Psychosomatics 47:152-157, April 2006
doi: 10.1176/appi.psy.47.2.152
© 2006 Academy of Psychosomatic Medicine
Models of Telepsychiatric Consultation–Liaison Service to Rural Primary Care
Donald M. Hilty, M.D.,
Peter M. Yellowlees, MBBS, M.D.,
Hattie C. Cobb, B.A.,
James A. Bourgeois, M.D.,
Jonathan D. Neufeld, Ph.D., and
Thomas S. Nesbitt, M.D., M.P.H.
Received March 28, 2005; revised July 14, 2005; accepted August 9, 2005. From the Dept. of Psychiatry and Behavioral Sciences, the Center for Health and Technology, and the Center for Health Services Research in Primary Care, UC–Davis Medical Center, Sacramento, CA. Address correspondence and reprint requests to Dr. Hilty, Dept. of Psychiatry and Behavioral Sciences, UC–Davis Medical Center. e-mail: dmhilty{at}ucdavis.edu
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ABSTRACT
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New models of psychiatric intervention are needed to improve the accessibility of mental health care in the primary-care setting, particularly in rural areas of the United States. Some models of service delivery have been successful in suburban and urban settings, but they do not always apply to rural settings. "E-health" innovations like videoconferencing, telephone, secure messaging (e-mail), and the Internet are increasingly being used to provide consultation–liaison service to primary care. This article briefly reviews successful models used in primary care, their application to rural sites, new models for rural sites, and suggestions for future e-health research.
Key Words: teleconsultation • rural populations
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INTRODUCTION
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Primary-care medicine is crucial to mental healthcare delivery in the United States for over half of those suffering from mental disorders,1 particularly in rural areas, where access to specialists is a greater problem. This lack of mental-health services leads to poor outcomes, such as higher rates of homicide and suicide, as well as increased use of emergency services, hospitalizations, and placement in mental-health institutions.2,3 Primary-care providers (PCPs) in rural areas also report having inadequate skills to manage mental-health issues, and they would benefit from assistance.4,5 However, rural areas inherently have provider shortages, particularly with regard to consultation–liaison psychiatrists.
Health providers use a number of psychiatric, health-service, and disease-management models to reach primary-care patients, predominantly in suburban and urban locales. Psychiatric consultation–liaison models include the traditional referral, the consultation-care, and the collaborative-care models.6–8 Variations on these models also include use of mental-health extenders and stepped care to use scarce psychiatric resources judiciously.9 Quality-improvement programs also improve treatment rates and outcomes for depressed patients with comorbid medical illness in primary care10 and are cost-effective, too.11 Chronic-disease management for depression is now being implemented subsequent to modules developed for asthma and diabetes.
Telemedicine technology is one strategy to improve the accessibility of mental health care, particularly to areas underserved by physicians.12,13 Telecommunications technology has been used to link specialists at academic health centers with healthcare professionals in rural areas for the management of patients.14 Videoconferencing, telephone, and computer-based (e.g., e-mail) communications connect specialists with PCPs for patient care.15–18 One format involved Internet-based store-and-forward video home tele-health systems used as part of disease management for children with asthma.19 Other computer-assisted approaches are being used in primary care for diabetes.20–22 Such research shows that those PCP patients receiving tele-health services are more likely to receive adequate doses of antidepressants and recover from depression.23
This article briefly reviews successful models used in primary care, as well as their benefits and limitations, when applied to rural sites. New models for rural primary care will be discussed, including the increasing use of communications technologies in psychiatry and medicine.
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MODELS OF CARE IN USE
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Several models of psychiatric consultation to the primary-care setting have been described in the health-services literature.6–8 The traditional referral, or replacement model, uses the psychiatrist as the principal provider of mental-health services. The consultation-care model includes the PCP as the principal provider of mental-health services, after a psychiatric consultation. The collaborative-care model involves mental-health services jointly provided by the PCP and the psychiatrist, using frequent communication between providers. Variations on the collaborative-care model include the type of mental-health providers used and their level of integration into the system.
