Ohio s Telepsychiatry Project for Intellectual Disability: Practicing Medicine in the Digital World

Transcription

1 Ohio s Telepsychiatry Project for Intellectual Disability: Practicing Medicine in the Digital World Julie P. Gentile, M.D. Allison E. Cowan M.D. Wright State University Department of Psychiatry

2 Objectives Ohio s Coordinating Center of Excellence in Mental Illness/Intellectual Disability Ohio s Telepsychiatry Project for Intellectual Disability

3 Ohio s CCOE in Mental Illness/ Intellectual Disability Coordinating Center of Excellence in Mental Illness/Intellectual Disability Initiated in 2004 Grant Funded Project: Ohio Dept. of Developmental Disabilities Ohio Dept. of Mental Health and Addiction Services

4 Ohio s Coordinating Center of Excellence in Mental Illness/Intellectual Disability Educational Programming Dual Diagnosis Intervention Teams Assessment Capacity

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6 Telemedicine Telemedicine uses communication networks for delivery of health care services and medical education from one geographical location to another. It is deployed to overcome issues like uneven distribution and shortage of infrastructural and human resources."

7 Historical View New concept? When using the broad definition (e.g., the provision of care between different locations using technology) there are historical examples over one hundred years old. 19th century: patients who were hospitalized in long-term psychiatric facilities and their families often would write letters to the doctors taking care of them describing their problems as well as the environments from which these patients came. Doctors would correspond back to these family members giving summaries of the patient's course and treatment. 20th century: not uncommon for psychiatrists and other providers to share information about complicated patients and get consultation via descriptive letters. Also, the telephone has been widely and extensively used to provide care, diagnosis, and treatment of patients.

8 Leigh et al 2009 Eighteen month period: 7,523 telepsychiatry appointments and 115,148 conventional No shows: 8% telepsychiatry vs 13 % Cancellation rate: 4.2% telepsychiatry versus 7.8%

9 Saint-Andre et al 2011 Telepsychiatry for patients with autism Autism Resource Centre/France Obstacles: lack of preparation, including too many individuals involved with no leader Benefits: availability of consultants, reduced wait time, more efficient use of resources, reduction of costs, reduced travel time

10 Why consider Telepsychiatry? In rural communities ~50% of mental health care is provided by primary care physicians. Patients may have to travel long distances or forgo such services altogether. Telemedicine helps disseminate skill set to PCPs. Many patients prefer to go to a PCP clinic for appointments as opposed to a MH clinic (decreased stigma). Increasing data shows reliability/validity are similar to face to face interaction.

11 Telepsychiatry Simms et al 2011 Research shows alliance is not compromised by use of videoconferencing Medium made some patients feel less embarrassed and more able to express difficult feelings (Fragile X) Clinicians length of time in the field affected their openness to the new technology

12 Telepsychiatry Reduction in travel time, costs, ER visits and hospitalizations Not necessary to be tech savvy Established programs use buffet menu (phone, , MD-MD, MDpatient, etc) (Nursing facility) Cancellation rate/show rate

13 Ohio s Telepsychiatry Project for Intellectual Disability Prototype from treating 90 individuals from 23 counties Telepsychiatry project initiated in 2012 Virtual software which abides by patient privacy guidelines (HIPAA compliant) Prioritize individuals from Developmental Centers and State Psychiatric Hospitals

14 Ohio s Telepsychiatry Project for Intellectual Disability Required Criteria for Individuals Referred Child or adult with co-occurring mental illness/intellectual disability Medicaid Enrolled Top 13 most populated counties can only refer children/adolescents

15 Ohio s Telepsychiatry Project Expectations of County Developmental Disabilities Board Arrange staffing/computer equipment Accept lead role in coordinating access to emergency services as deemed necessary, to include hospitalization. Develop a collaborative relationship with local MH Board in order to best support the person s full range of MH needs.

16 Grant Funding - Telepsychiatry Department of Developmental Disabilities $225,000/year Salary Support (Exclusively non-billable hours i.e record review, no insurance) Project Director, physician partners, IT (50%), RN (40%), MSW (40%) AA (75%), Project Manager (20%) Grant Writing/Reporting and Oversight

17 Academic Clinical Site Resident Physicians (Adult Psychiatry) Medical Students Child/Adolescent Psychiatry Fellows Protected supervision hours Electronic Health Records/Supervision of resident documentation/remote access Training for multidisciplinary team members

18 Logistics/Room Set-up Camera angle/position Lighting/audio Monitor Privacy Room environment Sound Zoom/Layout options Etiquette

