
Equipment and Line Charges: While telepsychiatry may be less expensive in provider costs, it is also important to consider the expense of the system. Gateway’s total fixed cost for equipment set up was $71,136, which included the equipment, installation and related parts. The monthly line charge for Gateway was $2230 after the subsidy.
Initial cost of equipment $39,136.00
Initial installation costs and related parts $32,000.00
TOTAL FIXED COSTS FOR EQUIPMENT $71,136.00
Analysis and Findings: Summary of Findings from Site Visits 21
Monthly line charge, two lines $13,177.00
Subsidized amount for line charges $ 10,947.00
TOTAL LINE CHARGES FOR GATEWAY $2230.00
2) Reimbursement
It is important to consider the cost of care both independently and in comparison to possible reimbursement. Medicare and Alaska Medicaid reimburse telepsychiatry at the same rate as in-person care. They reimburse $230.00 for a psychiatric evaluation and $75.00 for medication management. Third party reimbursement is not included in this scenario.
Figure 3: Medicaid Reimbursement Projection for 2-day Visit*
5 psychiatric evaluation sessions @ $230.00 ea $1150.00
9 medication management sessions @ &75.00 ea $ 675.00
TOTAL FOR A SAMPLE 2-DAY PSYCHIATRIST VISIT $1825.00 *Based on a real-life appointment schedule for a 2-day visit, approximately 12 hours of billable time. Anecdotally, this schedule kept the itinerating psychiatrist very busy.
This scenario suggests that psychiatrist costs, at $125/hr, may slightly exceed reimbursement. If some visits could be reimbursed by third party payers, reimbursement would exceed provider costs. Clearly, the “line” must be used more than 17 hours per month to cover the subsidized line charges. For Metlakatla, the telepsychiatrist was available and the line was used a minimum of 32 hours per month. c) No Cost Savings for this Pilot Project. Telepsychiatry did not actually save on costs for Gateway. There were four primary reasons for this:
1) As discussed previously, Metlakatla’s social services office lacked adequate training or supervision to meet the requirements for Medicaid billing. For example, patients had to be registered within the system, and intake assessments needed to be completed in a timely manner for reimbursement. This did not always occur.
2) The telepsychiatry contract for this pilot project was based on flat hours, not volume of services rendered. Sessions were set up for two four-hour blocks a week, and Gateway paid a set amount for that time, regardless of patient load.
Analysis and Findings: Summary of Findings from Site Visits 22
Consequently, when patients were improperly registered, did not comply with instructions to complete lab work, or simply missed appointments, it was a financial loss for Gateway.
3) The psychiatrist, as well as other staff, reported that services delivered using telepsychiatry took longer than in-person visits. This was attributed to the fact that even with sound equipment, clear connections and minimal delay, even the slightest lag time could make it difficult to conduct patient consults and gather patient information.
“For the same patient acuity, there is a lot more work over telepsychiatry. It saves travel time, but compared to someone coming to my office, it takes longer. As wonderful as the equipment is, it doesn’t allow for rapid interchange. It’s harder to read emotions and non verbal cues, and I think there were some cultural factors as well.” (Psychiatrist)
“Initially, after the first hour or hour and a half, I thought we would have enough diagnostic information. And we went back and there was like another hour before we were done on another day.” (Ketchikan Staff, Wave 3)
It should be noted this finding contradicts experiences documented in the telemedicine literature, where telepsychiatry is faster than in-person. However, the literature does not include data for telepsychiatry conducted across cultures. Clearly, more evaluations using other psychiatrists are necessary to extrapolate this finding for telepsychiatry overall.
4) Finally, telepsychiatry did not replace in-person consults as was originally intended for this pilot project, as Ketchikan staff did not choose to decrease utilization of their itinerant psychiatric services in lieu of this new service. These two services were used concurrently with itinerants serving patients in Ketchikan and the telepsychiatrist serving patients in Metlakatla. Dual usage was possible only because the telepsychiatric portion was grant funded for the purpose of this pilot project.
C. Summary of Findings from Post-Project Interviews Following the July 30th decision to not renew the telepsychiatry contract, ACRH conducted interviews with key staff. The purpose of the interviews was to determine perceived causes for the ending of the telepsychiatry relationship. This section summarizes findings from these interviews. a) Organizational Factors The termination of telepsychiatry activities in Southeast Alaska can be traced to organizational factors in the City of Ketchikan. First, the Gateway staff enjoyed a positive relationship with the existing itinerant psychiatrist. Second, not enough time
Analysis and Findings: Summary of Findings from Site Visits 23
was invested into building staff support for telepsychiatry. And third, to be successful, the Metlakatla staff needed a great deal of supervision and training – which Gateway staff were not able to provide.
Gateway staff have enjoyed itinerant child psychiatry services from an itinerant provider for seven years and were reluctant to lose her. Telepsychiatry posed a change to this relationship.
“She had relationships with families and staff – that’s a big issue.”
“Part of the positive aspects of [itinerant providers] somewhat spoiled the clinicians here. They like the good psychiatrists they already have.”
Due to the enormous time and energy investment required to establish the pilot project, there was little room for building Ketchikan staff interest in the project.
“I was pushing the project uphill.”
The project underestimated the amount of training and support required for Metlakatla. While Metlakatla staff did receive training at the onset of the project, they required extensive supervision, training and communication throughout the entire project. This was beyond Ketchikan’s established procedure, where a short training period is followed by monitoring from a distance.
“There was high interest from Metlakatla, but they were not appropriately trained. There was no support from Ketchikan.”
“Metlakatla had incredibly difficult crisis situations. One suicide creates a chain reaction. There were two staff dealing with it, but (they needed a lot more support from Ketchikan due to the extent of difficulties).”
Essentially, the telepsychiatrist acted as the clinical supervisor for Metlakatla staff during the period that telepsychiatry was used. When the telepsychiatry project ended, the Metlakatla therapist was once again ‘alone’ without the supervision and oversight she had grown accustomed to.
“He was helpful to me because if I had questions in regards to something, I could ask him. We worked as a team. It was not just him seeing the child, and he log off. We would spend time talking about treatment or concerns. Or the positive--if the child was doing really well. I appreciated that.”
“So now, I feel like I’m all alone again. When [the telepsychiatrist] was here, we could confer, and it was sort of a joint thing. That isn’t happening anymore. I find that burden very, very heavy.”
Analysis and Findings: Summary of Post-Project Interviews 24
b) Training and Supervision Compromised Billing While the Metlakatla site certainly valued telepsychiatry, the staff were not adequately trained or supervised to make it financially viable. In order to meet requirements for Medicaid billing, patients had to be registered within the system, and intake assessments needed to be completed in a timely manner. Though seemingly standard protocols, these tasks were major logistical hurdles. Combined with the huge mental health needs of the community, staff could not begin to keep up. “Assessments were not up to the quality we needed for billing Medicaid. This set back the billing for assessments, which then affected billing for telepsychiatry.” “A lot was based on case management. . . For this to occur, we had to register the client with SED criteria, do patient intake and an initial evaluation in Metlakatla. That was always problematic. The site wasn’t at the health clinic. It was at social services. They register them differently. The social services clinic didn’t have a strong system. The inadequate training and inexperience of [staff member] - would not get intakes done. Then [staff member] would use [the Telepsychiatrist] for supervision.” “We needed someone more skilled in that Met position, or ensure they had better supervision.” “We only saw…patients if they were registered. That was a problem. It took a long time to get them registered. If I knew they weren’t registered, I didn’t take them. There were a few that weren’t registered and I didn’t find out until after the fact. I couldn’t do anything about it then.”
c) Finances The demonstration project was not sustainable without some significant changes. Training Metlakatla staff is critical. In addition, the telepsychiatry contract was based on flat hours, not volume of services rendered.
“This year Gateway received $8,000 in billings from Metlakatla. That overall budget was $75,000. The telepsychiatrist alone was $48,000. And in-kind was another $20,000 from Gateway.”
d) Giving Telepsychiatry Another Try All interviewees felt that telepsychiatry could function better and were willing to do it again. While opinions varied on some aspects of the service, there was consistent support for the following:
• Metlakatla staff needs more support and back-up. A Clinical Director needs to supervise the Metlakatla site and visit it periodically. • Provide the service through the Metlakatla health clinic, which has the infrastructure for managing appointments and billing. • The telepsychiatry contract should be comprehensive, providing both adult and youth care, in-person and via teleconsult.
Analysis and Findings: Summary of Post-Project Interviews 25
V. DISCUSSION AND RECOMMENDATIONS
FACTORS CONTRIBUTING TO THE PROGRAM’S SUCCESS Several important aspects of the Ketchikan-Metlakatla project were quite successful. During the evaluation period, it was the only functioning telepsychiatry program in the state, despite the availability of videoconferencing equipment at other sites. The logistical preparations that were required to make telepsychiatry available were major obstacles in themselves. Below are some factors that contributed to the success of this program.
Director of the center believed in the project 100% and was committed to ensuring its success, including the funding necessary to make it work. The driving force behind the success of the telepsychiatry project at these sites was the solid commitment from the top. The center director made it his personal mission to ensure that the program received adequate funding, using creative methods to do so.
The program successfully increased access to care and delivered good quality services. Access to care was touted as the biggest benefit of telepsychiatry throughout the evaluation process, from all participating entities. Additionally, the quality of the consultations were generally very good. Especially in Metlakatla, telepsychiatry profoundly affected the lives of the patients it served.
Gateway purchased top-of-the-line equipment and overcame the technical difficulties in establishing video conference capabilities. Other attempted telepsychiatry projects could not get past the initial stages of setting up equipment and establishing line connections. Again, because the center director tenaciously pursued establishing connectivity, the Ketchikan-Metlakatla project had a good quality line connection, and participants reported few delays or loss of connection. The picture quality was also reported to be clear, making it easy to read facial expressions and even read body language of the patient or provider on the other side.
If there were technical problems, they were quickly resolved. Metlakatla had a case manager who was also a computer technician. He was generally present during the Metlakatla consults to solve technical problems whenever they arose.
Metlakatla demonstrated strong need for services and enthusiasm for program merits. Another contributor to the program’s success was that psychiatric services were desperately needed in the community of Metlakatla, and telepsychiatry was welcomed by clinicians and patients in that community. They had a strong incentive to make sure the program remained intact, because they could see how much it was helping their youth.
Discussion and Recommendations 26
BARRIERS WORKING AGAINST TELEPSYCHIATRY Despite its many successes, the program struggled in several key areas. With the exception of a few emergency consultations via telepsychiatry, Ketchikan continued to use their itinerant provider for their local patients instead of the telepsychiatrist. The expired contract with the Juneau telepsychiatrist was not renewed. Metlakatla lost a key administrator due to funding constraints. In the end, financial considerations made it impossible for Gateway to continue telepsychiatry past the demonstration period.
Gateway is to be commended for successfully navigating financial and technological hurdles to establish telepsychiatry in Ketchikan and Metlakatla. But this project has demonstrated that after those initial hurdles are conquered, there are still obstacles to overcome.
Financial Barriers This demonstration project was not financially sustainable due to a variety of factors. Metlakatla staff did not systematically register patients or conduct timely intake assessments for Medicaid reimbursements which caused a financial burden for Gateway. Though the need in the community was great, the number of actual registered patients did not mirror that need. In addition, telepsychiatry services were based on flat hours, and not the volume of clients served. Gateway often paid for psychiatric time even when no patients were seen.
Recommendations: • To be sustainable, the telepsychiatry contract should be based on volume of clients served. • Medicaid reimbursement is the same for telepsychiatry as in-person visits. Staff should be trained for all tasks related to reimbursement and corresponding procedures should be in place.
Infrastructure and Training The reality of introducing new services into rural communities is that skills, infrastructure and professional expertise necessary to carry out functions considered routine in an urban mental health center are simply unavailable in the village setting. Mental health providers in rural Alaska are often paraprofessionals. Therefore, supporting institutions must be able and willing to provide a great deal of training, support and oversight to the village workers administering the services needed.
The project underestimated Metlakatla’s supervision and training needs by employing standard training procedures - a brief training period followed by monitoring from a distance. As a result, Gateway found it difficult to work with Metlakatla. It would often take weeks for Metlakatla staff to complete intake assessments, which presented a problem for the center, as they did not register patients as clients until these assessments were complete. Meanwhile the services provided to these clients were not Medicaid reimbursable, and the organization had to absorb these costs.
Discussion and Recommendations 27
Recommendations: • For clinics with limited infrastructure, a hub facility must have the capacity and commitment to ongoing training and supervision. This should be a major consideration in forming a strategic plan for the implementation of telepsychiatry.
Standardization of procedures The following procedures were not formalized and systematically followed in Ketchikan and Metlakatla: new staff orientation to equipment, new patient orientations, post session debriefings, procedures for obtaining patient vital signs and medication information. Although their absence did not directly lead to the demise of the program, consistent procedures would have helped strengthen its effectiveness.
Recommendations: • Equipment orientation for new staff should be standardized. New staff must be trained to use the videoconferencing equipment prior to sessions. During this project, unintentional use the zoom function resulted in a clinician inadvertently enlarging the image of a patients’ chest area. Another patient was made uncomfortable when the picture-in-picture function was used. In order to avoid similar scenarios, all staff, including the remote psychiatrist, should become familiar with the machine so that care is uninterrupted by alarming situations caused by lack of knowledge of the equipment.
• New patients and parents should receive an orientation on what to expect during a telepsychiatry consultation. They should be told how the machine will operate, what kind of image they can view and what the remote provider will see.
• Though clients received a certain level of debriefing with local providers after their telepsychiatry sessions, this should be a standard procedure during all visits in all locations.
• Procedures related to clinical work should be in place. With new prescriptions or changes in medication, certain clinical work, especially vitals and blood draws must be done prior to the psychiatric consultation. Though the caseworker in Metlakatla had repeatedly reminded patients to go to the health clinic for clinical work, it was often neglected, and the psychiatrist could not proceed with the patient’s sessions. Obtaining vitals was a new requirement and an extra step for patients with no previous experience in receiving this type of care. Further, many patients receiving telepsychiatric services have trouble with life skills, follow through and utilizing resources. A standard procedure might require the case manager to make the appointment for the patient, or even to actually accompany the patient to the clinic.
• Local staff should systematically communicate information on prescribed medication with patients, including possible side effects and why it is important to have this information. When access to psychiatric services becomes a reality for rural patients, medications also enter the scene. Taking medications to control mental conditions can be traumatic for parents and patients alike, particularly for patients in
Discussion and Recommendations 28
communities with limited experience with anti-depressants, psychotropic drugs, or other forms of medications.
Patients in Metlakatla were not likely to question their prescriptions or their overall care plan, despite the staff’s efforts to provide in-depth information. In isolated communities, it is important to also educate patients on why it is important for them to have this information.
The Need For Local Control Though Metlakatla was an important participant in this project, they did not have an active voice in the implementation, nor the discontinuation of telepsychiatry. For example, the news that the telepsychiatric contract had not been renewed came to them as somewhat of a surprise and disappointment, as they had become accustomed to having the resource.
On the other hand, telepsychiatry program was not utilized in Ketchikan. Though the former director of Gateway was a strong champion for telepsychiatry, the rest of his staff did not share his enthusiasm for the project. This may be attributed to several factors, beginning with the fact that staff were not a part of the planning, goal setting and implementation of the process. After the program was implemented, the center director did not take the advice of his staff regarding changes that should be made. This problem was exacerbated when Ketchikan clinicians and case managers did not develop rapport with the remote psychiatrist, whose style of service delivery did not fit Gateway’s established organizational culture. Gateway staff had a long-standing relationship with their regular itinerant providers. The growth of the telepsychiatry program in Ketchikan had the potential to force them to discontinue this relationship.
Recommendations: • Local members should be called to the table for decisions that affect the community and the lives of residents. • Staff must be involved early in program planning and discussions related to implementation. Once the program is implemented, communication is the key to making thoughtful and necessary adjustments. • Staff should be involved in selecting the consulting psychiatrists.
Discussion and Recommendations 29
VI. CONCLUSION
The director of a mental health center in the community of Ketchikan had a dream to improve access to care for his rural child and adolescent patients by using high-tech videoconferencing equipment to provide remote psychiatric services. The director poured enormous energy towards this goal. Overcoming many obstacles, he secured the necessary funding, purchased and installed equipment, resolved technical problems and found a psychiatrist willing to provide remote services. In early 2002, the dream became a reality for the communities of Ketchikan and Metlakatla.
Gateway worked diligently for two and a half years to make telepsychiatry functional in these Southeast Alaskan communities. Despite these efforts, the telepsychiatry contract ended on July 30th, 2003 and was not renewed. As this report goes to print, a new version of telepsychiatry is emerging in Metlakatla. Metlakatla and Ketchikan maintain a videoconferencing connection, and Metlakatla receives telepsychiatric services when itinerating psychiatrists visit Ketchikan. The Metlakatla Director of Social Services is currently exploring funding sources to restore psychiatric services to the level of the pilot project.
As other communities consider telepsychiatry as a means for expanding local mental health services, equipment costs and logistics represent a small portion of the challenge. As this report documents, there are many lessons to be learned from their experiences. When all of these factors are thoughtfully considered, telepsychiatry can be a valuable and viable local service.
Conclusion 30
APPENDIX A
Wave 1 August 2002 Evaluation
Appendix A 31
I. EXECUTIVE SUMMARY
A. Overview and Purpose In August 2002, staff from the Alaska Center for Rural Health, UAA (ACRH) visited the City of Ketchikan Gateway Center for Human Services and Metlakatla Social Services. The purpose of the visit was to assess what was and was not working in the implementation of child telepsychiatry at these sites.
Both the Ketchikan and Metlakatla sites used the same child telepsychiatrist from Bartlett Hospital in Juneau. It is important to note that Ketchikan already received periodic in-person psychiatric consults. In contrast, prior to the introduction of telepsychiatry, Metlakatla had limited access to psychiatric care.
ACRH conducted focus groups and key informant interviews for this project. Because all patients included in this program are minors, ACRH interviewed the parents or guardians rather than the patients themselves, with the exception of one individual, who was a young adult patient. Parents and/or guardians were frequently present during the telepsychiatric consultations. Specifically, ACRH conducted one staff focus group, one parent interview, one guardian interview and an interview with the Center Director in Ketchikan. In Metlakatla, ACRH staff conducted one staff focus group and six parent interviews. Because ACRH only conducted two parent/guardian interviews in Ketchikan, comments cannot be generalized to users at that site. However, it is relevant to note the Ketchikan parent and guardian and the Metlakatla parents/guardians all expressed a high regard for telepsychiatry. This finding is corroborated in the literature, which has shown that patients using telepsychiatry report they would use it again, and they are satisfied with the care (Hilty, Luo, & Morache, 2002; Frueh et al, 2000).
