file · Web viewImproving Mental Health Care for Elderly Residents in a Rural Virginia...

Running head: IMPROVING MENTAL HEALTH CARE 1

Improving Mental Health Care for Elderly Residents in a Rural Virginia Long Term Care

Facility through Telemedicine Technology: A Grant Proposal

Brian Capel

University of Virginia

On my honor as a student I have neither given nor received aid on this assignment.

IMPROVING MENTAL HEALTH CARE 2

Improving Mental Health Care for Elderly Residents in a Rural Virginia Long Term Care

Facility through Telemedicine Technology: A Grant Proposal

Population and Purpose

Mental illness remains a debilitating and devastating phenomenon that causes great pain

and suffering for those not able to receive proper and effective mental health care. One typically

overlooked vulnerable population in regards to mental health has been the geriatric population.

Mental health remains as important for the elderly as with any other population. Mental illness

is not a normal part of growing older as some may assume. The World Health Organization

(2013), posits that over 20% of adults aged 60 and over suffer from a mental disorder. The four

most common mental disorders of the elderly include: dementia, depression, anxiety, and

substance abuse (World Health Organization, 2013) (see Figure 1). The elderly face increasing

life stressors that make them more vulnerable to mental illness. Loss of physical ability, pain,

loss of self-care and independence places many elderly persons at greater risk of experiencing a

mental illness. Concurrently, it is estimated that two-thirds of individuals who reach the age of

65 will need long term care (LTC) in their lifetime (World Health Organization, 2013). With the

projected population growth of residents residing in LTC facilities nationally (see Figure 2) and

the explosive projected growth of residents over the age of 64 in Virginia (Weldon Cooper

Center for Public Service, Demographics & Workforce Group, 2012) (see Figure 3), it is critical

that elderly persons have adequate access to mental health care especially if they are living in

LTC facilities in Virginia. Unfortunately, only 10% of elderly persons in LTC facilities receive

adequate mental health care treatment (Sumner, 2001).

Telemedicine in the form of telepsychiatry or telemental health could provide a feasible

solution to the growing mental health needs of this underserved population. Telepsychiatry is


defined as a use of electronic technologies to provide psychiatric care to persons at a distance

(Ellington, 2013). Telepsychiatry utilizes videoconferencing between a psychiatric provider and

a patient in order to deliver psychiatric services. The literature has ample examples of

telepsychiatry services being an effective and equivalent proxy for face-to-face psychiatric

services (Conn, Madan, Lam, Patterson, & Skirten, 2013; Grady & Singleton, 2011; Jacob,

Larson, & Craighead, 2012; Johnston & Jones, 2001; Rabinowitz et al., 2010; Ramos-Rios,

Mateos, Lojo, Conn, & Patterson, 2012; Shore, 2013). The purpose of this proposal is to

establish an efficient and cost-effective telepsychiatry program for elderly residents at a rural

Virginia LTC facility who require psychiatric care. It is expected that initiating a telepsychiatric

program will reduce mental health disparities facing this population and improve access to much

needed mental health care.

Background and Current Issues

Telepsychiatry was first introduced in the 1950’s as a means of providing psychotherapy

via two-way closed circuit television (Glover, Williams, Hazlett, & Campbell, 2013). It was not

until the 1990’s that telepsychiatry utilizing distance videoconferencing began to evolve and

become increasingly widespread (Norman, 2006). In the past two decades, advancing technical

progress has improved the delivery of telepsychiatry programs. Today, telepsychiatry has grown

to become an accepted standard of practicing mental health care. The use of telepsychiatry lends

itself well to the nature of psychiatric care due to the fact that most psychiatric interviews do not

involve physical examinations (Neufeld, Yellowlees, Hilty, Cobb, & Bourgeois, 2007). For

mental health providers, it is the structured psychiatric interview that culminates in a psychiatric

diagnosis and subsequent treatment. Medical students, psychiatry residents, and psychiatric

nurse practitioners are readily being introduced to telepsychiatry through clinical exposure and


