Telepsychiatry Delivers Help to Far-flung Patients
October 23, 2013 | By Kay Manning, Special to the Tribune
See the original article at the Chicago Tribune.
Practice is increasingly used to serve people in rural areas, the deaf and military veterans.
The 17-year-old girl had just been released from a Streamwood hospital after threatening suicide, psychiatrist Dan Martinez remembers.
He asked the girl to look her caseworker in the eye and promise that she would not harm herself.
She did, Martinez said. But watching her on a large-screen TV in Des Plaines as the teen spoke from a youth facility about 100 miles west of there, he was unconvinced. He asked her if she really meant it and when she hesitated, he tweaked the commitment — from open-ended to not hurting herself for a week, and if she had suicidal thoughts, to reach out to him, her parents or her caseworker.
“I told her, we’re not mind readers,” said Martinez, who was using telepsychiatry to treat youths sent to the facility in Nachusa, Ill., for substance abuse or behavioral issues.
Telepsychiatry, which connects patient and doctor through technology, is poised to expand in Illinois under legislation being negotiated to mandate its coverage by private insurers.
Used for years to treat military veterans, the deaf and patients in rural areas where
psychiatrists tend to be scarce, telepsychiatry is increasingly being considered for other underserved areas — including poorer parts of cities like Chicago — as a way to provide needed mental health services and reduce medical costs.
It’s also used in prisons, where the number of inmates with mental health issues is steadily growing. A recent report on Illinois’ youth prisons in response to a class-action lawsuit filed by the American Civil Liberties Union found the system to be violating the constitutional rights of youths by failing to provide adequate mental health care.
Insurance coverage of mental health issues, including substance abuse, has been spotty, but that changes under provisions of the Affordable Care Act taking effect next year. Insurance plans offered in the new marketplaces must have a core set of services and include behavioral health treatment, counseling and psychotherapy.
Studies by the U.S. Department of Veterans Affairs and others have shown telepsychiatry to be as effective as face-to-face treatment and sometimes more efficient in monitoring medications and symptoms because sessions are easier to schedule and involve other doctors, parents and caregivers.
Private companies and nonprofits — such as Lutheran Social Services of Illinois, which operates the Nachusa facility — offer telepsychiatry. So do psychiatrists in private practice and primary care physicians, who treat the majority of mental health patients.
Still, telepsychiatry has been held back, say proponents, because of the expense and security of videoconferencing equipment, licensing requirements and the lack of reimbursement for patients with private insurance. Legislation proposed in Congress in late September addresses one of those hurdles. It would allow the treatment of Medicare patients via telemedicine without doctors being required to have multiple state licenses, which has been a financial and administrative burden.
And in Illinois, the Illinois Psychiatric Society and Blue Cross Blue Shield have drafted a bill that would mandate the coverage of telepsychiatry by private insurers. Now, doctors treating Medicaid patients can be reimbursed, but patients who pay premiums can’t choose telepsychiatry and recover the cost, said Meryl Sosa, executive director of the society.
“So they get less care if they have private insurance,” she said.
Blue Cross Blue Shield, which has about half of the private insurance market in Illinois, sees the trend toward telemedicine, said Dana Popish, director of government affairs, and “because it affects our business, we wanted to be involved. When something new is coming out, we want to make sure it’s implemented properly.”
The shortage of psychiatrists is well known — with an estimated 70 percent of rural counties in the state lacking any — which leads to care by nonmental health specialists or no care at all. Lutheran Services stepped in to help at the Nachusa home because no psychiatrist could be found to visit there, Martinez said.
“I’ve worked in rural Illinois, and often patients get less quality care and are seen less frequently,” said Martinez, who operates Comprehensive Clinical Services, based in Lombard. “To ask individuals to travel one to two hours is impractical and unreasonable.”
Vets Got Support
Geography played a big role in why veterans decades ago were offered telemedicine, which includes counseling by psychologists or social workers. The VA recognized that specialists in substance abuse and post-traumatic stress disorder tended to be at facilities in metropolitan areas while many patients sought help at smaller clinics.
“Telemental health services have revolutionized mental health care delivery in the U.S. Department of Veterans Affairs by expanding access to services through use of remote videoconferencing,” said a 2012 article in a psychiatric journal outlining results of a study of almost 100,000 veterans using telemedicine from 2006 to 2010.
The study found that psychiatric admissions to hospitals decreased by an average of 24.2 percent among patients six months after beginning remote videoconferencing compared with the six months before. In addition, the days of hospitalization dropped by an average of 26.6 percent for those who had to be admitted. The study’s authors suggested more detailed study of the cost savings and outcomes of telemedicine patients compared with those getting face-to-face care.
Quality and frequency of care have long been reasons why telepsychiatry is effective for the deaf and hard of hearing, said Lisa Foster, a clinical therapist at Advocate Illinois Masonic Medical Center’s behavioral health services department.