19 Lessons Learned Designate one contact person for each patient on both ends of service Define what you CAN and CANNOT do (especially with regard to crisis intervention and hospitalization)

20 Lessons Learned Giving patients options is vital (web cam screen display; privacy; physical location of appt and ability to move for severe ID, etc) Intake in person usually Specific psychiatric pathology (Ideas of Reference regarding media, etc)

21 Suicidal patients Lessons Learned RN interface via webcom: AIMS/Metabolic Monitoring/Vitals/Rx RN signs on immediately after physician logs off; promotes rapport and adherence Psychotherapy via web cam

22 Lessons Learned Type/fax/ provider notes immediately following appointment Referral packet designed by Project Director 30/60/90 minute appointments On call strategy Increased labs, imaging, PCP collaboration Optimizing billable minutes

23 Lessons Learned Communication (among team and with counties) Provision of 24/7 coverage Partner working from home Flexibility (work from various locations) Ohio weather: no interruption in services

24 Lessons Learned MH and DD system integration/documents May consider grouping patients from one geographical area with an MD/RN team SSA/CM: differentiate roles Identify strong count(ies) and make them an advisory board

25 Clinical Correlation

26 Research/Data Collection Counties Adults/children Gender/ethnic origin/age/county of residence Diagnoses: Medical and Psychiatric Administrative Issues ($$$) ER Visits and Hospitalizations Trauma Research

27 Telepsychiatry Project Preliminary Results For the first 120 individuals engaged in the program, emergency room visits decreased from 195 to 8 and hospitalizations decreased from 74 to 10 (comparisons are 12 months prior to telepsychiatry use to 12 months post treatment ). A number of the individuals were discharged from state operated institutions and others were in danger of shortterm admission, none of the 120 involved in the project were admitted or readmitted to state operated institutions. This saves the state approximately $80,000 per person per year in support costs (currently 76 patients in this category). Travel costs were reduced in some cases by 68% by not having to travel distances for specialty psychiatric care.

28 Telepsychiatry Project Preliminary Results As of March 2017, >950 individuals from 63 counties engaged in the project Stats for > 900 patients: Hospitalizations/6 months: 24 ER Visits/12 months: 28 DC Admission: Discharged from DCs: (brief) No wait list, no referrals denied

29 Telepsychiatry Project Preliminary Results EOY stats for > 950 patients: 63 counties and counting Services offered: Psychiatry hrs/week (Adult psych 44 hrs/child psych 20 hours/20 hrs upper level residents) Counseling/psychotherapy MSW (20 hrs) Case Management (40 hrs) RN (80 hrs) Behavior Assessments (MSW)

30 Telepsychiatry Project Preliminary Results Second Opinion Assessments Available to all ages in all 88 counties Comprehensive Psychiatric Assessments Face to Face or Web Cam ~100 annually Diagnostic dilemmas, metabolic monitoring, poly-pharmacy, best practices, EBM, undiagnosed medical conditions, etc.

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32 Guidelines and Resources Each state may have unique guidelines and parameters for practicing medicine and each insurance carrier may have unique rules for approved billing

33 Psychotherapy for ID

34 Pharmacotherapy Currently no evidence based medicine in the area of dual diagnosed Prevalence studies, clinical cases, and side effect studies available Consensus-based and practice-based medicine will suffice

35 Evidence Based Medicine Four groups excluded from large, double-blind, placebo controlled trials Rationale for exclusion of individuals with ID Use timelines

36 Consensus Guidelines Rush AJ, Frances A. The Expert Consensus Guidelines : Treatment of Psychiatric and Behavioral Problems in Mental Retardation. American Journal on Mental Retardation 2000;105: Aman MG, Crismon ML, Frances A, et al.: Treatment of psychiatric and behavioral problems in individuals with mental retardation: an update of the expert consensus guidelines. Expert Consensus Guidelines, International Guide for Using Medication. The World Psychiatric Association (WPA): Section on Psychiatry of Intellectual Disability (SPID)1 st September 2008 CLINICAL BULLETIN of the DEVELOPMENTAL DISABILITIES DIVISION. International guide to prescribing psychotropic medication for the management of problem behaviours in adults with intellectual disabilities. World Psychiatry Assn 2010

37 Summary

38 Summary ID does not protect one from developing MI Telemedicine is a vehicle to connect individuals with MI/ID to specialized resources and clinicians Myth that patients with ID can t benefit from mental health services including trauma informed care, psychotherapies and state of the art medication regimens

39 Contact Information: Ohio s Coordinating Center Of Excellence in Mental Illness/Intellectual Disability Ohio s Telepsychiatry Project for Intellectual Disability

40 Software Info Omnijoin