integrated practice experiences (Glover et al., 2013). The proliferation of telepsychiatry has not

diminished the continued shortage of psychiatric providers for those living in rural areas. Many

providers choose to practice in urban areas for such reasons as cultural, recreational, and

academic, and professional. Disappointingly, this leaves psychiatric treatment in rural nursing

homes to the supervision of primary care physicians who have limited mental health training and

expertise. It is indeed a social injustice that some of the most vulnerable persons, namely

geriatric residents in rural LTC facilities, face the greatest difficulties in obtaining mental health

services due to lack of providers (Ramos-Rios et al., 2012). With telepsychiatry, psychiatric

providers are able to continue to live in urban areas while providing mental health treatment to

rural areas without having to travel long distances for face-to-face encounters.

Telepsychiatric skeptics are finding an expanding base of evidence supporting the

effectiveness of telepsychiatry. Two of the most prolific researchers in this area have been Drs.

Jay Shore and Donald Hilty. These two psychiatrists have identified in their studies that

telepsychiatry is a viable option to face-to-face interviews in the delivery of mental health care

(Hilty et al., 2006; Hilty et al., 2013; Marcin et al., 2005; Neufeld et al., 2007; Shore & Manson,

2005; Shore, Brooks, Savin, Manson, & Libby, 2007; Shore, 2013). Telepsychiatry programs

have not only resulted in clinical improvements in recipients (Hilty et al., 2013; Marcin et al.,

2005); there is high satisfaction among its users (Ellington, 2013; Hilty et al., 2013). It enables

psychiatric providers to overcome geographic barriers to provide a specialized service in real

time that could not be typically supported through traditional psychiatric services. Increasing

access to mental health via telepsychiatry ultimately reduces morbidity and the overall costs to

the health care system (Hilty et al., 2013; Shore, Thurman, Fujinami, Brooks, & Nagamoto,

2011).


Opponents to telepsychiatry have cited that implementing this form of technology

services is not cost-effective. Over the years, transmission and equipment costs for

telepsychiatry has steadily decreased. Shore et al. (2007) found that based on transmission and

equipment costs, telemedicine was less expensive than in-person interviews if the psychiatric

provider meets a quota of patient encounters. The ability of telepsychiatry as a preventive

treatment can be considered an additional cost-effective measure. Through telepsychiatry,

elderly patients can have reduced transfers to emergency departments and hospitalizations for

mental illness crises. Psychiatric providers using telepsychiatry have reduced costs of travel and

increased productivity. Unfortunately, some third-party payers for psychiatric care of the elderly

remain inconsistent in reimbursement for services thwarting cost-effectiveness (Sumner, 2001).

Because studies have repeatedly demonstrated the efficacy of telepsychiatry with equivalent

patient outcomes and reductions in overall health care costs, it is expected that third-party payers

will respond with appropriate compensation.

Any successful telepsychiatry program must meet the needs of the community it serves.

The program must be an efficient mode of consultation for all key stakeholders. Most

telepsychiatry services are based in consultative referrals, so it is paramount that a collaborative

relationship between the telepsychiatry provider, the primary care physician, and the staff of the

LTC facility be well established prior to implementation. The telepsychiatry provider must have

familiarity with the rural site and an understanding of the community culture (Hilty et al., 2006).

A significant number of primary care physicians delivering care in long term facilities may be

uncomfortable with this technological mode of care delivery. It is crucial to meet with these

individuals, explain the basic format of telepsychiatry, illuminate the effectiveness based in

extant research, and postulate the reduction of their burden to evaluate and treat mental disorders


with the advent of telepsychiatry. Facility staff must have a definitive acceptance that

telepsychiatry will improve the mental health of its residents. If either of these criteria are not

met, then the most likely event will be reduced number of referrals and kept appointments.

Thus, telepsychiatry is not implemented solely by the provider. An integrated interdisciplinary

trust must be developed where the telepsychiatry provider, primary care physician, and facility

staff are cohesively working “side-by-side” through telepsychiatry to improve mental health

outcomes in the residents served (Shore, 2013).

