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  • I am studying towards my professional practice in England despite being from the United States. I am already benefiting from teleconnection (Skype) with my family and am convinced that this move into the clinical area will erode the geographical limitations of offering this service. I hope your staff will become as diversified in ethic background and age as the citizens of the territory you serve. I hope you have the ear of the right people in government.
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    Merkel Merkel Presentation Transcript

    • Telepsychiatry at the University of Virginia TELEHEALTH SUMMIT Danville, VA March 18, 2010 Larry Merkel, MD, PhD; Department of Psychiatry
    • Rural Mental Health Issues
      • Residents of Rural Communities have decreased access to mental health care
      • Available mental health care is often sub-standard
      • Primary Care Providers are the main source of rural mental health care
      • Rural PCPs may be even less able to provide mental health care due to increased demands
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Rural Mental Health Alternatives
      • Telepsychiatry
        • Consultation Care Model (TP-Con)
        • Collaborative Care Model (TP-Col)
      • On-site mental health care
        • On-site Advanced Practice Mental Health Nursing (OSN)
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Larry Merkel, MD, PhD; Department of Psychiatry
    • Telepsychiatry Sites in SW Virginia Larry Merkel, MD, PhD; Department of Psychiatry
    • Larry Merkel, MD, PhD; Department of Psychiatry
    • Larry Merkel, MD, PhD; Department of Psychiatry
    • Larry Merkel, MD, PhD; Department of Psychiatry
    • What Do We Know About Telepsychiatry?
      • It is as reliable as in-person as to clinical diagnosis, use of clinical scales, use of the MMSE, and of neurological exams
      • It is given high marks for satisfaction by patients and rural practitioners, but less so by mental health professionals
      • It is at least as effective as in-person treatment for depression and serious mental illness via GAF scores, CIDI, Hamilton Depression Rating Scale, Hopkins Symptom Checklist 20
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Clinical Contacts Per Year Larry Merkel, MD, PhD; Department of Psychiatry
    • Telepsychiatry at UVA 2003-2007
      • 145 Initial Contacts — 139 Follow-ups
      • 103 Females 42 Males
      • Average Age: Females 42.8 years, ranging from 21 to 79
      • Males 41.8 years, ranging from 21 to 74
      • Most are indigent with no insurance (85%)
      • All but one is Caucasian
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Consultation Care Model
      • The local clinic identifies the cases
      • The patient is seen by us in consultation
      • We make recommendations
      • It is up to the local clinicians to act on these recommendations
      • They may contact us if there are problems
      • We may or may not see the patient again in follow-up
      • Ad Hoc education and coordination
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Show Rate 2007
      • Telepsychiatry: Intakes 36.5%
      • Follow-up 57.5%
      • Other Telemedicine Clinics 70%
      • Residents’ Clinic: Intakes 58%
      • Faculty Clinic: Intakes 95%
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Telepsychiatry at UVA 2003-2007
      • Average GAF Score: 49.5
      • (This is in the Serious Symptom range)
      • Ranging from 85 to 15
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Number of Diagnoses per Patient
      • 1 Diagnosis = 46 (35%)
      • 2 Diagnoses = 51 (39%)
      • 3 Diagnoses = 31 (24%)
      • 4 Diagnoses = 1 (0.7%)
      • 5 Diagnoses = 2 (1.5%)
      • Average Number of Diagnoses 2
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Percentage of Diagnoses Larry Merkel, MD, PhD; Department of Psychiatry
    • Satisfaction Survey 1=Not at all, 2=Somewhat, 3=Moderate, 4=Very Much
      • How anxious were you at the beginning of the appointment? --
      • How anxious were you at the end of the appointment?
      • How satisfied were you with the telemedicine process?
      • How easy was it for you to make an appointment?
      • 2.71
      • 1.85
      • 3.57
      • 3.28
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Satisfaction Survey 1=Not at all, 2=Somewhat, 3=Moderate, 4=Very Much
      • How helpful is the UVA staff during this process?
      • How likely are you to make another appointment with us?
      • How helpful has this appointment been today?
      • Are you likely to recommend this service to a friend/family member?
      • 4.0
      • 3.92
      • 3.64
      • 3.92
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Average Days to Follow-up Per Year Larry Merkel, MD, PhD; Department of Psychiatry
    • What are the problems?
      • Long wait for follow-up.
      • Low reimbursement
      • Lack of psychiatric availability
      • Decreased access to medications and therapy
      • High “no show” rate
      • Case identification
      • Outreach
      • Stigma
      • Structure may be confusing to the patient
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Collaborative Care Model
      • A local clinician is identified as the contact person and oversees the mental health care
      • There is a collaborative sense of team work
      • Frequent contact between UVA team and local mental health contact person
      • Team identification of patients and issues
      • Formal opportunities for mutual education
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Where ?
      • Clinch River Health Services, Inc.
        • A Community Health Center opened 1978 in Dungannon, Virginia; population 400
        • In 1991, one Physician and 800 users
        • In 2005, two Physicians and one NP with 3432 users
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Workload Issues
      • 12,967 Visits in 2005
      • Average visit time of face to face provider with patient is 13 minutes
      • 258 Patients with Behavioral Health Diagnosis
        • 7.5% of the practice
        • Which requires 30-60 minutes
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Is the Program Successful?
      • Show Rate is 83%
      • Diagnosis of Bipolar Disorder increased 3 fold
      • CRHS Provider satisfaction skyrocketed
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Why is the Program Successful ?
      • On-Site Behavioral Health StaffAble to answer patient questions 5 days per week
        • Understands the patient, prepares the patient for Telepsychiatry, thus less confusing
        • Supports CRHS Providers with Diagnosis and follow-up
        • Better triage of patients
        • May provide counseling
        • May do outreach
      • CRHS Providers write the Rxs to eliminate delay in starting or refilling medications
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Why is the Program Successful ?
      • Skilled Psychiatric Providers
        • Increased follow-up of the patients
        • More continuous contact allows verification or clarification of the Diagnosis
        • Initiating and managing complicated medication regimens is easier and more fine tuned
        • Offer In-service training
      Larry Merkel, MD, PhD; Department of Psychiatry
    • What are the problems?
      • More costly
      • More time consuming
      • Low reimbursement
      • Decreased access to medications and therapy, but better
      • Stigma
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Limitations of Telepsychiatry
      • Admission
        • Lack of Inpatient Resources
          • Insurance coverage
        • Distance from UVA
      • Complexity of Medications
        • Expensive
        • CRHS Providers unaccustomed to dosage
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Limitations of Telepsychiatry
      • Communication
        • Telepsychiatry note off-site
          • Time lapse before note to CRHS
          • Provider’s concern of writing Rxs without a note
        • Medical Chart not available to UVA
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Conclusions
      • Telepsychiatry is satisfying, effective, and cost efficient
      • Collaborative Model has advantages over the traditional Consultation Model
      • Increased investment is needed to increase mental health provider availability and support more effective Collaboration Model
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Thanks to Colleagues
      • Mudhasir Bashir, MD UVA Dept. of Psychiatry
      • Juliana Frosch, PMHCNS-BC, PMHNP-BC, PCNS, PNP, UVA Dept. of Psychiatry
      • Elizabeth McGarvey, EdD; UVA Dept of Public Health Sciences
      • Gary E. Michael, MD; Medical Director, Clinch River Health Services, Inc
      Larry Merkel, MD, PhD; Department of Psychiatry
    • Larry Merkel, MD, PhD; Department of Psychiatry