These models have been evaluated both in the United States and Great Britain. In Great Britain, the majority of psychiatrists function in the traditional-referral model, followed by the collaborative-care model, and then the consultation model.8 The majority of PCPs favored the collaborative-care model. The general consensus was that having the psychiatrist located in the primary-care clinic setting, versus an offsite mental health clinic, greatly improved the consultation process.6–8,25
The models above have several limitations with regard to reaching rural primary care. First, there is a dearth of specialists in rural areas.26 Bearing that in mind, even with significant funds available for travel, patients might prefer to see someone in a familiar place (e.g., a primary-care clinic). Second, the missions of rural primary care and other mental-health teams are often inconsistent. This leads to potential communication problems that may arise in situations where mental-health practitioners are not always familiar with rural primary-care systems. Third, rural primary-care systems may not function administratively in the same way as those in suburban or urban areas (e.g., a single clinic may have multiple payor streams and no local medical or psychiatric hospitals). Finally, some rural sites have unique needs and issues (e.g., high rates of substance use disorders and few treatment options at an Indian reservation or enmeshed small communities, wherein patients want an objective person from the outside).
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NEW MODELS OF SERVICE-DELIVERY FOR RURAL PRIMARY CARE
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Telemedicine was first used for medical purposes for psychiatric consultation in the 1950s and 1960s to help the Nebraska Psychiatric Institute provide education, patient care, and consultation to a variety of sites.27 In the 1960s, telemedicine was also used to connect academic centers with urban populations.28 Over the past several decades, academic health systems consisted solely of the medical center, which provided care mainly to urban and suburban populations and to rural patients who traveled to the medical center. Increasingly, university health systems are reaching out with telemedicine to rural clinics15 and suburban clinics in a capitated, academic health system.13 A consultation model of care is often used because it is practical and is able to disperse expertise to a broad number of sites.14 The University of California–Davis Health System (UCDHS) uses telemedicine to link the Medical Center with approximately 60 suburban and rural primary-care clinics up to 300 miles away.
Model 1: Randomized, Controlled Trial for Depression in Adults
A randomized, controlled trial recruited depression patients through self-report and structured psychiatric interviews.31 Subjects were randomized to 1) usual care with a disease-management module using telephone and self-report questionnaires; or 2) a disease-management module using telephone, questionnaires, and repeated televideo psychiatric consultation, coupled with training of the PCP. Subjects' depressive symptoms, health status, and satisfaction with care were tabulated at 3, 6, and 12 months after study entry. There was significant clinical improvement for depression in both groups, with a difference trend toward significance in the more-intensive module. Satisfaction and retention were statistically superior in the intensive group; there was no change in health functioning.
Model 2: Formal, Multispecialty Phone and E-Mail: Physician-to-Physician Consultation System Regarding Adults and Children With Developmental Disabilities
The UCDHS and California Department of Developmental Services (CDDS) developed the Physician Assistance, Consultation, and Training Network (PACT Net) to assist PCPs in the treatment of patients with developmental disabilities in rural California.18 PACT Net was a 24-hour "warm-line" in design and was funded from CDDS for approximately $450,000 over 3 years. Data were collected that included patients' sociodemographics and diagnoses; PCPs' satisfaction and preference for mode of consultation pre- and post-, and specialists' evaluation of the program. Data were collected on 30 consultations: 28 by telephone and 2 by e-mail; 24 of those consultations could be responded to within 1 business day of the referral. The average duration of consultation was 47 minutes, and the consultation was accompanied by a 4-page case summary for the referring physician. The top three services requested for consultation were psychiatry (e.g., management of behavioral disturbance), medical genetics (e.g., diagnosis), and gastroenterology. PCPs rated items' baseline satisfaction on a 7-point Likert scale: 1) preexisting local services were rated at a mean of 3.37; 2) timeliness of the PACT Net consultation was rated at a mean of 5.45; 3) quality of the communication was rated at a mean of 6.3; and 4) overall quality and usefulness of the consultation was rated at a mean of 6.2. Specialists rated the quality of the communication at 6.45 and ease of the service at 6.46. These ratings demonstrated that phone and e-mail consultation is a satisfactory method for providing specialty consultation to rural patients.
