SCDMH Emergency Department Telepsychiatry Consultation Program

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 20 telepsychiatrists. South Carolina was the first state to successfully connect patients in emergency departments (EDs) to off-site psychiatrists via telehealth.

Since implementation of the ED and Community Telepsychiatry programs predate 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.

Key partners in this program include:

• The Duke Endowment
• University of South Carolina School of Medicine
• South Carolina Department of Health and Human Services
• South Carolina Hospital Association
• South Carolina Telehealth Alliance

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 Telepsychiatry program, SCDMH offers several other telepsychiatry programs:

• Community Telepsychiatry
• Nursing Home Telepsychiatry
• 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 FY2022, SCDMH's Emergency Department Telepsychiatry program provided more than 9,000 psychiatric services rendered via telehealth, which is approximately 750 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 2022 reduced to 4.93 hours for psychiatric consults in EDs.

Built on the success of the SCDMH Emergency Department Telepsychiatry Program, SCDMH has equipped its community mental health centers and mental health clinics to provide psychiatric treatment services to its patients via telepsychiatry. In FY22, SCDMH's Community Telepsychiatry program delivered over 64,000 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.

The 2022 SCDMH Patient Satisfaction Survey was administered via text and online from April through June and 5,714 patients who received outpatient treatment services responded. Survey participants commented favorably about increased access to care through telepsychiatry. One patient stated, "Today I had a virtual appointment, so I didn't have to worry about finding a ride."

Another patient wrote, "No matter where I am or if I am in a lot of pain, I can still make my appointment." In addition, 93% 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 Telepsychiatry Consultation Program
803.898.8398
Margaret.meriwether@scdmh.org