STePs Toward Shortening ED Wait Times for Mental Health Patients

July 20, 2017 | By Taylor Knopf

About 40 percent of North Carolinians live in one of the state’s 80 rural counties, many of which lack ready access to health care. But in recent years, more and more North Carolinians are receiving care with telemedicine.

However, there remain a lot of gaps in state policy when it comes to virtual medical visits.

State legislators passed a bill last month that directs the N.C. Department of Health and Human Services to study and recommend a policy for the state. Every state has different definitions, standards, limitations, safeguards and payment methods for telemedicine, which DHHS should consider in making its recommendations.

According to the bill, the study and report will be presented to the Joint Legislative Oversight Committee on Health and Human Services by October 1. The governor signed the bill into law Thursday.

Peter Kragel, director of East Carolina University Telemedicine Center, said that uniform policy is always a good idea. He said there are still issues to be worked out, such as provider reimbursement for telemedicine visits.

“A lot of North Carolina is pretty rural, and transportation and access to care can be an issue,” Kragel said. “Telemedicine has a lot of potential good in terms of access. We still struggle with that in terms of connectivity and broadband. There are certain areas of North Carolina you still can’t get a cell signal.”

Tele-specialists

ECU’s Telemedicine Center, founded in 1992, is one of the longest operating telemedicine hubs in the country. In the past, providers came to the center on ECU’s campus to conduct virtual visits with patients in rural hospitals. With the advancement of technology, there is much more mobility and flexibility.

“We’ve changed from being the site where all the telemedicine encounters occur, to the site that helps promote and assists others with telemedicine capability where they might be,” Kragel said.

Telemedicine has dramatically helped increase access to certain specialists, such as psychiatrists, Kragel said.

ECU houses the North Carolina Statewide Telepsychiatry Program, called NC-STeP. The program provides hospital emergency departments with virtual access to a psychiatrist in real time. These are patients who otherwise might wait days to see a specialist, particularly in rural areas.

The program was formed in 2013 by ECU, the Office of Rural Health and Community Care and the General Assembly to deal with overcrowding in emergency departments by mental health patients experiencing a crisis, such as paranoia or psychotic symptoms.

At that time, lawmakers directed DHHS to study the issue and come up with a plan, not unlike the bill passed last month.

“When this discussion was starting, 10 percent of people in the emergency department were there for mental health reasons,” said NC-STeP director Sy Saeed. “The national average was 5 percent.”

Also at that time, he said mental health patients in the ED would wait an average of 72 hours to go to a state hospital and 36 hours to transfer to a community hospital. And that was just the average. There was anecdotal evidence of people waiting up to two weeks, Saeed said.

The wait time to get into one of the three state psychiatric hospitals is still really high. From July 2016- March 2017, the average wait time was 116 hours, reported by DHHS.

But in 2016, the average length of stay in the ED for NC-STeP patients was 32 hours.

A rural advantage?

While NC-STeP helps patients see a psychiatrist sooner, it doesn’t necessarily mean they will get to a state bed any faster. But for those patients with less complicated cases, seeing a psychiatrist faster means they can go home sooner if they don’t need to be transferred to another facility.

It’s important to note that the large urban counties that hold the majority of the state’s population and the most crowded emergency departments are not included in NC-STeP data. The program primarily serves people in smaller or rural counties with less access to mental health care.

For some smaller, rural emergency departments, mental health patients would be taking up half the capacity, Saeed added. Emergency departments had to juggle their usual people coming with heart attacks or fractures at the same time.

With NC-STeP, a patient in the ED who needs to see a psychiatrists doesn’t have to wait very long.

First, the ED nurses and physicians do everything on their end, such as monitor the patient’s vital signs. Then the physician logs onto the NC-STeP web portal and requests a psychiatrist. The psychiatrist has access to the medical information from the ED. A nurse wheels a cordless cart with a monitor into the patient’s room and the virtual psychiatric consultation begins. The psychiatrist shares notes with the ED physician who can then write any needed prescriptions.

According to Saeed, 29 of North Carolina’s 100 counties don’t have a psychiatrist. And 58 counties are considered mental health shortage areas.

NC-STeP has conducted more than 24,000 telepsychiatry assessments in about 60 hospitals since it began in 2013. Hospitals such as Wake County and other urban areas do not need NC-STeP because they usually have 24/7 on-site mental health staff.

NC-STeP is funded through state legislative funds, billing and collecting from insurance companies and grant funding from Duke Endowment while participating hospitals pay one- third of the consult cost.

Saeed said the program has saved about $4 million per year just in reductions in involuntary commitments, which saves money for everyone, from the hospital to the sheriffs’ deputies who often have to sit with a patient being involuntarily committed.

“There is a subset of these that don’t need to be hospitalized. So we link them with community services and they go home. That prevents unnecessary or inappropriate hospitalizations,” he said. “So the program has more than paid for itself from that standpoint.”

“Never mind that you’re providing better care to the patients closer to their home. How do you put a price tag on better quality of life, less crime and less burden on the family?” Saeed said.

In a survey by NC-STeP, 80 percent of ED staff who responded to the survey said that the telepsychiatry consults “have improved the quality of care for mental health and substance abuse patients in the ED.”

Saeed said that after the first 30 seconds of a consult, both sides usually forget the conversation is happening through a screen.

“In terms of the technique and skills set, you’re still doing the same exact thing. It’s the same assessment, same diagnostic process that you would do face-to-face. It’s just the medium of how you communicate that changes.”

The only difference, he said, is making sure there is no one else listening in. Saeed said he likes to turn his camera to show the patient his office and to demonstrate that the conversation is confidential.

He said none of the NC-STeP patients so far have refused to speak to a psychiatrist due to the medium of the visit.

“When you look at research, most of the time, the hesitation comes from the provider side that doesn’t think their patient will like it,” Saeed said. “Surveys show that patients don’t have an issue.”

Saeed said one of his colleagues found that his patients with autism actually prefer and respond better to virtual visits than in-person visits.

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