Where possible, this report includes findings that could benefit other Alaskan sites considering the implementation of this technology. This report does not have a summative conclusion; this was an interim assessment, and the Key Findings directly below summarize the analysis of the site visit.
B. Key Findings
1. Positive Regard For Telepsychiatry • Users of telepsychiatry spoke positively about the telepsychiatry program, and most were highly enthusiastic about its merits. • Overall, staff response to telepsychiatry was positive. However, the response was more positive among staff in Metlakatla than it was among Ketchikan staff.
2. Access To Care • Increased access to care was reported to be the greatest benefit of telepsychiatry by all groups and key informants. • All key informants reported that telepsychiatry prevented weather from inhibiting access to psychiatric care.
Wave 1: Executive Summary 32
3. Quality Of Care • Users of telepsychiatry (parents of users) and staff in Metlakatla reported the quality of mental health care had improved in Metlakatla since the implementation of telepsychiatry. • Users of telepsychiatry (parents of users) reported that the psychiatrist’s compassion and understanding towards the patient was communicated via telepsychiatry. • Conversely, the telepsychiatrist and staff in Ketchikan, reported that mental health care delivered via telepsychiatry resulted in compromised care when compared to live visits. • Staff in Ketchikan resisted the replacement of in-person visits with telepsychiatry.
4. Organizational Culture • Telepsychiatry affected the organizational culture of Metlakatla more than Ketchikan by changing the role and duties of local staff and by increasing logistical burdens, such as paperwork and coordination of activities.
C. Respondent-Specific Findings
Parents of Patients/Past Users Key findings from interviews with parents, guardians and past recipient of telepsychiatric services
1. Positive Regard For Telepsychiatry • Parent participants/users were either positive or highly enthusiastic about the merits of the telepsychiatry program.
2. Access To Care • Psychiatric services were acutely needed in their community (especially Metlakatla), and thus telepsychiatry has been a welcome and necessary program. It introduced needed expertise into the community and provided patients with consistent care with a psychiatrist. • It is convenient to receive care in one’s own community. • Weather no longer inhibits access to care. • The impact of increased access has been enormous for patients.
3. Quality Of Care • Telepsychiatry delivers care that is as good as in-person visits, or is at least a good alternative to in-person visits. • Patients were comfortable using telepsychiatry, and for some, it was more comfortable than in-person consults. • The psychiatrist’s compassion and understanding towards the patient was communicated via telepsychiatry. • Users perceived the continuity of care that resulted from telepsychiatry provided better mental health care than was previously available to them.
Wave 1: Executive Summary 33
4. Cost Was Not A Benefit Of Telepsychiatry For Respondents • Cost savings from prevented travel was not a major benefit of telepsychiatry for respondents.
5. Patient Suggestions For Improving Telepsychiatry • Patients suggested expanding telepsychiatry for even greater accessibility both for existing patients and those who live in other rural communities. • The telepsychiatry environment could be improved by providing a comfortable environment for patients. Furniture should be placed in such a way as to provide the psychiatrist with a full-body view of the patient. • Patients suggested that face-to-face consults in conjunction with telepsychiatry would improve the program.
Psychiatrist/Director Key findings from interviews with the telepsychiatrist and the director of the mental health center
1. Positive Regard For Telepsychiatry • Both key informants had high positive regard for telepsychiatry.
2. Access To Care • Telepsychiatry improved individual and community access to care, which was the greatest benefit of telepsychiatry. • Participants reported that weather no longer inhibited access to care for their patients.
3. Quality Of Care • Quality of care has been improved from a community perspective because telepsychiatry introduced another professional into the community and facilitated staff development and training. • Quality of care for individual patients, however, has been compromised due to logistical barriers in delivering telepsychiatric care, such as delayed coordination of the exchange of transcripts, lab results and patient vitals. • Telepsychiatry is not ideal for working with victims of sexual assault or trauma.
4. Telepsychiatry Has Great Potential • With improvements in logistics and coordination, telepsychiatry has the potential for providing excellent care.
Ketchikan Staff Key findings from the focus group of Ketchikan staff that administer telepsychiatry
1. Positive Regard For Telepsychiatry • The perception of telepsychiatry of the staff in Ketchikan was philosophically positive. In other words, though they recognized its many merits, they perceived it to
Wave 1: Executive Summary 34
be especially useful in communities where access to psychiatric care was extremely limited.
2. Access To Care • Ketchikan staff reported that telepsychiatry was an asset for rural communities. They also reported it gave their clients more options for psychiatric care.
3. Quality Of Care • In general, Ketchikan staff reported more concerns regarding telepsychiatric quality of care than staff in Metlakatla. For example, they reported that it is more difficult to read patient body language and build rapport when compared to live visits.
Metlakatla Staff Key findings from the focus group of Metlakatla staff that administer telepsychiatry
1. Positive Regard For Telepsychiatry • The perception of telepsychiatry of staff in Metlakatla was genuinely positive.
2. Access To Care • Metlakatla staff reported that the access to a psychiatrist has had an enormous impact on Metlakatla. • Weather and travel are no longer major barriers to psychiatric care for patients in Metlakatla.
3. Quality Of Care • Metlakatla staff reported that telepsychiatry improved the quality of care both from a community perspective, as well as for individual patients. For example, telepsychiatry allowed patients to receive medication in a more timely fashion than was previously possible before the introduction of telepsychiatry. • Through telepsychiatry, professional providers outside Metlakatla shared the mental health care concerns of community residents. It also provided local staff with extra support and outside expertise. • Because of their connection to Ketchikan, the telepsychiatry program provided telemental health services in addition to psychiatric services for Metlakatla. • Metlakatla staff expressed concern that telepsychiatry posed the danger of keeping children in the community who were in serious danger and needed care more extensive than Metlakatla could provide.
4. Organizational Culture • Metlakatla staff reported telepsychiatry introduced new logistical hurdles, such as increased paperwork, coordination with various entities and modified roles for some staff members.
Wave 1: Executive Summary 35
II. BACKGROUND and PURPOSE
Alaska is currently a leader in telemedicine activities with over 235 sites using the technology under the funding and leadership of the Alaska Federal Health Care Access Network (AFHCAN). However, telepsychiatry is not an established practice.
Forkner (1996) reported that two major health care challenges in Alaska were cost and distance. The cost of living in Alaska was almost 25% higher than in the Lower 48 states and the cost of health care was almost 90% higher. Patients go without needed care or are transported to a facility hundreds of miles from their home. This can cost thousands of dollars and put individuals at risk, as access to critical care may be delayed or forgone. Alaska’s unique environment, coupled with the shortage of health care resources and access to specialty care, may leave health care providers vulnerable to heavy workloads, professional isolation and burnout (Forkner, Readon, & Carson, 1996)
The 2001 Allied Health Workforce Assessment (Degross, et al, 2001) emphasized the need for strengthening the behavioral workforce in Alaska, as the current climate showed a shortage of behavioral health workers in rural areas and a future forecast of increased need. Extremely remote locations have heightened recruitment and retention issues, especially for mental health professionals, who are often subjected to unique workforce issues that stem from isolation and limited resources. Paraprofessionals are often the only resource available to address many of the psychiatric situations that arise in these remote, frontier locations. Individuals who require a higher level of care must travel to a hub location to access appropriate behavioral health resources. More often, they go without.
Considering this gap in access to behavioral health resources, Alaska can potentially benefit from telepsychiatric services. Telepsychiatry could bring access to psychiatrists for remote locations unable to attract resident behavioral health specialists. Moreover, these locations often have inclement weather that makes itinerant services inconsistent, and often, non-existent.
To meet these challenges, there are currently pilot projects in two rural Alaska sites that have installed equipment and are moving forward in the implementation of telepsychiatry. The Alaska Center for Rural Health (ACRH), UAA, contracted with the Alaska Science & Technology Foundation (ASTF) and the Alaska Telehealth Advisory Council (ATAC) to evaluate the progress of telepsychiatry at these sites.
The purpose of this assessment was to collect participant feedback on their impressions of the telepsychiatry program. It focused on perceptions of how telepsychiatry had either positively or negatively altered access to and quality of psychiatric services.
Wave 1: Background and Purpose 36
III. METHODOLOGY
A. Respondent Profiles
Metlakatla & Ketchikan Parents/Users Key Informant Interviews Key informant interviews were conducted with eight individuals with telepsychiatry services experience. Because telepsychiatry services at Gateway were generally administered to children, only one participant interviewed was an actual patient. The rest were parents or guardians of children receiving telepsychiatry services. The respondent profiles are as below:
Metlakatla participants 1 - actual patient who had received telepsychiatry services 3 - Parents of teenagers 1 - Guardian of 3 siblings receiving care, ages 3, 5 and 7. 1 - Parent of the 3 siblings described above (interviewed separately from guardian)
Ketchikan participants 1 - Guardian of a teenager 1 - Parent of the same teenager described above (interviewed separately from guardian)
Staff Key Informant Interviews and Focus Groups Psychiatrist: A key informant interview was conducted with the psychiatrist who practiced telepsychiatry from Juneau. Specifically, this psychiatrist conducts consultations and prescribed medication via videoconferencing to patients in Ketchikan and Metlakatla.
Center Director: A key informant interview was conducted with the Center Director who oversaw the administration of telepsychiatry in both Ketchikan and Metlakatla.
Staff at Ketchikan: A focus group interview was conducted with two case managers, a children’s coordinator and a therapist. The data was supplemented with a separate interview with the therapist, who had to leave the focus group early.
Staff at Metlakatla: A focus group interview was conducted with one case manager, the director of social services, an administrative employee and a therapist. The data was supplemented with a separate interview with the therapist, who had to leave the focus group early.
B. Research Methods
Recruitment Metlakatla & Ketchikan Parents/Users Key Informant Interviews All parents of children receiving telepsychiatry services in Ketchikan and Metlakatla were asked to participate in this research study. Staff both at the Ketchikan and
Wave 1: Methodology 37
Metlakatla sites scheduled the participants for interview. Letters from the ACRH office were provided to the staff as additional information and contact information for the participants.
Staff Focus Groups and Key Informant Interviews All key staff members who were involved in implementing the telepsychiatry program in Metlakatla and Ketchikan were invited to participate in a focus group interview. The Center Director and psychiatrist were interviewed separately, because their roles within the program were uniquely different from the other participants.
Location Ketchikan: The key informant interviews and focus groups were conducted in a private meeting room at the Gateway Center for Human Services office.
Metlakatla: The key informant interviews and focus groups were conducted in a private office at the Metlakatla Social Services Center.
The interview of the psychiatrist was conducted via telephone.
Research Questions A team of ACRH researchers developed the key informant interview questions.
Metlakatla & Ketchikan Parents/Users Key Informant Interviews • Overall patient experience with telepsychiatry • What patients like best and least about telepsychiatry • General perceptions about telepsychiatry equipment • Quality differences between telepsychiatry and in-person consultations • Role of telepsychiatry in patient-physician relationship • Suggestions for improvement
Staff Focus Groups and Key Informant Interviews • Overall staff experience with telepsychiatry • What staff believed was and was not working for telepsychiatry • How telepsychiatry had changed their jobs • How it has changed the quality of care for their patients • Greatest benefits and drawbacks of telepsychiatry
Provisions for Ethical Considerations All respondents were asked to read and sign a form consenting to participate in this research study. Parents were informed that interview questions would ask how telepsychiatry has been good or bad for them or their child, but that no personal questions about the patients’ condition would be asked.
Participants assured that participation in this study was voluntary, and no penalty or loss of benefits would result from declining to participate or withdrawing participation at any time.
Wave 1: Methodology 38
The interviewer asked for respondents’ permission to record the interview session on audiotape. One respondent did not wish to be recorded. The tapes were only used to refer to as needed during the reporting process. Only the report writer had access to the tapes, and the tapes were destroyed after the writing of the report.
Analysis A systematic, sequential approach was used to tabulate the data collected in this study. The analysis was conducted using a transcript-based approach, whereas themes were identified from the record, and verbatim comments were coded and placed into categories. This report contains a descriptive summary of participants’ responses.
Because of the similarity of the responses between parents/users in Metlakatla and Ketchikan, these interviews were analyzed together.
As this report is the first installment of a 3-part study, it does not include a ‘discussion’ and ‘conclusion’ section.
C. Data Limitations
Metlakatla & Ketchikan Parents/Users Key Informant Interviews
• Only two interviews were conducted for Ketchikan Telepsychiatry Project, while six participants were from Metlakatla. Therefore, the data in this report may more strongly reflect the opinions of those using telepsychiatry in Metlakatla.
• Parents of children receiving telepsychiatric services were interviewed for this study; the children themselves were not interviewed, with the exception of one participant who was an actual patient. Though parents themselves were not receiving treatment, in some ways, they were also users of telepsychiatry; they were often physically present for all or part of their child’s sessions and communicated with the psychiatrist via telepsychiatry regarding the mental health care for the child.
• In some cases, parents were asked to guess their child’s perceptions of telepsychiatry. It is possible that they may not have responded in the same way their child would have to the interview question.
• The ages of the children represented in this study spanned a wide range. Use and satisfaction with telepsychiatry that may be related to patient age was not explored in this study.
• The severity and variety of patients’ conditions were not discussed in terms of telepsychiatry and how well it worked for people. Nor was it a part of the questioning route. Use and satisfaction with telepsychiatry that may be related to patient condition was not explored in this study.
Wave 1: Methodology 39
• Some respondents had more than one child enrolled in the program. Again, due to the small pool of respondents, differences in perception that may be related to multiple children versus one child enrolled in the program were not explored in this study.
• In an interview with only eight participants, one participant’s testimony may be explained at length. However, this may reflect the unique experience of only one individual. A strong opinion of one individual may not necessarily represent the consensus of the group.
Staff Focus Groups and Key Informant Interviews
• The staff members represented in the focus groups represented a wide range of different duties and job responsibilities. Differences in staff perception that may be related to differing job responsibilities were not explored in this study.
Wave 1: Methodology 40
IV. METLAKATLA & KETCHIKAN PARENTS/USERS
A. Telepsychiatry Environment
Telepsychiatry sessions take place in a room that generally includes the patient, the patient’s guardian, the patient’s therapist, case manager, or both. The psychiatrist on the screen is alone in a room at a remote location (in this case, Juneau). On one or more occasions, a student or intern was also present at the remote location.
In both Ketchikan and Metlakatla, telepsychiatry sessions took place in a room that contained a TV screen, a table, chairs and toys for small children. Generally, the patient was linked directly to the psychiatrist, but in some instances he/she was linked to more than one location. In one case, a child in Metlakatla was not stable enough to be alone with the psychiatrist, so he was also linked to a case manager and therapist in Ketchikan, and the screen was set up in quarters—one section the patient, the second section the psychiatrist, the third section the staff in Ketchikan, and the fourth section was blank.
All participants had been in the room during a telepsychiatry consultation at least once, and many reported sitting in for most sessions. In addition to the child and guardian, the child’s therapist, case manager, or both, were generally present. In one instance, additional staff members (totaling 4) were present during the first session.
B. Analysis of Findings
1. Positive Regard For Telepsychiatry All participants spoke positively about the telepsychiatry program, and most were highly enthusiastic about its merits. Most of the positive feedback regarding telepsychiatry centered around how it has increased the availability of psychiatric services in general, as well as the successful way in which care was delivered. Respondents also reported fascination with the capability of the technology.
The feedback from users was not only positive, but was enthusiastically positive. As this was a very new program at the time of the interview, this optimistic attitude towards telepsychiatry may be compared to a “honeymoon period” with the program for patients. In a community where psychiatric access had been unreliable or non-existent, they had little preconceived expectations for the program. They were pleasantly surprised when telepsychiatry came along and provided a level of care they would have otherwise had to wait long periods or travel long distances for. This everything-is-wonderful perspective may adjust as the novelty of access wears off and patients begin to form higher expectations for the program over time.
2. Telepsychiatry Increases Access To Care Telepsychiatry provided psychiatric care on a consistent basis to individuals who needed it, eliminating the stress and disruption of traveling outside the community and delivering services regardless of climactic considerations. This had a major impact on
Wave 1: Detailed Findings – Metlakatla & Ketchikan Parent/User 41
the lives of participants. Bringing an itinerant psychiatrist into these communities had been unreliable and sporadic, resulting in fragmented care, and telepsychiatry provided reliable, ongoing services.
Telepsychiatry is Necessary for the Community – “We really need it here” For reasons further outlined in this report, respondents in both Ketchikan and Metlakatla reported that the need for telepsychiatry services was clearly present in their communities. One respondent reported that with the problems in the community, he felt his peers could benefit from this program. Another respondent who currently had a child using the program felt this service was needed for her second child as well.
Simply Having a Psychiatrist Available – “She can, within a few hours or a day, see a psychiatrist” Just to know that help could be available should they need it, was a significant source of strength and reassurance for parents with children receiving services. Respondents compared this to a time when they could not be assured that such help would be available. This was especially true for the residents of Metlakatla, a particularly remote location when compared to Ketchikan, who were especially lacking in regular, psychiatric services.
Consistent Care with a Psychiatrist – “It would help to see somebody more often” Prior to telepsychiatry, psychiatric care available to the participants had been unreliable and sporadic, resulting in fragmented care. In a couple of interviews, respondents noted that accessing regular, consistent care was helpful for their children.
Brings Needed Expertise to the Table – “They have the training” Respondents noted that with telepsychiatry, they had access to expertise that was not previously available. One respondent described her child’s depression and how she was not able to recognize it, but the psychiatrist and the therapist together had recognized it and made help available for her son. Another respondent discussed the importance of a psychiatrist’s role in medication management in the context of her child’s need for medication. The same respondent later mentioned how the doctor closely monitored her daughter’s physical state, which made her feel comfortable about the medication.
The Benefit Of A Provider Outside Of The Community – “good to talk to someone not from the community” Having another provider outside of the community was beneficial in several different ways. First of all, it simply provided another choice beyond the providers available in their community. One respondent noted the advantage to having the alternative of another provider who lived outside of the community.
