Telepsychiatry: Enhancing Access to Mental Health Care

Transcription

1 Telepsychiatry: Enhancing Access to Mental Health Care Jonathan Evans Chief Executive Officer Safe Harbor Behavioral Health and InnovaTel Telepsychiatry, LLC., Erie, PA Meera Narasimhan, MD Associate Provost for Health Sciences, University of South Carolina, Columbia, SC Professor and Chair Department of Neuropsychiatry and Behavioral Sciences, University of South Carolina School of Medicine, Columbia, SC Otsuka Pharmaceutical Development & Commercialization, Inc. Otsuka Pharmaceutical Development and Commercialization, Inc., Rockville, MD Lundbeck, LLC. August 2016 MRC2.CORP.D advice or professional diagnosis. Users seeking medical advice should consult with their physician or other healthcare professional.

2 Jonathan Evans Position: Mr. Evans is the Founder, President, and CEO of both InnovaTel Telepsychiatry, a private telepsychiatry provider servicing community based clinics, and Safe Harbor Behavioral Health, a public behavioral health clinic in Erie, PA. Education: Mr. Evans earned his BA degree in Psychology and MA degree in Clinical Psychology from Edinboro University of Pennsylvania. Meera Narasimhan, MD Position: Dr. Narasimhan serves as the Associate Provost for Health Sciences at the University of South Carolina, as well as the Professor and Chair in the Department of Neuropsychiatry and Behavioral Sciences at the University of South Carolina School of Medicine. Education: Dr. Narasimhan completed her residency in psychiatry and a neuroscience fellowship at Yale University, and she attended medical school at Gandhi Medical College in Bhopal, India. 2

3 This program was developed with the support of Otsuka Pharmaceutical Development & Commercialization, Inc. and Lundbeck, LLC. The speakers are compensated contractors of Otsuka Pharmaceutical Development & Commercialization, Inc. advice or professional diagnosis. Users seeking medical advice should consult with their physician or other healthcare professional.

4 PsychU Virtual Forum Rules of Engagement: Otsuka Pharmaceutical Development and Commercialization, Inc. (OPDC) and Lundbeck, LLC. have entered into collaboration with Open Minds, LLC. to explore new ways of bringing/increasing awareness around serious mental illness. OPDC/Lundbeck s interaction with Open Minds is through PsychU, an online, non-branded portal dedicated to providing information and resources on important disease state and care delivery topics related to mental illness. One of the methods employed for the sharing of information will be the hosting of virtual fora. Virtual fora conducted by OPDC/Lundbeck are based on the following parameters: When conducting medical dialogue, whether by presentation or debate, OPDC/Lundbeck and/or its paid consultants aim to provide the viewer with information that is accurate, not misleading, scientifically rigorous, and does not promote OPDC/Lundbeck products. OPDC/Lundbeck and/or their paid consultants do not expect to be able to answer every question or comment during a PsychU Virtual Forum; however, they will do their best to address important topics and themes that arise. OPDC/Lundbeck and/or their paid consultants are not able to provide clinical advice or answer questions relating to specific patient s condition. Otsuka and Lundbeck employees and contractors should not participate in this program (e.g., submit questions or comments) unless they have received express approval to do so from Otsuka Legal Affairs. OPDC and Lundbeck operate in a highly regulated and scrutinized industry. Therefore, we may not be able to discuss every issue or topic that you are interested in, but we will do our best to communicate openly and directly. The lack of response to certain questions or comments should not be taken as an agreement with the view posed or an admission of any kind. 4

5 Objectives Discuss current barriers in mental health care and the goals of telepsychiatry Consider the potential benefits of telepsychiatry Discuss settings and patient populations for which telepsychiatry may be appropriate/useful Review factors for consideration when implementing telepsychiatry 5

6 Polling Question What barrier in mental health care do you feel to be most relevant in your clinical experience? A. Cost of therapy/insurance coverage B. Time constraints C. Stigmas D. Patients who have difficulty visiting the office E. Access to available care 6

