Philanthropy Profile

A Hospital Driven Telepsychiatry Initiative to Improve Patient Care and Reduce Costs

Hospital emergency departments across the dards, where a psychiatric provider in one location country are struggling with the challenges of pro- provides services to a patient in another location. viding specialized psychiatric care in a cost-effec- Telepsychiatry has been found to be especially use- tive manner [1]. In North Carolina this challenge ful in rural areas where access to specialty care is has led to lengthy visits for patients in rural hospi- limited or non-existent [4]. tal emergency departments, ranging from numer- Under the Vidant Health/TDE project, mobile ous hours to multiple days [2]. Data collected video conferencing units have been placed in 7 by the North Carolina Division of Health Service hospitals and desktop video conferencing systems Regulation documented that, during the first 6 have been placed at the psychiatric practice that months of calendar year 2010, more than 3,000 performs the patient consults/assessments. This behavioral health patients waited in excess of 2.6 practice, Coastal Carolina Neuropsychiatric Center days in North Carolina emergency departments (Coastal Carolina), is located in Jacksonville and for specialized treatment or inpatient placement. was selected as the psychiatric contractor because Additionally, over 200 of those patients waited in of the agency’s experience, capacity, and record of excess of 7 days, with the largest lengths of stays quality psychiatric service delivery. occurring in rural hospitals [3]. The problem with The primary objective of the Vidant Health/ extended lengths of stay is not just an issue of the TDE telepsychiatry project is to make psychiatric quality of care received, but also an issue of cost assessments readily available for all patients pre- and financial burden for hospitals. senting to the emergency department with behav- ioral health related issues. Additional goals and Telepsychiatry Project Overview objectives include: increase the number of patients In late 2010, the Albemarle Hospital Foundation, receiving comprehensive psychiatric assessments part of Albemarle Health in Elizabeth City, utilizing telemedicine technology; secure better North Carolina, received a grant from The Duke quantitative information on the diagnosis of men- Endowment (TDE) to implement telepsychiatry in tal health, substance abuse, and co-occurring dis- Vidant Health hospital emergency departments. orders; reduce the average length of stay (LOS) Year 1 of the project was designed to estab- in the emergency department; reduce the cost of lish telepsychiatry in 7 Vidant Health hospitals: mental health care to the community by decreasing Albemarle Health (Elizabeth City), Vidant Bertie the utilization of sheriff deputies, probate judges, Hospital (Windsor), Vidant Chowan Hospital and designated examiners; reduce unnecessary (Edenton), Vidant Duplin Hospital (Kenansville), involuntary commitments; reduce financial burden Vidant Edgecombe Hospital (Tarboro), the Outer to hospitals from extended emergency department Banks Hospital (Nags Head), and Vidant Roanoke- LOS; improve patient outcomes through early ini- Chowan Hospital (Ahoskie). Two new hospitals, tiation of specialized treatment, and; improve com- Vidant Beaufort (Washington) and Vidant Pungo munity discharge planning for both outpatient and (Belhaven), joined the Vidant Health system in late inpatient follow-up services as needed. 2011, with telepsychiatry services implementation Electronically published June 7, 2012. projected for late spring 2012. Year 2 of the grant Address correspondence to Ms. Sheila F. Davies, Albemarle expands the project’s focus to serve non-Vidant Hospital Foundation, 1144 Road St, Elizabeth City, NC 27906 Health hospitals. ([email protected]). Telepsychiatry is the use of 2-way, real time, N C Med J. 2012;73(3):228-230. ©2012 by the North Carolina Institute of Medicine and The Duke Endowment. All interactive audio and video. It is run on a secure rights reserved. network, which meets all confidentiality stan- 0029-2559/2012/73322

228 NCMJ vol. 73, no. 3 NCMJ vol. 73, no. 3 ncmedicaljournal.com ncmedicaljournal.com Project Implementation and Operations surveys. The survey responses reveal that 86% of patients report having a good experience with Albemarle Hospital began piloting the use of telepsychiatry and that the services they received telepsychiatry in May 2011 for several months. were helpful. Between September and October 2011 the remain- Table 1 provides Vidant Hospital emergency ing 6 Vidant Health hospitals initiated telepsy- department data since telepsychiatry services were chiatry services. Coastal Carolina providers offer implemented. One of the biggest early successes of telepsychiatry assessments/consults in each of the the project has been the reduction in patient lengths 7 hospitals 7 days a week from 8am to 6pm. While of stay in the emergency department. The initial goal the project was initially designed for the emer- for the project was to reduce patient lengths of stay gency department, hospitals expressed a need to to less than 48 hours. Since the implementation of conduct assessments for admitted patients as well. telepsychiatry, the average patient length of stay for Coastal Carolina providers now have privileges to the 7 participating hospitals has been reduced to 22 provide telepsychiatry services for both inpatient hours. Another early outcome that has a signifi- units and the emergency departments. cant potential to reduce state costs associated with To initiate a telepsychiatry assessment, an order inpatient psychiatric treatment is the reduction of is placed by the physician at the hospital where the unnecessary involuntary commitments. Since the patient is located and a telephone call is placed inception of telepsychiatry, 87 involuntary com- to Coastal Carolina. Intake specialists at Coastal mitments have been overturned after the psychia- Carolina are able to access the patient’s electronic trist’s assessment. Instead of needing to be sent to medical record (EMR) and prepare for the assess- inpatient treatment, the psychiatrists determine ment. The psychiatric assessments take between they are candidates to receive treatment locally 45 minutes to an hour and at the conclusion of the and do not need to be committed to an inpatient assessment, the Coastal Carolina provider makes a facility. In the first ten months since implementing disposition and medication recommendation. The telepsychiatry at Albemarle Hospital, rough calcu- disposition and medication recommendations are lations, based on a per diem inpatient psychiatric documented by the Coastal Carolina provider in the rate of $1,080 and a 5-day inpatient treatment stay, EMR. Following disposition and recommendations, indicate a potential savings of $469,800 through the Coastal Carolina provider conducts a peer-to- the elimination of 87 unnecessary commitments peer telephone follow up with the patient’s onsite to the state facility. This is based on the per diem physician to ensure delivery of recommendations Medicaid rate of inpatient psychiatric services of and to answer questions. The entire process takes $665.71, an average 5 day inpatient treatment stay, approximately 60-90 minutes. and a 45% self pay population.