Second, it was a fresh channel of insight and input into the problem. For example, a respondent remarked that being able to communicate with someone outside the community helped his children overcome their shyness. Another respondent discussed the difficulty of maintaining confidentiality in a small community.
Wave 1: Detailed Findings – Metlakatla & Ketchikan Parent/User 42
The Convenience of Receiving Care in Your Own Community – “a lot less stressful” For respondents who had to travel to receive services in the past, telepsychiatry reduced this hassle. Patients did not have to be encumbered with the burden of disrupting their lives and worry about being weathered out of their destination, often times for a short session with the psychiatrist. Those receiving mental health services were under tremendous burden even without these additional pressures.
Weather No Longer Inhibits Access To Care – “You don’t have to worry about planes not landing” In the past, weather conditions often restricted travel for respondents. One advantage to telepsychiatry was that it increased accessibility to care by taking weather off their list of considerations in receiving such services.
The Enormity Of The Impact of Increased Access – “If they didn’t have this, I would give up my son or we would all move” Telepsychiatry was regarded positively in a variety of ways, but it was the enormity of the effect of access that resonated with users. Parents poignantly articulated the ways in which the access to a psychiatrist had greatly impacted their children and their families.
One parent mentioned that without the availability of this service, either the child or the entire family would have had to move from the community. Another respondent’s son had a mental health emergency that was attended to immediately, despite the fact that the psychiatrist was not physically present. This incident had a tremendous impact on their lives and left them with a significant impression of the service. A respondent also mentioned that her son was in a vulnerable state, which would have gone unrecognized by his family, but was thankfully identified because of the professionals involved. Again, this service brought previously unavailable expertise into their lives at a time when the child was “in danger,” as the parent described.
3. Telepsychiatry Delivers Good Quality Of Care The quality of the consultations given via telepsychiatry was well received by the parents. Some specifically mentioned that it was just as good as traditional in-person visits.
Some respondents implied telepsychiatry resulted in better quality of care than what they had received previously from itinerant visits, because it gave the patient and the psychiatrist an opportunity to more thoroughly develop an on-going relationship. They felt they received better professional attention because of the increased availability of care. For example, one respondent felt that the attention he received from mental health providers in the past had been sporadic, but with installation of telepsychiatry, his family no longer felt overlooked by the professionals.
Wave 1: Detailed Findings – Metlakatla & Ketchikan Parent/User 43
As Good as In-Person Visits – “to me, telepsychiatry is face to face…I don’t see any difference” Some respondents reported that the quality of consultations received via telepsychiatry was nearly the same as in-person consults. Much of what contributed to this perception may be attributed to the observations discussed further in this section, including the reliable and high-tech equipment used.
Or At Least a Good Alternative to In-Person Visits While some respondents reported telepsychiatry and in-person visits garnered similar quality of service, others felt that in-person visits were still the best method of care. However, these respondents still spoke highly of telepsychiatry and felt it was a sound alternative when in-person visits were not possible.
Concern That Body Language May Be Overlooked By Psychiatrist One parent was concerned that because there was a table in the room where telepsychiatry took place, her child’s nervous habit of picking her nails may have been out of the psychiatrist’s visual range. The parent suggested removing the table to capture the entire body language of patients.
Patients Are Comfortable Using Telepsychiatry – “It was real natural” Parents reported that from their child’s perspective, telepsychiatry was no big deal. The children were quite comfortable during the telepsychiatric consults, and they were able to incorporate it into their lives as a natural, normal aspect of their care.
One parent noted that the child felt more comfortable when she was given the remote control to zoom in on the psychiatrist on the other side.
For Some, Telepsychiatry May Be More Comfortable than In-Person Consults One patient explained that he was more comfortable opening up to the provider from the safe distance that telepsychiatry provides. Further, it was possible for him to speak to the psychiatrist without having to look him in the eye.
Local Providers Enhance Comfort During Consultations As mentioned in an earlier section, the case manager, the local therapist, or both were physically present with patients during the videoconference consultations with the psychiatrist. Respondents reported that their presence helped the patients feel more at ease during consults for a variety of reasons. A couple participants explained their children had formed a close and trusted relationship with the local clinician, so it was reassuring to have them present during consultations. One respondent with small children explained that the local clinician provided the physical touch that was absent with telepsychiatry. Another respondent said he could look to the local clinician during consults as a source of strength when he did not want to look directly at the psychiatrist on the TV screen.
Wave 1: Detailed Findings – Metlakatla & Ketchikan Parent/User 44
This sample was too small to differentiate between patient perceptions of local therapists versus case managers present during consultations, but these interviews suggested that whoever was present locally that had a close relationship with the patient contributed to their feelings of comfort.
Distracting for Local Providers to Pop In and Out of a Session Though the presence of a local provider during sessions contributed to patient comfort, a respondent reported that it disrupted the continuity of a session when different clinicians entered and exited the session throughout the consult.
Helps to meet the psychiatrist separately A couple of respondents reported it might have been helpful to meet the psychiatrist in- person before starting telepsychiatry in order to help them feel even more at ease when beginning consults. One respondent who had met the psychiatrist beforehand felt it was good that the meeting had taken place before telepsychiatry sessions began.
Understanding Towards the Patient was Communicated Via Telepsychiatry – “He is the first guy I have explained myself to” One area of concern with telepsychiatry is whether or not compassion or empathy towards the patient can be adequately conveyed using telepsychiatry equipment. When patients were asked whether they felt the physician communicated understanding, nearly all answered affirmatively. There were other comments made during the interview that also indicated that there was genuine exchange taking place with the psychiatrist. One patient explained that he felt that he was able to open up for the first time when he talked to the psychiatrist. He felt that the psychiatrist was giving him “110% of his time”. Another respondent talked about how there were many strong feelings covered during the session with his children.
Though there were two examples raised during the interviews of situations in which the client did not feel that the psychiatrist showed understanding, the overall consensus revealed that telepsychiatry did not inhibit the communication of understanding.
Further, some remarks indicated patient trust for the physician providing telepsychiatric services. For example, one respondent indicated that the psychiatrist is the only person he will talk to about the things running through his mind. Another respondent reported that her child trusted the psychiatrist’s advice to seek treatment outside the community.
Conversely, one respondent described the psychiatrist as “rigid”, but explained that it was her perception of his personality, rather than a function of the telepsychiatry equipment.
Ongoing Care is Better Care – “The psychiatrist developed his own personal relationship with them” More Complete Care One parent felt that through more frequent sessions with the psychiatrist, the provider was able to more accurately learn the personality and characteristics of his children,
Wave 1: Detailed Findings – Metlakatla & Ketchikan Parent/User 45
since they were learned over a span of time. He compared this to having to travel to a psychiatrist, where he did not feel that the “notes” taken about the children were completely accurate, which he attributed to the psychiatrist’s limited exposure to the children. Telepsychiatry has also made it possible for the patient to be observed by the psychiatrist under varied circumstances, such as with both parents and child, as opposed to with just one parent and the child. Again, the client perceived to be receiving more thorough care for his children because of this.
More Personal Care Further, the same respondent reported that more frequent care resulted in more “personal” care for the patient, since time allows the psychiatrist to form a closer relationship with the patient.
Telepsychiatry Gets Right to Task – “Get to the heart of what you need to get to” One respondent reported that the telepsychiatry sessions got to the most important part of the appointments right away. The reason cited was that when the patient traveled to a psychiatrist or received itinerant services, some therapy time was spent making small talk about the weather and travel. Though this aspect of the session may have been an important for gathering data from the psychiatrist’s perspective, the patient perceived it to be extraneous chitchat taking up valuable therapy time. They felt they were receiving higher quality care when this type of small talk did not take place. Further, they perceived the doctor to be more completely focused on them with his undivided attention, and therefore, were receiving better care.
Telepsychiatry Facilitates Teamwork for Patient’s Care – “You could feel the difference” Respondents discussed how a group of providers could work together as a team to care for a patient by using telepsychiatry. This was another way in which the program was successful. The participants of the “team” were able to fully concentrate on the problem, which enhanced the care the patient received.
Telepsychiatry Provides Privacy – “I think there was enough privacy involved” Most participants were satisfied with the privacy offered during telepsychiatry consultations. A respondent in Ketchikan listed specific efforts made by the Ketchikan staff to ensure privacy during consults. A Metlakatla parent reported that privacy was not an issue in their situation, and “very personal” matters were discussed during the session.
Privacy of the Room May Be Improved in Metlakatla One participant described an incident where her child became violent during a telepsychiatry session. A stranger who happened to be in the building overheard the commotion and talked about it with others in the community. It was traumatic enough for the parent to have her son lose control, but to have it be the source of local gossip made it even more painful. Because of this occurrence, the parent suggested a more soundproof facility. She did acknowledge, however, that this unfortunate episode did not cause her to be negative about telepsychiatry itself.
Wave 1: Detailed Findings – Metlakatla & Ketchikan Parent/User 46
The Equipment Works Well – “I have been very impressed” One factor that contributed to the positive delivery of telepsychiatry was the equipment itself working successfully with little delay. Not only did the equipment work the way it was supposed to, the capability of the technology surpassed patient expectations. For example, it allowed patients to scan the room of the remote location from their station or view in screen-in-screen mode.
Minor, short-term problems reported included: video screen not working so the psychiatrist couldn’t see the patient during one session; a bright glare from the window behind the psychiatrist was distracting on the screen (the window was covered to take care of the glare); and problems with the speakerphone. These problems, however, were regarded as minor, temporary set-backs and respondents who had experienced them still felt that telepsychiatry was a positive program, overall.
4. Cost Was Not A Benefit For Respondents Cost saved from prevented travel expenses was not a major benefit of telepsychiatry for respondents. Most patients who traveled to see the psychiatrist reported they did not incur high costs from travel, since insurance and other benefits covered the costs. However, they acknowledged that costs would be prohibitive for anyone who did not have insurance or other forms of coverage.
One participant had coverage for the telepsychiatry sessions, but not for travel, which was extremely expensive.
5. Patient Suggestions For Improving Telepsychiatry Participants offered a number of suggestions for improving the telepsychiatry program. These include: 1) expanding the program for even more instant access and to reach more people 2) making the telepsychiatry room more comfortable and perhaps more soundproof; 3) providing face-to-face contact in conjunction with telepsychiatry
Expanding Telepsychiatry – “I am getting chills thinking about it!” When respondents were probed on what would improve telepsychiatry, suggestions primarily centered not on making changes to the status quo, but were instead related to expanding the program even further. They liked the benefits of the program and wanted more of it – more for themselves and more for those without it.
Even More Enhanced, Instant Access Several respondents mentioned the wish to have telepsychiatry available over a portable unit where they could access a psychiatrist even from their home. This may be reflective of their enthusiasm for the access to care that telepsychiatry has afforded them and eagerness to raise it up another level.
Wave 1: Detailed Findings – Metlakatla & Ketchikan Parent/User 47
A Potential Asset to Others Based on their own positive experiences with telepsychiatry, participants felt that their peers, as well as others in communities more rural than their own, could benefit greatly from the same services. A few of the participants responded quite excitedly to the prospect of having such a service available to others that do not currently have the same level of access they enjoy.
The Telepsychiatry Environment – “Something more comfortable would make someone relax easier” Ensure Confidential Sessions with a Soundproof Room Though this concern was raised by only one respondent and though it may be impossible to completely soundproof a room from very loud commotions, it would be prudent to make certain that the sessions are private and cannot be overheard by those outside the consult room.
Create a Comfortable Environment Participants in both Ketchikan and Metlakatla suggested specific improvements to the telepsychiatry room to make it more be more comfortable for patients. While this comment was not on the top of the priority list, it was mentioned when probing participants for specific improvements that could be made.
A guardian of small children in Metlakatla suggested a larger room for play therapy.
Each Ketchikan resident made a suggestion to make the consult room more comfortable, and both suggested including a couch.
Ensure Full-Body View of Patient from Remote Location As mentioned earlier, a parent expressed concern that her child’s nervous habit of picking at her fingernails was not seen by the psychiatrist because her child’s hands were under the table.
Providing Face-To-Face Contact In Conjunction With Telepsychiatry Many participants indicated that the patient-psychiatrist relationship could be enhanced if the psychiatrist provided face-to-face sessions in conjunction with telepsychiatry or at least met the patient in person in addition to the telepsychiatric venue.
Wave 1: Detailed Findings – Metlakatla & Ketchikan Parent/User 48
V. PSYCHIATRIST AND CENTER DIRECTOR
A. Analysis of Findings
1. Telepsychiatry Improves Individual And Community Access To Care
Greatest Benefit of Telepsychiatry is Improved Access to Care The greatest benefit of telepsychiatry reported by these key informants was improved access to care. There was a simple, direct correlation between the implementation of telepsychiatry and improved access to care for individuals, as well as for the community as a whole.
Weather No longer Inhibits Access Related to increased access is the notion that telepsychiatry takes “weather” out of the equation. Inclement weather is a major barrier to mental health care access in these small communities. Telepsychiatric services were found to eliminate this as a factor.
2. Quality Of Care Is Improved From A Community Perspective The quality of care of the community at large was reported to have improved with the implementation of telepsychiatry. Several reasons were cited for this, including: the increase in access to professionals; the ability to solve problems locally; and the increase in staff training opportunities presented by telepsychiatry.
Brings Another Professional to the Community The quality of care available to the community was reported to have increased with the implementation of telepsychiatry due to the fact that it made other professionals available to care about the mental health care of the people in the community. It allowed the local staff to work with the psychiatrist to provide encouragement to them in working with difficult issues.
The director mentioned an incident in which a suicide threat was handled over videoconference, which enabled the family to stay in Metlakatla instead of using emergency transport. The patient would follow up with travel to Ketchikan if needed, but the problem was resolved locally. This would not have been possible without the availability of other professional mental health workers outside the community.
Telepsychiatry Facilitates Staff Training The director mentioned that because of telepsychiatry, the staff in Metlakatla was able to gain experience putting a household on suicide watch, something that had never been done before by Metlakatla behavioral health providers. He also reported that the equipment could be used for general staff training. A better-trained workforce in a remote location would also contribute to improvement in the quality of services available in a community.
Wave 1: Detailed Findings – Psychiatrist and Center Director Interviews 49
3. Quality Of Care Is Compromised For The Individual Quality of care delivered to individual patients was a more complex issue from the perspective of these health care professionals. Though access to mental health care increased the quality of the care available to the community overall, the care delivered to individuals was reported to be slightly less than traditional consultations that occur in a regular psychiatrist’s office. The psychiatrist rather than the director more distinctly discussed this point.
Logistical Difficulties of Delivering Telepsychiatric Care Telepsychiatry introduced an array of logistical requirements for the local provider not previously present. In order to follow the high standards of ‘best practices’ protocol, vital information had to be documented. Patients in those communities were now responsible for having their vitals (weights, blood pressure and pulses) completed at a local health clinic, and the mental health center had to make them available to the psychiatrist. Other preparations such as lab work and transcripts had to be completed and delivered in a timely fashion before the psychiatrist was able to prescribe medication. Increased tasks for the local mental health care sites were obstacles in providing streamlined, uninterrupted care to individuals.
When there were delays in providing data to the psychiatrist, it took longer to deliver services. The psychiatrist pointed out that when a patient is in-person, the logistical issues can be resolved immediately. Services via telepsychiatry meant a longer waiting time between consults and patient receipt of medication treatment due to these delays.
Lab Results Not Timely The psychiatrist reported difficulties in getting lab results back in a timely fashion. This was a concern, since abnormal lab results would require immediate follow up. Case managers were being asked to follow up more rigorously with patients to ensure a faster turnaround time for labs.
Difficulty getting vitals The psychiatrist also reported delays in receiving patients’ blood pressure, pulse and weight information in a timely fashion. Having accurate vitals was especially important when the psychiatrist treated the patient with medications. The psychiatrist recommended having an on-site person qualified to taking patient vitals to ameliorate the trouble in making sure this is accomplished.
Difficulty getting transcripts back quickly The psychiatrist also reported difficulties in getting transcripts back in a timely manner.
Sessions Starting On Time As for the actual timeliness of consulting sessions, sessions in Ketchikan generally began in a timely manner, but the director reported that this was not always the
Wave 1: Detailed Findings – Psychiatrist and Center Director Interviews 50
case in Metlakatla. The director attributed this to a cultural difference in attitudes towards timeliness. The remote provider is bound to a schedule of appointments wherein it is important to move from one appointment to the next in a timely manner, yet he is providing care in a community where “the culture for medical care” is not bound by rigid scheduling constraints. The director felt that the issue with sessions beginning on time in Metlakatla may have been related to such cultural differences.
Presence of Case Managers to Help with Logistics The psychiatrist reported that having the case manager in the room during sessions released the therapist from having to perform some case management duties. This better assured some of the logistical issues discussed previously. Further, it provided the psychiatrist with additional help and feedback and also allowed the case manager to stay informed about the patient.
Not Ideal For Working With Victims of Sexual Assault or Trauma The director reported that patients appear to find telepsychiatry more intrusive than face-to-face contact when the topic of discussion relates to violence or sexual abuse.
Cultural Concerns and Telepsychiatry The director of the mental health center felt that it was possible that technology may exacerbate cross-cultural misunderstandings that have been present in the Alaskan health systems. He felt that also noted that kids tend to be more comfortable with the equipment than their parents.
Note: The key informant interviews with parents and actual users of telepsychiatry, however, suggested that the introduction of telepsychiatry was met with enthusiasm by parents, and to date, there were no examples of cultural misunderstandings raised.
4. Bright Future Potential Participants were optimistic about the future of telepsychiatry – optimistic that improvements would be made to the current state of telepsychiatry and positive about the benefits of expanding the program into other areas.
Potential For Excellent Care The psychiatrist was highly optimistic that the aspects of telepsychiatry needing improvement would eventually be resolved and will be of great benefit to Alaska in the future.
Wave 1: Detailed Findings – Psychiatrist and Center Director Interviews 51
Possibility of Expansion Based on current positive experiences with telepsychiatry, the director foresaw expansion of services into other needed areas, such as follow-up services to alcohol treatment. Although there is currently no formal plan to expand the telepsychiatry program beyond Ketchikan, Metlakatla and Prince of Wales (POW), the director envisioned a program that would reach the smaller communities of Southeast Alaska.