7 Telepsychiatry Overview There are many barriers to accessing optimal mental health care 1,2 One goal of telepsychiatry is to reduce disparities in patient access to mental health care 3 Telepsychiatry may be feasible for patients diagnosed with serious mental illness (SMI), and may potentially offer multiple benefits 4-6 Patient appropriateness should be determined based on the professional s assessment of the patient s ability to arrange a suitable setting for videoconferencing services and cooperativeness regarding managing safety issues 7 State-specific regulations and other challenges must be considered and addressed for implementation of telepsychiatry 8,9 1. Thomas KC, et al. Psychiatr Serv. 2009;60: Mohr DC, et al. Ann Behav Med. 2006;32: Grady B, et al. Telemed J E Health. 2011;17: Preschl B, et al. BMC Psychiatry. 2011;11: Sheeran T, et al. Telemed J E Health. 2011;17: Rotondi AJ, et al. Rehabil Psychol. 2005;50: Turvey C, et al. Telemed J E Health. 2013;19: APA Council on Psychiatry & Law. 2014; American Psychological Association. Accessed September 30,

8 There Are Many Barriers to Access to Optimal Mental Health Care in the United States SHORTAGE OF MENTAL HEALTH PROFESSIONALS 1 TRANSPORTATION DIFFICULTIES 2 $ COST OF THERAPY 2 TIME CONSTRAINTS 2 CONCERNS ABOUT WHAT OTHERS WOULD THINK 2 A LIMITED ENGLISH PROFICIENCY 3 1. Thomas KC, et al. Psychiatr Serv. 2009;60: Mohr DC, et al. Ann Behav Med. 2006;32: Bauer AM, et al. Med Care. 2010;48:

9 Digital Technology Is Poised to Become the Fourth Wave of Evolution in Mental Health Care 1890s 1952 Psychoanalysis 1 Psychopharmacology s- 90s 2015 Evidence-based practice in Digital psychiatry 5,6 mental health care 3,4 Suboptimal treatment response remains an ongoing concern 7 1. Gleitman H, et al. Psychology. 8th ed. W. W. Norton & Company. 2011: Ahuja N. A Short Textbook of Psychiatry. 7th ed. Jaypee Brothers Medical Publishers (P) Ltd. 2011: Spring B. J Clin Psychol. 2007;63: APA Presidential Task Force on Evidence-Based Practice. Am Psychol. 2006;61: Kumar S, et al. Am J Prev Med. 2013;45: Mohr DC, et al. Gen Hosp Psychiatry. 2013;35: Lehman AF, et al. Am J Psychiatry. 2004;161: advice or professional diagnosis. Users seeking medical advice should consult with their physician or other healthcare February professional US16EUP0006

10 Telepsychiatry, a Form of Telemedicine, May Help Improve Access to Mental Health Care TELEMEDICINE Provision of health services over distance through the use of electronic information and telecommunications technologies 1,2 Examples of applications include patient consultations, liaisons with emergency personnel, telesurgery 1 In addition to patient care, these varied technologies may have a multiplicity of current and possible uses in professional education, research, public health, and administration 1 Goal: to eliminate disparities in patient access to quality, evidence-based, and emerging health care diagnostics and treatments 3 TELEPSYCHIATRY (OR TELEMENTAL HEALTH) Provision of mental health services from a distance 3 May include two-way, interactive videoconferencing or other technologies such as virtual reality, electronic mail, remote monitoring devices, chat rooms, and web-based clients 4 May be used for mental health assessment, treatment, education, monitoring and collaboration 3 1. Field MJ. Telemedicine: A Guide to Assessing Telecommunications for Health Care Fong B, et al. Telemedicine Technologies: Information Technologies in Telemedicine and Telehealth. 2011: Grady B, et al. Telemed J E Health. 2011;17: Yellowlees P, et al. Telemed J E Health. 2010;16: advice or professional diagnosis. Users seeking medical advice should consult with their physician or other healthcare February professional US16EUP0006