Improvement via Technology

According to a recent Institute of Medicine report (Institute of Medicine of the National

Academies, 2012), an estimated 5.6-8 million or one in five elderly American citizens have at

least one mental health issue. However, because of psychiatric provider shortages, elderly

residents remain underserved or receive psychiatric treatment from primary care professionals

who have limited mental health training (Rabinowitz et al., 2010). Unfortunately, these

shortages of psychiatric providers are especially prominent in rural geriatric LTC settings and do

not appear to be ceasing in the near future (Shore et al., 2011). Telepsychiatry could be a

practical alternative to face-to-face psychiatric treatment. According to Shore (2013),

telepsychiatry has no restrictions for any psychiatric treatments or populations. Telepsychiatry

services reduces wait times for care and provides access to treatment by trained mental health

professionals. Videoconferencing may seem to be an impersonal care delivery method; however,

a telepsychiatry program can have equivalent patient satisfaction and outcomes as any traditional

psychiatric treatment (Hilty et al., 2013; Shore, 2013).

Constructing a viable telepsychiatry program for a rural Virginia LTC facility will be a

challenging but doable endeavor. The plan for implementing this program can be understood by


five basic steps (see Figure 4). However, there will be a number of preliminary actions that will

need to be undertaken before treatment sessions are initiated. (see Figure 5). A LTC facility in

rural Virginia will be chosen as a primary site for implementation. The site will be at least fifty

miles from a major Virginia metropolitan area and have a town population of less than 10,000

persons. Policies used to guide implementation will be extracted from the American

Telemedicine Association guidelines for telepsychiatry services (Turvey et al., 2013). Before

starting the process of gathering equipment and designing the practice environment, the program

director and designated program personnel will obtain clinical telepsychiatric training at a

Virginia academic university health setting. An informational technologist with experience in

videoteleconferencing will be part of the salaried personnel.

Once the environment and technological equipment have been obtained, the program

informational technologist will set up installation of telepsychiatry equipment for video

transmission. Upon successful set up of equipment, the clinical office site and the chosen LTC

facility will have several practice sessions to make sure equipment is functioning properly. To

begin the program process, the LTC facility will fax referrals and informed consent to treatment

forms, current medications, and resident facesheets to the clinical office. The telepsychiatry

provider will videoteleconference with key LTC staff to discuss pertinent patient history and

present psychiatric and associated medical status before interviewing the resident. A nursing

staff member trained in using the telepsychiatry equipment will accompany the resident for

safety and optimal equipment use. After the interview has finished, the telepsychiatry provider

will document the encounter via portable electronic health record and fax recommendations back

to the LTC. Finally, a salaried administrative assistant with experience in third-party payer

billing will send appropriate forms and documentation for reimbursement purposes.


Challenges and Barriers to Implementation

Undertaking the development of a telepsychiatry program is a worthy feat; however,

considerations must be made for issues that could hinder the process of implementation. One of

the most profound challenges to implementation is the cultivation of professional relationships

between the proposed facility staff, primary care providers, and telepsychiatry professionals.

Past research by (Conn et al., 2013; De Weger, Macinnes, Enser, Francis, & Jones, 2013) posit

the necessity of actively involving clinical and administrative staff in the planning and

implementation of any electronic health technology. If facility gatekeepers are not convinced

that telepsychiatry is a worthwhile and viable service, use of the service will be minimal.

Another challenge to implementation will be the need for additional facility nursing staff to

accompany residents during telepsychiatry sessions. It is highly likely that geriatric residents in

rural LTC facilities have not been exposed to videoconferencing for their health needs. In

addition, some residents may not have the physical or cognitive capacity to independently attend

a telepsychiatry session. Thus, it is crucial that a staff member be present with working

knowledge of the equipment who can introduce residents to the service and manage

technological mishaps. Many geriatric LTC facilities have a shortage of nursing staff available;

thus, requiring a staff member to be present may place a strain on limited staff resources.