Initial Outcomes of the Project table 1. The early outcomes of the project look very Vidant Health/TDE Project Initial Outcome promising. Various data indicators and measures Summary are tracked including patient and provider satisfac- Measure Value tion, patient lengths of stay, number of involuntary Total number of ED telepsychiatry consults 878 commitments overturned, 30 day recidivism rates, Average number of telepsychiatry assessments 158 and payer mix. Electronic surveys are distributed per month (all 7 hospitals combined) quarterly to providers and staff at Coastal Carolina Average length of stay in hours (from time of ED 22 and the participating hospitals, and the feedback admission to time of patient discharge from ED) received to date is very positive. Responses indi- Number of involuntary commitments admitted 318 cate a high level of comfort with using the tech- to ED (all 7 hospitals combined) nology and with the quality of the assessments Number of involuntary commitments overturned 87 after telepsychiatry assessment being delivered via telemedicine. Providers in the Percent of involuntary commitments overturned 27% emergency departments indicate high satisfac- Note. Timeframe for data collection is from implementation of tion with timely access to specialized psychiatric telepsychiatry up through February 29, 2012. Albemarle Health treatment for the patients. Data are also collected began services in May 2011. The remaining 6 hospitals began on patient satisfaction via telephone satisfaction services in October 2011.

NCMJ vol. 73, no. 3 NCMJ vol. 73, no. 3 229 ncmedicaljournal.com ncmedicaljournal.com Project Funding and the Future Conclusion While early measures indicate strong project The Vidant Health/TDE telepsychiatry project success, several additional measures and plans are is making promising strides in reducing patient being developed to ensure the project’s sustainabil- lengths of stay, initiating early treatment, and ity once the grant funding ends. One area of focus improving care for patients presenting in the is measuring the financial impact telepsychiatry is emergency department with an acute behavioral having on emergency department costs by reducing health crisis. Early findings indicate the develop- patient lengths of stay. Current sustainability plan- ment and implementation of this hospital driven ning of the project requires each hospital to pay a telepsychiatry network is a promising means of monthly subscription fee (based on each hospital’s addressing the challenge of providing specialized volume of use) to bridge the gap between the cost psychiatric emergency care in a cost-effective of the service and the amount of reimbursement manner. collected. The project is tracking reimbursement Sheila F. Davies, MPA telepsychiatry project director, rates and comparing those with telepsychiatry Albemarle Hospital Foundation, Elizabeth City, North related expenses for each hospital as well as com- Carolina. paring projected cost savings from length of stay Acknowledgment reductions. It is anticipated that the hospitals will Potential conflicts of interest. S.F.D. has no relevant con- actualize significant cost savings which will more flicts of interest. than cover the monthly subscription fee each hos- References pital pays for the telepsychiatry service. 1. Yellowlees P, Burke MM, Marks SL, Hilty DM, Shore JH. Emergency telepsychiatry. J Telemed Telecare. 2008 As noted in the project overview, an additional ;14(6):277-281. focus of the project is to extend the telepsychiatry 2. Bender D, Pande N, Ludwig M. A Literature Review: Psy- network to non-Vidant hospitals beginning in 2012. chiatric Boarding. Washington, DC: US Department of Health and Human Services; 2008. http://aspe.hhs.gov/ As of this publication, Carteret General Hospital in daltcp/reports/2008/PsyBdLR.pdf. Accessed February Morehead City will be the first non-Vidant hospital 28, 2011. to join the telepsychiatry network. It is anticipated 3. Akland G, Akland A. State Psychiatric Hospital Admis- sion Delays in North Carolina. January-June 2010. Ra- that telepsychiatry services will begin at Carteret leigh, NC: National Alliance on Mental Health North General Hospital by summer 2012. Additionally, 4 Carolina; 2010. http://naminc.org/nn/publications/ other non-Vidant hospitals in North Carolina have namiwakerpt.pdf. Accessed January 3, 2011. 4. Saeed SA, Diamond J, Bloch RM. Use of telepsychiatry to expressed interest in joining the telepsychiatry net- improve care for people with mental illness in rural North work this year. Carolina. N C Med J. 2011;72(3):219-222.

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