Title: Rural Primary Care and Behavioral Health Access for Children and Adolescents Through Telepsychiatry in Hawaii
1Rural Primary Care and Behavioral Health Access
for Children and Adolescents Through
Telepsychiatry in Hawaii
- Unheard Voices in Healthcare Access to Care
and Communication Issues - Dan Alicata MD, Dan Ulrich MD, Dan Lieberman MD,
Sara Chiu MD, Courtenay Matsu MD, Ricardo Bayola
MD, Iwa Else PhD, Susana Helm PhD - University of Hawaii-Manoa, JABSOM, Department of
Psychiatry - State of Hawaii, Department of Health, Child and
Adolescent Mental Health Division - Mayo Clinic, Rochester Minnesota
- Pulama I Ke Ola Healthcare Conference, Hilo,
Hawaii - May 21, 2009
2Disclosures of Potential Conflicts
3Role of telepsychiatry in meeting the challenges
for rural Hawaii
- Access improve access to health care in rural
and other underserved areas. - Specialty care provide centralized specialty
health care consultation to decentralized primary
care physicians, therapists and educators. - Quality improve quality of care by providing
follow-up after discharge from hospitals
specialty services. - Cost provide specialty care at lower costs to
providers and patients.
4Factors Driving Telepsychiatry
- Increased efficiency.
- Increased convenience / decreased travel time
- patients
- providers
- Decreased costs of care.
- Increased access to care for underserved
populations. - Increased patient compliance and follow-up.
- Because we can!
5Geographic isolation
- Models of telepsychiatry on the mainland can be
effective in Hawaii
6Federally Designated Medically Underserviced
Areas and Populations
7Federally Designated Mental Health Provider
Shortage Areas
8Background Telepsychiatry in Hawaii
- JABSOM, Department of Psychiatry
- Administration, technical, clinical, education
and research cores. - Funding State of Hawaii, Department of Health,
Adult Mental Health Division. - Telepsychiatry consultation services to mental
health clinics on Maui and Molokai. - - resident supervision
- - training curriculum and research development
9Background Telepsychiatry in Hawaii
- JABSOM, Department of Psychiatry
- Developing partnerships with Family Medicine and
Bay Clinic Hawaii Island. - Federally Qualified Community Health Centers.
10Background Telepsychiatry in Hawaii
- Rural Child and Adolescent Telepsychiatry
Molokai - JABSOM, Department of Psychiatry
- Schools are serving children with increasingly
broad spectrum of health care needs. - Remote school districts experience great
difficulty obtaining psychiatric and
psychological consultation within the time frames
mandated by the IDEA. - Virtual office hours through telemedicine
provides timely access. - School staff need ongoing in-service education to
serve them. - School districts have the capacity for
videoconferencing (Teleschool Network).
11Child and Adolescent Telepsychiatry Molokai
- Develop partnerships with
- Department of Education
- Molokai General Hospital and health clinics
- Maui Community College School of Nursing
- University of Hawaii Telehealth Research
Institute - Hawaii Educational Treatment Interventions (HETI)
12Child and Adolescent Telepsychiatry Teleschool
Network
- Teleschool Network with gt 250 VTC units in
schools and district offices. - 7 remote VTC sites on Molokai.
- IP network
- - secure, enclosed network using internet
protocol with a data stream of 384 Kb/s. - Polycom VSX 7000 VTC units with monitors gt 37 in.
- Sending / receiving sites anywhere along the hub.
13Teleschool Network DOE goals
- Facilitate the provision of timely and quality
staff development activities in spite of
geographic challenges. - Deliver sustained and focused support services to
schools. - Provide students with quality remedial and
enrichment programs. - Reduce the time lost in traveling to workshops or
meeting sites.
14(No Transcript)
15 16Project Parameters
- Provide 4-direct patient care/consult hours/week.
- Reimbursement Agency contract with DOE to
provide Child and Adolescent psychiatric
services. - Youth and their families with any psychiatric
condition. - Initial evaluation, ongoing care as well as
consultation with treatment, education and
support staff (DOE, DOH, Family Court,
Probations, DHHS-CWS). - Patients / parents agreed to receive care via
telepsychiatry. - Frequency monthly visits to Molokai weekly
telepsychiatry clinics.
17Preliminary data
- Telepsychiatry clinics 117
- Total hours 392 - hours
- Telepsychiatry encounters total 1,012
- students total 283 (28.0 )
- - adolescents 13-19-years-old (78.1 )
- Parents/guardians total 355 (35.1 )
- - staff total 374 (37.0 )
18Pearls
- Telepsychiatry program collaborated with the
multiple community systems serving these needy
youth, including primary care medicine,
community- and school-based therapists, day
programs, addictions programs, Family Court,
Juvenile Corrections, Child Welfare Services, and
the education system. - In this type of consultation, telepsychiatry can
provide the glue that binds these community
systems and youth together.
19Future Project Goals
- Infrastructure development.
- Bridge Teleschool Network with medical clinics
and health centers across the state. - Utilize existing Teleschool network to expand
telepsychiatry services to other rural school
districts (Hawaii Island, Lanai, Hana, Waianae
and Waimanalo). - Recruit child and adolescent psychiatrists.
- Develop medical student education and resident
training curriculum. - Develop administration, research and technical
cores.
20Research Goals
- Improve assessment of mental health outcomes.
- Examine predictors of effective care delivered
through telepsychiatry. - Evaluate the impact of cultural factors on the
success of interventions. - Investigate the economic impact of access to
services through telepsychiatry. - Explore the barriers to care delivered through
telepsychiatry. - Assess the impact of telepsychiatry in preserving
the rural mental health workforce.
