Reference no: EM133242799

Case : Implementing Tele-Psychiatry in a Community Hospital Emergency Department

Westend Hospital is a midsize, not-for-profit, community hospital in the Southeast. Each year, the hospital provides care to more than twelve thousand inpatients and sixty thousand emergency department (ED) patients. Over the past decade, the hospital has seen increasing numbers of patients with mental illness in the ED, largely because of the implementation of the state's mental health reform act, which shifted care for patients with mental illness from state psychiatric hospitals to community hospitals and outpatient facilities. Westend ED has in essence become a safety net for many individuals living in the community who need mental health services.

Largely considered a farming community, Westend County has a population of 120,000. Westend Hospital is the third largest employer in the county. However, Westend is not the only hospital in the county. The state still operates one of three psychiatric facilities in the county. Within a five-mile radius of Westend Hospital is a 270-bed inpatient psychiatric hospital, Morton Hospital. Morton Hospital serves the citizens of thirty-eight counties in the eastern part of the state.

Westend Hospital is fiscally strong with a stable management team. Anika Lewis has served as president-CEO for the past fifteen years. The remainder of the senior management team has been employed with Westend for eight to thirteen years. There are more than 150 active or affiliate members of the organized hospital medical staff and approximately 1,600 employees. The hospital has partnered with six outside management companies for services when the expertise is not easily found locally, including HighTech for assistance with IT services.

In terms of its information systems, Westend Hospital has used Meditech since the 1990s, including for nursing documentation, order entry, and diagnostic results. The nursing staff members use bar-coding technology for medication administration and have done so for years. CPOE was implemented in the ED four years ago and hospital-wide two years ago along with a certified EHR system.

The Challenge

Westend Hospital has seen increasing numbers of mental health patients in the ED over the past decade. For the past three years, the ED has averaged one hundred mental health patients per month. Depending on the level of patient acuity and availability of state- or community-operated behavioral health beds, the patient may be held in the ED from two hours to eight days before a safe disposition plan can be implemented.

The ED mental health caseload is also rapidly growing in acuity. Between 20 percent and 25 percent of the behavioral health patients are arriving under court order (involuntary commitment). The involuntary commitment patients are the most difficult in terms of developing a safe plan for disposition from the ED. The Westend Hospital's inpatient behavioral health unit is currently an adult, voluntary admission unit and does not admit involuntary commitment patients. The length of stay for involuntary commitment patients in the ED can be quite long. In some cases, it may take three to four days to stabilize the patient on medication (while in the ED) before the patient meets criteria for discharge to outpatient care. Approximately 40 percent of the mental health patients in the ED, both involuntary commitment and voluntary, are discharged either to home or outpatient treatment.

The psychiatrists and the emergency medicine physicians have met multiple times during the past six years to develop plans to improve the care of the mental health patients in the ED. Defining the criteria for an appropriate Westend psychiatrist consultation remains a challenge. The daily care needs of the mental health patients boarding in the ED are complex. The physicians have not been able to reach an agreement on this topic. Senior leaders have suggested that tele-psychiatry may be a partial solution to address this challenge.

Tele-psychiatry as a Strategy

Westend Hospital has chosen to consider contracting with a tele-psychiatry hospital network to provide tele-psychiatry services in the ED. The network has demonstrated good patient outcomes and is considered financially feasible at a rate of $4,500 per month. This fee includes the equipment, management fees, and physician fees. The director of tele-psychiatry in the

hospital network has verbally committed to work very closely with the Westend Hospital team to ensure a smooth implementation.

Technology to support tele-psychiatry uses two-way, real-time, interactive audio and video through a secure encrypted wireless network. The patient and the psychiatric provider interact in the same manner as if the provider were physically present. The provider performing the patient consultation uses a desktop video conferencing system in the psychiatric office.

Tele-psychiatry as a solution to the mental health crisis in the ED was not immediately embraced by the medical staff members. They did agree to the implementation of tele-radiology four years previously. However, the most recent revision of the medical staff bylaws to support telemedicine explicitly states that the medical executive committee must approve, by a two-thirds vote, any additional telemedicine programs that may be introduced at the hospital. The medical staff leaders wanted to preserve their ability to maintain a financially viable medical practice in the community as well as protect the quality of care.

The idea of tele-psychiatry was introduced to portions of the medical staff. The psychiatrists realized that tele-psychiatry could relieve them of the burden of daily rounds in the ED for boarding patients. They were also concerned about their workload when tele-psychiatry was not available.

The emergency medicine physicians immediately verbalized their disapproval on several levels. First, they were concerned about the reliability of the technology based on their experiences over the past several years with video remote interpreting. Then, the emergency medicine physicians were skeptical about the continued support from the psychiatrists when an in-person consultation might be clinically necessary.

Physicians outside of the ED and psychiatry could not understand why the current psychiatrists could not meet the needs of the ED. The barriers to adoption of tele-psychiatry crossed three arenas: financial, behavioral, and technical. Subsequently, many conversations were conducted. Eventually, the medical executive committee approved tele-psychiatry as a new patient care service on June 25 of this year.

Implementation Plan

The CEO appointed the vice president of patient services as the executive sponsor. The implementation team includes the IT hardware and networking specialist, IT interface specialists, nursing informatics analyst, ED nurse director, behavioral health nurse director, assistant vice president patient services, physician clinical systems analyst, and the medical staff services coordinator. These individuals represent the major activities for implementation: provider credentialing, physician documentation, equipment and technical support, and patient care activities. Because of competing projects and psychiatry subject matter expertise, the executive sponsor will also serve as the project manager.

The mental health crisis affecting the ED is the focal driver for change. Patient safety is at risk. Barriers to implement tele-psychiatry have been well documented. The strategies to overcome the barriers include defining the new role for the Westend psychiatrists, developing a process for ease of access and reliability of equipment for the ED physicians, and development of a plan when the tele-psychiatry program is not available.

An unexpected barrier has been recently identified. On initiation of the tele- psychiatry provider credentialing process, the medical staff services coordinator discovered that the bylaws do not have a provision for credentialing of physician extenders in the telemedicine category. The tele- psychiatry providers include six board-certified psychiatrists and twelve mental health-trained nurse practitioners. The medical executive committee has agreed to ask the medical staff bylaws committee to convene and revise the bylaws accordingly. The original go-live date of September has been changed to December.

The executive sponsor, along with the implementation team, will be responsible for managing the organizational changes necessary to support the introduction of technology and new patient care flow processes. Managing organizational change will be essential to the success of this project. Some items in the project will be viewed as incremental change, and other items will be viewed as step-shift change. Communication strategies will be developed to support the change.

Provide an overview of the problem for Case 13: Implementing Tele-Psychiatry in a Community Hospital Emergency Department and analyze the approach taken to address it.

Question 1: Was this approach successful? Why or why not?

Question 2: What types of population health networking were incorporated in the proposed solution?

Question 3: What additional approaches or alternatives to solving this challenge would you suggest?