The Vermont Emergency Telepsychiatry Network (VETN) is envisioned as a statewide system where patients presenting to emergency departments with acute mental health crises will receive timely psychiatric assessment via videoconferencing technology.
In a recent presentation to the National Consortium of Telehealth Resource Centers, leaders of the VETN effort discussed the current challenges EDs face, their approach and goals, and some results with the first two hospitals to participate in the grant-funded project.
In October 2023, an average of 28 patients of all ages were boarding in Vermont EDs on any given day, awaiting transfer or discharge to mental healthcare. Furthermore, one out of seven ED beds, on average, was occupied by a patient waiting for mental healthcare. In a survey of 191 psychiatrists statewide, only 0.6 psychiatrist FTEs report having the emergency department as the main practice location.
The project began with two demonstration pilots, one at Rutland Regional Medical Center (RRMC) and the other at Northeastern Vermont Regional Hospital, a 25-bed critical access hospital in the state’s Northeast Kingdom region. Its emergency department has the highest number of mental health visits per capita in Vermont, yet they are in a “psychiatry desert.”
RRMC developed a telepsychiatry service delivery model that includes four credentialed providers offering consults during business hours, two days a week.
RRMC targeted subset of pediatric patients, ages 18 years and younger referred to Brattleboro Retreat, a local provider for inpatient behavioral health. RRMC’s start-up leveraged existing telehealth procedures, training, and equipment, which reduced start-up costs.
Northeastern Vermont Regional Hospital (NVRH) developed a telepsychiatry service delivery model that includes 17 credentialed providers affiliated with a national telepsychiatry vendor, ARRAY, offering off-hours (5 p.m. to 8 a.m. and weekends) telepsychiatry consults at the attending physician’s request. NVRH start-up expenditures were $56,325, which includes ARRAY’s fees, equipment, and training costs.
Mark McGee, M.D., a Burlington psychiatrist and president of Alpine Telehealth, is one of the subject-matter experts on the project, which he said seeks to address a persistent need in the system of mental healthcare in Vermont — timely access to psychiatric care, particularly in emergency or crisis situations.
“The reality that we've faced in Vermont is one that is faced in many communities throughout the country. The issue results in backlogs, in patients awaiting placement at inpatient psychiatric facilities, resulting in a problem of emergency department boarding of psychiatric patients,” McGee said. “This results in frequent and persistent delays in needed care and considerable system costs in that patients are often in emergency departments with needs that are beyond the capacity of those settings to address and this represents significant stress within the broader system.”
McGee noted that research comparing in-person psychiatry to telepsychiatry shows that they're more or less equivalent in terms of quality and satisfaction. “That being said, I think this is somewhat of an inaccurate comparison, because the real world that we're talking about is a comparison between the response to telepsychiatry on the one hand and the response to a lack of psychiatric care. on the other hand, because that's the more accurate comparison that we're dealing with, because most, if not all, of the settings that we're working to support do not have access to any psychiatric care in the emergency department settings. And many of these are small critical access hospitals in predominantly rural communities throughout Vermont.”
Ali Johnson, M.B.A., is quality improvement specialist for the Vermont Program for Quality in Health Care Inc. (VPQHC), a nonprofit organization that is leading the effort. “The hope is that through our experience in the demonstration projects, we will generalize that to Vermont and have information about what this service costs and the unreimbursed part of that, so we can try to request funding, hopefully through general funds. We want to establish a statewide telepsychiatry program and statute and this will be based on our mentor state of North Carolina. We have had the opportunity to evaluate patient and provider satisfaction, quality and cost of the demonstration projects and the level of engagement with our collaborators.”
At RRMC, staff reported increased satisfaction managing pediatric mental health patients because of the proactive management being offere. Also, creating a therapeutic relationship with a Brattleboro provider has convinced some reluctant patients/families to agree to transfer. Rutland also was able to expand their project to patients who are going to be referred to other locations for treatment, Johnson said.
At Brattleboro Retreat, the relationship-building with the RRMC ED referral team is proving valuable, with expanded communications and improved understanding of the referrals helping to expedite the admissions process.
McGee said that Vermont has taken a fairly bold step from a legislative standpoint as it relates to telemedicine. With its telemedicine law that went into effect in 2017, the state placed telemedicine on essentially equal footing to other forms of healthcare that are provided in person.
“In terms of prescribing, they were very clear that prescribers and providers may issue prescriptions via telemedicine without the need for an in-person exam,” he said. “And treatment recommendations and prescriptions delivered through telemedicine are held to the same standards of appropriate practice of those for in-person settings. I think that's a fairly bold and exciting legislative development in creating an equivalency in the telemedicine space, which I think really enhances what care can be effectively and safely delivered through this platform.”
He added that informed consent is required at the initiation of telemedicine treatment, and that can be done either verbally or in writing. Vermont law also explicitly prohibits the recording of any telemedicine encounters out of privacy concerns.
