Ray Cordry,D.O. Associate Professor Department of Psychiatry and Behavioral Sciences University of Oklahoma Health Sciences Center

Transcription

1 Ray Cordry,D.O. Associate Professor Department of Psychiatry and Behavioral Sciences University of Oklahoma Health Sciences Center

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4 Workers absent or working less than optimum capacity (presenteeism) due to stress, anxiety, depression or substance abuse than to physical illness or injury

5 In Oklahoma, 70,000 / severely mentally ill are receiving mental health treatment 35% of population is rural so that leaves 25,000 rural severely mentally ill patients not treated

6 313,000 people live in northwest Oklahoma In this area 18% children live in poverty 20% uninsured patients, 14% Medicare and 11%medicaid patients. This leaves uninsured lives. 250,000 covered lives above poverty or Medicaid and to no avail regarding mental health access locally

7 Patients with jobs or insurance have less local access to care than the patients that qualify for the Mental Health Center services One adult inpatient unit in northwest Oklahoma a 28 bed ODMHSAS facility The ODMHSAS inpatient units are NOT hospitals and patient must be medically stable to be considered for admission

8 These figures are dismal but not inclusive of the number of patients with mental illness in rural Oklahoma One has to have experience in the rural area to realize not only indigent but every income level lacks access to care

9 Rural providers have unique clinical strengths based on their training yet trying to treat mental illness many times alone. 30% of patients receive services 1/3 of that population receive minimally adequate care Providers delivering care are locked in an inadequate system

10 Chronic mentally ill patients with inadequate medical care die 20 years earlier than other patients

11 One out of 5 hospital stays (8.4 million) had either a principal or secondary diagnosis of a mental health condition 1.4 million principal and 7.1 million secondary diagnosis

12 50% of inpatient stays were mental health from the emergency department compared to 44% of all other diagnosis admitted Mood disorders and schizophrenia were the majority of diagnosis with twice as many mood disorders

13 Assumed financial losses with longer inpatient stays for mental health can be deceiving. Project figures of 4.6 days average for medical admits and 8.2 for mental health were the standards per day medical and per day mental health Total stay costs medical and mental health.

14 Cost results do not support an impossible financial task to treat mental illness Discrimination by reimbursement sources persists Hospitals pursuing more profitable bed usage No consideration of the newer medications and much more successful results

15 If secondary diagnosis neglected with medical admission medications may be stopped with relapse Clinical and financial costs then rise again Rural providers can have this happen due to no consultation available

16 A PUBLIC HEALTH approach is recommended Define the global needs of the area identified with the psychiatrist as a member of the provider team Develop ways to integrate primary health providers into the team for underserved areas

17 Psychiatrists must be at decision making levels to have clinical integrity Systems must consider areas unique needs Psychiatrists must assume core clinical and flexible roles for the teams to succeed

18 Psychiatry must anchor for the team to expand to include all the rural providers The team enhances the productivity of the rural areas and involves the rural providers Telepsychiatry has the potential to include the specialty aspect locally The possible role is expansive to more than patient visits with telepsychiatry

19 Administrative issues in telepsychiatry include: Licensure in state patient is located when seen by provider and a license person available at patient s location Credentialing, malpractice insurance Technology evolving equipment must meet HIPPA

20 Guidelines on laptop videoconferencing are expected within the next year (2014) from the American Telemedicine Association Laptops add more versatility Most hospitals large and small In rural Oklahoma have telemedicine equipment as does mental health centers

21 Oklahoma has been caught doing the same thing over and over expecting a different outcome Everyone cannot see a psychiatrist face to face Currently the option is inadequate care as it takes the psychiatrist out of the loop leaving the PCP, therapist and the patient adrift in many rural cases

22 Inpatient psychiatry beds are going to remain almost non existent Outpatient has a goal to keep patients functioning, working and to be productive for themselves, family and society It is economically imperative to establish best practices to serve rural Oklahoma as a standard

23 New Mexico, Michigan, Ohio, Arkansas as well as Canada and Australia have rural psychiatry programs that are a collaboration of agencies in their states Residency programs must have a rural tract with telepsychiatry to train for the future Primary care specialties must have more mental health experience in training

