By: James Varrell, M.D.

Originally published on Arizona Telemedicine Program

As a child and adolescent psychiatrist practicing in person for a number of years, and eventually making the shift to telepsychiatry, I have observed the subtle differences and nuances between the two mediums of care.

In my experience, telepsychiatry can be particularly powerful when working with children and teens. I had one experience with a 15-year-old adolescent who was admitted to the hospital for the fourth time with continued severe abdominal pain that could not be attributed to a medical cause. The hospital staff was puzzled, as the diagnostic tests did not show any signs of ailments and there were no physical afflictions present in the child. Interestingly enough, the teen had already been evaluated by another psychiatrist at the hospital, who was unable to get the teen to “open up.”

However, a caring on-site staff member had noted the teen admired technology. She recommended that the telemedicine cart that was normally used in the ED be brought up to the teen’s room to connect him to a telepsychiatrist who specializes in child and adolescent psychiatry. It was clear he felt much more at ease talking with me on a screen than he had been talking with his in-person providers. During our session, I was able to leverage his interest in technology, as well as my child and adolescent psychiatry experience, in order to ease his reservations about sharing his story.  I found that in the past the teen had seen his brother shot in the stomach, causing psychological trauma that resulted in his abdominal pain.

Just as my experiences have shown, the effect of technology on children in a clinical setting has been researched and shown to have positive impacts in a number of ways.  In one study, adolescents reported that telemedicine promoted a transfer of power and control by allowing them to feel more comfortable with terminating a consultation or walking out of it, that the process is more structured, and that the adolescents feel better informed when speaking with a telepsychiatry provider, which can result in a better understanding, sense of shared responsibility and better decision making.

Although telepsychiatry is almost identical to in-person psychiatry, there are small adaptations providers can make to facilitate responses, especially in the case of special populations, including children and adolescents. Provider flexibility is often the key to success. Slowing down your speech, communicating with gestures and remembering to not infantilize your speech when evaluating children can all contribute to establishing a more effective patient-provider relationship. I educate other telepsychiatrists about games they can play and questions they can ask to encourage children to interact with them more freely. It can also sometimes be beneficial to involve a child’s parents or an on-site facilitator in the session to observe interactions. These tactics have helped me gain trust and encourage meaningful responses from children I have treated through telepsychiatry.

In the case of the boy with stomach pain, instead of providing continued costly and time-consuming medical intervention, we were able to get him the appropriate psychiatric treatment after our conversation.

The best care, especially for children, adapts to the preferences and needs of each individual. Telemedicine is a fantastic tool for increasing specialty care options and making sure that every person can access the right provider and the right type of care for them.

 

By Dr. James Varrell

The concept of “connected community” holds great potential for elevating and improving behavioral health outcomes for all patients. Connected communities proactively address a patient’s whole health—both physical and mental—and benefit from a comprehensive, multi-faceted behavioral health strategy.

Health care leaders recognize the potential of these models to positively impact clinical outcomes and reduce the need for higher-cost interventions by improving access to care at various points along the continuum. Yet, today’s communities often struggle to achieve this framework amid a severe shortage of psychiatric providers.

The reality is 96 percent of U.S. counties have unmet needs for mental and behavioral health services at a time when demand is soaring.1 Current shortages leave those needing care with less-than-optimal choices. People often turn to primary care doctors, or alternatively, opt for no treatment at all—leading to further deterioration or crisis situations that result in costly interventions.

The good news is that direct-to-consumer (D2C) telepsychiatry can help fill these gaps and improve the outlook on connected community models. While D2C is a relatively new concept, other settings across the care continuum have leveraged telepsychiatry for the past two decades, including hospitals, inpatient units, community-based case centers and correctional facilities.

Leveraged through easy-to-use videoconferencing technology, D2C offerings are opening new doors to psychiatric providers for evaluation, consultation and treatment.

D2C Telepsychiatry: Expanding Access And Referral Options

Growth of D2C telepsychiatry in recent years has expanded as patients become more empowered and seek out convenient ways of managing their care. Patients increasingly prefer “anywhere, anytime” options like the D2C model because it enables access to care from the comfort of home—or other private locations—on their own schedule.

This type of care allows providers to be more proactive and address issues before conditions reach what Mental Health America (MHA) refers to as a “stage four” level of severity. In effect, better patient engagement can trigger greater follow-through with care plans and minimize the potential for symptoms and issues to escalate.

Telepsychiatry often gives providers greater insights into their patients’ environments. For instance, a colleague of mine is a therapist in New Jersey, and she’s been treating one of her patients for years in person. When my colleague started using D2C Telepsychiatry, she was able to see her patient online through real-time video calls rather than in person, and noticed right away that her patient was hoarding her belongings. My colleague was able to learn about her patient’s living condition and other factors that influenced her treatment plans. Further, her patient reported feeling more comfortable and at-ease during their appointments.

D2C telepsychiatry also provides more referral options, enabling earlier interventions and greater access to services. While frequently sought out as a mental health alternative, many primary care providers are uncomfortable prescribing psychotropic medications or lack psychiatry expertise.

By providing a reliable behavioral health referral option, D2C telepsychiatry takes the pressure off of primary care providers. Moreover, collaboration and information exchange between the referring physician and D2C provider can allow for more comprehensive care.

Outside of primary care, D2C expands referral options for discharge planning from acute and inpatient settings. The current mental health provider shortage can slow down referral processes, leading to disjointed transitions where patients must “settle” on whatever is available in the nearby area instead of what is best.

