Increasing Access and Improving Outcomes

While news outlets today are heralding the explosive growth of telehealth amidst a global health pandemic, the field of telemedicine was new to me when I left my fellowship in child and adolescent psychiatry over 10 years ago.  I eagerly researched jobs while living in my new home state of South Carolina.  While looking for a career in crisis and emergency room psychiatry, I realized that there were no free-standing psychiatric emergency rooms in the state of South Carolina.  Having left one of the busiest psych ERs in Los Angeles, I wondered how I would be able to see and serve the patient population that I loved without an actual ER.  It was then that I stumbled upon a job listing for a crisis telepsychiatrist.  My career in telemedicine began then and has continued now for over a decade as I have been privileged to provide care for some of the sickest and most vulnerable of our mentally ill patients.

As a telepsychiatrist in the crisis setting, I see mentally ill patients of all ages in ERs across the state.  In a single day, I might interface with a 6-year-old sent in from school for threatening to self-harm, a middle-aged schizophrenic individual who has been noncompliant with medications and has decompensated, and a 92-year-old brought in from a nursing home for increasing confusion and agitation.  As a result of telehealth, each one of these patients has the benefit of seeing a physician or other specialist who has been trained and board-certified in psychiatry and who has the experience and knowledge to best direct their care. 

According to the National Institute of Mental Health, one-fifth of American adults live with mental illness (over 46 million people), and the prevalence of mental illness among adolescents ages 13-18 is almost 50%.  These individuals live in a wide range of geographic settings and have varying socioeconomic backgrounds.  What they all, however, have in common, is a need for consistent and compassionate access to mental health services.   Most of them have greater health care needs and are at risk for poor health outcomes and regardless of their location or their economic status, they have limited access to services. 

Telehealth offers access to mental health services that would otherwise not be available.  Through the use of computers, phones, and video conferencing, psychiatrists, and therapists can interface with patients that might not otherwise be seen.  The use of this technology can be implemented across all settings: from the ER to inpatient medical and psychiatric units, outpatient clinics, prisons, intensive outpatient programs, nursing homes, and even within the patient’s own home.  Telehealth offers those with mental illness an opportunity to interface with a skilled and knowledgeable provider who might not otherwise be available.

Rural locations, urban neighborhoods, and community mental health centers are just a few of the areas that can benefit immensely from the use of telehealth services.  These areas face critical shortages of psychiatrists and other mental health providers, but the use of technology now allows individuals who suffer from severe and chronic mental illness to access highly trained professionals.  Additionally, it reduces some of the burdens that people face in accessing services by eliminating long drive times to far away appointments thereby decreasing absences from school and or work for patients and family members.    

The ultimate goal of providing care in this manner is to improve outcomes for mentally ill individuals.  This may mean fewer ER visits, fewer inpatient hospitalizations, and improved functioning whether within a family structure, job, or living environment.   For society as a whole, this translates into fewer healthcare costs, and in an era of burgeoning costs, reducing health care expenditures is ideal.  As a key example, having access to a psychiatrist in a rural ER could mean that a psychiatric patient is seen, evaluated and inpatient hospitalization is recommended.  The patient could be transferred within hours instead of days which is frequently what occurs when psychiatric patients are managed by other health care providers who are not as familiar with medications, conditions, or levels of care. 

The coronavirus pandemic of 2020 has brought to the forefront what those of us who have been practicing telemedicine for years have long known.  The use of technology to reach individuals who might not otherwise have access to services is a highly effective means of providing care.   In the field of psychiatry, in particular, telehealth offers a vulnerable population access to skilled specialists while reducing health care costs and eliminating some of the barriers that these individuals face in obtaining treatment.  In response to Covid-19, many states and lawmakers have begun to relax state regulations limiting access to and funding for telehealth services thereby allowing greater access to telehealth for individuals covered by Medicaid.  As we move forward, we must take with us the lessons that we have all learned during this pandemic: technology is available and can be used to help serve those most in need.