Telehealth, psychiatry a good match for some ED patients: Q&A with Vituity physicians

Telehealth technology is transforming healthcare delivery across the country, and in emergency departments, it's helping reduce stays of behavioral emergency patients by connecting them with the expert care they need. 

Over the course of the past decade, EDs have seen a steep increase in numbers of emergency health patients, including behavioral health, Scott Zeller, MD, vice president of acute psychiatry at Vituity, told Becker's Hospital Review. The Emeryville, Calif.-based company provides telehealth services for EDs and urgent cares in 14 states.   

"About 15 years ago, emergency health patients made up about 4 percent or 5 percent of visits, whereas now about one in eight, or even one in six, of patients are emergency health patients at some locations," he said.

Telehealth has emerged as a solution to this issue by virtually connecting behavioral health patients who come to the ED with a psychiatrist, who can ensure these patients get the proper care they are seeking.

Here, Dr. Zeller and Herb Harman, MD, associate director of telepsychiatry at Vituity, discuss how telehealth can help improve care for behavioral health patients as well as their predictions of how telepsychiatry will evolve in the near future.

Editor's note: Responses have been lightly edited for clarity and length.

Question: How does telepsychiatry impact the workflows of ED providers and care teams?  

Dr. Scott Zeller: EDs used to use a historic algorithm with the acute psychiatry patients, which was basically transporting them to an inpatient psychiatric unit because it was the only resource they could offer. This was when these patients were only accounting for about 4 percent to 5 percent of their population and there was a certain number of inpatient beds available. This method probably worked fairly well, but now there's actually fewer inpatient beds than there were years ago and the number of behavioral health emergencies has gone way up. The result of this has been a lot of patients backing up with behavioral emergencies in the ED. These EDs don't have a lot to offer these patients, except holding them or transferring them to an inpatient bed, but sometimes those inpatient beds might be 100 or more miles away. People can wait for long hours, sometimes for days, and the average length of stay of one of these patients is between eight hours and 34 hours. In EDs, this is called 'boarding,' because the clinic isn't really doing anything for these patients other than holding them for a disposition.

One of the things that has been really neat about on demand telepsychiatry is that rather than just having the system where you evaluate and hold for transfer, we're now able to bring psychiatrists into these systems. Whereas most of these patients did not have access to a psychiatrist in a timely fashion, they can now consult with a psychiatrist who can see them, do a diagnostic evaluation, and recommend treatment – which they can maybe start in the ED – all within a relatively brief amount of time. The psychiatrist can recommend treatment that might have such a positive effect that a few hours later the patient might be good enough to go to a community disposition rather than being held for inpatient.

Dr. Herb Harman: Telepsychiatry improves response times for comprehensive evaluations for hospitals that don't have an on-location psychiatrist 24/7. At a large academic center, for instance, where a psychiatrist might happen to be available to the ED at all times, telepsychiatry is less useful. In most hospitals in most of our communities, psychiatrists are not available for quick ED consultation. A patient that presents to the hospital at 5 p.m. in a rural ED will likely not be seen by a mental health professional for up to 24 hours and possibly not at all by a psychiatrist. With telepsychiatry, the odds that the patient will have an expedient evaluation go up. The evaluation will have the opinion of a specialist expert. This service decreases length of stay, improves clinical outcomes and improves patient and staff satisfaction.

Q: What factors are contributing to the increasing number of behavioral health emergency patients?

SZ: I think there are people who have postulated different ideas for why this is happening, but I don't know if anyone has really nailed it down entirely.  I do know that it's extremely difficult to get an outpatient psychiatrist even if you have really good insurance, so it may be that some folks who could have been helped earlier just are not able to access mental health providers. There's a huge shortage of psychiatrists in the U.S. right now, and, unfortunately, I think something like more than half of the psychiatrists in the country are 55 years old or over, so it's not something that's going to be improving anytime soon. However, something good to know is that there has been an increase in the number of psychiatry residencies in the past few years.

Q: How can telemedicine help expand access to psychiatrists and improve the care experience of behavioral health patients?