Closing The Loop To A Connected Community

Even as health care leaders increasingly embrace telepsychiatry models, most are currently used in siloes across community settings. However, there’s opportunity to leverage existing resources and establish community-wide telepsychiatry networks to connect all appropriate care settings.

This connected community model improves both information sharing between providers and continuity of care for patients. Patients can use telepsychiatry to see the same provider or same network of providers across different care settings or from home with D2C care. In tandem, primary care doctors, community organizations and telepsychiatry providers can better collaborate on patient care.

Telepsychiatry networks not only improve care outcomes, but also create economies of scale. For instance, health care settings can benefit from sharing a telepsychiatry provider network. This option places less pressure on community resources to recruit and retain local behavioral health providers.

Communities can take steps to utilize a telepsychiatry network across care continuums by:

  • Bringing together payers, primary care, hospital systems, outpatient behavioral health, corrections, schools, skilled nursing and other community organizations
  • Assessing their current behavioral health resources to identify gaps and opportunities
  • Setting multiple locations up with technology to access telepsychiatry
  • Establishing a telebehavioral health network of licensed providers who are aware of community services and resources
  • Utilizing shared scheduling tools for booking psychiatric resources and appointments

Telepsychiatry helps address the gaps in behavioral health care across the continuum by proactively treating patients’ whole health through the concept of the connected community. By increasing patient access to care and referral options, this evolving model supports timely, proactive intervention, minimizing the potential need for more costly care and enabling better outcomes.

About The Author

James R. Varrell, M.D. is a child and adolescent psychiatrist who has been practicing telepsychiatry for 18 years and is the Medical Director of InSight Telepsychiatry. InSight’s direct-to-consumer division that accepts patient referrals for psychiatry and therapy is called Inpathy.

Original article posted on Health IT Outcomes

By Rajiv Leventhal

With a dwindling supply of psychiatrists nationwide, telepsychiatry services are starting to become more mainstream

It was nearly 20 years ago when a clinician (non-psychiatrist) brought up the notion of telepsychiatry to James Varrell, M.D., a licensed psychiatrist himself who at the time didn’t know much about the telemedicine subsector. “This was 1999 and it was like voodoo to me,” Varrell says, adding that after that conversation he needed to do his due diligence and research.

What came from that conversation, and ensuing exploration into telepsychiatry, was a realization that there was more support for it than Varrell initially assumed. In fact, the American Psychiatric Association (APA) put out a significant paper in 1995 in support of telepsychiatry, and it was around that time when research began on its ability to facilitate access to care, overcome geographical obstacles and how it compared to in-person care. “All of the go-to organizations in the [industry] have always been supportive of it. Clinicians individually have been skeptical since they’ve never done it. But now, many [places] are incorporating into their residency programs,” Varrell says.

Indeed, folks might not be as familiar with telepsychiatry as they are with other forms of telemedicine, since behavioral health often flies under the radar compared to its physical health brethren. But according to the APA, by the 2000s, the field began to see it as effective, but slightly different, than in-person care, and research in outcome studies provided a platform for practice guidelines, via the American Telemedicine Association.

Varrell says that today’s mental health landscape is characterized by an increased need for services coupled with a dwindling supply of psychiatrists. Indeed, more than 55 percent of U.S. counties are currently without any psychiatrists, and the mental health landscape is facing shortages in more than 4,600 areas, according to Kaiser. Varrell, who has been practicing telepsychiatry for 18 years ever since it was brought up to him back in 1999, now works at telepsychiatry service provider organization InSight, a Marlton, N.J.-based company that he founded in 2008 and where he currently oversees a team of more than 200 psychiatrists and psychiatric nurse practitioners—many of whom work full-time doing telepsychiatry.

Speaking to the growth in the sector, Varrell says that his company began with telepsychiatry mostly in ERs where patients in crisis environments were prioritized. But, he notes, “The place more than anywhere where it started to develop was in rural environments, where access to basic psychiatry care would be otherwise inaccessible. That’s still growing,” he says. “Now, the new wave is that we are starting to do integrated care in medical offices, and that was a big push with Obamacare. We think the next trend is in-home services for consumers, which is telepsychiatry direct-to-patients in their homes or wherever they are [in a private space].”

The reason InSight started to provide telepsychiatry services was because it was located in a rural environment, but Varrell says beyond that, there have been valuable lessons learned since the organization’s inception: primarily that telepsychiatry works well for most people in most areas. “For people in crises, you don’t want to do an in-home visitation if they are psychotic or suicidal. You want them in more supported environments like outpatient mental centers or ERs if it’s very acute,” explains Varrell. “Over the years, we have learned that we can accommodate all types of people.”

Among these are: translations [for people who speak] different languages; the geriatric population, for which a great sound system is needed for older folks who have hearing issues; and also for those with cognitive and intellectual disabilities in which the patients’ families are present to make it easier and provide the psychiatrists with the necessary information, says Varrell.

Over the years, telepsychiatry has continued to grow both in volume and acceptance. Varrell notes how educating organizations such as the University of Virginia and Johns Hopkins University have big electives for all of their psychiatry residents who are mandated to learn telepsychiatry. And, InSight as a sole organization performed more than 100,000 encounters via telepsych in all settings last year (hospitals, clinics, treatment centers, universities), while its in-home platform, Inpathy, is still growing but has around 100 direct-to-consumer sessions in a week, according to officials.

“This is an area that used to be weird and hard, but now people are jumping into it,” says Varrell. “Doctors are calling us all of the time saying they want to work with us. That’s good since there’s a national shortage and we’re often begging doctors to work with us in person, but this is the opposite of that,” he says, noting how on one recent day alone, eight psychiatrists called looking for work.

Original article posted on Healthcare Informatics