“Use of a videophone has really given us an option to continue to provide services to the deaf and hard of hearing who truly need mental health and psychiatric medication services, but cannot secure transportation or find services closer to home,” Foster, who is hard of hearing, wrote in an email.
Clients for the center’s deaf and hard of hearing program, for which she works, are in Chicago and the suburbs.
While the psychiatrist in the program does not use American Sign Language, a licensed ASL interpreter sits in on sessions. There are too few such interpreters, she said, and if they had to travel throughout the region for appointments, fewer people could be seen.
With “deafness an invisible disability that is often overlooked,” Foster said, it’s important that therapists be sensitive to issues particular to the deaf, something generally not possible in offices or facilities serving few deaf patients. Concentrating services and specialists in one place and connecting them to patients via technology is very efficient, she said.
Telepsychiatry takes some getting used to, said Martinez and Olivia Boyce, marketing coordinator for InSight Telepsychiatry LLC, a New Jersey-based private provider.
“We offer training on how virtual encounters are slightly different,” Boyce said. Doctors have to look into the camera and learn to compensate for not having the ability to see — or smell — details such as whether the patient has poor hygiene. “But we’ve found it’s as effective as face to face,” Boyce said. “Children, in particular, are very receptive; they use technology for everything.”
Martinez said he’s learned to pay more attention because this “”is a setting where one needs to be glued to the TV.”
He’s mastered the controls to allow him to observe a patient from closer up than if he maintained typical personal space in a room.
“This is never ideal and should never substitute for face to face,” he said. “But I’ve come to feel very comfortable and in some ways better,” because he has more information — from a nurse, case manager or parent, if the patient is a child or adolescent.
“I have never felt like the patient or family had qualms about inadequacy of the service,” he said.
Martinez believes the system he uses to communicate is secure. Yet he is dissuaded from using telepsychiatry in his private practice, where he supervises 10 psychiatrists, because of the cost of the equipment and the measures needed to ensure security.
He and others do see telepsychiatry evolving, especially in underserved urban settings and in hospital emergency departments where mental health patients either have to wait hours for an evaluation or are admitted without one because of uncertainty over their condition. In an era of cost containment, quicker and more precise evaluations make sense, Martinez said.
InSight Telepsychiatry was hired earlier this year to provide consultations 24/7 for patients in the emergency departments of hospitals in two Illinois cities — Galena and Freeport — as part of a pilot program funded by a grant channeled through the Metropolitan Chicago Healthcare Council.
And, according to Boyce, MCHC and InSight recently have developed a “telepsychiatry solution to support the substantial demand for services at Chicago-area hospitals.”
School Had Help
Advocate Illinois Masonic provided telepsychiatry services to Ames Middle School in Chicago’s Logan Square neighborhood for about three years until the spring, when grant funds ran out. The need was great, said Odalinda Avila, who was a counselor with Illinois Masonic at the school for five years.
“There were a lot of issues in these families that were struggling with limited finances,” Avila said, with students suffering attention deficit hyperactivity disorder, depression, dysfunction and the inability to handle certain situations.
Up to 20 percent of children and adolescents in the U.S. are said to suffer from significant mental health disorders and it’s estimated only 1 in 5 is receiving treatment, experts say.
A psychiatrist was brought in when the problems of an Ames student were affecting school and interrupting sleep, Avila said. If medication was advised to stabilize the situation, a parent had to be involved, but often that didn’t happen, causing treatment to be truncated.
“There was a lot of frustration on my part, the school’s part and the child’s part,” Avila said. “There was a real need to reach out to parents and educate them. Some were just not involved, and in some Latino families, there were myths and stereotypes on what it means to take medication.”
Denise Shaeffer, a clinical psychologist and coordinator of outpatient services for Illinois Masonic’s behavioral health services, said telepsychiatry at the school’s medical clinic seemed like a good answer, but in the end it was underused.
“Of those who used it, they overwhelmingly loved it,” Shaeffer said, but too few parents of students referred for the services followed through and there was no care in the summer.
Carroll Cradock, a psychologist and telemedicine consultant in Chicago, was involved early on with trying to bring telemedicine to school-based clinics.
“The need is growing in urban areas,” she said, because of language barriers, transportation issues and the very real fact that some children find it dangerous to cross gang boundaries to try and reach a mental health clinic. “Some kids will use school-based services because they don’t have to go somewhere else,” she said. “They think of the school clinic as their medical home.”
Telemedicine also helps adult patients in urban areas, she said, by integrating mental health care with medical care. She cited a new mother who may have post-delivery physical issues and postpartum depression. Her care for both can be coordinated via technology.
Dr. James Varrell, medical director of InSight Telepsychiatry, has been using the technology for almost 15 years and also knows the possibilities.
“The increased access to care from telepsychiatry makes it easier to address behavioral health concerns before they reach a level of crisis or tragedy,: he said in an email. “Telepsychiatry may seem like an innovative model of care today, but in a few years, it will be commonplace.”
See the original article at the Chicago Tribune.