A telepsychiatry network in North Carolina is alleviating stress in hospital emergency rooms statewide. As of March 2019, there were 56 hospitals in the network, and 4,942 involuntary commitments were overturned. The cumulative return on investment from preventing unnecessary hospitalizations is estimated to be $26.7 million.
Healthcare Innovation recently interviewed Sy Saeed, M.D., M.S., professor and chair in the Department of Psychiatry and Behavioral Medicine at the Brody School of Medicine at East Carolina University (ECU) and director of the North Carolina Statewide Telepsychiatry Program (NC-STeP).
Saeed noted that ECU has long had a focus on telemedicine. “We are one of the longest, continuously running telemedicine centers in the world,” he said. “We started in the early 1990s, long before people were using telemedicine to do much of anything. It was very different technology with different issues and reimbursement back then.,” he said. ECU started work on telepsychiatry in 2004. “We started to work more intensely in this area for the simple reason that the population density in Eastern North Carolina is such that there are small towns separated by long drives. It doesn’t make sense to put clinics in those areas because of low population densities. And it is hard for those people to come to the medical center here in Greenville. Those are the driving forces.”
When it came to mental health, Saeed said, in North Carolina the state had begun closing mental health centers and privatizing the delivery of care. “The end result was, since many of these patients using mental health centers were either uninsured or underinsured, the private sector was not that keen on picking up the tab,” he said. “People started showing up in emergency departments for their basic care or in crisis. In 2012, that had gotten to the point where the number of people showing up in North Carolina emergency departments was twice the national average. Nationally about 5 percent of patients using EDs use it for mental health reason. In North Carolina, that number reached 10 percent. There were roughly about 160,000 people per year who were showing up in North Carolina EDs for that reason.”
Many hospitals don’t have enough psychiatrists to provide care for those patients. Entities like the college of emergency physicians in North Carolina, the state hospital association and other organizations realized they needed help, because when behavioral healthcare patients show up in the ED, they tend to stay a lot longer than other patients. The state convened a meeting of stakeholders, who asked if telepsychiatry could be a solution. Saeed told them that if they were trying to build a telepsych program just to get the patient out of the ED, they would be building the wrong program, because the real need was to create programs in community-based settings, so people don’t end up in the ED in the first place. State leaders asked Saeed to help solve the immediate problem in EDs, and then later they would address community-based solutions. In 2013, the Legislature agreed to fund the creation of a statewide program.
The state agreed to give the program $2 million per year in recurring budget funding, which is predominantly used for equipment. The program also got funding from a Duke Endowment grant. “The state funding pays for development of infrastructure, including a web portal to deal with multiple EHRs and the development of our own EHR system. Also, if we had a patient not covered by a third party, it would cover that cost,” Saeed said. “We bill when the patient has insurance.” Hospitals that participate in the program pay a subscription fee, which is linked to the volume they have. The service is available from 8 a.m. to 6 p.m., seven days per week.
Every quarter NC-STeP publishes metrics on its impact. “The state has given us $12 million so far. For that we saved about $27 million just from admissions, never mind the impact on the ED throughput.”
With the model well-established, Saeed said NC-STeP could scale the program on any scale. “I have had interest from five other states who would like to replicate it,” he said. “We are predominantly funded by the state, so we can’t take that to other places, but we are freely sharing our findings and are happy to help any state that is interested in doing this.”
In addition, the state has started following through on expanding telepsychiatry to community-based settings. Although they still need to pursue additional funding, they already have seven community-based sites up and running. “That is an interesting model,” Saeed said. “Instead of opening our own behavioral health clinics, we are going to primary care sites that take all patients, including uninsured. Those are mostly FQHCs or health department clinics. We said, if you can bring in a licensed clinical therapist such as a social worker, and embed them in your primary care clinic, we will give you a psychiatrist via telehealth.” The patient gets screened and seen for an initial assessment by the embedded provider, and that provider would make a referral for consultation by the psychiatrist, who would go to that clinic via telepsychiatry at least once per week. “Their recommendations go back to the primary care provider,” he said. “It is a collaborative, integrated care type of model.”
Saeed was named the 2019 recipient of the O. Max Gardner Award, given to one faculty member within the UNC System who made the greatest contribution to the well-being of humanity during the current academic year.
