When an overburdened ED in North Carolina turned to telepsychiatry, it streamlined the admit process, but time-to-transfer remained the same.
Emergency Department (ED) visits by patients with mental health disorders are increasing at a faster rate than ED visits for other disorders , and constitute a growing burden on EDs across the nation. According to a survey conducted by the American College of Emergency Physicians, this has led to ED overcrowding, violent behavior by distressed patients, and ED staff distraction . Some emergency departments are beginning to turn to telepsychiatry to stem the tide, but will it be enough? We examine one specific ED that has been on the leading edge of these new care pathways.
The Case Study
Southeastern Regional Medical Center in Robeson County, North Carolina provides a typical scenario of the growing ED mental health challenges. Like many EDs in 2013, the medical center experienced rising ED visits with psychiatric patients consuming many ED beds on a daily basis. At the time, North Carolina was already embroiled in a statewide mental health crisis due to cuts in psychiatric services. The state simply mirrored a nationwide trend.
A decade earlier, North Carolina embarked on a mental health reform and decided to reduce the number of state psychiatric beds. Theoretically the move would save $51 million annually by shifting mental health treatment to local community-based services. The problem was that the community-based services never effectively materialized .
At over 65,000 visits annually, Southeastern Regional Medical Center is one of the busiest emergency departments in North Carolina. Situated in one of the poorest communities in the nation, it was forced to absorb the burden of mental health patients. Patients would wait an average of 3.5 days in the ED for transfer to facilities that could provide definitive treatment. The area is rural and terribly impoverished with an average median worker income of $21,650. The county is only 10% smaller than the state of Rhode Island, with a county population of 135,000 that serves parts of surrounding counties as well. The ED was overrun with patients seeking access to community mental health services that didn’t exist.
Southeastern Health’s acute inpatient psychiatric unit has 26 beds. In 2013 the psychiatric service was faced with 6-10 hospital consults and 8-10 ED consults daily for patients with mental health disorders. Many were boarded in the ED, only adding to those still boarded from the previous day waiting for placement to beds that were scarce. The backlog grew daily. Telepsychiatry-based solutions seemed to be an option to access much needed mental health care while diminishing ED overcrowding.
Working on a Solution
By May of 2013, in a joint agreement between psychiatric providers seeking solutions and an administration struggling to meet growing demands, the medical center evaluated three private telepsychiatry companies. One company was selected based mostly on three criteria:
- The company was already providing other telemedicine services to the Medical Center
- The company had the capacity to provide emergent evaluations
- The promised turnaround time for consults was two hours from the request
Southeastern Health was ahead of statewide initiatives designed to address the rising problem. It would not be until the summer of 2013 that state legislators would establish the North Carolina Statewide Telepsychiatry Program (NC-STeP). At that time, the state appropriated $2 million annually to provide EDs across the state with remote access to psychiatric expertise .
Texas was establishing a similar model through mental health emergency centers (MHEC) utilizing telepsychiatry to access patients in rural areas. The Texas model hoped to achieve medical clearance without the need for an ED visit. Both North Carolina and Texas were at the forefront of developing solutions. It was anticipated that savings from the NC initiative would derive from overturning involuntary commitment orders, and reducing the need for more expensive inpatient care.
Southeastern Health Telepsych Experience
During the past year 3,045 patients with a primary psychiatric diagnosis presented to Southeastern Health’s ED, which is staffed with EMA/EmCare physicians. One out of every three patients was still being admitted (1,169) for a psychiatric condition. Even with two years of experience with telepsych services, the admission ratio had not changed significantly and overcrowding was still a factor. However, ED physicians were pleased with the backup of a psychiatrist 24 hours a day.
But Anthony Grimali, Director of Behavioral Health at the facility, says that despite the state’s goal of decreasing expensive inpatient care with the state initiative and local solutions, the Medical Center mostly wanted to decrease the time it took to admit an involuntarily committed patient to aid an overcrowded ED. In that sense, some success has been achieved.