Nursing staff must be able to accept benefit versus staffing costs for this service. Next, although

it is not ubiquitous, it is expected that some residents might have communication problems in

terms of hearing impairment during a telepsychiatry session (Ramos-Rios et al., 2012).

Headphones with increased volume capabilities could be issued to those with hearing deficits.

Lastly, with any technological pursuit, there are bound to be technological misfortunes in terms

of periodic connectivity issues. According to Turvey et al. (2013), a contingency plan should be


in place when there are connectivity problems. This program will allow for substituting

videoconferencing for teleconferencing during technical difficulties. Feedback in the form of

electronic or written surveys will be collected from residents, responsible parties or guardians of

residents who do not have capacity, facility staff, and primary care providers as a means of

continuous quality improvement.

Future Implications

With the expected successful implementation of telepsychiatry services, there are a

number of future directions to progress and expand this program beyond the limits of a solitary

facility service. The first promising strategy would be to develop telepsychiatry in additional

Virginia LTC facilities thereby improving the cost-effectiveness of the service. Next,

telepsychiatry could be introduced into primary care offices as a consultation service to

comprehensively address patient medical and mental health issues. Another future endeavor for

this program would be the provision of psychoeducation and clinical training via

videoconferencing. (Chung-Do et al., 2012) recommends that telepsychiatry be used to train

future psychiatric providers in this mode of care. Virginia schools of nursing with a psychiatric

nurse practitioner program could have clinical experiences using this technology. Having

additional Virginia psychiatric nurse practitioners engage in telepsychiatry will reduce anxiety

and increase comfort with this service. Learning the skill of videoconferencing for psychiatric

assessment and treatment could be resourceful in decreasing the professional shortage of mental

health providers in rural Virginia areas. Finally, there is a dearth of research related to the

incorporation of telepsychiatry for rural geriatric LTC facilities (Jacob et al., 2012; Rabinowitz et

al., 2010; Ramos-Rios et al., 2012). Telepsychiatry must be continuously vetted for its efficacy

and cost-effectiveness. A future endeavor will be to formulate and initiate research studies that


address quality assurance related to patient satisfaction, costs of service delivery, and ultimately,

clinical outcomes. Telepsychiatry is a promising approach to reduce mental health disparities in

the elderly and improve access to psychiatric care for one of the most vulnerable populations in

Virginia.


References

Chung-Do, J., Helm, S., Fukuda, M., Alicata, D., Nishimura, S., & Else, I. (2012). Rural mental

health: Implications for telepsychiatry in clinical service, workforce development, and

organizational capacity. Telemedicine Journal & E-Health, 18(3), 244-246.

doi:http://dx.doi.org/10.1089/tmj.2011.0107

Conn, D. K., Madan, R., Lam, J., Patterson, T., & Skirten, S. (2013). Program evaluation of a

telepsychiatry service for older adults connecting a university-affiliated geriatric center to a

rural psychogeriatric outreach service in northwest ontario, canada. International

Psychogeriatrics, 25(11), 1795-1800. doi:http://dx.doi.org/10.1017/S104161021300118X

De Weger, E., Macinnes, D., Enser, J., Francis, S., J., & Jones, F., W. (2013). Implementing

video conferencing in mental health practice. Journal of Psychiatric & Mental Health

Nursing, 20(5), 448-454. doi:10.1111/j.1365-2850.2012.01947.x

Ellington, E. (2013). Telepsychiatry by APRNs: An answer to the shortage of pediatric

providers?. Issues in Mental Health Nursing, 34(9), 719-721.

doi:http://dx.doi.org/10.3109/01612840.2013.784386

Glover, J. A., Williams, E., Hazlett, L. J., & Campbell, N. (2013). Connecting to the future:

Telepsychiatry in postgraduate medical education. Telemedicine Journal & E-Health, 19(6),

474-479. doi:http://dx.doi.org/10.1089/tmj.2012.0182


Grady, B., & Singleton, M. (2011). Telepsychiatry "coverage" to a rural inpatient psychiatric

unit. Telemedicine Journal & E-Health, 17(8), 603-608.