11 Telepsychiatry May Be Associated With Several Potential Benefits Feasible to deliver various types of psychotherapy 1 Potential Benefits of Telepsychiatry Decreased costs in terms of time and travel expenses 1 Comparable levels of patient satisfaction 1,2 Increased access to care 3 Improved retention 4,5 1. Backhaus A, et al. Psychol Serv. 2012;9: Jenkins-Guarnieri MA, et al. Telemed J E Health. 2015;21: APA Council on Psychiatry & Law. 2014; Mohr DC, et al. JAMA. 2012;307: Leigh H, et al. J Telemed Telecare. 2009;15:

12 Telepsychiatry May Be Feasible and Offer Potential Advantages for Patients Diagnosed With SMI Studies have shown that telepsychiatry may offer advantages when used in the management of patients diagnosed with SMI: Major depressive disorder May be acceptable 1 May be associated with a high level of patient satisfaction 1 May facilitate a strong working alliance comparable to that formed in face-to-face settings 2 May be feasible for use in elderly, homebound depressed patients 3 Schizophrenia May be used to interview and assess patients 4 May be acceptable 4 May increase patients ease of expression 4 May improve perceptions of social support 5 1. Chong J, Moreno F. Telemed J E Health. 2012;18: Preschl B, et al. BMC Psychiatry. 2011;11: Sheeran T, et al. Telemed J E Health. 2011;17: Chae YM, et al. J Telemed Telecare. 2000;6: Rotondi AJ, et al. Rehabil Psychol. 2005;50:

13 In a Study of Veterans, Remote Treatment* of Depression With Telepsychiatry Was Comparable to In-Person Treatment In a randomized, controlled trial of veterans referred for outpatient treatment* (N=119; 105 men and 14 women), management of depression using telepsychiatry was comparable to in-person management, in terms of Significant improvement in symptoms Study drop-out rates Medication adherence Patient satisfaction Treatment costs *Treatment consisted of antidepressant medication management, psychoeducation, and brief supportive counseling 1. Ruskin PE, et al. Am J Psychiatry. 2004;161:

14 DISCUSSION

15 Polling Question For which patient population would you be most inclined to utilize telepsychiatry? A. Patients in emergency mental health care situations B. Patients who live in rural settings C. Patients who are veterans D. Patients in correctional facilities E. Patients in primary care settings 15

16 Telepsychiatry May Help Extend the Reach and Facilitate the Delivery of Psychiatric Care RURAL SETTINGS May reduce travel for patients and providers 1 May help decrease stigma 2 May support continuity of care 3 VETERANS May enhance therapeutic alliance 4 May help reduce hospital admissions 5 May facilitate group therapy 6 CORRECTIONAL FACILITIES May help address provider shortage 7 May allow for evaluation and consultation without compromising public safety 7 1. Horn BP, et al. J Telemed Telecare. 2016;22: Chakrabarti S. World J Psychiatry. 2015;5: García-Lizana F, et al. Prim Care Companion J Clin Psychiatry. 2010;12:e1-e5. 4. Morland LA, et al. J Clin Psychiatry. 2010;71: Godleski L, et al. Psychiatr Serv. 2012;63: Greene CJ, et al. J Consult Clin Psychol. 2010;78: American Psychiatric Association. Work Group to Revise the APA Guidelines on Psychiatric Services in Correctional Facilities. Psychiatric Services in Correctional Facilities. Arlington, VA: American Psychiatric Publishing; advice or professional diagnosis. Users seeking medical advice should consult with their physician or other healthcare February professional US16EUP0006