SZ: One of the beauties of on-demand telepsychiatry is that with those limited number of psychiatrists, there are definitely not enough psychiatrists to have one in every ED around the clock. That would certainly be expensive anyway. Now you can have a psychiatrist on a shift that might see eight different people in eight different hospitals over the course of eight hours. That's a really good use of the physician's time, and really does give people the access they need. 

HH: Patients seen by telepsychiatry will have quick and thorough evaluations targeting their primary complaint and specific needs. Patients are more likely to be released from the hospital if on an involuntary hold, and they are more likely to have a comprehensive and coordinated treatment plan developed from the ED than if not seen by psychiatry.

Q: How does a telepsychiatrist's workflow compare to an in-person psychiatrist's?

SZ: In terms of the actual psychiatric evaluation there is very little difference between doing it via video technology as opposed to being there in person. Both are pretty much going to do the same evaluation. In psychiatry we don't, for the most part, have a hands-on part of our evaluation. We don't need to use a stethoscope, for example, so it makes using telehealth technology particularly applicable to psychiatry in that our work is all about being face to face with somebody and talking with the person and asking them questions and trying to help figure out what's going on and what we can do to help improve the situation. I think it's particularly well suited for telehealth. Having an on-site psychiatrist driving between different hospital campuses would take hours between each patient, so being able to see people at different sites one after another is a real game changer and really gets people access that's not possible otherwise with brick and mortar.

Q: How do you anticipate telepsychiatry to grow in the next few years, whether in EDs or other clinical settings?

HH: Telepsychiatry will expand in all areas – hospital-based, outpatient, employee assistance programs, consultative services, etc. The next frontier is to leverage technology to allow the psychiatrist to harness data to spend less time on each case, such as reviewing records, conducting full interviews with redundant questions, documenting a note, and more time making meaningful connections with the patient and the staff caring for them.

SZ: Over the next five years, I think you're going to see a lot more EDs embracing telepsychiatry and getting on demand consultations for patients that are beyond the capabilities of what a standard emergency medicine physician might be comfortable with. It's already in hundreds of hospitals around the country, and I think we're going to see those numbers go way up over the next five years. 

I think something else that's really exciting and interesting we're going to see with emergency telepsychiatry is EmPATH units. Hospitals have been creating these EmPATH units, which stands for emergency psychiatry assessment treatment and healing unit. These are kind of separate, dedicated EDs specifically for psychiatric emergency patients and are much more therapeutic settings with personnel who are trained to work with mental illness and behavioral emergencies. Patients in EDs can be moved to the EmPATH unit and in some cases can just go there first. To ensure these units work, we want the patients to see the psychiatrist or a psychiatric provider as quickly as possible when they arrive at those units, which is made possible by emergency on-demand telepsychiatry.  We can have these very effective and wonderful units that help people promptly, and we can get the appropriate providers via telepsychiatry and have on site staff that are then able to work with the treatment plan that is recommended by the telepsychiatrist. 

Q: What do these EmPATH units typically look like?

SZ: They are usually able to keep people for up to 24 hours in a comfortable setting. Patients are usually in a big room with recliners, as opposed to being in small, little treatment areas in an ED – or worse, strapped to a gurney. Instead, they're able to freely move about and they're in a comfortable setting. They have a place where they can sit and play board games, read magazines or watch TV. There's a place where they can serve themselves something to eat or drink, so it's a really comfortable, therapeutic setting where someone comes in, you start a treatment plan and, if medications are indicated, you start those. 

Q: What has the patient response to EmPATH units been like?  

SZ: We find that people do really well, much better than if they had been in a standard ED. Just changing that environment does wonderful things. We find that usually between 70 percent and 80 percent of these patients who would have needed inpatient hospitalization, and 70 percent to 80 percent can be stabilized within 24 hours and be discharged to some kind of community program or even home. That's great because it helps us be more judicious with the use of inpatient beds, and we're really meeting the needs of people much more promptly. We're getting them into a setting that's much more therapeutic, and what's nice about that is that we find there's far less need for any coercive treatment. 

We're already seeing an explosion in the interest in these kinds of units — and I think that's going to expand exponentially in the next five years. 

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