Wave 1: Detailed Findings – Psychiatrist and Center Director Interviews 52
VI. KETCHIKAN STAFF
A. Background
This focus group consisted of four individuals from the Ketchikan office: • Two case managers, who contact the individuals using telepsychiatry equipment. Case managers also coordinate with Public Health or a child’s private physician to provide the psychiatrist with medical records; • One children’s coordinator who makes appointments, turns the telepsychiatry equipment on and sometimes sits in on the sessions “depending on what is going on;” and • One therapist working with patients who receive telepsychiatric care. (The focus group data was supplemented with a key informant interview of the therapist, who had to leave the session early.)
The relatively new telepsychiatry program had been in Ketchikan about six months. Reportedly, at the time the focus group took place, the program had served a total of three clients who had a maximum of three visits each.
B. Analysis of Findings
1. Staff Perception Of Telepsychiatry – Philosophically Positive In general, staff in Ketchikan was positive about the idea and intentions behind the telepsychiatry program. They reported the most important merit of telepsychiatry was that it provided rural communities with access to psychiatric care. Further, it gave Ketchikan consumers increased access to a psychiatrist for emergency situations, regardless of poor weather conditions. Further, it gave patients a choice between seeing a telepsychiatrist right away versus waiting for a period of time or traveling to see their regular psychiatrist.
Patients are Comfortable Using the Equipment Ketchikan staff reported that from their perspective, the patients who used telepsychiatry seemed generally comfortable during the consults.
A staff member described how one client no longer wanted to use telepsychiatry, but this staff suspected the patient was afraid the telepsychiatrist would require she return to treatment.
Staff is Satisfied with Equipment Telepsychiatry equipment generally worked well and was reliable. One participant reported occasional technical difficulties, but concluded the equipment worked well overall.
Wave 1: Detailed Findings – Ketchikan Focus Group 53
Sessions Start On Time Ketchikan staff reported that sessions generally started on time for telepsychiatric sessions occurring at their facility.
Privacy is Adequate Staff reported that privacy was not reported to be a problem in Ketchikan.
Staff Members Present During Consultations When telepsychiatry consultations took place, a number of staff may be present. Whether in a regular session or a telepsychiatry session, the decision regarding who is present in the room was determined on a case-by-case basis. The presence of various individuals during sessions with the psychiatrist was not reported to be a point of debate or contention, as it was for Metlakatla.
2. Telepsychiatry Improves Access To Care Participants agreed that the biggest benefit of telepsychiatry was improved access to psychiatric care, especially for communities without regular psychiatric visits. Telepsychiatry has given individuals regular, timely consults they would otherwise have had to wait to receive, travel away from their community to access, or be forced to do without.
Telepsychiatry Gives Clients More Options Participants reported telepsychiatry offered their clients more choices for psychiatric care. For example, they can present a choice to clients – whether they want to wait to receive face-to-face care with a psychiatrist, or get a consult within a few days using telepsychiatry.
Telepsychiatry Increased the Level Of Caseworker Contact With the Psychiatrist Telepsychiatry impacted the caseworkers by increasing the contact they have with the psychiatrist. Further, they became better acquainted with the system of health care through their coordination of telepsychiatry cases. Participants reported increased contact, opened lines of communication, increased collaboration and better-informed providers, which indirectly helped the patient.
3. Quality Of Care Is Compromised With Telepsychiatry
Telepsychiatry Is Just Not as Good As Face-to-Face Visits Ketchikan staff raised several concerns regarding telepsychiatry. Overall, they expressed more concerns than did the staff in Metlakatla. This could be attributed to the fact that Ketchikan had itinerating psychiatrists available on a regular basis. Telepsychiatry was perceived to be a second choice for these staff. That is, Ketchikan staff questioned the relevance in conducting “virtual visits” when access to real, live, visits were available with a provider with whom they had an established rapport.
Wave 1: Detailed Findings – Ketchikan Focus Group 54
More difficult to read body language Ketchikan staff expressed concern that during telepsychiatry sessions the psychiatrist is more likely to miss a client’s body language than during face-to-face consults. A suggestion was made to remove the table from the telepsychiatry room, which can block important body language.
Difficult To Build Rapport Staff in Ketchikan were particularly concerned that telepsychiatry was less personal than face-to-face contact, and thus, more difficult to develop an emotional connection with clients. One staff member described the telepsychiatry environment as “sterile” when compared to real visits. She noted that the remote provider could soften the sterility with his body language during consultation. Because it was perceived to be more difficult to build rapport with clients through telepsychiatry, staff emphasized their concern that the psychiatrist selected to provide services should be able to convey sensitivity and understanding.
Participants suggested combining face-to-face contact with telepsychiatry to help psychiatrists build rapport with clients.
“Telepsychiatry Is Better Access, Not Better Psychiatry” Though respondents had positive feedback for telepsychiatry in general, they also raised concerns that telepsychiatry was not to be regarded as the end-all answer to all mental health care. Staff enthusiasm for the program was dampened by the possibility of telepsychiatry replacing the “live” itinerating psychiatrist they liked. As much as they highly regarded the intentions of telepsychiatry, they did not feel that they needed it as much as other communities did.
Telepsychiatry Better Suited for More Remote Locations Because the best merit of telepsychiatry was for access, staff felt that telepsychiatry was best suited for communities in which access was a problem, which did not actually include Ketchikan.
Instead, Ketchikan staff reported that the program was more suited to rural communities that have fewer psychiatric options, such as Metlakatla, Craig and other Prince of Wales Island communities, which do not have the psychiatric resources that Ketchikan already enjoyed.
Benefits outweigh drawbacks Though respondents raised several concerns regarding telepsychiatry, they concluded that its benefits outweighed any drawbacks for communities without access to in-person psychiatric care.
Wave 1: Detailed Findings – Ketchikan Focus Group 55
VII. METLAKATLA STAFF
A. Background Information
The focus group consisted of: • the director of the social services activities and children’s mental health for Metlakatla; • an administrative staff member; • a case manager, who was also a computer technician for the Social Services office; and • a youth and child therapist.
The focus group data was supplemented with a key informant interview of the therapist, who had to leave the focus group early.
B. Analysis of Findings
1. Staff Perception Of Telepsychiatry – Genuinely Positive
Staff in Metlakatla were able to readily and eagerly provide concrete examples of how telepsychiatry had improved mental health in their community over the past few months. Telepsychiatry, and regular access to a psychiatrist, had made a big difference in the lives of their patients and in their community in the few short months it had been available.
2. Telepsychiatry Improves Individual And Community Access To Care
Provides Patients With Immediate Access To a Psychiatrist For Metlakatla staff, as was the case in all interviews, telepsychiatry’s foremost benefit was the access it provided to their current patients and to the community of Metlakatla. Telepsychiatry made it possible for patients to get care without waiting long periods of time for an appointment with a visiting psychiatrist, or having to travel to another community. Because of this, it brought needed care to children who were not previously served with psychiatric services.
Access is Immediate One way in which access was improved was the speed with which a psychiatrist could be contacted.
Weather and Travel No longer Inhibits Access With telepsychiatry, patients and providers alike are not faced with the hassles of traveling to and from Metlakatla. Unreliable weather in particular, was a constant concern.
Wave 1: Detailed Findings – Metlakatla Focus Group 56
3. Quality Of Care Is Improved From A Community Perspective
Brings Another Professional to the Community Similar to the point raised by the Center Director as well as the psychiatrist, telepsychiatry increased the level of professional expertise available to the community. For example, in Metlakatla, it was perceived to be an asset that the psychiatrist providing the telepsychiatric services also had training in pediatric medicine.
Provided Local Staff Greater Access To Outside Professionals As was mentioned by the psychiatrist and Center Director, telepsychiatry facilitated the opportunity for community access to other health professionals. It also reduced staff isolation and increased professional contacts, training opportunities and clinical supervision. This was not only true because of the access to the psychiatrist, but because of the access they had to the mental health center in Ketchikan.
Telepsychiatry Not Only Provides Psychiatry but Also Telemental Health Services Telepsychiatry not only provides psychiatric services from the psychiatrist to the patient, but it also provides other telemental health services such as functional assessments and case reviews.
Addressed Problems in the Community Telepsychiatry has been advantageous for the community by increasing awareness of mental health issues in Metlakatla.
4. Telepsychitry Has Improved Quality Of Mental Health Care For Individuals
Increased Continuity of Care Leads to Better Quality Care for Individuals Staff members described a time when the patients had very limited contact with a psychiatrist. As physician-patient contact increased, it allowed for a more thorough review of patient needs. Metlakatla staff noted that frequent contact with the client improved care decisions. This is consistent with the feedback from patients, who felt that their needs were better understood by the psychiatrist due to having regular sessions.
Children get Medication More Quickly As a result of telepsychiatry, the providers are able to get kids on medication more quickly than before. In contrast to the perspective of the psychiatrist, who pointed out that medication could not be administered as quickly with telepsychiatry, staff in Metlakatla reported that medication could be administered to patients faster than if they had to make travel arrangements or wait for an itinerant provider.
Wave 1: Detailed Findings – Metlakatla Focus Group 57
Patients are Comfortable with Telepsychiatry Staff members in Metlakatla were asked to discuss their patient’s comfort level with telepsychiatry. They reported that younger children tended to be quite comfortable with the telepsychiatry equipment, and that familiarity enhanced patient comfort. They also mentioned that some children fared better with a supportive person in the room during sessions.
Some More Uncomfortable Seeing Their Own Image on the Screen The equipment has the capacity to show the patient both the image of the remote location and the patient’s own image. Participants said it is better not to show the kids their own image on the screen because it is distracting and makes them feel self-conscious.
Having A Supportive Person In The Room Added To Patient Comfort Some participants discussed that having a supportive person in the room during telepsychiatry sessions helped kids feel at ease and act as a stabilizing force. Whether or not case managers should act in this role during telepsychiatric sessions is a topic of further discussion for staff.
Telepsychiatry Room is Soundproof Participants reported the room where telepsychiatry took place was sound proof. It is also equipped with a buzzer to mask voices when someone opened the door. It is possible that the soundproof room contributed to staff perceptions of patients’ comfort with telepsychiatry.
One participant suggested it would increase confidentiality if the telepsychiatry room was further away from the waiting room.
Suggestion for a More Comfortable Room Several participants said they would like to improve the setting of telepsychiatry by providing a more comfortable and intimate room and having a larger building. Some of these improvements were being planned at the time of the interview.
Psychiatrist’s Sensitivity Communicated Via Telepsychiatry Even through the medium of telepsychiatry, staff felt they were able to establish a working relationship with the psychiatrist, much in the same way described by users of telepsychiatry. The staff at Metlakatla indicated that the psychiatrist was able to communicate sensitivity and understanding, even through the medium of telepsychiatry.
Wave 1: Detailed Findings – Metlakatla Focus Group 58
5. Quality Of Care Is Compromised For The Individual
Concern That Telepsychiatry May Lead To Retaining Kids Inappropriately Participants expressed some concern that the availability of telepsychiatry in the community may prevent some children from receiving more extensive care in a larger community. Metlakatla staff reported they did not have the facility or resources to deal with a child who is a danger to him/herself, or a danger to others. There was a suggestion that standards should be set for severity of psychiatric need that requires the next level of care.
Providers expressed concern about potential delays in the process of “proving” the severity of their patients’ psychiatric needs to outside decision-makers. They expressed concern that these delays had the potential to exacerbate patient problems and could result in a patient requiring more extensive care.
Sexual Abuse Cases and Telepsychiatry The difficulty of conducting telepsychiatric sessions for sexual abuse cases was also mentioned. This difficulty was primarily discussed in the context of the case manager’s role during these sessions. As is described in the following section, there were some concerns raised regarding the case manager’s presence in sessions where a patient has a background of sexual abuse or there is a possibility of disclosure. The case manager reported that if the topic were mentioned during a consult, he would withdraw himself from the session.
6. Telepsychiatry Brings Changes To Organizational Culture
More Logistical Hurdles Telepsychiatry affected the organizational culture of the mental health center in Metlakatla more than Ketchikan. Metlakatla staff spoke more readily about their increased logistical burdens, such as more paperwork and more complicated coordination with various entities for this program.
Increased Administrative Paperwork Telepsychiatry increased paperwork and “red tape” for staff. Telepsychiatry required additional forms for registration, Medicaid, arrangements with the psychiatrist, etc.
More Communication and Coordination Between Sites Required The participants reported that increased communication was required with Ketchikan, their partner organization. This added to the burden of administration. There were lines of communication that needed to be organized, including how to handle situations where no one can be reached. Respondents recognized that communication with Ketchikan could be improved.
Wave 1: Detailed Findings – Metlakatla Focus Group 59
Occasional Equipment Problems Participants briefly discussed an equipment problem when T1 lines were down, but this was not discussed as a barrier to providing telepsychiatry services.
Change in the Role of Case Managers Historically Metlakatla has had limited experience with consistent psychiatric care, and telepsychiatry added another dimension of care to the mental health clinic. Consequently, the role of the case manager had adjusted in response to this new level of care. The telepsychiatrist has requested the presence of the case manager during all consults to increase the quality of the continuity of care. In this new role, the case manager has an increased awareness of the client’s care needs and in- depth understanding of the required follow-up.
However, one concern was raised regarding the case manager’s new role. A participant discussed the manner in which the dynamic of the session changed when another provider (i.e. the case manager) was present, which had the potential to complicate the disclosure of sensitive information during consults. The therapist strived to provide the client with a trusted relationship by keeping their sessions as private as possible.
Incidentally, parents and users reported the presence of a local provider during sessions to be a benefit, but the distinction between the different types of local providers was not clearly defined by respondents.
7. Expanding Telepsychiatry
Availability of Telepsychiatry is Still Not Well Known in Community Metlakatla staff did not believe that the community at large was aware that this service was available in the community. Staff participants exchanged ideas regarding how to better advertise the service to the larger community.
One participant reported that the telepsychiatry program had helped to identify high-risk kids that have consequently been sent away for more extensive treatment. Because of this, the participant expressed concern that some community members may have become suspicious of the program.
Expanding Services Participants reported that they would like to expand the telepsychiatry program to include adult patients as well.
Additionally, staff reported plans in Metlakatla to expand telepsychiatry to include drug/alcohol rehabilitation.
Wave 1: Detailed Findings – Metlakatla Focus Group 60
APPENDIX B
Wave 2 February 2003 Evaluation
Appendix B 61
EXECUTIVE SUMMARY
I. BACKGROUND / INTRODUCTION Ketchikan’s Gateway Center for Human Services is participating in a demonstration telepsychiatry project for child and adolescent patients. This report describes findings from the Alaska Center for Rural Health (ACRH) second evaluation site visit to Ketchikan and Metlakatla, which took place February 2003. The purpose of the trip was to assess the benefits and drawbacks of telepsychiatry for quality, access and cost of care. It was also an opportunity to determine how perceptions of these factors had changed since the first site visit, which took place August 2002.
II. METHODOLOGY ACRH conducted key informant interviews with leadership, staff and parents of telepsychiatric users at the mental health centers in Ketchikan and Metlakatla. The data was analyzed using ATLAS ti qualitative software.
III. FINDINGS
A. Positive regard for telepsychiatry: increased access to care, good quality of care. As was the case during the previous phase of assessment of the telepsychiatry program, the parents of users were generally positive about the merits of the program and continued to cite increased access and good quality of care.
B. Telepsychiatry services more useful for Metlakatla than Ketchikan. While staff continue to voice their positive regard for telepsychiatry, the Metlakatla staff were more enthusiastic than the staff from Ketchikan, who continue to view telepsychiatry not as an enrichment of their services, but as a last-ditch alternative. Staff at both locations and parents of users all agreed that it is more challenging and time intensive to build rapport while using telepsychiatry in the current assessment.
C. Telepsychiatry reduced some costs for patients. During the earlier stage of assessment, cost of prevented travel was not found to be a benefit from telepsychiatry for the participants. The current assessment revealed that, six months later, the cost of prevented travel was reported to be a savings for parents of users and the Metlakatla staff. Metlakatla staff and parents reported that prior to telepsychiatry, travel by boat or plane to Ketchikan, and the cost of lodging and meals if weathered in, were cost prohibitive for both Metlakatla Social Services and parents of users.
D. Suggestions for improvement. Staff concerns about patient education are new to this report. The executive, Metlakatla and Ketchikan staff all stated that the level of patient education needs to be increased with regards to telepsychiatry. Patients need more information about: • The equipment and session procedures. According the participants, pre-session education holds the potential to increase patient comfort with telepsychiatry. • Medication information, including possible or expected side effects.
Wave 2: Executive Summary 62
Certain policies and protocols may also increase the smooth delivery of telepsychiatric care. These include the following: • A structure for reminding patients they need their vitals prior to sessions. • Staff orientation to use of the equipment, specifically the zoom feature. • Modification of the session timing to allow for time for patients to debrief with staff.
Wave 2: Executive Summary 63
I. BACKGROUND / INTRODUCTION
In Alaska, many communities experience difficulties with recruitment and retention of mental health professionals. These professionals often feel isolated and have limited resources. Many times, individuals in need of psychiatric services in these remote Alaskan communities must travel by air to access appropriate services. This travel is expensive and time-consuming. More often, individuals go without the services they need.
Considering this gap in access to behavioral health resources, Alaska can potentially benefit from telepsychiatric services. Telepsychiatry could bring access to psychiatrists for remote locations unable to attract resident behavioral health specialists. Moreover, these locations often have inclement weather that makes itinerant services inconsistent, and often, non-existent.
To meet these challenges, there are currently pilot projects in three rural Alaska sites that have installed equipment and are moving forward in the implementation of telepsychiatry. They are hosted by Eastern Aleutian Tribes (EAT) and the City of Ketchikan Center for Gateway Human Services. The Ketchikan sites are in Ketchikan and Metlakatla. The Alaska Center for Rural Health (ACRH), UAA, contracted with the Alaska Science & Technology Foundation (ASTF) and the Alaska Telehealth Advisory Council (ATAC) to evaluate the progress of telepsychiatry at these sites. Because the EAT site has not been active, ACRH conducted to Ketchikan and Metlakatla only.
The City of Ketchikan Center for Gateway Human Services receives itinerant services from a child psychiatrist at the University of Washington in Seattle. However, they contract for child telepsychiatric services from Bartlett Hospital in Juneau. These services are provided to the center in Ketchikan and in Metlakatla. Metlakatla does not receive regular itinerant psychiatric services.
