SCDMH Emergency Department and Community Telepsychiatry Programs

Description

In response to long wait times for patients experiencing mental health crises, the South Carolina Department of Mental Health (SCDMH) partnered with The Duke Endowment to create the Partners in Behavioral Health Emergency Services (referred to as the SCDMH Emergency Department Telepsychiatry Program). This statewide program made it possible for emergency departments to reach a psychiatrist to assess a patient via telehealth.

The program's goal was to increase access to mental healthcare throughout the entire state, with a focus on underserved and rural communities. What started with 4 hospitals and 6 psychiatrists in 2007 has since expanded to 28 participating hospitals and 22 psychiatrists. South Carolina was the first state to successfully connect patients in emergency departments (EDs) to off-site psychiatrists via telehealth.

Built on the success of the Emergency Department Telepsychiatry Program, SCDMH launched the Community Telepsychiatry Program in 2013. The program connects SCDMH's 16 mental health centers and associated clinics (approximately 60 locations in total) with psychiatrists, who provide high-quality services to patients in various settings. This availability not only creatively addresses the national psychiatrist shortage, but also increases access to specialized healthcare services. In FY2023, over 35,000 psychiatric treatment services provided in SCDMH's community settings - 42% of all psychiatric treatment services - were telemedicine.

Since implementation of the ED and Community Telepsychiatry programs predates the COVID-19 crisis, there was a different context for developing the practices and operations supporting the programs. This steady growth, rather than rapid program expansion in response to the pandemic, has benefited patients, program staff, physicians, and administrators by providing time for individual and system acclimation to changes, including the increased use of technology.

The SCDMH Emergency Department Telepsychiatry Program received early financial support from the South Carolina Department of Health and Human Services, and initial program support from the South Carolina Hospital Association, with program evaluation from the University of South Carolina School of Medicine. Today, the program is supported by a combination of state appropriations, grants, and earned revenue.

Services offered

The following services are included with the ED Telepsychiatry program:

• Regular availability – Psychiatrists rotate schedules and are available 7 days a week, 365 days a year, 18 hours a day.
• Enhanced Communication – Participating psychiatrists provide approximately 750 services per month to hospital EDs across the state. Prior to the video exchange, the SCDMH psychiatrist reviews the patient's medical records.
• Assessment via telemedicine – After the encounter, the SCDMH psychiatrist provides a diagnosis and recommended course of treatment to the patient's physician in the hospital as well as to the nearest SCDMH community mental health center for follow-up care.
• Training – The program's medical director provides comprehensive training on how to conduct an evaluation through a telemedicine platform to participating psychiatrists. A complete training manual is provided to every physician for reference.
• Peer Evaluations – Peer reviews are performed quarterly for all SCDMH telepsychiatry physicians. New psychiatrists are scheduled with experienced physicians until they are comfortable enough to work independently. The Program's medical director and experienced psychiatrists are also available should new psychiatrists have questions.
• IT Support – SCDMH offers 24/7 IT support for the Telepsychiatry Program.

In addition to the ED and Community Telepsychiatry programs, SCDMH offers several other telepsychiatry programs:

• Highway to Hope Mobile Telehealth Services
• Telepsychiatry partnership with South Carolina Department of Juvenile Justice
• Inpatient Services Telepsychiatry
• School Mental Health with Telepsychiatry Component

Results

SCDMH is the largest provider of telepsychiatry services in the state. In FY2023, SCDMH's Emergency Department Telepsychiatry program provided more than 8,400 psychiatric services rendered via telehealth, which is approximately 705 psychiatric consults per month.

Ongoing evaluations have found that the program has improved and increased the quality and timeliness of triage, mental health assessment, and initial treatment of patients. Other successes for patients seen through the telepsychiatry program include:

• Higher follow-up and retention of patients seen using telepsychiatry services compared to a those in a control group in an outpatient setting
• Shorter lengths of stay
• Fewer inpatient admissions
• Significantly lower total charges at the encounter level for the index emergency department visit including subsequent inpatients admissions
• The average wait time for FY2023 was 4.9 hours for psychiatric consults in EDs.

In FY23, SCDMH's Community Telepsychiatry program delivered over 80,000 services. These services are for patients of all ages and the Community Telepsychiatry program has provided psychiatric treatment services to DMH patients since August 2013. Almost exclusively (in 99% of cases), the Community Telepsychiatry program service codes are for psychiatric medical assessment.

SCDMH's Community Telepsychiatry program received the 2023 Telehealth Program of Excellence Award at the 11th annual Telehealth Summit of South Carolina. The award recognizes a mature academic or community-based program that demonstrates considerable outcomes in the areas of clinical intervention, improved access, and community engagement.

The 2023 SCDMH Patient Satisfaction Survey was administered via text and online from April through June and 6,984 patients who received outpatient treatment services responded. Survey participants commented favorably about increased access to care through telepsychiatry. One patient stated, "I always schedule the next appointment at the end of each meeting. The SMS reminders help to ensure I do not forget the appointment time is near."

Another patient wrote, "The doctor has been a great help teaching me ways to deal with my issues. I always learn a new way to help me feel better about myself and to deal with my condition." In addition, 91% of respondents who had a telepsychiatry appointment with an MD agreed or strongly agreed that "After coming here today, I believe I will get better." These survey responses suggest that telepsychiatry patients have positive expectations about treatment efficacy.

Challenges

In the beginning, the effectiveness of using telemedicine to treat patients was a general concern raised by established clinicians. Additional concerns included care coordination logistics, definition of responsibilities among clinicians and psychiatrists, and the qualifications of on-call psychiatrists. Initially, SCDMH addressed these concerns in materials sent to all participating medical facilities. Program organizers also followed up in person with each site to discuss additional hesitations, answer questions, and provide additional training.

Replication

• Host stakeholder meetings regularly to collaborate, share best practices, and brainstorm ideas for program improvement.
• When building partnerships with hospitals, look for those that already have a strong relationship with their community mental health centers and other agencies that can take referrals quickly following a telepsychiatry evaluation.
• Be intentional with follow-up care for patients. Involve family members and caretakers and ensure that patients take the next steps recommended by their psychiatrists.
• Broaden your partnerships to include those at the healthcare, academic, and state levels. Having these representatives involved with a telemedicine program, whether through delivery of care, recruitment, or policy, can enhance its effectiveness.

Contact Information

Margaret B. Meriwether, PhD, Director of Organization Improvement & Telepsychiatry
SCDMH Division of Medical Affairs
SCDMH Emergency Department and Community Telepsychiatry Programs
803.898.8398
Margaret.meriwether@scdmh.org