Model 3: An Integrated Program of Mental Health Screening, On-Site Therapy, and Telepsychiatric Consultation to Rural Primary Care
The UCDHS and Northern Sierra Rural Health Network collaborated to develop a program for rural Northeastern California, funded by the California Endowment.32 Over a 3-year period, 10 rural sites learned how to utilize screening instruments for multiple disorders (e.g., depression, alcoholism, and anxiety disorders) and collect basic outcome measures for depression at regular intervals, in concert with telepsychiatric consultations and on-site therapy visits. Continuing medical education (CME) was provided annually for PCPs and other providers. Services included a telepsychiatry consultant and a therapist on site 25%, for specific brief therapy and integrated planning meetings between rural primary and mental-healthcare staff. Outcomes being measured at present include depression outcomes and PCP knowledge. System problems are also being identified to better inform policy.
Model 4: Use of Videoconferencing, Secure E-Mail, and Phone Consultation to Adults and Children in Rural California
The UC–Davis Center for Health and Technology received a $250,000 grant from California Telemedicine and E-Health and Technology, to provide telepsychiatry and telepsychology service to 10 rural sites over a 1-year period.33 The overall goals of this project are to 1) increase consultations by at least 70%; 2) assist PCPs with triage of cases, using urgent telephone and e-mail consultations for clinical advice; and 3) shift the method of consultation for PCPs and staff from the more time-consuming videoconferencing consultation to the more efficient e-mail and telephone consultation. Preliminary results show that the number of consultations increased by 120% over 1 year. Although PCPs have been slow to use the secure e-mail, there continues to be a gradual shift toward these methods through the impact of the program.
Model 5: Cultural Consultation to Rural Primary Care by Use of Telemedicine
Early in the telepsychiatry service of the UC–Davis Department of Psychiatry and Behavioral Sciences, in 1996, culturally-informed consultation became incorporated into the telemedicine rural primary-care collaboration. Some rural patients faced language and cultural barriers to seeking and receiving care from their local PCP. For example, a 56-year-old Mexican American woman who became depressed after the sudden death of her husband of 30 years, was diagnosed with major depression and started on an antidepressant, but did not improve despite 4 months of treatment.34 She did not take her medication as recommended and did not communicate concerns to the PCP because of cultural differences and the stigma of depression. A 60-minute telepsychiatric evaluation was conducted by a Mexican American psychiatrist, who met with the PCP and the patient. At follow-up, the patient reported daily compliance with medication; thereafter, the depression had remitted, and the frequency of medical visits decreased from 1-to-2 times per month over a 1-year period to only a single visit in the 6 months after the consultation.
Model 6: Disaster Response to a Bioterrorism Attack
The literature on disaster response is replete with examples of rapidly set-up debriefing programs that have had limited success. Such programs have usually been put in place after sudden environmental or man-made disasters, such as major rail accidents or bushfires. Such programs generally involve pretrained mental-health professionals, who receive mentoring and support from more-experienced colleagues, depending on their availability. Planning is now being advanced for how to manage the potentially much more widespread disaster scenarios envisioned after a bioterrorism event, where there be would not only substantial trauma-related issues, but also the possibility of public panic related to the possibility of ongoing infection in a community. In this event, psychiatrists will need to impart expertise in mental health, and this knowledge will be best delivered electronically via the Internet in emergent briefings and short courses. Hence, in this model of consultation, new skills will be taught in an emergency situation to a potentially relatively unpredictable and untrained group of mental-health counselors, some of whom may have only very basic skills in either mental health or infectious disease, but who are the only available group in a major community emergency.
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DISCUSSION
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Successful intervention models and modules in telemedicine have some common denominators. Our work and others' internationally in Australia, Canada, and England suggest that these denominators are 1) mutual incentives for primary care and specialty partners (e.g., improved quality of care); 2) commitment from physicians, staff, and administration to pursue telemedicine and alternate modes of consultation; 3) systematic or multiple interventions that meet the needs of the site; 4) a system approach for the primary-care system to monitor the flow of patients and measure outcomes; and 5) consultants who are able to bridge the differing approaches that may be unique to rural primary care and urban academic settings and to specific cultural groups.33–35 Successful disease-management modules have been developed for asthma and diabetes, primarily focusing on the delivery of care in the home; secondarily, at the clinic; and, lastly, at the hospital. The PCP, with the specialist's help, provides most of the physician-based clinical care, in combination with educators, nurses, and other providers. They encourage self-management by patients with chronic illness, provide emotional support, and monitor adherence to mental-health treatment.