In February 2003, ACRH conducted key informant interviews with leadership, staff and parents of telepsychiatric users at the mental health centers in Ketchikan and Metlakatla. This was the second ACRH site visit, following one in August 2002. The purpose of the trip was to assess the benefits and drawbacks of telepsychiatry for quality, access and cost of care. It was also an opportunity to determine how perceptions of these factors had changed since the previous site visit.
Wave 2: Introduction 64
II. METHODOLOGY
A. PARTICIPANT PROFILES
ACRH conducted key informant interviews with a variety of individuals in Ketchikan and Metlakatla. Because the Ketchikan site had not facilitated any telepsychiatric consultations since August 2002, no parents were interviewed at that site during the February visit.
1. KETCHIKAN
a. Leadership Participants included the outgoing and incoming Center directors. This position is responsible for the administration of telepsychiatry in Ketchikan and Metlakatla.
b. Staff Participants included one mental health clinician, one case manager and one program coordinator. In addition, ACRH conducted an interview with one mental health clinician from a community organization who has telepsychiatry services experience.
2. METLAKATLA
a. Parents All five participants were parents or guardians of children receiving telepsychiatry services.
b. Staff Participants included one case manager, the director of social services and a mental health clinician from the Metlakatla Social Services Center. A key informant interview was conducted with one mental health clinician from a separate community organization who has telepsychiatry services experience.
B. RECRUITMENT
1. METLAKATLA PARENTS
Staff in Metlakatla selected and scheduled the ACRH interviews with the parents of children who had used telepsychiatry services since August 2002.
2. STAFF KEY INFORMANT INTERVIEWS
ACRH invited all key staff with experience in the telepsychiatry program, for Metlakatla and Ketchikan, to participate in interviews.
Wave 2: Methodology 65
C. LOCATION The Ketchikan interviews were conducted in private offices at the Ketchikan Center for Gateway Human Services office. The Metlakatla interviews were conducted in private offices at the Metlakatla Social Services Center.
D. RESEARCH QUESTIONS
1. USER PARENTS KEY INFORMANT INTERVIEWS • Overall patient experience with telepsychiatry • What patients like best and least about telepsychiatry • General perceptions about telepsychiatry equipment • Quality differences between telepsychiatry and in-person consultations • Role of telepsychiatry in patient-physician relationship • Suggestions for improvement
2. KETCHIKAN AND METLAKATLA STAFF KEY INFORMANT INTERVIEWS • Overall staff experience with telepsychiatry • What staff believed was and was not working for telepsychiatry • How telepsychiatry had changed their jobs • How it has changed the quality of care for their patients • Greatest benefits and drawbacks of telepsychiatry
E. PROVISIONS FOR ETHICAL CONSIDERATIONS
All participants were asked to read and sign a form consenting to participate in the research project. Parents were informed that interview questions would ask how telepsychiatry has been good or bad for their child, but that no personal questions about the patient’s condition would be asked. The participants were informed that their participation was voluntary and they could stop at any time without penalty.
The interviewer asked participants for their permission to audio record the interview session. They were informed that tapes were to be used during the report writing process, only the research team would have access to the tapes, and the tapes would be destroyed after the report was written.
F. ANALYSIS
The data was analyzed using ATLAS ti qualitative software. An inductive analytic technique was used where coding moved from the specific to the general in a systematic fashion. After codes were abstracted from the raw data, codes or categories then began to form into themes. The themes that emerged under each heading are described in detail below.
As this report is the second installment of a 3-part study, it does not include a ‘discussion’ and ‘conclusion’ section.
Wave 2: Methodology 66
G. DATA LIMITATIONS
The Metlakatla parent key informant interviews had the following limitations:
• This report reflects the opinions of the Metlakatla parents and not those of the Ketchikan parent users or the Metlakatla users. • The parents of the users of telepsychiatry were interviewed and not the users themselves. Many times, the parents were present during the sessions and they participated in discussions with the telepsychiatrist. The Metlakatla parents were secondary, not the primary, recipients of the service. • The parents were speculating about their child’s opinion of the services. This speculation may not be accurate. • The specifics of the patient’s symptoms, diagnosis and treatment and their relationship to the use of telepsychiatry were not discussed. The patient’s condition and its relationship to use and satisfaction with telepsychiatry were not investigated in this study. • Only five parents were interviewed for this study, which may result in a participant’s testimony being explained in great detail. This testimony is reflective of that individual and may not represent the opinions of the entire group.
Wave 2: Methodology 67
III. FINDINGS
A. METLAKATLA PARENTS AND STAFF
1. POSITIVE REGARD FOR TELEPSYCHIATRY
In general, participants spoke positively about telepsychiatry and were highly enthusiastic about its value. They believed the community, families and staff benefited from the technology. Further, some staff members envisioned a bright future for expanding the use of the technology in their community, as well as in other rural villages.
• “It’s just like being there in person with him.” • “I like everything about it...”
2. TELEPSYCHIATRY IMPROVED ACCESS TO CARE
Participants articulated that telepsychiatry circumvented barriers caused by weather. It also enabled families to receive care in the comfort of their own environment. They believed Metlakatla youth were especially troubled and in need of this level of care. At the same time, some parents expressed discomfort with their children being labeled mentally ill.
• “They don’t want to have their children known as having a mental problem.”
The matter of the immediate access to care was seen as a core benefit. In the past, weather often prevented or delayed access to psychiatric care. The availability of the technology meant the patients did not have to wait for evaluations and medications. Some parents mentioned that their children and families benefited from having access to consistent psychiatric care. In the past, the weather was often a barrier to getting timely assessments and pharmacological interventions. With telepsychiatry, patients and their guardians did not have to leave their home and job and face the risk of being weathered out of their destination. Staff echoed this observation, mentioning that telepsychiatry increased the patient’s level of comfort and ease by receiving care in their own community.
• “The weather is a big factor living on an island.” • “We’re in our own environment.”
Some of the staff voiced a concern regarding the potential loss of telepsychiatric consultations to Metlakatla. Staff was uneasy about potential negative consequences to the community if the consultations, assessments and pharmacological interventions provided by telepsychiatry were no longer available. The youth of Metlakatla are seen as high-risk and access to the technology provided a link to valuable services not available to them in the past. Wave 2: 68 Metlakatla Parents and Staff Interviews
• “I don’t know what this community would do without it.” • “There is a definite need.”
3. QUALITY OF CARE
a. Generally positive Overall, parents and staff spoke positively about the quality of care provided through telepsychiatry. Staff saw great benefits to objective professional input from an outsider. One parent reemphasized in this wave that using the technology had enhanced the children’s assertiveness skills, and his children became less withdrawn and more verbal as a result of the care they received.
• “He did really well.”
However, one parent stated that her child felt uncomfortable with the manner in which the telepsychiatrist focused on the negative aspects of the treatment. The impact of negative focus, apparently, served as the impetus for the child’s decision to discontinue treatment.
b. Satisfied with the equipment Both parents and staff stated that they were pleased with the functioning of the equipment. The equipment worked well and contributed to the positive delivery of telepsychiatry. In one situation where glare compromised the psychiatrist’s ability to see the client, a curtain was installed to manage the lighting. On a related note, the telepsychiatrist’s style of operating the equipment was not intrusive to the patients. In fact, staff described the session as a dialogue between patient and telepsychiatrist.
• “It was pretty good.”
c. Sessions are timely The telepsychiatrist was punctual with regards to starting sessions on time. On more than one occasion, when patients had overlooked their scheduled sessions, a staff member alerted them and provided transportation.
• “He [telepsychiatrist] is very prompt.”
d. Confidentiality and privacy are adequate According to staff, the room used for the sessions provided an adequate space for the telepsychiatry consultations. The use of a noise reduction unit and closed loop connection enhanced the privacy of the sessions.
One staff member explained that highly stressed families felt comforted and respected if staff requested additional reassurance from the telepsychiatrist about the privacy of the session. On occasion, the staff requested that the telepsychiatrist scan the room, which
Wave 2: 69 Metlakatla Parents and Staff Interviews
reassured families about the level of privacy. However, one individual noted that a new soundproof building would be beneficial.
e. Praise for the telepsychiatrist The Metlakatla staff was highly enthusiastic about the quality of the consultations provided by the telepsychiatrist. The staff found him to be exceedingly professional, thorough in his assessments and diagnoses and compassionate toward patients. The participants viewed the telepsychiatrist’s unique training first as a pediatrician, then as a psychiatrist, as an important contribution to the quality of care he provided to patients.
• “His expertise is really valuable.”
In addition, staff members said having a telepsychiatrist who lived outside the community might actually have been an advantage rather than a disadvantage, since an objective outsider may enhance the health of community.
f. Difficult to build rapport Participants talked about the necessity for the telepsychiatrist to take the time to build rapport with patients in order to increase mutual understanding and to break down walls of resistance. As an illustration of this point, one participant stated that his children were more accepting of the telepsychiatrist after meeting him in person. Staff members also observed that telepsychiatry was impersonal compared to in-person sessions and decreased the strength of the therapeutic relationship.
• “I think to understand someone you really have to get to know them.”
Participants also discussed the potential for the telepsychiatrist to miss the subtle aspects of body language while using the equipment.
• “Foot tapping or any nervous gestures.”
In addition, parents expressed concern about cultural disconnection between their child and the psychiatrist. They pointed out that the psychiatrist came from a larger, urban community and, as a result, he might not have understood the differences between his urban lifestyle and their rural, subsistence lifestyle. The participants speculated that professionals from outside of their community did not truly understand the unique issues facing Alaska Native youth living on a remote island, who have a history of trauma.
• “He comes from the outside; he doesn’t know.”
g. A team approach has improved the quality of care The parents felt that having access to a team of professionals during the telepsychiatry sessions enhanced the quality of care. In fact, because of this team approach, some parents said they actually preferred to use the equipment rather than see the psychiatrist directly.
The Metlakatla staff talked about how telepsychiatry increased the professional contacts for staff members, thus decreasing their sense of professional isolation. They discussed Wave 2: 70 Metlakatla Parents and Staff Interviews
the advantage of getting input from outside mental health professionals in order to improve quality of care. Prior to telepsychiatry, staff members often felt isolated from other health professionals who could potentially provide training opportunities and clinical supervision.
• “Sometimes we operate in a vacuum here.”
4. TELEPSYCHIATRY REDUCED SOME COSTS FOR PATIENTS
Though cost saving was not the primary advantage of telepsychiatry from a patient perspective, participants spoke of the incidental expenses related to traveling to Ketchikan to seek psychiatric services. In the past, individuals had to travel by boat or plane to Ketchikan and sometimes needed to stay overnight due to weather. Though actual transportation costs were generally covered by insurance or IHS benefits, the costs of meals and extra costs of lodging were financial barriers for families coming from a remote village with a limited job market and a high unemployment rate. Telepsychiatry saved patients and parents money, as well as saving the organization money. Staff members stated that telepsychiatry reduced costs incurred by bringing a psychiatrist to Metlakatla. The organization operates on limited funding, and flying in a psychiatrist is costly.
• “From the island it gets really expensive to keep shipping people over.” • “We don’t have to travel.”
5. SUGGESTIONS FOR IMPROVEMENT
a. Need for patient education Equipment and session protocol orientation The staff discussed the need for additional programmatic structure for patient support and education. They reported that, due to initial hesitation to the telepsychiatry equipment, pre-session education could have enhanced the patient’s comfort with the equipment, although familiarity with the process of telepsychiatry over multiple sessions also increased patient comfort.
• “I’d say more education is really needed.”
Participants also talked about the need for patients to develop therapeutic relationships with Metlakatla staff while using telepsychiatry in order to enhance the quality of the intervention. Patients needed to have staff available to provide support, debrief, clarify, contain and answer questions post-session.
Medication and side effects information Staff members also emphasized the need for educating patients on the side effects of medications. They stated that access to pharmacological interventions was a vital service that telepsychiatry provided to the community. Timely, professional medication consultations, ongoing medication management and patient medication education were
Wave 2: 71 Metlakatla Parents and Staff Interviews
important components of the services that were and could potentially be provided by the telepsychiatric service.
However, some parents were alarmed by the medications their children were prescribed. For these participants, the negative side effects of the medications were overwhelming. In fact, some participants and their children decided to discontinue the medication due to the magnitude of the negative side effects.
• “Let the doctor’s sons take all that medication. I don’t want them taking all that stuff.”
b. Need for debriefing time after sessions The staff talked about the need to adjust the timing of the telepsychiatry sessions in order to allow time for patients to debrief with staff. Patients needed time to talk about what just happened, ask questions and receive support, if needed.
• “There should be a gap in case you do need to kind of talk.” c. Need a procedure for patient vitals Staff suggested the need for a structure to remind patients to have their vitals checked before they come in for a telepsychiatry session. d. Other One parent suggested that giving young children a small gift following a telepsychiatry session might be a positive reinforcement.
• “They smile when they get a prize.”
6. RECENT CHANGES WITH TELEPSYCHIATRY
a. Broader use of telepsychiatry equipment The Metlakatla staff was enthusiastic about the unexpected community use of the equipment. The University of Alaska Southeast used the equipment to provide classes for teachers’ aides and the Annette Island Service Unit used it for emergency evaluations with Center for Gateway Human Services. b. Improved reporting forms for telepsychiatry Staff stated that required paperwork for the telepsychiatry program was improved over the past six months. c. Increased long-term residential placement Participants reported that the community experienced an increase in suicidal ideation, which resulted in youth being placed in long-term residential treatment programs.
Wave 2: 72 Metlakatla Parents and Staff Interviews
d. Reduction in intake assessments The procedure for intake assessments was modified, reducing the number of clients able to access the psychiatrist. This upset staff in Metlakatla.
• “Intake assessments weren’t being accepted.”
Wave 2: 73 Metlakatla Parents and Staff Interviews
B. KETCHIKAN STAFF
1. STAFF PERCEPTION OF TELEPSYCHIATRY
a. Staff liked having the option of telepsychiatry available Overall, the staff remained philosophically positive about telepsychiatry, as they were during the previous phase of the evaluation. They talked about the merits of having the option for increased access during emergency psychiatric situations in Ketchikan. This technology has revolutionized the manner in which services were delivered.
• “…nice to have the option…” • “…it was kind of helpful to have that other set of eyes saying…yes…”
b. Telepsychiatry provided essential connections Participants talked about the benefits telepsychiatry provided to Metlakatla and to organizations in the community of Ketchikan. The equipment allowed staff members in Ketchikan to have closer links with other staff and to have oversight of complex patient care in Metlakatla.
• “…at times helpful in terms of being able to oversee some stuff that goes on with Metlakatla…” • “…..the consistency at least from Metlakatla in that ongoing regular connection with somebody that they can actually talk to, they can actually see and sit down and talk to…”
Participants said telepsychiatry provided an effective link to psychiatric care and a deepened understanding of client treatment needs.
• “…[telepsychiatry] has given a completely different perspective on treatment…it is much more understanding of the client.” • “…the telepsychiatrist provides very good comprehensive psychiatric evaluations. That is number one…”
2. TELEPSYCHIATRY IMPROVED ACCESS TO CARE
As was the case in the previous phase of assessment of the telepsychiatry program, participants reported that improved access to care was the single most important benefit of telepsychiatry.
• “…the most important benefit is access to care…” • “…if push comes to shove, we can always get the psychiatrist on the telepsych system. I mean if we get backed into a corner with a client and need that psychiatric input, we have got it.”
Participants spoke positively about the ability of telepsychiatry to meet the emergent psychiatric needs of patients in Ketchikan. The ease of access, immediacy and consistency of care were seen as huge improvements over delays of the past. Telepsychiatry reduced costs incurred by travel delays due to inclement weather.
Wave 2 – Ketchikan staff interviews 74
• “…I liked being able to come back in a week with client for follow- up…Theoretically we can have eight sessions in a month instead of one.” • “…have someone who is experienced in child psychiatry with a much shorter waiting period with a much quicker follow up…” • “…Metlakatla…have high-risk …youth problem…they have to send that person, get a plane...with an escort…one of the most important safety areas…” • “…it is really cost-effective, consumer friendly, immediately accessible service…”
However, several participants stated that the telepsychiatry services were better suited to Metlakatla, since Metlakatla was without access to ongoing psychiatric care prior to telepsychiatry.
• “…consistency at least from Metlakatla in having that ongoing regular connection with somebody…” • “…in Metlakatla they don’t have anything.”
3. QUALITY OF CARE
a. Satisfied with the equipment In general, participants felt the telepsychiatry equipment worked well.
• “…I think the machine and the unit itself is very easy to use…The system itself is, I think from the times I’ve used it, been very good.” • “…[a lot] like having that person in the room with you…” • “..Just in term of clarity, in terms of how the mechanics of that, I thought it went well.”
Some staff discussed experiencing minor difficulties, yet did not see these difficulties as significant.
• “…There was one time where there was a delay in the sound coming from Juneau. He wasn’t experiencing a delay with us, but we were…it wasn’t drastic.”
The outgoing director described the quality of the equipment as a fundamental element of the telepsychiatry program. The equipment provided clear images that were devoid of delays, which came very close to emulating a face-to-face consultation with a psychiatrist. For the outgoing director, this level of excellence was an essential part of providing quality telepsychiatry services.
• “…if we want to go beyond supervision and administrative mediums, then it has to come as close as possible to emulating a wide face-to-face visit inside someone’s office….that should be our standard…” • “…I don’t like to see shitty equipment around the state…some of the other systems were brought up because of the price tag…some of it Polycom stuff, where they just didn’t mix the audio and video signals right with the bandwidths….”
Wave 2 – Ketchikan staff interviews 75
• “…then people come down here and look at our system and they just can’t believe it…they wonder why they are not getting the same results…” b. Sessions were timely For the most part, the telepsychiatry sessions started on time.
• “…give or take five minutes here or there.” • “They got started on time...”
However, one participant said the telepsychiatrist had been concerned about the timeliness of the sessions in Metlakatla.
• “There has been some complaint about that in Metlakatla from the telepsychiatrist…people are slow to get to the clinic there.”
The staff talked about the additional tasks involved with the coordination of the sessions, although this was viewed as a minor matter.
• “Not always…it’s just more stuff to coordinate. If you look at it in that respect, I don’t think it’s a big deal.” c. Confidentiality and privacy were adequate Staff members reported that the confidentiality of the telepsychiatry sessions was intact.
• “…I think the way they have it set up is fairly private…I haven’t noticed it being an issue.” • “No question about it.” • “…it seems adequate…separate room for the equipment and it appeared that was what was happening in Met side. So I think that is important.”
