Not unlike many states across the country, Nebraska is experiencing a severe shortage of psychiatrists.
Nebraska has a population of roughly 1.9 million people, yet only has 156 practicing psychiatrists. Eighty-four percent of these psychiatrists are practicing in metropolitan areas such as Omaha and Lincoln, which leaves 25 psychiatrists to cover the remaining 70,000 square miles of the state.
As the only freestanding children's hospital in Nebraska, Children's Hospital & Medical Center viewed this as a major issue; an issue that was further complicated by our geographic location in Omaha, which is located on the far east side of the state. We were in a situation where we had families driving six hours roundtrip for a 20-minute psychiatry follow-up appointment. We knew we could do better.
In 2016, we turned our attention to telehealth to better care for our pediatric patients. Here is a glimpse into our health system’s approach and success with telepsychiatry:
Engaging a strong physician champion
At the time we began looking at telepsychiatry, we were lucky enough to have Jennifer McWilliams, MD, a child and adolescent psychiatrist, join our team. Dr. McWilliams was not only a strong physician champion in psychiatry, she had an extensive background in telehealth at both the University of Iowa and Nebraska Medicine. Dr. McWilliams brought with her meaningful connections with primacy care offices and clinics around the state, which really helped us build a robust telepsychiatry network.
Working around barriers and forming meaningful connections
Children's chose American Well as its telehealth platform provider and began to strategize how best to build this telepsychiatry program. Something that was very important to our program was the ability to prescribe medication remotely, and for psychiatry that meant controlled substances. Our team did a lot of research and due diligence into prescribing controlled substances via telehealth. We thoroughly reviewed the Ryan Haight Act and determined that our team could legally and safely prescribe controlled substances if our patients were located within a primary care office, hospital or physician clinic when receiving telepsychiatry care.
Children's partnered with primary care offices, hospital systems in rural communities, and with our own physician clinics across the state to set up sites where patients could go to receive psychiatric care. To begin, we established six different sites throughout Nebraska and Iowa. We determined the best locations for these sites by looking at rural communities that had the most need for this type of service and then reaching out to primary care offices in those communities.
Establishing a pediatric telepsychiatry workflow
At each PCP, health system or provider clinic site, a room is designated for remote psychiatry visits. A nurse or social worker acts as the "telepresenter," and is responsible for bringing the patient and family into the room, obtaining vital signs, ensuring the connection was working, and troubleshooting any issues. They then step out of the room to allow for our psychiatrists to conduct the video visit. Younger children are seen together with their parents, while adolescents are seen on their own.
We use this workflow for general pediatric psychiatry, including evaluations and follow-up appointments. The breakdown of conditions is very similar to what we see in outpatient clinics: depression, anxiety, ADHD and autism. We are also able to establish new relationships through this program and bring new patients into the health system.
Results: Better care and more demand
The results we've seen in the first year of this program have been outstanding. Dr. McWilliams — on her own — has conducted more than 600 telepsychiatry visits. We have added a second telehealth provider and are projected to complete over 2,000 visits in 2018.Through the program, we were able to reduce the no-show rate of follow-up psychiatry appointments initially by 50 percent, our current trends reflect reduced and stable no show rates for telehealth and in person. We were also able to reduce physician windshield time by 26 hours per week, as well as save our patients and their families significant travel time by allowing them to see a psychiatrist closer to home.
The response from patients has been overwhelmingly positive and has caused a surge in demand from clinics who want access to these telepsychiatry visits. Due to the demand, Children's has expanded to two additional clinics, with pending requests from a half dozen more. We have also added an advanced practice provider to provide psychiatry visits through the program.
As health system in a rural state, we have access issues for conditions beyond psychiatry, but the success of our telepsychiatry program is proof that a well throughout telehealth initiative can help expand care for any condition.