Technology services need to be integrated in these systems if they are to be successful in providing psychiatric care as part of the team approach to rural sites. A successful telemedicine model involves more than just integration of technology with a consultation service. The model must accommodate the needs of the rural medicine sites and yet maintain an efficient mode of consultation from specialists to PCPs.33,34 Not all technology programs are new, per se, as they employ methods used in the past but are new to the rural health setting. For example, telephone and e-mail consultation have been used for "curbside" consultations for some time, as a central feature of clinical practice.36 Typically, "curbside" or "hallway" consultations originate from clinical questions that may arise during patient care in day-to-day practice. These requests meet approximately 33% of PCPs' informational needs,37–39 given that specialist colleagues can provide accurate and reliable answers quickly.40 Both telephone and face-to-face contacts are common, with the former allaying time-delays. More recently, e-mail has been used, with similar "quick-consultation" intentions, with good results.41 Overall, these consultations do not include patient evaluations, but they are inexpensive, rapid, brief, and often readily available.41,42 Curbside consultations, however, may have limitations because of their brevity (i.e., a few minutes), lack of in-depth analysis, and assumptions that are made as to what "the question" is (e.g., a more important question is not being addressed, or there is more than one question). The PACT Net system described above is an advance on the curbside consultation in terms of depth and analysis.18 Although the integration of this type of consultation into rural healthcare through telemedicine has worked, it may not be desirable for all PCPs, and there may be some difficulties in being heavily reliant on the PCP–specialist relationship.
Areas of exploration include large-scale, population-based management programs that are now being designed for the family unit. One such program, for 401 pediatric asthma patients from 17 regional areas, analyzed completed surveys before and after 12 months of participation in an asthma-management program.40 Program interventions, administered according to risk and need status, included various staggered educational mailings, reminder aids, videos, peak expiratory flow-rate meters, and telephone case-management. Measurements included quality of life, asthma-management skills and knowledge, and lost work/school days related to asthma. Positive findings included a reduction in adverse utilization, symptomatology, and restricted-activity days for children and lost workdays for adult caretakers. These findings demonstrate that a large-scale, population-based intervention program can produce measurable clinical and economic benefits where remote monitoring has been applied.41
Despite the popularity of telemedicine consultation options, there are certain factors that should not be overlooked in the model of delivery. Since referrals are usually made on the basis of the professional relationship, it is generally critical that the specialist and primary-care physician develop a relationship built on trust by working "side-by-side." Not only is the familiarity of the specialist with the rural site an important aspect in developing a relationship, but, also, the specialist's understanding of the rural site and its community is critical. Finally, patients and primary-care physicians may be uncomfortable with telemedicine or technology in general, which could reduce the number of referrals and/or adherence to appointments. Despite these factors, the literature on the adoption of new technologies indicates that about 10% are zealous, 80% will participate if there is a "good" reason, and 10% are quite avoidant.42 Overall, satisfaction with telepsychiatry services is high for patients and providers.13
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CONCLUSION
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A number of encouraging models of service delivery are available in health care, and these may be particularly useful in rural settings. Telemedicine, in the form of video, secure e-mail, and phone consultation, is one strategy to improve the accessibility of mental-health care in rural and suburban settings. Successful applications of telemedicine will be facilitated by an awareness of consultation and disease-management models, as well as patient, physician, and system factors that affect psychiatric consultation–liaison service to the primary-care setting. Future studies in rural settings need to thoroughly evaluate the models proposed above (randomized, controlled trials). They must also carefully study the adaptation of new models from other health settings, including those that use technology for part or most of service delivery.
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This article has been cited by other articles:
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P. M. Yellowlees and S. Marks
Pedagogy and Educational Technologies of the Future
Acad Psychiatry,
December 1, 2006;
30(6):
439 - 441.
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ABSTRACT
INTRODUCTION
