Merkel

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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

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

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