Although participants felt the privacy of the room was adequate, they reported that the location was not ideal due to distracting sounds and high traffic.
• “…this room is not ideal because you have got that large room on the other side that people can come in and out of…” • “…we didn’t have any concern about anyone hearing us. We could hear kids banging around in the background…” d. Patient’s comfort with the telepsychiatry format was variable Participants stated that the patients’ ease with telepsychiatry depended upon their personality. Although some patients were uneasy initially, with familiarity, they became comfortable with the equipment.
• “…I think at first, they were a little bit nervous…they adjusted well…” • “…The patients in Metlakatla say they are very comfortable…” • “…some yes and some no…depends on the personality…do some training for comfort level…” • “…The ones that have tried it, don’t like it.”
Wave 2 – Ketchikan staff interviews 76
Some participants acknowledged that a traditional face-to-face session does not allow for the increase of distance from the psychiatrist, if necessary. Thus, they felt that vulnerable or fragile clients might actually have felt a sense of safety and comfort with the impersonal nature of telepsychiatry.
• “…Having the distance of this person on video …probably felt more comfortable than if they had met this person face-to-face and didn’t know him.” • “…it seemed safer with him on the TV in a different community… • “…they actually like him better on the TV…”
Participants discussed the manner in which the telepsychiatrist operated the zoom option on the equipment. On one occasion, the zoom feature was disturbing and uncomfortable for a patient who did not want the psychiatrist to see her self-inflicted injuries.
• “She can kind of tell when it zooms in and zooms out. He’d say, ‘I’m going to zoom in,’ and you can kind of see where the little eye…” • “…The way the zoom in and zoom out was being used was uncomfortable for her…” • “….has a tendency to cut and the psychiatrist asked to see one of the cuts… didn’t want to show him. So he then zoomed in to see if he could see it… was not comfortable…”
In another case, lack of experience led to the misuse of the zoom feature. The improper use of the zoom feature could be perceived as intrusive and embarrassing for patients.
• “…that zoom camera is a very powerful feature and it could be misused just as well as used effectively…” • “…We still have to have space and distance issues and we want to make sure that we are not too close with our zoom camera that we appear to be intrusive…” • “…The way we like to do this is have the picture-in-picture mode, so the person at our end, if you are viewing the picture, you can see how [the doctor] is seeing you…” • “…until you know what you are doing it can be embarrassing…”
Staff reported both an increase and decrease in the use of the service. One participant reported that the referrals from Gateway to the telepsychiatrist decreased since the last assessment of the program, while another participant reported an increase in use.
• “…There has probably been a decrease in referrals from Gateway clinicians to the telepsychiatrist and there weren’t many to begin with, but no one at this point is referring to the telepsychiatrist…” • “…I think it’s getting more use. I mean just because my kids aren’t using it, I think it is being used more frequently.”
e. Patients comfortable with the telepsychiatrist Participants in Ketchikan stated that patients were mostly comfortable with the telepsychiatrist and responded well to him:
Wave 2 – Ketchikan staff interviews 77
• “It was positive…” • “…they did real well with the psychiatrist. I think his opinion carries a lot of weight and although he was very serious...he was there to diagnose and prescribe…responded well to it…” • “…He is not as warm and friendly guy as the visiting doctors…he is more for adults.”
However, several participants talked about a specific situation in which the telepsychiatrist recommended hospitalization to a patient who became uncomfortable and upset. Consequently, some of the youth in Ketchikan did not wish to utilize the technology due to this abrupt suggestion.
• “…he was recommending hospitalization… child wasn’t going to hear that…bit of an altercation verbally…not a comfortable session…” • “…the telepsychiatrist is very quick to suggest to a teenager that they may need hospitalization. Teenagers don’t like to hear that…” • “We (Gateway in Ketchikan) have had teenagers say they don’t want to see that doctor on the TV anymore…” f. Difficult to build rapport through telepsychiatry Some Ketchikan staff remained skeptical about the telepsychiatrist’s ability to build rapport while using the equipment. The sessions were perceived as somewhat limited and stilted by the impersonal nature of the technology.
• “…the idea of not having a personal, face-to-face…” • “…harder to joke or relax, there is a little bit of you are talking to a box…the follow up…he did come to town and the clients did get to meet him…” • “…more limited through telepsychiatry..” • “I think it’s limited.” • “…I didn’t see a real connection…” • “The person is not in the room.” • “…I have heard a few negatives…checklist guy…doesn’t take a lot of time to build rapport…”
When using telepsychiatry, it took extra effort to build rapport by paying special focused attention to non-verbal cues and using empathetic communication.
• “I think you have to work at it…when I am using the equipment, I want to see what I look like in the picture-in-picture….make sure I am communicating empathically with non-verbal gestures.” • “…I mean its both person-to-person, you are still doing it, they are just not in the room.”
Due to the impersonal nature of the technology, one participant stated that the quality of the therapeutic relationship would be improved by increasing the time spent developing rapport.
Wave 2 – Ketchikan staff interviews 78
• “…he doesn’t spend much time developing a relationship with the family….”
Another said that having a staff member and/or family members present during sessions enhanced the quality of the sessions, because there was an increased risk of omitting details when using the technology. Staff and family members improved the assessment by verbalizing details that could have been overlooked.
• “…there is a potential for missing stuff, but because we have someone skilled in the room, anything I thought he was going to miss, I said it or the parents said it…”
g. Staff preferred itinerating psychiatric care over telepsychiatry Overall, participants preferred to utilize psychiatric services from the itinerating staff due to the familiarity and trust they have in their quality of work. They discussed the long- standing relationship and positive regard they have for the itinerating psychiatrists.
• “…we are incredibly privileged to have the caliber of psychiatrists that we have that come up from Washington…I think that in itself plays a big role…” • “…We are used to dealing with child psychiatrists who travel here…” • “Ketchikan, where you do have a little more accessibility to stuff is different…” • “…we already have very good child psychiatrists already…people like them…prefer to use them..”
Perhaps due to their established relationship with the itinerating psychiatrists, the participants did not view telepsychiatry as a fully flourishing program. Some individuals did not perceive telepsychiatry as an enrichment of their services.
• “…for psychiatric services, I don’t know what is working…” • “…for Gateway, it has not necessarily been, I don’t think horribly successful…’ • “…I don’t know what is particularly working for Ketchikan, to be frank with you…” • “…Gateway clients, I don’t know that it has done much to improve the quality of care.” h. A team approach through telepsychiatry improved the quality of care The availability of telepsychiatry enhanced the quality of mental health services. A thorough assessment of patient needs while using a team approach was viewed as beneficial.
• “…it has improved to Metlakatla….” • “I see the assessment piece working well.” • “…Bringing more members of the team to the table or to the camera to be able to work with the client…”
Wave 2 – Ketchikan staff interviews 79
4. SUGGESTIONS FOR IMPROVEMENT
a. Need for patient orientation to equipment Participants discussed the need for educating and familiarizing patients with the telepsychiatry equipment. For example, pre-session education might increase patient comfort with the equipment and procedures.
• “…if you don’t do the proper prep work with orientation to the equipment and all that other stuff, it can become intrusive….” • “…we could have an orientation for the first five minutes of every session with the client that says: these are the ways you can appear on the screen. Let’s walk through that. How would you like to do this?” • “….I think the person could probably explain why and what they’re doing a little better…”
b. Can facilitate staff training The participants talked about the potential for staff training when using telepsychiatry. The technology could provide an opportunity for increasing staff knowledge of mental health symptoms, treatment plans and the process of recovery.
• “…they could learn about the positive and negative symptoms of mental health…really get into the nitty gritty of the treatment plan and the recovery process with the child, adolescent or adult. That is where they could even learn more…” • “…it definitely could do that…I can see where it would… • “I think the potential for that is very high…”
One participant discussed the ways in which sitting in on telepsychiatry sessions was valuable in terms of enhancing knowledge of DSM diagnosis and assessment.
• “…it was good for me to be in there listening to the doctor kind of go though the DSM and questions, working the diagnosis…” • “…It was a learning opportunity for me to watch someone doing an assessment.” • “…I didn’t expect to kind of learn as much as I sat in on the session…there was this learning curve for me…” • “…It was useful for us to sit in...it can be effective and useful for us. I found it useful.”
c. Staff access to itinerant psychiatrists reduces acceptance of telepsychiatry The executive staff talked about the attitude Ketchikan staff has had toward telepsychiatry. The Gateway staff was viewed as having less appreciation of telepsychiatry services because they have access to itinerating psychiatrists. It was a difficult transition due to the impersonal nature of the technology in contrast to in-person sessions with psychiatrists with whom they have an established rapport.
• “I think that we are just scratching the surface at Gateway…we know that it is not appreciated as much...”
Wave 2 – Ketchikan staff interviews 80
• “…I don’t think it has measurably improved the quality of care at Gateway, because we have other options…” • “…Metlakatla has got it and has got the vision…we (Gateway in Ketchikan) continue to add itinerant child psychiatrists visiting us from Seattle… staff has a choice…don’t think staff will really come to terms with the new technology…” • “…tough for staff (Ketchikan) to switch over to another doctor…” • “..People (Ketchikan staff) were more critical from this staff…I think it is probably personality.” • “…I was kind of surprised at some of the resistance to initially use the equipment. I heard a bit of that from the clinicians (Ketchikan staff)....the process with the equipment as opposed to you and I sitting in the room talking and interviewing...doing this over a TV monitor.”
The incoming director stated that with the onset of telepsychiatry in Metlakatla, the reality of the issues facing them was difficult for them to accept.
• “...I would imagine it has been tougher for the people on the Met side to get used to it, kind of like opening a door to people being able to really see what is going on.”
5. FUTURE PLANS a. Increased use of telepsychiatry The executive staff in particular talked extensively about the potential for expanding and deepening the use of the telepsychiatry technology. Due to anticipated budget cuts, the expanded use of telepsychiatry within the organization was viewed as cost effective.
• “…I see things coming down the pike that could alter how our organization uses telepsychiatry…widely anticipated…reductions in grant funding next year… telepsychiatry becomes more cost-effective to use…” • “…reduced Children’s University Medical group from three days to two days…bumped their rates up on us…trying to bump their rates up again…city will do a cost comparison….telepsychiatry will prevail…”
The executive staff talked about expanding into psychological testing, aftercare, clinical supervision, program supervision and discharge planning.
• “…We could be doing psych testing in Metlakatla…” • “...We could be doing a lot from an emergency perspective and we are not…” • “...I think the potential to change things are tremendous…but certainly the aftercare piece , that family piece…” • “…I think, clinical supervision would really lend itself, that telepsych would really lend itself…” • “…when we hospitalize patients at Bartlett from our CSP program, we can do some very interesting discharge planning by video conferencing and we are not taking the time to do that…”
Wave 2 – Ketchikan staff interviews 81
• “…I would see clinical supervision and program supervision along with emergencies for both Metlakatla and Prince of Wales would really be a benefit to this area…”
• The director talked about the possible addition of two more psychiatrists onto the telepsychiatry equipment.
• “...if we could get to the point that the adult psychiatrist could probably do a lot of work in Anchorage, instead of having to travel…then the itinerant child psychiatrist could visit us…once she gets that part set up, it would probably be easy to follow up with some patients here. ” b. Expanded community use of the equipment Participants thought community use of the equipment by the University of Alaska Southeast might expand next year.
• “…so I think what is working is the synergy that is beginning to tie us together and the University is looking at expanding their role next year…” • “…We are able to do staffings and we are able to do other things collaboratively that you just wouldn’t believe….University of Alaska Southeast is using the equipment right now to do a Remedial English class.”
Participants saw the potential for telepsych equipment to be used by other entities in the community:
• “…it (equipment) is open to anyone.” • “…Community Connections is the only one using it so far…” • “…One of the pediatricians in town actually chooses not it use it…does not believe in telepsych, that the whole process is quite as good as having face-to- face….”
The executive staff was eager to add more rural sites onto the equipment.
• “…I think a limitation to the technology right now is you are kind of locked into a few sites…more accessibly with other sites…be a plus for the equipment…” • “…if sites could be opened up more easily and maybe that will happen in the future…” c. Plan for progress toward staff acceptance The directors discussed ways to improve the utilization and enhance acceptance of the technology in Ketchikan. The idea of on building relationships between staff and the telepsychiatrist by conducting case staffing together was suggested by the director. Staff training that focuses primarily use of the technology and team-building sessions were recommended. Requiring staff to complete one intake per week using the technology with the telepsychiatrist was mentioned as a way to overcome the lack of staff eagerness to embrace the technology.
Wave 2 – Ketchikan staff interviews 82
• “…I think in order to make this thing work, we are going to have to have more staffing with the telepsychiatrist, so that our staff begins to develop a working relationship with him.” • “…very soon staff will be required to have one intake per week on the video conferencing equipment, just to do the intake, not take the kid on their case load, but just to do a comprehensive assessment and evaluation…” • “…some training needs or some getting used to needs that I am hearing…it is going to take some training of how best to use the technology…” • “…training and a familiarity issue with the technology…working with people to get the most out of the technology…probably a barrier at this point…” • “…I do think of there is going to be a team working together, that it is probably indicated, some time to just get used to each other…(staff and telepsychiatrist).” • “…having the team there as opposed to one-on-one on the camera. If you can get some people in there, get the momentum going.”
Wave 2 – Ketchikan staff interviews 83
APPENDIX C
Wave 3 July 2003 Evaluation
Appendix C 84
EXECUTIVE SUMMARY
I. BACKGROUND/INTRODUCTION
Ketchikan’s Gateway Center for Human Services participated in a demonstration telepsychiatry project for child and adolescent patients. This report describes findings from the Alaska Center for Rural Health’s third and final evaluation site visit to Ketchikan and Metlakatla, which took place July 2003. The purpose of the trip was to assess the benefits and drawbacks of telepsychiatry for quality, access and cost of care. It was also an opportunity to determine how perceptions of these factors had changed since the previous site visit, which took place February 2003.
II. METHODOLOGY
ACRH conducted key informant interviews with leadership, staff and parents of telepsychiatric users at the mental health centers in Ketchikan and Metlakatla. Actual patients were not interviewed, as they were all minors.
III. FINDINGS
A. Telepsychiatry used regularly in Metlakatla; rarely used in Ketchikan. Telepsychiatry’s biggest benefit continues to be drastically increased access to psychiatric care in Metlakatla. Ketchikan received face-to-face psychiatric services from an itinerant provider with whom they had a long-established relationship. Thus, they did not have a major gap in access, and telepsychiatry did not significantly impact their access to psychiatry.
B. Positive regard for telepsychiatry: increased access to care, good quality of care. As in previous evaluations, the parents were generally positive about the merits of the program and continued to cite increased access and good quality of care. If given the choice, all parents preferred face-to-face consultations for their children over telepsychiatry. However, telepsychiatry was a good alternative given the lack of available access to care.
C. Hint of ambivalence toward consequences of increased access. As the initial novelty of new access wore off, the reality of the unpleasant aspects of psychiatric care set in. Parents struggled with the distress of adjusting to psychiatric medications and the disturbing side effects. Responses were mixed regarding the children’s comfort with telepsychiatry.
D. Higher expectations for care. As psychiatric services became more established in the community, participants expected a higher standard of care. For example, during the first evaluation visit, parents had positive feedback regarding the cultural sensitivity of the psychiatrist. In this last visit, however, parents were more likely to express doubts that a person from the ‘outside’ could truly understand the difficulties they had in their
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small community. One participant said the telepsychiatrist needed to spend more time in the community in order to get a “feel for the island’s background.”
E. Lack of training presented challenges for Metlakatla. Telepsychiatry introduced new hurdles for the social services office staff in Metlakatla. Their job roles had suddenly increased in complexity, and they were required to submit difficult paperwork and increase coordination with various entities. Staff had no previous experience coordinating psychiatric services. They would have benefited from more training and oversight than they were actually able to receive, especially in the areas of registering patients, completing intake assessments and ensuring patient compliance.
F. Telepsychiatry reduced some costs for patients. Although participants received financial aid to travel outside the community for services, they still incurred out-of pocket costs, such as meals, cab fares and expenses from being weathered in.
G. The importance of local control for Metlakatla. Metlakatla was not invited to the planning process for telepsychiatry. Though the Metlakatla community was a primary stakeholder in the telepsychiatry project, their input was not solicited for the planning, implementation, discontinuation of the project. Further, the news that the telepsychiatric contract had not been renewed was a surprise and disappointment.
On a more empowering note, telepsychiatry allowed the Metlakatla clinic to have more autonomy from Gateway Center for Human Services and increased their ability to have more localized control over their access to care.
H. The importance of local control for Ketchikan. Local control for Ketchikan meant using providers with whom they were comfortable. Ketchikan staff did not use telepsychiatry, because they did not want to lose their regular itinerant providers. Ketchikan staff agreed that they would have participated if the telepsychiatrist had been their regular provider.
This telepsychiatry demonstration project was championed by the former director of Gateway. No other staff were involved in the initial stages of planning, goal setting and implementation. After the Center director left, those remaining in Ketchikan did not have a clear vision of how to maximize telepsychiatry to the benefit of their patients and organization.
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I. BACKGROUND / INTRODUCTION
This report is the third and final installment of a three-part evaluation of the City of Ketchikan Gateway Center for Human Services telepsychiatry demonstration pilot project.
The City of Ketchikan Gateway Center for Human Services has traditionally employed itinerant services from child psychiatrists at the University of Washington in Seattle. Though the community of Metlakatla did not receive these services, patients in Ketchikan received these periodic psychiatrist visits. With the availability of telepsychiatry technology, Gateway implemented a contract for child telepsychiatric services from Bartlett Hospital in Juneau.
At the onset of this pilot, telepsychiatry services were intended to be provided from Bartlett Hospital via distance delivery to clients in both Ketchikan and in Metlakatla. For a variety of reasons also noted in the Wave 2 report, Ketchikan continued to use their itinerant providers instead of using the newly available technology, with only a couple exceptions.
Metlakatla regularly utilized telepsychiatric services for four-hour blocks, twice a week.
In July 2003, ACRH conducted key informant interviews with leadership, staff and parents of telepsychiatric users at the mental health centers in Ketchikan and Metlakatla. This was ACRH’s third site visit, following visits in February 2003 and August 2002. As with the previous visits, the purpose of the trip was to continue to assess the benefits and drawbacks of the service. It was also an opportunity to determine how perceptions of these factors had changed since the previous site visits.