17 Telepsychiatry May Help Extend Care to Populations Who Face Language Barriers Race, ethnicity, culture, language, geographic region, and other social factors affect the perception, availability, utilization, and potentially, the outcomes of mental health services. US Public Health Service, Mental Health: Culture, Race, and Ethnicity 1 Telepsychiatry has been explored in populations that face language and/or cultural barriers 2-5 Patient-reported benefits of telepsychiatry reported in 4 studies included Convenience and easy access 2 Comfort, security, and confidentiality 2 Decreases in language and cultural barriers 2,5 Access to treatment in native language without needing to travel 5 Facilitation of therapeutic relationship 3,4 1. US Department of Health and Human Services. Mental Heatlh: Culture, Race, and Ethnicity A Supplement to Mental Health: A Report of the Surgeon General. USDHHS, Ye J, et al. Telemed J E Health. 2012;18: Jang Y, et al. Gerontologist. 2014;54: Chong J, Moreno F. Telemed J E Health. 2012;18: Mucic D. J Telemed Telecare. 2010;16:

18 Telepsychiatry May Play a Role in Emergency Mental Health Care May be used to assess psychiatric patients in the emergency department (ED) 1 In a study of patients presenting to the ED (N=73), telepsychiatric and face-to-face assessments showed agreement in disposition recommendation and diagnosis In a retrospective analysis of a state-wide, ED-based telepsychiatry program (N=14,522), compared to a matched control group, recipients of telepsychiatry 2 : were less likely to be admitted were likely to have a shorter length of stay, if admitted were more likely to receive 30-day and 90-day outpatient follow-up had lower total health care charges in 30-day follow-up period 1. Seidel RW, et al. J Telemed Telecare. 2014;20: Narasimhan M, et al. Psychiatr Serv. 2015;66:

19 Telepsychiatry May Be Acceptable for Use in Correctional Facilities Multiple individual and institutional factors may complicate the provision of psychiatric services to individuals in correctional facilities 1 The Work Group to Revise the APA Guidelines on Psychiatric Services in Correctional Facilities (2016) indicates that telepsychiatry may be well-suited for use in correctional facilities as a supplement to on-site services 1 Prisons and jails are often located in rural communities with limited access to psychiatric services Use of telepsychiatry avoids the need to transport inmates to an off-site location for psychiatric consultation, which enhances the safety of the community Telepsychiatry may also allow for the observation of patients during an afterhours crisis or for monitoring of suspected medication side effects 1. American Psychiatric Association. Work Group to Revise the APA Guidelines on Psychiatric Services in Correctional Facilities. Psychiatric Services in Correctional Facilities. Arlington, VA: American Psychiatric Publishing;

20 Cost Savings of Telepsychiatry Have Been Evaluated in Various Rural Settings Geriatric: Data analysis on the use of telepsychiatry among rural nursing home residents (N=106) over 278 encounters suggests that it could potentially result in cost savings in the following areas 1 : provider travel time, direct travel costs (eg, gasoline), patient transport, and related personnel costs Pediatric: Use of telepsychiatry among rural pediatric patients (N=132) over 257 consultations suggested substantial cost savings to patients and families 2 Veteran: Use of telepsychiatry among rural combat veterans (n=74) resulted in significant provider-level cost reductions, relative to in-person services 3 Native American: Use of telepsychiatry among rural Native American patients (762 total visits) resulted in savings on both provider and patient travel, relative to in-person services 4 In some cases, the costs of telepsychiatry may exceed the threshold for adoption 5 ; the quality of the existing literature on cost-effectiveness varies 6 Break-even point analyses suggest that telepsychiatry may result in cost savings when travel distances exceed about 30 km (19 miles) 6 1. Rabinowitz T, et al. Telemed J E Health. 2010;16: Spaulding R, et al. Telemed J E Health. 2010;16: Morland L, et al. Telemed J E Health. 2013;19: Horn BP, et al. J Telemed Telecare. 2016;22: Pyne JM, et al. Arch Gen Psychiatry. 2010;67: Chakrabarti S. World J Psychiatry. 2015;5:

21 Telepsychiatry May Potentially Offer Benefits to All Stakeholders in Mental Health Care Service and Delivery PATIENTS Improved access to care 1 Treatment satisfaction 2,3 Convenience 1 Overcome language and cultural barriers 4 PROVIDERS Diagnostic accuracy and reliability 4,5 Non-inferior to in-person treatment 6 Convenience 1 PAYORS Cost-effective 4 Savings 4 Costs Travel Time 1. APA Council on Psychiatry & Law. 2014; Backhaus A, et al. Psychol Serv. 2012;9: Jenkins-Guarnieri MA, et al. Telemed J E Health. 2015;21: Hilty DM, et al. Telemed J E Health. 2013;19: Chakrabarti S. World J Psychiatry. 2015;5: Turvey C, et al. Telemed J E Health. 2013;19:

22 DISCUSSION

23 Medicaid and Private Coverage and Reimbursement Policies for Telepsychiatry Vary by State Medicaid Mental/Behavioral Health Services Highest Grades (12 states and DC) Other Grades (38 states) Reproduced by permission of American Telemedicine Association from Thomas L, Capistrant G. State telemedicine gaps analysis: coverage and reimbursement. January State policies for telemental health vary in specificity and scope Map represents state rankings for Medicaid coverage of mental and behavioral health services provided via telemedicine, based on scope and conditions of payment 1. Thomas L, et al. Accessed February 11,

24 Several Factors Must Be Considered and Addressed for Successful Telepsychiatry Implementation Level of Technological Competence 1,2 Licensing and Other Legal Concerns 1,2 Confidentiality and Security 1-3 Reimbursement 4 Data Storage and Other Technical Issues 1,2 Management of Emergent Situations 1-3 Therapeutic Relationship 5 Provider Skepticism and Acceptance 6,7 1. APA Council on Psychiatry & Law. 2014; American Psychological Association. Accessed September 30, Turvey C, Coleman M, Dennison O, et al. Telemed J E Health. 2013;19: Thomas L, et al. Accessed February 11, Sucala M, et al. J Med Internet Res. 2012;14:e García-Lizana F, et al. Prim Care Companion J Clin Psychiatry. 2010;12:e1-e5. 7. Chakrabarti S. World J Psychiatry. 2015;5:

25 Summary Telepsychiatry may improve access to mental health care 1 and offer multiple benefits (eg, improved retention, 2,3 decreased time and travel expenses 4 ) Patient appropriateness should be determined based on the professional s assessment of the patient s ability to arrange a suitable setting for videoconferencing services and cooperativeness regarding managing safety issues 5 Telepsychiatry may be acceptable for use among patients diagnosed with SMI 6 and for assessment of patients in the emergency department 7 Telepsychiatry may also be feasible for use among various underserved patient populations 8-11 Telepsychiatry may offer advantages to all stakeholders in the service and delivery of mental health care, ie, patients, providers, and payors 1,4,12,13 Despite the potential promise, for greater uptake and successful implementation of telepsychiatry, several challenges will need to be effectively addressed 1,13,14 1. APA Council on Psychiatry & Law. 2014; Mohr DC, et al. JAMA. 2012;307: Leigh H, et al. J Telemed Telecare. 2009;15: Backhaus A, et al. Psychol Serv. 2012;9: Turvey C, et al. Telemed J E Health. 2013;19: Chong J, Moreno F. Telemed J E Health. 2012;18: Seidel RW, et al. J Telemed Telecare. 2014;20: Ye J, et al. Telemed J E Health. 2012;18: Moreno FA, et al. Psychiatric Services. 2012;63: Rabinowitz T, et al. Telemed J E Health. 2010;16: Morland L, et al. Telemed J E Health. 2013;19: Hilty DM, et al. Telemed J E Health. 2013;19: Chakrabarti S. World J Psychiatry. 2015;5: American Psychological Association. Accessed September 30,

26 DISCUSSION

27 QUESTIONS

28 QUESTIONS

29 CLOSING