Hilty, D. M., Ferrer, D. C., Parish, M. B., Johnston, B., Callahan, E. J., & Yellowlees, P. M.

(2013). The effectiveness of telemental health: A 2013 review. Telemedicine Journal & E-

Health, 19(6), 444-454. doi:http://dx.doi.org/10.1089/tmj.2013.0075

Hilty, D. M., Yellowlees, P. M., Cobb, H. C., Bourgeois, J. A., Neufeld, J. D., & Nesbitt, T. S.

(2006). Models of telepsychiatric consultation--liaison service to rural primary care.

Psychosomatics, 47(2), 152-157. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?

T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=med5&AN=16508028

Institute of Medicine of the National Academies. (2012). The mental health and substance abuse

workforce for older adults: In whose hands? Retrieved from

http://www.iom.edu/~/media/Files/Report%20Files/2012/The-Mental-Health-and-

Substance-Use-Workforce-for-Older-Adults/MHSU_olderadults_RB_FINAL.pdf

Jacob, M. K., Larson, J. C., & Craighead, W. E. (2012). Establishing a telepsychiatry

consultation practice in rural georgia for primary care physicians: A feasibility report.

Clinical Pediatrics, 51(11), 1041-1047. doi:http://dx.doi.org/10.1177/0009922812441671

Johnston, D., & Jones, B. N.,3rd. (2001). Telepsychiatry consultations to a rural nursing facility:

A 2-year experience. Journal of Geriatric Psychiatry & Neurology, 14(2), 72-75. Retrieved

from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&

D=med4&AN=11419570


Marcin, J. P., Nesbitt, T. S., Cole, S. L., Knuttel, R. M., Hilty, D. M., Prescott, P. T., &

Daschbach, M. M. (2005). Changes in diagnosis, treatment, and clinical improvement

among patients receiving telemedicine consultations. Telemedicine Journal & E-Health,

11(1), 36-43. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?


Neufeld, J. D., Yellowlees, P. M., Hilty, D. M., Cobb, H., & Bourgeois, J. A. (2007). The e-

mental health consultation service: Providing enhanced primary-care mental health services

through telemedicine. Psychosomatics, 48(2), 135-141. Retrieved from

http://ovidsp.ovid.com/ovidweb.cgi?


Norman, S. (2006). The use of telemedicine in psychiatry. Journal of Psychiatric & Mental

Health Nursing, 13(6), 771-777. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?


Rabinowitz, T., Murphy, K. M., Amour, J. L., Ricci, M. A., Caputo, M. P., & Newhouse, P. A.

(2010). Benefits of a telepsychiatry consultation service for rural nursing home residents.

Telemedicine Journal & E-Health, 16(1), 34-40.


Ramos-Rios, R., Mateos, R., Lojo, D., Conn, D. K., & Patterson, T. (2012).

Telepsychogeriatrics: A new horizon in the care of mental health problems in the elderly.

International Psychogeriatrics, 24(11), 1708-1724.

doi:http://dx.doi.org/10.1017/S1041610212000981


Shore, J. H. (2013). Telepsychiatry: Videoconferencing in the delivery of psychiatric care.

American Journal of Psychiatry, 170(3), 256-262.

doi:http://dx.doi.org/10.1176/appi.ajp.2012.12081064

Shore, J. H., Brooks, E., Savin, D. M., Manson, S. M., & Libby, A. M. (2007). An economic

evaluation of telehealth data collection with rural populations. Psychiatric Services, 58(6),

830-835. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?


Shore, J. H., & Manson, S. M. (2005). A developmental model for rural telepsychiatry.

Psychiatric Services, 56(8), 976-980. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?


Sumner, C. R. (2001). Telepsychiatry: Challenges in rural aging. Journal of Rural Health, 17(4),

370-373. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?


Turvey, C., Coleman, M., Dennison, O., Drude, K., Goldenson, M., Hirsch, P., . . . Bernard, J.