24 Integration with primary care is an essential component in the rural areas for mental health care New innovations and improved payment for integrated care is promising Integrated care is especially helpful with the population discretely seen in the family practice setting in a rural area

25 Scattered resources are not able to function as a team to provide maximum clinical production Scapegoating overstretched facilities counterproductive Fostering more resource cooperation benefit everyone with a win / win

26 Teams that can compliment each others expertise is productive, clinically sound, encompasses the entire state,cuts long term treatment costs and benefits the economy Patients remain productive clinically and tax payers not tax takers

27 Telepsychiatry is a viable tool for multiple purposes in rural Oklahoma Telepsychiatry s integration with primary care as part of the process is a proven educational and clinical tool Primary care providers become more comfortable with diagnosing and treating mental illness Most of the equipment is in place to utilize

28 The Health Manpower Training Commission of Oklahoma should count psychiatry as a primary need specialty for rural Oklahoma as it has previously 75 of 77 counties are designated underserved for psychiatry

29 Many depressed patients present to PCP with nonspecific pain secondary to mood disorder No psychiatric referral opportunities except miles from their home Only 30% psychiatric patients receive service and only 1/3 of those adequate care Mental health patients die and average of 20 years sooner than other patients

30 21% of hospital admits contain either primary or secondary psychiatric diagnosis No consult help available to rural providers Over utilization of Emergency Department as 50% of total admits are psychiatry Criminalization of mental health due to no available treatment

31 (cont.) Two leading causes of inpatient admissions are (mood disorder and schizophrenia) treatable in an outpatient clinic Medical inpatients getting psychiatry medication stopped, not adjusted or not restarted due to unavailable help for the rural providers leading to relapse

32 People and systems in place but not coordinated for care and cost effectiveness in rural areas Approach each rural quadrant of the state as unique then tailor services to that area Telepsychiatry allows the psychiatrist to remain a part of the team from a distance

33 Develop team templates for different areas of the state Template to lay ground for establishing best practice models with the team approach

34 Stop verbalizing over and over what we can t do Keep patients functioning and out of inpatient Educate providers and public about mental health as a part of medicine Today s suggestions are a cost effective, clinically and financially sound

35 A most recent update article from Am J Psychiatry 170: , March 2013 regarding telepsychiatry yields updated use and brief history Videoconferencing has been employed since 1950 s but past two decades have created the most literature discussion and study To add peer reviewed studies to the discussion articles of reference to support some of the following statements will be

36 1. Saba K. Dani, Lewit R. Katherine, Elixhauser Anne: Hospital Stays Related to Mental Health from Heath Care Cost and Utilization Project, Agency for Healthcare Research and Quality Statistical Brief 62, Oct Gillig Paulette Marie, Conner Edward A: A Residency Training in Rural Psychiatry, Acad Psychiatry 2009; 33:

37 3. Shore Jay H, Thurman Michael T, Fujinami Laurie, Brooks Elizabeth, Nagamoto Herbert: A Resident Rural Telepsychiatry Service; Training and Improving Care with Rural Populations, Acad. Psychiatry 2011; 35: Shore Jay H, Brooks Elizabeth, Savin Daniel M, Libby Anne M.: An Economic Evaluation of Telehealth Data Collection with Rural Populations, Psychiatry Services 2007; dol: /appd

38 5. Bachrach Leona L: Psychiatric Services in Rural Areas: A Sociological Overview, Hospital and Community Psychiatry 1983; vol 34,3; Focus on Mental Health is a Big School Issue, The Oklahoman Mar 2013; 18-A 7. AACP Positions on Access to Psychiatric and Psychopharmacology Services in Underserved Areas, Available at ip.html

39 8.The University of Colorado Denver, has developed a web site for Telehealth guide Telemental Health Guide ( developed by University of Colorado Denver, with support from the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration and the American Telemedicine Association s Practice Guidelines for Videoconferencing- Based Telemental Health

40 Two examples of reference feasibility and outcome research are the following: Baer L.,Elford DR, Cukor P: Telepsychiatry at forty: what have we learned? Harv Rev Psychiatry 1997;5:7-17 Chung- Do J, Helm S, Fukuda M, Alicata D, Nishimura S, Else I: Rural mental health: implications for telepsychiatry in clinical service, workforce development, and organizational capacity. Telemed J E Health2012;18: