Traversing the 114 Mile Gap at the Speed of Light A D A M B I U C - PowerPoint PPT Presentation

Traversing the 114 Mile Gap at the Speed of Light A D A M B I U C K I A N S , M D E R I N G L E N N , L S W

Who We Are  Adam Biuckians, MD  Community Services Group, Medical Director Board Certified Child and Adolescent Psychiatrist  Erin Glenn, LSW  TrueNorth Wellness Services, Fulton County Outpatient Clinical Supervisor

History of Communication Figure 1: Timeline of communication tools, 2014 update. Ref: Khourdajie, A. (2008), Marketing for the Wireless World. Individual Term Paper, MARK1051, University of Greenwich, UK.https://commons.wikimedia.org/w/index.php?curid=31202496

History of Communication in Psychiatry  Old School  Face to Face  Telephone  Snail Mail  Facsimile  New School  Email  Instant/Text Messages  Patient Portal  Virtual Visits (telepsychiatry)  Apps (ie MyStrength)

Brief History of Telepsychiatry  Nebraska Psychiatric Institute 1959  Debut of audio and video transmissions in psychiatric setting  Starting with teaching medical students at Medical College of Nebraska, but evolved into providing consultation, diagnostic assessment, and even group psychotherapy (American Psychiatric Association (APA))  NIMH 1968  Funded the first microwave relay to facilitate a direct consultation to a patient’s remote location  Occurred between Dartmouth Department of Psychiatry and a rural hospital (Solow, C.; Weiss, RJ.; Bergen, BJ., 1971)

Brief History of Telepsychiatry  Massachusetts General Hospital 1973  Use of closed circuit television for psychiatrists to see patients at a nearby airport  Reportedly the term “ telepsychiatry ” came from this project  Also introduced the use of remote control cameras to pan, zoom, and tilt (APA)  From mid- 70’s onward  Slow growth, but gradually increasing acceptance and overcoming of various obstacles/barriers  Ongoing, and often dramatic, improvements in technology help to facilitate growing acceptance (APA)

Brief History of Telepsychiatry  2000 Onward  More rapid growth  Larger institutional programs utilizing more frequently  VA  Health Maintenance Organizations  Academic Centers  Smaller clinics and hospitals begin utilizing as well  Individual practitioners direct to patients’ homes with the explosion of the internet and patients’ increasing familiarity and comfort with web-based videoconferencing  Telepsychiatry companies begin offering services to clinics/hospitals unable to sufficiently staff for their communities’ needs (APA)

What is Telepsychiatry?  Form of videoconferencing  Uses video cameras and microphones  Able to connect psychiatrists to patients in otherwise remote and/or underserved locations  Direct services provided include diagnostic assessment, ongoing medication management, individual and group therapy  Indirect services provided include consultation and collaboration between professionals  One of the most effective ways to increase access to psychiatric care

The Goal Navigating the obstacle course of accessing care

The Goal

Our Community  Fulton County, Pennsylvania – By Numbers  Total Population: 14,747 (US Census Bureau – American Community Survey 2010-2014)  15.7 % of population eligible for Medical Assistance (PA Department of Health, Bureau of Health Statistics & Research 2014)  56/67 ranking among PA counties for Health Factors (County Health Rankings 2015, Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute)  Measured considering Health Behaviors, Clinical Care, Social and Economic Factors, and Physical Environment

Our Community  Fulton County, Pennsylvania – By People  Largest Employer: JLG Industries, Inc. (Center for Workforce Information & Analysis 4 th Quarter 2014 Initial Data)  Fun Fact: Only county left in PA with more cows than people! Figure 2: 400S Telescopic Boom Lift, JLG.com

Our Community  Fulton County, Pennsylvania – By Location  112,201 Acres Farmland (2012 US Census of Agriculture)  Surrounded by three mountains

Our History  Statewide, there is a significant shortage of Psychiatrists, specifically Child and Adolescent Psychiatrists.  Prior to TrueNorth Wellness opening in Fulton County, there was 1 psychiatrist, 1 day per month, to entire population.  American Academy of Child & Adolescent Psychiatry

Our History  Population Health estimates that there should be a ratio of 10,000 citizens to 1 full time psychiatrist.  Most individuals sought medication management through Primary Care.  Two major PCPs in area.  Overwhelmed by having to provide mental health care on top of physical health care.

Our History  Prior to True North Wellness Services, distance to services:  Chambersburg, PA – Approximately 25 miles, 35-40 minutes  Hagerstown, MD – Approximately 30 miles, 45 minutes  Harrisburg, PA – Approximately 75 miles, 1 hour 20 minutes

Our History  The joining of Brilliant Minds  Susan Blue, Mary McGrath, James Martin, Gary Minnier  An established relationship between CSG and TrueNorth Wellness

Our History  Began Child and Adolescent Psychiatry June 2013  Every other Tuesday  110 Services in Year 1  Began Adult Psychiatry January 2014  Every other Thursday  155 Services in Year 1

The Model  Synchronous  Directly interacting with the consumers and providing treatment  Asynchronous  Consultation provided to another provider, regarding a consumer

The Model  Agency partnership  Contracted telehealth provider  InSight  InnovaTel  Web based platforms  Secure Telehealth

Our Process  Referral made for psychiatry  Majority made by area Primary Care Physicians  Referrals made to Centralized Intake Department  Same process for seeing on site physician  6 years old and up, scheduled  5 years old and younger, clinical supervisor consulted  Looking for other supports and services being tried prior to psychiatry  Appointments scheduled with nurse and psychiatrist

Our Process  Nursing Visit  Weight (each visit)  Blood Pressure (each visit)  Medical History (first visit)  Assess (each visit)  Safety, medication compliance, side effects, etc.

Our Process  Psychiatric evaluation/medication management  Can request additional observation by nurse for anything unable to determine (i.e. gait)  Can zoom in and out, without the client being aware  Prescriptions printed to front office  IMs sent for any questions, concerns, assistance

Our Process  Nurse and Physician communicate throughout session  Nurse can follow up on lab work requests, additional information gathering  Nurse and/or front office assist in completion of releases for additional providers or supports

The Challenges and Solutions  I need to talk to you!  This challenge really is based more on timing than providing services via teleconferencing  Once every other week is not always enough time  Let’s talk!  First half hour of each day is scheduled for physician, nurse, and therapists  Conference calls scheduled for “off weeks”  Nurse is able to email for any emergent concerns  On site meetings, alternating locations, 2 times per year

The Challenges and Solutions  I need a day off!  Having physicians working with multiple agencies makes meeting sufficient psychiatric coverage more complex  We can make that work!  We found that we had to be flexible on each side  Offer other days to replace days off  Utilize on site physicians when necessary

The Challenges and Solutions  Who can help?!  Not living in the community in which you work can make learning about that community more difficult  It is often a challenge to locate needed resources, especially when assumed Fulton County does not have them  We’ve got this!  Created a resource list for physicians to have on hand

The Challenges and Solutions  Where did they come from?  Often very little information when a client is referred  Telehealth physicians are not linked to local providers  I found them!  We have learned to utilize our nurse as a detective  We are working to determine better ways to access information prior to appointments  We have taken telehealth providers to local agencies in order to facilitate linkages

The Challenges and Solutions  Can you hear me now?  Technology is not always reliable  What happens when there is a disconnect?  I copy you loud and clear!  “Tech guys” for each agency worked on developing the system and are aware of the importance of smooth operating  We do have “back up plans”

The Challenges and Solutions  Technology failure back up plans  Turn it off and turn it back on  Call the “tech guys”  Urgent matters addressed via telephone in interim  Offer a different location  CSG and TrueNorth Wellness both have the ability to use telepsych equipment from other locations  Our adult provider one time even drove to Fulton County!