(2013). ATA practice guidelines for video-based online mental health services.

Telemedicine Journal & E-Health, 19(9), 722-730.


Weldon Cooper Center for Public Service, Demographics & Workforce Group. (2012). 2020-

2040 population projections by age and sex for virginia and its PDCs and member localities.

Retrieved September 19, 2014, from http://www.coopercenter.org/demographics/virginia-

population-projections


World Health Organization. (2013). Mental health and older adults: Fact sheet. Retrieved

September 19, 2014, from http://www.who.int/mediacentre/factsheets/fs381/en/


Dementia Depression Anxiety Substance Abuse

10%

7%

4%

1%

Figure 1. Percentages of mental disorders in adults older than 60 years old. Adapted from

Mental health and older adults: Fact sheet, In World Health Organization, 2013, Retrieved

September 19, 2014 from http://www.who.int/mediacentre/factsheets/fs381/en/. Copyright 2013

by World Health Organization. Adapted with permission.


1990 2000 2010 2020 2030 2040 2050 20600

5

10

15

20

25

30

Year

Pers

ons

in M

illio

ns

Figure 2. Projected number of elderly residents in millions residing in long term care facilities.

Adapted from Mental health and older adults: Fact sheet, In World Health Organization, 2013,

Retrieved September 19, 2014 from http://www.who.int/mediacentre/factsheets/fs381/en/.

Copyright 2013 by World Health Organization. Adapted with permission.


2020 2030 2040

822,206 879,952 993,408

388,094582,518

712,088149,689

191,424

282,229

65-74 75-84 85+

Figure 3. Projected populations of elderly persons aged 65 and older living in Virginia by

decade. Adapted from 2020-2040 population projections by age and sex for Virginia and its

PDCs and member localities, In Weldon Cooper Center for Public Service, Demographics &

Workforce Group, 2012, Retrieved September 19, 2014 from

http://www.coopercenter.org/demographics/virginia-population-projections


Figure 4. Fundamental steps of proposed telepsychiatry intervention. This figure illustrates the

progression of steps that will be undertaken to achieve the telepsychiatry intervention proposal.

Step 1Initial Telepsychiatry Environment and Equipment Set Up

Step 2Liaison with Rural Long Term Care Facility and Primary Care Providers to Initiate Telepsychiatric Intervention

Step 3Administer Telepsychiatry Intervention to Elderly Residents in Rural Long Term Care Facility

Step 4Gather Feedback From Stakeholders on Effectiveness of Intervention

Step 5Improvement in Access to Mental Health Care for Elderly Residents Living in Rural Long Term Care Facility


Telepsychiatry Practicum

Clinical Office & LTC Facility Selection

Environmental Setup

Facility Staff Training

Equipment Testing

Intervention Initiation

Feedback Collection

Findings Report

10/01/14 10/31/14 11/30/14 12/30/14 01/29/15 02/28/15 03/30/15 04/29/15 05/29/15

Figure 5. Timeline for proposed telepsychiatry program. This figures illustrates the specific

amounts of time needed to complete facets of the telepsychiatry program.

Notes:

Telepsychiatry Practicum: October 1, 2014-November 14, 2014 (45 days)

Clinical Office & LTC Facility Selection: November 14, 2014-December 14, 2014 (30 days)

Environmental Setup: December 14, 2014-January 14, 2015 (30 days)

Facility Staff Training: January 14, 2015-January 21, 2015 (7 days)

Equipment Testing: January 22, 2015-January 29, 2015 (7 days)

Intervention Initiation: January 30, 2015-April 30, 2015 (90 days)

Feedback Collection: May 1, 2015-May 14, 2015 (14 days)

Findings Report: May 14, 2015-May 28, 2015 (14 days)

file · Web viewImproving Mental Health Care for Elderly Residents in a Rural Virginia...

Documents

Transcript of file · Web viewImproving Mental Health Care for Elderly Residents in a Rural Virginia...