21Hawaii Island Telepsychiatry Initiative Project
Scope
- Contract established with CAMHD and UH
(Psychiatry). - Establish telepsyhchiatry consultation with Mayo
Clinic. - Telepsychiatry case conference with Tripler Child
and Adolescent Psychiatry resident training
program. - Establish VTC linkages between UH psychiatry
(Queens Medical Center), Hawaii Family Guidance
Centers (CAHMD), Mayo Clinic, Tripler Army
Medical Center and DOE. - Develop policies and procedures for participating
sites, staff training, and the education and
training curriculum for students and residents. - Develop administration, technical and research
cores.
22Child and Adolescent Telehealth (UH-DOP / CAMHD
/ Mayo Clinic) Working Group
- Family Guidance Center
- Mental health care coordinator clinical
director - Review and completion
- CAFAS
- Mental health assessment
- Qualifying diagnosis
- Eligibility determination
- Final approval via Division (medical director)
referral
Triage and Assembly of Patient panel
Acute hospital DOE Family Court DHS Primary care
Family
Telehealth Service
23Family Guidance Center Levels of Care
Less intensive In-home Out-of-home More
intensive
Levels of care Intensive in home
(IIH) Multisystemic therapy (MST) Functional
family therapy (FFT) Therapeutic foster home
(TFH) Multimodal therapeutic foster care
(MTFC) Therapeutic group home (TGH) Community
based residential (CBR) Hospital based
residential (HBR)
24Telepsychiatry Initiative Progress
- VTC units installed at UH, Queens Counseling
Services, and Hawaii Family Guidance Centers
(Hilo, Waimea, Kona). - TeleSchool Hawaii State DOE, Pahoa HS
- Develop policies and procedures.
- Develop trainee curriculum and clinical
schedules, faculty supervision - - first patients were seen at the Hilo FGC in
September 2008. - Administration core developed (UH
psychiatry-FGCs) - - provider licensing, credentialing, insurance
(Hawaii-Mayo) - - clinical scheduling, registration,
billing/tracking data
25Telepsychiatry Initiative Progress
- Technical core developed (Hawaii-Mayo) equipment
/ connection development, maintenance, quality
assurance, encryption. - Research core evaluate program efficacy,
quality, satisfaction, clinical outcomes and
sustainability in rural Hawaii communities. - Collaboration with Mayo Clinic (monthly
telepsychiatry case conferences started in April
2008 consultation) - - provide specialized expertise for the
evaluation of complex diagnostics,
pharmacogenomics and cross-cultural psychiatry
and its relevance to multi-ethnic communities in
rural Hawaii. - - evaluate the role of telepsychiatry in global
service, training and education, research and
staff development.
26Telepsychiatry Research
- Overview
- Child and Adolescent Psychiatry
- Adult Psychiatry
- Integrated Service System
27Child Adolescent Research
- Goal 1 Mental Health Outcomes
- Measure the extent to which mental health
outcomes are stable and improved via
telepsychiatry - as compared to no treatment and comparable
face-to-face treatment. - Goal 2 Service Satisfaction
- Are people satisfied with telepsychiatry
- Providers
- Clients/patients and their family
- Goal 3 Organizational Development
- What does the Department of Psychiatry need to
know and do to meet the psychiatric services
needs of children and adolescents in rural areas? - Research and evaluation
- Translated to action.
28Results Service Satisfaction
- 1. Telehealth Equipment/Technology (5 items,
mean4.5) - Knowing there is help available at the UH
provider's site made me feel comfortable using
telepsychiatry. (mean 4.8). - 2. Communication Quality (7 items, mean4.4)
- I was able to understand the client's verbal
(mean4.5) and nonverbal communication (mean
4.3). - 3. Travel/Distance (3 items)
- 100 RT - commute time and airfare
- I would rather provide telepsychiatry than travel
to the client's location to provide face-to-face
care for him/her (mean4.1). - 4. General Service (7 items, mean4.4)
- Overall, I was satisfied with the quality of the
services provided by telepsychiatry (mean4.3). - The participation of the distant site provider
was essential to obtain an adequate history or
information (mean4.7). - 5. Training (4 items, mean3.4)
- I feel confident in using telepsychiatry after
training (as a result of this rotation)
(mean3.5).
29Future Directions
- Research evidence-based data driving culturally
sensitive training and education, clinical
service and work force development and
sustainability. - Linking all Hawaii FGCs through telepsychiatry.
- Strengthening the continuity of care of youth in
transition to/from hospital-based and
community-based treatment programs. - Providing child and adolescent psychiatric
services to military families living in rural
Hawaii. - The role of telepsychiatry in bridging the FGCs,
primary care clinics and the local school
districts.
30Collaboration/Partnerships
- JABSOM A. Guerrero, C. Bell, J. Huh, C.
Koyanagi, M. Fukuda, I. Else, S. Helm, M. Horton,
T. Unten - Hawaii Family Guidance Centers (CAMHD) D.
Lieberman, S. Chiu, K. Acquaro, P. Azevedo - Mayo Clinic D. Mrazek, C. Swintak, B. Koplin,
M. Williams - Community Child and Adolescent Psychiatrists
(Hilo) Drs. Ching, Eaglin, Kagawa - Tripler Army Medical Center S. Uthiol (Program
Director, Child and Adolescent Psychiatry) - TeleSchool (Hawaii State DOE) D. Miyamoto, S.
Miyazono
31Thank you!