Here’s how the telepsych system works at our facility. The Medical Center owns the equipment. The private company provides remote access to an intake specialist and psychiatrist. An ED nurse works with the intake specialist to set up the exam before the psychiatrist comes online. The private telemedicine company trains the nurses and technicians at each site regarding equipment setup and prepping the patient. The nurse may also stand by during the exam.
Previously, it took up to 13 hours (800 minutes) to actually admit a patient to the psychiatric floor, even though admission with involuntary commitment was known at the time of ED presentation. The paperwork process, involving the legal system and medical clearance, simply took time. Today the process at Southeastern Health is down to about 8 hours (512 minutes) as different parts of the process have been adjusted.
However, the average length of stay for a patient waiting for placement at another facility is still 65 hours or 2.5 days. And even for an ED patient waiting for discharge back to the community, the many process requirements take up to 6 hours (366 minutes).
With this experience and $300,000 spent annually on private telepsych services, Grimali says the medical center is now partnering with the growing state NC-STeP system. Normally one would simply bill the patient’s insurance. But the medical center was forced to absorb the entire cost of the service as the company would not release billing rights for its tele-psych physicians. The cost of each evaluation averaged about $225.
So the economic benefit resulted because the state offset much of the expense.
In addition to adding Physician Assistants and Nurse Practitioners to help Psychiatrists provide the needed services, a care management model is also being designed to include licensed social workers that will provide first line ED triage assessment of psychiatric patients. Such licensed professionals make a determination if inpatient criteria are met and initiate the involuntary commitment process if necessary. Similar to the Texas model, this process removes some of the ED involvement.
Whether financed through private or public means, telepsychiatry has both advantages and disadvantages. The primary advantage is 24-hour availability and quicker psychiatric evaluation. Medications and interventions can be quickly adjusted even while patients are awaiting transfer. Telepsychiatry even facilitates out patient treatment plans, and emergency physicians manage patients who do not require admission. Another advantage is access to pediatric psychiatrists.
The primary disadvantage is loss of continuity of care. Having different psychiatrists managing patients held each day in the ED sometimes results in disjointed care. A comprehensive approach to treatment, with a team of dedicated social workers, nurses and child life specialists is sometimes needed to complement the consulting telepsychiatrist.
The Bottom Line
Southeastern Health’s two year experience with tele-psychiatry demonstrated only a minimal impact on the number of involuntary commitments that were enacted through the ED. But the primary ED goal – streamlining the processing time of involuntary commitments – was achieved by the telemedicine services.
More personally, the primary benefit to emergency physicians was something much less tangible – an added confidence level in managing psychiatric patients knowing that a psychiatrist was at the ready. This benefit is hard to quantify, yet is extremely important. In addition, tele-psychiatry provides the added benefit of pediatric psychiatric experts available to rural centers.
While there was no appreciable improvement in the number of days patients wait for transfer to centers for definitive care, this is an area beyond the purview of tele-psychiatry. The service does impact local admissions to a degree and aids the psychiatric staff work load. But mostly it should be viewed as an element within a comprehensive system of emergency psychiatric care, and is not a stand alone answer to a growing challenge. Budgetary considerations are forced to drive many decisions.
A growing number of EDs share the problems Southeastern Health has faced. Across the nation medical centers are working at maximum capacity with minimal resources and limited comprehensive networks for psychiatric emergencies. While telepsychiatry is not a solution – it certainly is a valuable resource and a step in the right direction.
- 1. Morbidity and Mortality Weekly Report (MMWR). June 14, 2013 / 62(23);469-472
- 2. Emergency department visits increase since ACA implementation. US NewsWire. May 21, 2014.
- 3. Hoban, R. Wake Mental Health Patients Face Long Emergency Department Stays. NC Health News. February 11, 2015. http://www.northcarolinahealthnews.org/2015/02/11/wake-mental-health-patients-face-long-emergency-department-stays/
- 4. PubMed No authors listed. State Leverages telepsychiatry solutions to ease ED crowding, accelerate care. February, 2015; 27(2): 13-7.