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II. METHODOLOGY
A. PARTICIPANT PROFILES
ACRH conducted key informant interviews with a variety of individuals in Ketchikan and Metlakatla.
Metlakatla Parents of Patients - Three parents or guardians of children receiving telepsychiatry services were interviewed in Metlakatla. No actual patients were interviewed in this evaluation, as they were all minors.
Ketchikan and Metlakatla Staff - Staff participants from Ketchikan included one mental health clinician and the executive director. In addition, ACRH conducted an interview with a mental health clinician from Community Connections, an organization who also contracted for telepsychiatric services. The mental health clinician from the Metlakatla Social Services Center was also interviewed in this installment. In past waves, the Metlakatla case manager and director of Social Services were also included, but these individuals were unavailable during the time of our July visit.
B. RECRUITMENT
Metlakatla parents - Staff in Metlakatla selected and scheduled the ACRH interviews with the parents of children who had used telepsychiatry services since February 2003.
Ketchikan and Metlakatla Staff - ACRH invited all key staff in Metlakatla and Ketchikan with experience in the telepsychiatry program to participate in interviews.
C. LOCATION
The Ketchikan interviews were conducted in private offices at the Ketchikan Center for Gateway Human Services office. One interview was conducted at Community Connections. The Metlakatla parent interviews were conducted in private offices at the Metlakatla Social Services Center. The Metlakatla staff interview was conducted telephonically.
D. RESEARCH QUESTIONS
1. METLAKATLA PARENTS KEY INFORMANT INTERVIEWS • Overall patient experience with telepsychiatry • Quality differences between telepsychiatry and in-person consultations • Role of telepsychiatry in patient-physician relationship • Adequacy of orientation prior to and debriefing after sessions • Adequacy of information about medications received
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2. KETCHIKAN AND METLAKATLA STAFF KEY INFORMANT INTERVIEWS • Overall staff experience with telepsychiatry • What staff believed was and was not working for telepsychiatry • How it has changed the quality of care for their patients • Adequacy of orientation prior to and debriefing after sessions • Adequacy of information about medications made available • The future use of telepsychiatry in their communities
E. ANALYSIS
A systematic, sequential approach was used to tabulate the data collected in this study. The analysis was conducted using a transcript-based approach, whereas themes were identified from the record and verbatim comments were coded and placed into categories. This report contains a descriptive summary of participants’ responses.
In this installment, the interviews of Metlakatla parents were analyzed together and reported in section A. Similarly, the interviews of Ketchikan staff were analyzed together and reported in section B. As there was only one interview conducted with a Metlakatla staff member, this single interview was integrated into both sections. The opinions of the Metlakatla clinician are indicated in the text.
As this report is the third installment of a 3-part study, it does not include a ‘discussion’ and ‘conclusion’ section.
F. PROVISIONS FOR ETHICAL CONSIDERATIONS
All participants were asked to read and sign a form consenting to participate in the research project. Parents were informed that interview questions would ask how telepsychiatry has been good or bad for their child, but that no personal questions about the patient’s condition would be asked. The participants were informed that their participation was voluntary and they could stop at any time without penalty.
The interviewer asked participants for their permission to audio record the interview session. They were informed that tapes were to be used during the report writing process, only the research team would have access to the tapes, and the tapes would be destroyed after the report was written.
G. DATA LIMITATIONS
• The parents of the users of telepsychiatry were interviewed and not the actual patients themselves. Many times, the parents were present during the sessions and they participated in discussions with the telepsychiatrist, but they were the secondary, not primary, recipients of the service.
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• The parents are speculating about their child’s opinion of the services. This speculation may not be accurate. • The specifics of the patient’s symptoms, diagnosis and treatment and its relationship to the use of telepsychiatry were not discussed. The patient’s condition and its relationship to use and satisfaction with telepsychiatry were not investigated in this study. • Only three parents were interviewed for this study, which may result in a participant’s testimony being explained in great detail. This testimony is reflective of that individual and may not represent the opinions of the entire group. • Only one staff member from Metlakatla was interviewed in this wave. This interview may not be representative of opinions of all Metlakatla staff.
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III. FINDINGS
A. METLAKATLA PARENTS
1. OVERVIEW OF TELEPSYCHIATRY USE
a. Use of telepsychiatry Metlakatla parents generally reported that their children had telepsychiatric consultations about four times each.
• “In June and part of July I think he saw him maybe twice on the TV, and then when he came back home I think maybe twice now, so four times.”
b. Patients received an orientation to telepsychiatry Parents met with the local therapist and case manager before their first session. They viewed the equipment and were given an orientation of what to expect from the consultation. Participants agreed this session was helpful.
• “They just let me know about what to expect, what kind of questions, not to be uncomfortable and just to be ourselves on the screen.”
• “[The therapist] and [the case manager] …called me and they said that [my son] needed to be seen by [the telepsychiatrist]. They told me what it was all about and what things could happen.”
One Metlakatla parent reported she did not receive an orientation to telepsychiatry, but that it would have been helpful.
• “No, they didn’t really tell us.”
The therapist explained that the only occasion in which patients would not receive an orientation was for emergency consultations.
• “We usually had it set up, and we showed them what to expect and how it would work, how the camera would work. We tried to do that in every incident, but sometimes they were emergencies…and we just got on with it.”
c. Patients received debriefing after telepsychiatry sessions Parents reported that at some point, someone had debriefed the telepsychiatry session with them. One participant said her child sometimes talked with the therapist after a session, and another participant reported that she and her son had talked with both the Metlakatla Center Director and the local therapist following a session.
• “Sometimes [my daughter] had a follow up or some extra time with [the therapist] that they may have spoken about what happened, but not directly to me. If [the telepsychiatrist] had any suggestions on medication changes or anything, he faxed them down in writing and [the case manager] could call and tell me.”
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• “One time it was [the Metlakatla Center Director] and [the therapist], both of them, and they all sat down and talked…about what was said with [the telepsychiatrist], and he recommended that [my son] go to [residential treatment] and we all just talked about it.”
Participants said it was helpful to talk afterwards about what happened during the sessions.
• “It’s always helpful to [my daughter] to be able to talk to [the therapist].”
The therapist noted that some patients preferred to meet separately as a family to gather their thoughts and formulate questions. She described this approach as a culturally-appropriate alternative to debriefing immediately following a session.
• “Sometimes they wanted to go off on their own and debrief, and then come back to the table, so to speak. We had them scheduled to come back to see how they felt about how it went, but it wasn’t always after the session… They have to get it together and understand in their own mind what it was that they heard and compare notes and then they come up with the questions. It is a different culture. I’m reminded of that all the time.”
d. Patients ambivalent about new access to medications All participants had a child receiving medications. Some children were on medications prior to seeing the telepsychiatrist, while others began taking them upon the telepsychiatrist’s prescription. For the most part, parents reported that the medications had been beneficial.
• “[One of my sons] just started. He was stubborn but I said you better try it; it’s going to make you do better. And he is doing a lot better…”
• “Yeah, it helped.”
However, as was evident in the previous evaluation period, parents struggled with the disturbing side effects and the distress of adjusting to psychiatric medications. As the initial novelty of new access wore off, the reality of the unpleasant aspects of psychiatric care set in.
• “It was [the itinerant psychiatrist] that put him on something…but it made him go really crazy…He started crawling in the closet and hanging from the bottom of the stairs and he would want to do crazy stuff… he even pulled [scissors] on a teacher. I said I told you it was going to make him go crazy but nobody listened to me. I said I didn’t want him to take it. It started making him really itch all over and he would scratch his head like he was really nervous.”
• “The side effects for [my son] is that he likes to eat a lot and they said it would have to do with the pills, but sometimes he just really eats a lot.”
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e. Patients received information about medications Participants reported they received adequate information about their children’s medications.
• “[The telepsychiatrist] gave me papers with the names of each one and what they were for, what they were made of, the side effects.”
• “[The telepsychiatrist] talked to us about it because [my daughter] had trouble sleeping at night and her hands would tremble, so he cut her back on a few things, cut her back on one of them. He explained to us the different things that could happen, or maybe changing this will make it better.”
The local therapist also reported that medication information provided to patients had been thorough and adequate. They provided patients with a handout and verbally described the side effects of the medication. Whenever possible, the telepsychiatrist gave the patient a choice of medications.
• “He would make his recommendation, and we had print outs of the medications, and gave it to patients and the family before they left. And sometimes they didn’t make choice until they saw [the telepsychiatrist], which could be next week.”
Despite the staff’s efforts to provide in-depth information, the therapist noted that her patients were not likely to question their prescriptions or their overall care plan. Whereas someone from a different cultural background would use medication information to maximize the care provided, her patients generally deferred to the recommendation of the doctor.
• “We’re in a culturally different land in Metlakatla. In some of the lower 48, people have stronger voices, and just because someone is a doctor doesn’t mean they necessarily take their word as Holy… Here in Metlakatla…if it is voiced by someone that has an education, they are pretty willing to go with the program…they seemed to be less questioning of the agenda.”
2. QUALITY OF CARE
a. Quality of care is good As in the previous evaluations, parents were satisfied with the quality of care their children received via telepsychiatry. One parent was initially hesitant, but concluded the outcome had been positive, as it enabled her daughter to get quicker access to psychiatric care. One reported the consultations were “okay,” though they seemed a bit rushed or repetitive.
• “I thought it was really good. He asked a lot of questions and really delved into their lives and personalities to see what was going on with them, and he talked about why they were depressed and why they had these suicide thoughts.”
• “I think it helped them, both of them…”
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• “I thought it was a little weird, sitting in front of a screen. The first time I was kind of hesitant to come. When [the therapist] approached us about it, I was like, ‘don’t you have to have like a one-on-one kind of meeting?’ But it turned out for the best I think…I could see where [my daughter] was probably going to be needing more treatment in the long run, whether it was going to be as soon as it was or further on down the road. So maybe [the telepsychiatrist] just kind of enabled her to get that help a little quicker.”
• “Sometimes it feels kind of rushed like we are just in a hurry. One other time I felt like we were just going over the same things that we spoke about the last time. But, overall, I have never been to a psychiatrist or any kind of telepsychiatry at all, so it seemed to be okay.” b. Helped in making better decisions about care One participant said the biggest benefit of telepsychiatry was that the contact with the telepsychiatrist resulted in her son being sent to a behavioral clinic.
• “The benefits are really good, the outcome of it. When they left I was so lonesome and I wanted them with me, but now that [one of my sons] is home I see the difference in him and I feel like it’s helped…I felt like in the end it was a good decision to send them…I feel like [telepsychiatry] is something we need because he can’t come down here for all the patients, so it’s the next best thing, the TV. So I feel like it’s a good thing.”
c. Telepsychiatry is less personal but a good alternative to limited access If given the choice, all Metlakatla parents preferred face-to-face consultations over telepsychiatry. However, telepsychiatry was a good alternative given the lack of available access to care.
• “[Face-to-face is] what I would prefer. It seems like they would be able to get a better opinion of you and your family rather than seeing you on a screen.”
• “It would be great if we had him here or somebody like him, but since we don’t the telepsychiatry is really good…I felt like the TV was really good but it would have been better if he was here. But since he wasn’t, the TV was very good.”
Participants preferred face-to-face because telepsychiatry made the physician-patient relationship more impersonal.
• “I was really hesitant about this whole telepsychiatry. What kind of opinion can you formulate when we are not in the same room and we are just looking at each other over a screen? It just kind of seems so impersonal.”
• “A lot of the times, when [the telepsychiatrist] was asking questions and [my son] was answering, there was no real back and forth…it was like we stayed right with the question in the interview, so there was no discussion about what [my son]
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liked or what he does or anything…I don’t really think [my sons] have a relationship with [the telepsychiatrist]. They will answer his questions and when they leave they don’t even think about it any more after that. It’s just a visit to the doctor.”
One participant said she felt comfortable with telepsychiatry. She reported the psychiatrist seemed to get all the information he needed.
• “I always feel comfortable with the TV; I don’t really feel like anything was lost. I don’t know…it seems like he got enough information with all the questions he was asking for somebody on the TV and not there in person.”
d. Presence of local clinician helped make sessions more personal Several participants reported their children had a close relationship with the local therapist. They noted her presence helped bridge the gap between the patient and the impersonal nature of telepsychiatry.
• “It’s a really good relationship with [the therapist]…[The therapist] seemed to be kind of like a mediator, explaining to [my daughter] or to myself later on what [the telepsychiatrist] formulated from the last visit, how we can change the medication and get a good explanation on that and gave [the telepsychiatrist] stuff from her intense visits together. She just kind of seemed like the go between.”
e. More difficult to read body language Participants agreed that it could be more difficult to read body language through telepsychiatry and wondered if the psychiatrist was able to see their child’s physical subtleties.
• “Yeah because sometimes he was asking [my daughter] a question and…I can see like her nervous knee bouncing up and down or I could hear the tone in her voice, that maybe he couldn’t pick up. And then at the same time when he would speak to her, I couldn’t really read his facial expressions too well so I couldn’t tell what he was thinking as he was talking, so it was a little [uncomfortable].”
However, one participant said the telepsychiatrist seemed to know what to look for, that he was quite astute and able to pick up on their child’s subtle body language.
• “Every time that [my son] would get agitated he would notice it and comment on it, so where I’m concerned, we didn’t see his [body language], but he saw ours.”
f. Comfort with telepsychiatry is mixed Responses were mixed regarding the children’s comfort with telepsychiatry. Several participants felt their children seemed to be comfortable with the equipment, or at least did not indicate otherwise.
One said her son was not as comfortable using the equipment as seeing the psychiatrist in person, because he had become accustomed to in-person visits with a psychiatrist in
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Ketchikan. Another parent indicated they trusted the recommendation of the psychiatrist and encouraged compliance from her children.
• “Yeah, they were okay. They didn’t complain about him, and if they don’t like something they complain and say, ‘I don’t like it, I don’t want to do it any more,’ but they were okay.”
• “[The itinerating psychiatrist] really sat down and talked to him and stuff.”
• “It was helpful to the kids to hear that another doctor recommended things for them…It wasn’t just us saying you need to change…It was helpful that [the telepsychiatrist] told him.”
g. Telepsychiatrist does not understand child’s background As psychiatric services became more established in the community, participants expected a higher standard of care. In the first site visit, parents had positive feedback regarding the cultural sensitivity of the psychiatrist. In this last visit, however, parents were more likely to express doubts that a person from the ‘outside’ could truly understand the difficulties they had in their small community. One participant said the telepsychiatrist needed to spend more time in the community in order to get a “feel for the island’s background.”
• “He is from the city or whatever, a bigger town…I just think because he’s not from here, he doesn’t know what goes on here or see what goes on here. It’s a smaller town.”
• I think he really needs to be here or maybe fly in and out of here to really formulate an opinion. We can sit in a room and talk to him and tell him about it, but he probably doesn’t understand unless he takes the time to really see what our background is.”
3. COST OF SERVICES
a. Telepsychiatry reduced some costs for patients Although participants received financial aid to travel outside the community for face-to- face psychiatric services, they still incurred additional costs not covered by insurance or Medicaid. In one case, a participant received financial aid through Medicaid to fly her son and her to Ketchikan for services. However, when weathered in, they had to pay for the ferry ride to return to Metlakatla. They also paid for cab fares and meals. Telepsychiatry reduced these out-of-pocket expenses.
• “If we got weathered in then we had to pay our own way on the ferry. I remember the last time we couldn’t fly back because it was ugly so we came on the ferry.”
• “They used to pay for the hotel but it sounds like they are trying to cut costs so they don’t pay for the hotel any more.”
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B. STAFF INTERVIEWS
1. OVERVIEW OF TELEPSYCHIATRY USE a. Participant profiles Participants included a psychologist from Gateway, the director of Gateway, a therapist from Community Connections of Ketchikan and the therapist from Metlakatla. These individuals all reported use of telepsychiatry. b. Telepsychiatry used mostly in Metlakatla As in the previous evaluation period, staff reported limited use of telepsychiatry in Ketchikan. They used itinerant, face-to-face psychiatric services from a provider other than the telepsychiatrist.
• “We haven’t used it that much here. We are a hub; we have access to most of the services here.” Telepsychiatry had been used between Metlakatla and Ketchikan two times between February and July 2003. Two different itinerant psychiatrists provided services for Metlakatla clients during their visit to Ketchikan: one psychiatrist performed a psychological assessment and the other conducted an emergency assessment.
• “Every once in a while, an emergency case will come up that somebody needs to be seen by a psychiatrist which we get…We are trying to stabilize the situation in order to get them to a hospital or some place else. It’s been helpful with them.”
Metlakatla used telepsychiatry for four-hour blocks twice a week. At the time of the interview, their patient load was 5-6 clients. c. Patients received an informal orientation to telepsychiatry Staff reported that most new patients received an informal orientation to telepsychiatry, but that a formal orientation would be useful. One participant said it would be “a good idea” to have a formal set of written instructions—for both patients and clinicians.
• “On this end there is not going to be a formalized process talking about what it’s like…it’s been more informal.” d. Patients received an informal debriefing after sessions Patients received an informal debriefing following telepsychiatry sessions, where they could ask questions and process what happened during the session. Staff were working on formalizing this procedure.
• “Yeah, again, it’s very informal. It’s usually, ‘what was that like for you and what do you think about that?’” • “I hope that is going on. That is part of my push for formal clinical training. It’s difficult to get that track record going.”
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e. No formal staff orientation to telepsychiatry Participants reported no formal staff orientations prepared for telepsychiatry, largely due to the newness of the technology. One participant said he was able to orient himself with the help of the telepsychiatrist just before and during a session.
• “It’s something we are still kind of experimenting with...”
• “When we got there, [another staff member] kind of showed us around and got the equipment going on that. But, no, there wasn’t a lot…[the telepsychiatrist]… in session, told us some of the controls. But he worked them from his end.”
f. Lack of training for Metlakatla staff presented challenges for Medicare reimbursements Staff in Ketchikan reported trouble applying for Medicaid reimbursement for telepsychiatry in Metlakatla. One contributing factor was that Metlakatla staff did not always register patients before receiving services. Ketchikan staff also noted that Metlakatla staff’s intake assessments were delayed or not “thorough enough” and needed revisions. Additionally, staff reported delays in obtaining patient vitals, which were often required before a follow-up appointment with the psychiatrist. Because patients often missed their clinic appointment, or failed to make them to begin with, their appointment with the psychiatrist would also be delayed. To expedite this process, a Ketchikan provider made appointments for the patients as well as arranged for transportation and sent out reminders. All of these problems could be addressed with additional training for Metlakatla staff.
