Tag Archives: ED

The Value of Telepsychiatry in the ED – Six Benefits to Cutting Psychiatric Boarding Through Telehealth

Originally Published in Telemedicine Magazine 

By: Olivia Boyce and Christopher Adams

Hospitals throughout the nation are plagued with psychiatric patients boarding in their emergency departments (EDs). The wait times for psychiatric patients to see a psychiatrist for that evaluation can take hours or even days. A report of 300 ED directors found that 41% of EDs have a wait time of over two days to see a psychiatrist.[1]

One solution that is helping to reduce psychiatric boarding in EDs across the country is on-demand telepsychiatry.

“The goal of on-demand telepsychiatry evaluations is for the remote psychiatrist to decide on the most appropriate and least restrictive level of care,” says Dr. Jim Varrell, Medical Director of InSight Telepsychiatry, the largest private telepsychiatry company in the US.

“By having a psychiatrist available to do the assessment, on-demand telepsychiatry programs help hospital systems avoid inappropriate admissions, shorten length of stays and improve overall ED patient flow,” explains Dr. Varrell.

1. Shorten ED Wait Times 

According to Dr. Varrell, with on-demand telepsychiatry, psychiatric assessments are able to occur within about an hour of a request on average. Since psychiatric patients typically spend over 3 times longer in the ED than medical patients,[2] telepsychiatry’s timeliness means that psychiatric patients are able to move on to the next level of care much more quickly.

This improvement results in shortened wait times for all patients within the ED, and ultimately an increase in revenue for the hospital system.

2. Increase Hospital Revenue

A study done on the impacts of psychiatric boarding found that boarders prevent an average of 2.2 bed turnovers which results in a lost opportunity cost for the hospital of $2264 per psychiatric patient.[3] By implementing telepsychiatry and improving the rate of bed throughput, a hospital is ultimately able to increase revenue.

3. Reduce Inappropriate Commitments 

Another way telepsychiatry programs are adding value to hospital systems is by reducing costly inappropriate commitments.

South Seminole Hospital in Longwood, FL is an Orlando Health Facility that implemented a telepsychiatry program in November 2014. Through videoconferencing, South Seminole’s ED staff accesses a telepsychiatrist when they have difficult cases or when they need to determine whether an individual who came in under Florida’s civil commitment law, merits psychiatric hospitalization. According to the hospital’s data, during the first six months of the program, one third of the involuntary commitments assessed by telepsychiatrists were rescinded. [4]

“Telepsychiatry allows us to make sure that the psychiatric patients in our ED move on to the most appropriate treatment, whether that is hospitalization or community-based care quickly,” says Charles Webb Manager of the ED at South Seminole Hospital. “When patients don’t have to wait as long for care, they are able to get on a path to better health sooner.”

4. Improve Compliance with Joint Commission Standards

Access to timely care means that hospitals are more likely to be able to meet standards for patient care set by regulating bodies like The Joint Commission who advocate that patient boarding times not exceed 4 hours.

“When hospitals are able to reduce psychiatric boarding from say 14 hours to under 4, there are other financial benefits,” explains Dr. Varrell. “The average sitter for a psychiatric patient costs $15 per hour. By cutting 10 hours from the time a psychiatric patient waits for care, that’s $150 per patient saved on just sitter costs.”

5. Empower and Support Onsite Staff

At a more operational level, the implementation of a telepsychiatry program is reported to better empower onsite staff to handle psychiatric patients. For example, after a telepsychiatry program had been in place for several months at Chester County Hospital in Pennsylvania, the hospital saw an increase in their clearing and placing psychiatric patients without telepsychiatrybecause staff reported greater confidence in their abilities to assess difficult cases knowing that they had a specialist available for consult or assessment when needed.[5]

Dr. Varrell explains that this case study is an example of why collaboration between remote and onsite staff lends itself to the most effective telepsychiatry programs. “Telepsychiatrists are most effective when they establish a rapport and team-approach with the onsite staff. The remote psychiatrists benefits from onsite staff sharing difficult-to-collect information like odor or agitation in the waiting room while the onsite staff benefits from having the expertise of a team of psychiatrists who they know and trust on-call.”

 6. Expand Psychiatric Capacities Within Hospitals and Beyond

Because telepsychiatrists are able to work from remote or home offices and don’t have to be in-person at the emergency department, it is much easier to staff difficult hours like weekends, nights and holidays.

Ultimately, establishing an ED telepsychiatry program can set up a health system to more effectively manage the psychiatric needs of an entire community or population. In addition to using telepsychiatrists within EDs, many systems are also expanding programs into other settings within the hospital and beyond.

“It’s important to design a telepsychiatry system with growth in mind from the beginning,” explains Dr. Varrell.

For example, hospitals are using telepsychiatry on their Med/Surg floors and on their inpatient units for weekend and overnight rounding.

Within communities, telepsychiatrists commonly serve community mental health centers, outpatient clinics, correctional facilities, primary care offices and other settings where it is difficult to staff and retain onsite physicians.

More creatively, newer direct-to-consumer models of telepsychiatry are gaining popularity as a convenient way to access services and follow-up care outside of a traditional setting and potentially from home or another private space. Some health systems and insurance companies are beginning to refer psychiatric patients leaving the hospital to in-home telehealth options that make them more likely to attend their follow up appointments and less likely to end back up in the hospital.

“Telepsychiatry can be challenging to implement because it’s a change and it requires the buy-in of many parties,” says Webb. “But ultimately, the return on investment is clear.”

 

Sources

[1] Schumacher Group. (2010) Emergency department challenges and trends. 2010 survey of hospital emergency department administrators.

[2,3] Nicks and Manthey. “The Impact of Psychiatric Patient Boarding in Emergency Departments.” Emergency Medical International. 2012.

[4] Orlando Health Telepsychiatry Data 2014-2015.

[5] Cuyler, Robert. Chester County Hospital Emergency Psychiatry Case Study, 2012.

 

Next Generation Model for Addressing Crisis Behavioral Health in the ED

By: Geoffrey Boyce

Originally posted on The Healthcare Guys

The telemedicine revolution touches nearly every aspect of health care today. Notably, behavioral health was called out in a recent Forbes article as the sector within the industry experiencing the greatest impact. And hospital emergency departments (EDs) are taking note.

In recent years, EDs have faced notable challenges meeting growing needs for mental and behavioral health services, particularly for crisis psychiatric care, amid severe professional shortages. The reality is that all U.S. states have unmet psychiatric needs, and 60 percent of U.S. counties lack a single psychiatrist.

Telepsychiatry—offered via videoconferencing models—has emerged as an effective resource for filling these gaps and improving patient triage, throughput and overall behavioral health outcomes in the ED. As adoption of these technology-enabled models increases, hospitals need to thoughtfully consider what it takes to build a successful, sustainable 24/7 telepsychiatry program to address this type of care. Best practices dictate the need for robust provider networks, administrative teams and support infrastructures to facilitate collaboration between all stakeholders.

Our telepsychiatry organization is addressing these needs through a browser-based platform that is designed to deliver telepsychiatry services around the clock, better positioning hospital EDs and other crisis settings to provide timelier psychiatric assessments and patient triage to the most appropriate level of care via technology-enabled care.

Telepsychiatry in the ED: Opportunities and Considerations

The telepsychiatry opportunity is not lost on today’s EDs, and many hospitals are looking to incorporate these care options into their broader telehealth strategy. Use of telehealth promotes better patient outcomes and satisfaction, and lowers costs associated with ED boarding of psych patients. Yet, health care organizations must consider key elements of a strategy to extract the full value of these models, including technology and workflow design and a framework that supports comprehensive care delivery from the start.

For instance, one of the primary goals of a telepsychiatry program is to shorten wait times for evaluation. Many hospitals do not have an around the clock, full-time psychiatrist and must find available providers on an “as needed” basis to complete evaluations—an approach that often lends to protracted wait times, especially since most patients who come into the ED in crisis arrive during night and weekend hours.

While on-demand telepsychiatry provider networks are uniquely suited to address this challenge, the right infrastructure must also be in place to support the scheduling complexities of offering 24/7 telepsychiatry access to a busy ED.

Cloud-based applications can help to address this challenge and increase efficiency. ED staff can simply log into a platform and fill out a request for telepsychiatry services. Then, an automated system can identify the most appropriate telepsychiatry provider to do the assessment, consult or follow-up, taking into consideration which telepsychiatry providers are credentialed at the organization, on shift and available. Working directly within the hospital’s EMR, the assigned provider can then review patient background information and connect with hospital staff to determine any other relevant collateral information that may be necessary before the secure video connection with the patient is initiated. When all videoconferencing sessions and documentation are routed through a singular system, it decreases the potential for bottlenecks and allows for each session to be logged and reported on.

Data from our services revealed that patients receiving on-demand telepsychiatry services for crisis encounters in the ED waited just under an hour on average. This is an improvement over the findings of another report that revealed 23 percent of psychiatric patients wait longer than six hours for in-person evaluation in the ED, and 7 percent wait more than 12 hours.

Performance metrics for telepsychiatry programs should also point to reduced costs and better outcomes. Partnering with an on-demand telepsychiatry provider enables EDs to reduce length of stay, improve throughput, minimize risk and stress for onsite providers, and ultimately get patients to the least restrictive and most appropriate level of care quickly. Patients benefit from on-demand telepsychiatry by receiving timelier evaluations, minimizing the potential for further escalation. When patients in psychiatric crisis are not triaged quickly, conditions can quickly spiral out of control, opening the door to safety issues and the potential need for higher-cost interventions.

Additional data from our organization points to notable improvements in outcomes and the level of care required following a telepsychiatry visit. For example, in 2017, one-third of patients in Florida who had been involuntarily committed under their state law called the Baker Act had their commitments rescinded after meeting with a telepsychiatry provider. This allowed the patients to move to a more appropriate and less costly level of care, saving resources across the board.

Building a Robust, Impactful Telepsychiatry Operation

EDs are seeing an uptick in psychiatric cases due to the limited options of specialized providers in the community. Current estimates suggest that one in eight ED visits involve a behavioral health condition.

Forward looking health care organizations recognize the advantages of telepsychiatry models and are expanding their telemedicine portfolio to more fully address growing needs both within the ED setting and in community-based settings. Sustainable strategies consider the value of industry partnerships and third-party expertise, especially as it relates to building provider networks and utilizing infrastructures that optimize efficiency and support collaboration between administrators and specialty provider groups.

At their foundation, successful telepsychiatry programs are supported by strategic partnerships, robust provider networks and infrastructures that address scheduling, workflows and logistics. These underlying tactics must work in tandem to promote better care delivery, efficiency and connected care teams.

A Better Approach to Crisis Behavioral Health

Original article published on Becker’s Health IT & CIO Review

Mark Alter, M.D., InSight Associate Medical Director of On-Demand Services

By: Mark Alter, M.D.

Today’s hospital emergency departments (EDs) are facing a perfect storm of behavioral health challenges. A combination of professional shortages and rapid growth in need for behavioral health services is creating significant supply and demand issues across U.S. communities. The overwhelming reality is that 42.5 million Americans struggle with mental health conditions, and professional shortages exist in all 50 U.S. states.

For many communities, the hospital ED has become one of the primary entry points for behavioral health access. Yet, few EDs are equipped with the expertise to handle the scope and complexities of this evolving challenge, leading to lengthy wait times and overcrowding, especially for patients in needs of psychiatric care.

To improve the outlook, hospitals are increasingly turning to the promise of on-demand telepsychiatry—an approach to care providing psychiatric evaluation or consult as needed via videoconferencing. These forward-looking care delivery models not only improve response times and access to services, but they also positively impact patient satisfaction and the bottom line.

The ED Behavioral Health Challenge: A Deeper Look
Current estimates suggest that one in eight ED visits involves a mental health condition, yet patients in need of evaluation often wait much longer than those in need of general medical care. One report found that 23 percent of psychiatric patients had emergency visits that were longer than six hours and 7 percent waited longer than 12 hours—that’s compared to 10 percent and 2.3 percent of other medical patients respectively. In addition, almost 21 percent of patients in need of an inpatient psychiatric bed wait between two and five days.

In terms of adequate staffing for psychiatric issues, today’s hospitals face the same supply and demand issues as consumers in need of services, especially in rural communities, where the existence of even one qualified psychiatrist is often lacking. EDs typically have limited or non-existent in-house hospital expertise available to them, and patients must wait until an appropriate professional is available. These present-day realities lead to crowded ED waiting areas, protracted waits, and the common practice of “boarding” individuals in need of psychiatric evaluation.

The Growing Influence of ED Telepsychiatry Models
Overall, hospital executives are prioritizing telemedicine models to prepare for value-based care. The “2017 U.S. Telemedicine Industry Benchmark Survey” revealed that 51 percent of executives rank deployment and adoption of telemedicine high strategically.

On-demand telepsychiatry models are certainly gaining traction as hospital EDs look to more effectively deliver behavioral health care and address the growing need for services. Provided via video-conference, telepsychiatry providers offer on-call professionals that can be accessed based on need. This framework enables telepsychiatrists to deliver care remotely to numerous organizations at once, increasing efficiency and workflows for all stakeholders.

Credentialed telepsychiatrists first collaborate with ED physicians, nurses and social workers, and review a patient’s medical record. An evaluation is then conducted with a patient in a private area through a computer, tablet or other mobile device. Ultimately, the goal of these one-time encounters is to ensure timely recommendations and triage of patients to the most appropriate level of care. On-demand providers provide valuable consultation services to ED staff and can also prescribe medications directly.

Benefits of on-demand telepsychiatry in the ED include:

Early stabilization and better outcomes
Timely psychiatric treatment initiated in the ED promotes earlier stabilization of conditions and improves patient safety—for both those facing a psychiatric crisis and other patients in the ED. It also ensures patients are triaged to the appropriate level of care or community service.

For instance, it is not uncommon for police officers in some states to bring individuals behaving erratically directly to the ED for psychiatric evaluation. Many of these patients do not require inpatient psychiatric hospitalizations, which can be often be avoided by having timely access to psychiatric professionals who can determine the appropriate level of care.

Many telepsychiatrists also report that patients in crisis situations, particularly those who are agitated or paranoid, can feel less intimidated by video conferencing as opposed to in-person evaluation.

Increased patient throughput
When evaluations are conducted in a timely manner, ED providers can help get patients to appropriate levels of care, opening needed beds to other patients and improving wait room crowding.

Greater patient satisfaction
A combination of timely evaluation and the right expertise ensures a better overall experience for any patients in crisis, including those with behavioral health concerns. When patients are forced to wait for hours or days to see a behavioral health professional, frustration is understandable.

Lower costs
Timely access to care lends to greater efficiencies in the ED and positive bottom-line impacts. In addition, telepsychiatry reduces the need for full-time emergency psychiatrists and ongoing recruitment costs and challenges.

Many hospitals—especially those in rural areas—simply lack the financial resources needed to hire specialized behavioral health professionals to provide services the ED. Additionally, hospitals benefit from the on-demand model by paying for usage as opposed to a full-time equivalent. EDs also reduce liabilities with timely access to on-demand telepsychiatry services, minimizing the potential for litigation that might otherwise occur if conditions escalate and difficult situations arise.

Reduced provider burnout
This approach to care also takes the burden off in-person psychiatric providers who are on call or responsible for covering night-shifts. Telepsychiatrists can work these shifts remotely from another location, even in different time zones, offering added flexibility and an enhanced work/life balance—critical components in addressing provider burnout.

Providing a telepsychiatry resource can also reduce stress on ED directors and other ED providers who do not have the specialty training in psychiatry, but are often faced with treating psychiatric patients.

Future Crisis Behavioral Health Models
While the current outlook on behavioral health professional shortages is grim, the good news is that telepsychiatry holds great promise for filling needed gaps, especially in critical environments such as EDs. Hospitals can realize notable gains by leveraging on-demand telepsychiatry services to improve outcomes, patient and provider satisfaction and the bottom line.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker’s Hospital Review/Becker’s Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

The Value of Telepsychiatry in the ED – 6 Benefits to Cutting Psychiatric Boarding Through Telemedicine

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August 15, 2015 | By Olivia Boyce and Christopher Adams

Originally published in Telemedicine Magazine.
One solution that is helping to reduce psychiatric boarding in EDs across the country is on-demand telepsychiatry.

Hospitals throughout the nation are plagued with psychiatric patients boarding in their emergency departments (EDs). The wait times for psychiatric patients to see a psychiatrist for that evaluation can take hours or even days. A report of 300 ED directors found that 41 percent of EDs have a wait time of over two days to see a psychiatrist.[1]

One solution that is helping to reduce psychiatric boarding in EDs across the country is on-demand telepsychiatry.

“The goal of on-demand telepsychiatry evaluations is for the remote psychiatrist to decide on the most appropriate and least restrictive level of care,” says Dr. Jim Varrell, Medical Director of InSight Telepsychiatry, the largest private telepsychiatry company in the U.S.

“By having a psychiatrist available to do the assessment, on-demand telepsychiatry programs help hospital systems avoid inappropriate admissions, shorten length of stays and improve overall ED patient flow,” explains Dr. Varrell.

1. Shorten ED Wait Times

According to Dr. Varrell, with on-demand telepsychiatry, psychiatric assessments are able to occur within about an hour of a request on average. Since psychiatric patients typically spend over three times longer in the ED than medical patients,[2] telepsychiatry’s timeliness means that psychiatric patients are able to move on to the next level of care much more quickly.

This improvement results in shortened wait times for all patients within the ED, and ultimately an increase in revenue for the hospital system.

2. Increase Hospital Revenue

A study done on the impacts of psychiatric boarding found that boarders prevent an average of 2.2 bed turnovers which results in a lost opportunity cost for the hospital of $2,264 per psychiatric patient.[3] By implementing telepsychiatry and improving the rate of bed throughput, a hospital is ultimately able to increase revenue.

3. Reduce Inappropriate Commitments

Another way telepsychiatry programs are adding value to hospital systems is by reducing costly inappropriate commitments.

South Seminole Hospital in Longwood, Fla. is an Orlando health facility that implemented a telepsychiatry program in November 2014. Through videoconferencing, South Seminole’s ED staff accesses a telepsychiatrist when they have difficult cases or when they need to determine whether an individual who came in under Florida’s civil commitment law, merits psychiatric hospitalization. According to the hospital’s data, during the first six months of the program, one third of the involuntary commitments assessed by telepsychiatrists were rescinded.[4]

“Telepsychiatry allows us to make sure that the psychiatric patients in our ED move on to the most appropriate treatment, whether that is hospitalization or community-based care quickly,” says Charles Webb Manager of the ED at South Seminole Hospital. “When patients don’t have to wait as long for care, they are able to get on a path to better health sooner.”

4. Improve Compliance with Joint Commission Standards

Access to timely care means that hospitals are more likely to be able to meet standards for patient care set by regulating bodies like The Joint Commission who advocate that patient boarding times not exceed four hours.

“When hospitals are able to reduce psychiatric boarding from say 14 hours to under four, there are other financial benefits,” explains Dr. Varrell. “The average sitter for a psychiatric patient costs $15 per hour. By cutting 10 hours from the time a psychiatric patient waits for care, that’s $150 per patient saved on just sitter costs.”

5. Empower and Support Onsite Staff

At a more operational level, the implementation of a telepsychiatry program is reported to better empower onsite staff to handle psychiatric patients. For example, after a telepsychiatry program had been in place for several months at Chester County Hospital in Pennsylvania, the hospital saw an increase in their clearing and placing psychiatric patients without telepsychiatry because staff reported greater confidence in their abilities to assess difficult cases knowing that they had a specialist available for consult or assessment when needed.[5]

Dr. Varrell explains that this case study is an example of why collaboration between remote and onsite staff lends itself to the most effective telepsychiatry programs. “Telepsychiatrists are most effective when they establish a rapport and team-approach with the onsite staff. The remote psychiatrists benefit from onsite staff sharing difficult-to-collect information like odor or agitation in the waiting room while the onsite staff benefits from having the expertise of a team of psychiatrists who they know and trust on-call.”

 6. Expand Psychiatric Capacities Within Hospitals and Beyond

Because telepsychiatrists are able to work from remote or home offices and don’t have to be in-person at the emergency department, it is much easier to staff difficult hours like weekends, nights and holidays.

Ultimately, establishing an ED telepsychiatry program can set up a health system to more effectively manage the psychiatric needs of an entire community or population. In addition to using telepsychiatrists within EDs, many systems are also expanding programs into other settings within the hospital and beyond.

“It’s important to design a telepsychiatry system with growth in mind from the beginning,” explains Dr. Varrell.

For example, hospitals are using telepsychiatry on their med/surg floors and on their inpatient units for weekend and overnight rounding.

Within communities, telepsychiatrists commonly serve community mental health centers, outpatient clinics, correctional facilities, primary care offices and other settings where it is difficult to staff and retain onsite physicians.

More creatively, newer direct-to-consumer models of telepsychiatry are gaining popularity as a convenient way to access services and follow-up care outside of a traditional setting and potentially from home or another private space. Some health systems and insurance companies are beginning to refer psychiatric patients leaving the hospital to in-home telehealth options that make them more likely to attend their follow up appointments and less likely to end back up in the hospital.

“Telepsychiatry can be challenging to implement because it’s a change and it requires the buy-in of many parties,” says Webb. “But ultimately, the return on investment is clear.”

Sources

[1] Schumacher Group. (2010) Emergency department challenges and trends. 2010 survey of hospital emergency department administrators.

[2,3] Nicks and Manthey. “The Impact of Psychiatric Patient Boarding in Emergency Departments.” Emergency Medical International. 2012.

[4] Orlando Health Telepsychiatry Data 2014-2015.

[5] Cuyler, Robert. Chester County Hospital Emergency Psychiatry Case Study, 2012.

 

Originally published in Telemedicine Magazine.