• “I think the hang up was that the family is not a great one for making and keeping appointments, so there would be some sort of mix up or they would miss the appointment…We notified them when the appointments were, found out if they needed transportation to the appointments, tried to stress with them that psychiatric time was very valuable and they couldn’t miss these appointments.” • “I was sort of disappointed with my clients and how slow they were to get the blood work done and the follow through.”
As was discussed in previous reports, telepsychiatry introduced new hurdles for the social services office staff in Metlakatla. These included greater complexity in their job responsibilities, difficult paperwork and increased coordination with various entities. Staff had no previous experience coordinating psychiatric services. They would have benefited from more training and oversight than they actually received.
2. ACCESS TO CARE
a. Access to care continues to be the biggest benefit for Metlakatla As was the case in the previous two evaluation sessions, telepsychiatry’s biggest benefit was drastically increased access to psychiatric care in Metlakatla.
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• “It was very dramatic because not only did they have me [the therapist]…they had access to a psychiatrist. They had a second opinion…We’re functioning, don’t get me wrong, but it was such a wonderful tool.”
• “The ones that were [acting impaired] for attention quit because they didn’t want the consequences. The ones that were really impaired, we were able to get them the help that they needed, and pretty quickly.” b. Telepsychiatry improved access to care in Metlakatla more than Ketchikan As mentioned previously, Ketchikan received face-to-face psychiatric services from an itinerant provider with whom they had a long-established relationship. Thus, they did not have a major gap in access, and telepsychiatry did not significantly impact their access to psychiatry.
• “I think in the few cases that we have worked with it, it has. I don’t think it’s radically changed [access].”
• “I have had one client that I used for it, and that’s it. I don’t have a clue. I hate to see any service disappear. The temptation is to say, ‘Oh, if it were to go away we would really miss it.’ I don’t know. I’ve had one client.” c. Even in Ketchikan, it allowed quicker access to emergency care On the other hand, Ketchikan staff felt telepsychiatry was a benefit for providing patients with quick access in emergencies. One participant emphasized that telepsychiatry provided early intervention for kids in crisis; without it, children would have required hospitalization.
• “In the few cases that we have used it…it’s allowed for intervention sooner than would have happened otherwise. That’s been important in terms of quality of care. The times that we have used it, it’s raised the quality of care.”
• “If they get a kid who’s in real crisis, they are going to bring them over to the emergency room at the hospital, calling up mental health to come down and evaluate the kid.”
• “In Ketchikan, it is always worthwhile when trying to improve services. Some of the interventions were effective.” d. Telepsychiatry increased patient follow-through The therapist in Metlakatla noted that patients often failed to keep appointments outside the community. With telepsychiatry, patients were more likely to follow through with their care requirements.
• “With weather, a lot of times folks won’t follow through because it’s difficult. And if you have to cancel once, they may not follow through. If the services are brought to them, and it’s pretty easy to access, there is a bigger likelihood to follow through. And I think that’s important.”
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3. QUALITY OF CARE
The Metlakatla therapist reported the patients spoke positively regarding the quality of care provided by telepsychiatry.
• “Folks thought it was pretty credible. That gave it a step up in their eyes. That was a good thing.”
a. It saved lives The Metlakatla therapist emphasized that the telepsychiatry program was directly responsible for saving the lives of numerous children in Metlakatla. With the ability to move quickly, providers were able to intervene with potential suicide candidates in time to prevent disaster.
• “It saved lives here. I can name people. I know numerous young people here that if it hadn’t been for the telepsychiatry and the prompt intervention by [the telepsychiatrist]…we may not have had that child…There’s no price you can put on it. We’ve saved lives.”
b. Patients readily accepted telepsychiatry The Metlakatla therapist was surprised at the matter-of-fact manner in which patients accepted telepsychiatry. She wondered if this was attributed to a cultural factor in which patients do not readily question the validity of programs.
• “I think one thing that surprised me is that more people didn’t question…instead of people just marching in and spilling their guts, they didn’t ask more questions like, ‘Is it recorded? Is there anyone else in the room? Can anyone else see this?’ It’s kind of out there, and you’re talking about pretty personal things. I guess that surprised me, the acceptance of it…I think, in Ketchikan or in other areas, people would have more questions, or say, ‘I want a real person, I don’t like this.’”
c. “Distancing” nature of telepsychiatry may make patients more comfortable Staff in both Ketchikan and Metlakatla reported that telepsychiatry distanced patients from the psychiatrist by muting eye contact and making them feel more “safe.” Further, it gave them more confidence about confidentiality.
• “Yeah, I think if you are concerned about confidentiality, if you are concerned about talking to someone who is 300 miles away, you don’t worry about having to see them on the street when you walk down the street. I think it does lessen maybe the threat some…I think in a very small community it’s even more comforting to have that distance.”
• “There’s a safety about it, when you’re trying to do a mental health exam and you’re trying to get eye contact. I think it makes a big difference where you have a screen, where you’re looking at the screen where there’s certain things like eye
Discussion and Recommendations 100
contact that you can kind of tell, but not as much as you would if you were in an office.” d. Allowed greater involvement of families One staff member explained that telepsychiatry enabled families to become more involved in the care of their children, which “wouldn’t happen otherwise.” e. Telepsychiatry gave patients more options The Metlakatla therapist felt telepsychiatry gave patients more options by giving them contact with a psychiatrist able to prescribe medications.
• “That in itself it is tremendous… So you’re getting all that.” f. Telepsychiatry assessments took a long time to complete Staff in both Ketchikan and Metlakatla noted that the telepsychiatrist’s assessments took longer than they might have taken with face-to-face consultation. These evaluations generally took two sessions of about 90 minutes each.
• “I thought the assessment was an excellent assessment…I think the assessment period was longer without being able to see the doctor face to face.”
• “Initially, after the first hour or hour and a half, I thought we would have enough diagnostic information. And we went back and there was like another hour before we were done on another day.”
• “He would be very thorough, and he spent time in getting historical information…It should take some time before a medication is prescribed or a diagnosis is put on the child, because that follows them for a long time. So I felt he was excellent in that regard.” g. More difficult to build rapport Staff agreed that it takes longer to build a rapport between the doctor and the patient when using telepsychiatry. Some individuals felt that rapport may also be influenced by the personalities of the remote psychiatrists or the patients.
One staff member explained that telepsychiatry makes services available to patients on a more regular basis, which serves to increase rapport. Another felt that having face-to- face contact before starting telepsychiatry would be beneficial. He emphasized that building rapport is extremely important; the telepsychiatrist needs to be “creative and tactful when engaging the family,” as well as “personable to make a good fit.”
• “I have found it difficult to build a rapport with some of the people we have worked with on the telepsych. I’m not sure if that’s because of technology or because of the personnel…I think it has more to do with the personality, not only with psychiatrists but the people that are using the equipment.”
Discussion and Recommendations 101
• “You get more frequent contact, so instead of once a month, you can actually see a psychiatrist three times in a month to begin with, which I think probably worked to build a rapport.”
While the Metlakatla therapist emphasized the importance of the telepsychiatrist being kind and courteous, she did not feel her patients expected the telepsychiatrist to have the same level of rapport with them as a therapist would.
• “I don’t think the patients are that invested to be honest…They really aren’t that interested in [having a close relationship with the telepsychiatrist].”
• “I think he’s there for a specific purpose, and he’s pleasant and he’s respectful and he’s mindful. But as far as having a relationship, like with a therapist that you see couple times a week, I don’t think it’s that necessary…. As long as the person is respectful, and culturally sensitive, which he definitely was.”
h. Mixed concerns for adequately reading body language and other subtleties Staff were more confident than parents regarding the ability to read body language through telepsychiatry. Several participants reported that they could adequately pick up the necessary body language through telepsychiatry.
• “I think [the psychiatrist] could pick up on a lot of body language over the telepsych, which was real clear.”
• “I think that works really well. [The telepsychiatrist] can pan without having them realize it, and go up close and ask a question… he can look at mom’s face, and get an idea of how they’re taking it.”
A parent can be an important help in interpreting body language.
• “My client played with everything on the table and drew on himself. Some of it was his parents saying, ‘you know what he is doing right now? He is drawing on himself,’ so the doctor kind of said, ‘why don’t you hold your hand up and I’ll zoom the camera in on that...”
In contrast, one staff member felt it was harder to read body language through telepsychiatry.
• “Yeah, just in terms of the technology aspect I have found it harder…For example…one parent and child would talk…under their breath about how they wanted to respond to that question, then turn to the camera. That would not happen in a session where the person was physically present. I think both from the client’s perspective and the clinician, there is a sense that the person is not quite as present.”
Discussion and Recommendations 102
4. THE IMPORTANCE OF LOCAL CONTROL
a. Metlakatla not invited to the planning and implementation process Though the Metlakatla community was a primary stakeholder in the telepsychiatry project, their input was not solicited for the planning, implementation or discontinuation of the project. Further, the news that the telepsychiatric contract had not been renewed was a surprise and disappointment.
• “That might have been beneficial to us—to have more of a say so in it, than just kind of like the tag along…If we in fact were part of why you got it in the first place, then we’d like a voice…It’s just like, ‘here you are and there you go.’…I’m sorry we lost this service for the community and for the kids.”
• “We thought it was going to be something that would be staying. That was going to be a 3-year project and grant that was going to be staying. They dismissed [the telepsychiatrist], and just said ‘we’re not doing it’…I don’t know what the decision making process was.”
• “It’s like you’re given something and then it’s taken away. The next year, it’ll be interesting to see what happens. It’s like we went forward into the 22nd century, and now we’re going back to the old ways. That to me is very sad.” b. Telepsychiatry reduced Metlakatla’s dependence on Gateway The participant reported that telepsychiatry allowed the Metlakatla clinic to have more autonomy from Gateway Center for Human Services and increased ability to have more localized control over the fate its community members.
• “ A lot of the times, we bypassed Gateway and went to whatever hospital or whatever type of treatment necessary. [The telepsychiatrist] had the ability to do that… We could stand alone a little better.” c. Local control for Ketchikan meant using providers they are comfortable with The main reason Ketchikan staff did not use telepsychiatry was because they did not want to give up their regular providers for their local patients. Using telepsychiatry in this demonstration project would have required them to do so. Ketchikan staff agreed that they would have more readily participated if the telepsychiatrist had been their regular provider.
• “[The itinerant psychiatrists] know our program, know the way we work and our clinicians. We already have established a relationship with them, so when they are here, and even when they are not here, we have contact with them. I think if we could link them to the telepsychiatry thing it would be very different. I think we would be using it much more, not only for emergency cases but to monitor cases, where a kid is having some side effects or something and needs to see it. It would be much more handy for them to see the person over the telepsych rather than just having them describe over the phone what’s going on. They would feel
Discussion and Recommendations 103
more in touch with us and us more in touch with them. So I think, in theory, that’s got a huge potential.” d. The importance of local staff transitions This telepsychiatry demonstration project was championed by the former director of Gateway. No other staff were involved in the initial stages of planning, goal setting and implementation. After the center director left, those remaining in Ketchikan did not have a clear vision of how to maximize telepsychiatry to the benefit of their patients and organization.
• “It wasn’t clear to me in what capacity we were going to use it and how it was going to affect the services we are already getting from psychiatrists… so now we are left with this legacy. And even while [the former director] was here, we were just beginning to experiment with how it was going to be used.”
• “[The staff] were not a part of the project, which limited the effectiveness of the project… If the staff felt like they were part of the interview, or their observations were important, the program would be more successful.”
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APPENDIX D Outline of Key Findings
Key: Blue – Parents Red – Metlakatla Staff Green - Ketchikan staff Black – Executive staff
Overall Perception and Attitudes Wave 1 – August 2002 Wave 2 – February 2003 Wave 3 – July 2003 Highly enthusiastic Very positive Generally positive about the program
Genuinely positive Genuinely positive, valuable Genuinely positive
Philosophically, cautiously positive Overall positive, but not suited for Ketchikan Overall positive, but not suited for Ketchikan
Access to Care Issues Wave 1 Wave 2 Wave 3 Telepsychiatry is needed in the community Metlakatla needs telepsychiatry; regret that the program will be discontinued Need for the service is vast, youth are facing unique issues Telepsychiatry provided access. A good alternative for care
Access is the biggest benefit Access is the biggest benefit
Access is the biggest benefit Access is the biggest benefit Provides patients with immediate access, Immediate access enhanced care speed of access Provides immediate and consistent care Even in Ketchikan, provided immediate access to emergency care Immediacy of access is good
Outline of Key Findings
Just to know help is available is great Gives clients more options Gives clients more options Nice to have the option Telepsychiatry is a back-up option Weather no longer an issue Weather no longer an issue
Weather doesn’t inhibit care
Weather no longer inhibits access Weather no longer inhibits access
Brings needed expertise to the table
Brings another professional to community Brings another professional to the community Brings another professional into the community
Brings another professional to the community Improved quality of assessments using team approach Convenient to get care in own community Convenient to get care in own community
Comfort and convenience of care in their own community Benefit of a provider outside the community Objective professional outside the community Objective professional outside the community
Impact of increased care is huge Impact of increased care is huge
Better suited for more remote locations Essential connection to Metlakatla Better suited for Metlakatla
Better suited for Metlakatla
Quality of Care Issues Wave 1 Wave 2 Wave 3 As good as in person visits, or at least a good Similar to face to face Not as good as face-to-face, but good alternative. alternative
Preferred over in-person visits
Not as good as face to face– “better access,
Outline of Key Findings
not better psychiatry”
Patients are comfortable using telepsychiatry Mixed opinions, but generally, patients are Mixed opinions of patient comfort comfortable. some felt telepsych was more comfortable than in-person visits
Patients are comfortable Patients are satisfied with the services Distancing nature of telepsychiatry make patients more comfortable Patients are comfortable with it Patients are comfortable with it and with telepsychiatrist Distancing nature of telepsychiatry make patients more comfortable Mixed opinions, but generally, patients are comfortable with it.
Ongoing care, more complete care, more Helps for better decision making about care personal care
Increased continuity of care Quality of care is good Increased patient contact Addressed problems in community Parents resisted having their children Huge impact on community. Telepsychiatry stigmatized by mental illness program saved patient lives
Ambivalent about new access to medications Ambivalent about new access to medications
Quick access to medication Immediate access to pharmacological treatment Not just psychiatry, but telemental health services provided
Psychiatrist showed adequate compassion and Telepsychiatrist was thorough and attentive Provider from the ‘outside’ can not truly understanding towards patients. They raved understand child’s cultural background about it. Telepsychiatrist did not truly understand child’s cultural background.
Psychiatrist sensitivity communicated via Compassionate towards patients, professional telepsychiatry in assessments and diagnosis
Outline of Key Findings
Helpful to meet telepsychiatrist in person as Helps to meet him in person Good to meet telepsychiatrist in person well. Provide face to face in conjunction Patients not invested to meet psychiatrist in person Helped to work with local clinician Helps to work with local clinician
Helps to have local staff there Staff and family member presence can enhance consultations Facilitates teamwork for patient care Had access to a team of people Facilitates teamwork for patient care.
Local staff have access to outside Telepsychiatrist provided needed supervision professionals for local therapist
Caseworker contact with psychiatrist increased Potential for staff training
Facilitates staff training Has the potential to facilitate staff training Privacy is good. Room could be improved. No change
Room is soundproof Privacy is ok, confidentiality is adequate
Privacy is adequate Privacy is adequate
Confidentiality is adequate Equipment works well, only a few short term Satisfied with the equipment No change problems Equipment is satisfactory
Equipment is good Equipment is good
Equipment functioning well Equipment is skillfully operated
Improper equipment use can compromise care
Outline of Key Findings
Gets right to task, don’t waste so much time
Sessions are timely
Sessions are timely Sessions are timely
Sessions in Met are untimely
Difficult to build rapport Difficult to build rapport Difficult to build rapport.
Therapeutic relationship can be compromised
Hard to build rapport
Respondents talked about how it took longer to build rapport.
More difficult to read body language Difficult to read body language Concern that body language may be overlooked Concern that body language may be overlooked, ensure full body view
Establish to establish formalized policies and Though patients are given informal session procedures, such as patient orientation and orientation and debriefings, these are not debriefing after sessions; medication formalized. information and procedures for obtaining patient vitals. Medication information is thorough and adequate.
Telepsychiatry increases risk of retaining kids inappropriately
Not ideal for working with sexual assault or trauma victims
Cultural concerns and telepsychiatry
Outline of Key Findings
Cost of Care issues Wave 1 Wave 2 Wave 3 Cost of service was not perceived as a benefit Respondents cited money saved from Respondents cited money saved from for respondents prevented travel prevented travel
Saves travel money for patients Though telepsychiatry had potential to be cost effective for the organization, this Potential to be cost effective for the telepsychiatry pilot project did not save money organization for various reasons.
Changes to Organizational Culture Wave 1 Wave 2 Wave 3 More logistical hurdles, including more Intake assessments rejected by Gateway Metlakatla needed training in various areas, paperwork, more intra-site communication, including: promptly registering patients; occasional equipment problems completing quality intake assessments; and making sure their patients follow through with Logistical difficulties, including untimely lab lab work. results, vitals, transcripts and session timeliness. Having case manager in the room helped with logistical issues Ketchikan staff prefer itinerating psychiatric Ketchikan staff still prefer itinerant provider care
Presence of itinerant psychiatrists reduces staff acceptance Change in staff roles Metlakatla social services staff unprepared for complexity of tasks necessary to sustain psychiatric activities Issue of local control: Metlakatla staff was not a part of the implementation nor the decision to cease telepsychiatric activities
Outline of Key Findings
The Future of Telepsychiatry Wave 1 Wave 2 Wave 3
Potential for excellent care Potential for excellent care
Possibility for expanded services, including Possibility for expansion of services expanded community use
Desire to see expanded services Potential for program expansion
Plans to expand services Staff disappointed to lose access to Staff is apprehensive about losing services telepsychaitry
Plan for progress towards staff acceptance
Telepsychiatry is not well known in community Unanticipated use of equipment in Metlakatla
Outline of Key Findings
APPENDIX E
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