Where do we go from here?
Serving Low-Incidence PopulationsTelePsychiatry and Video Remote
Interpreting Serving the Deaf Community Roger C. Williams, LMSW,
QMHI-S, CT, NAD V1The Challenge:South Carolina has about 12,000
culturally Deaf residentsAbout 250 Deaf individuals across the
state who need services from SC Department of Mental
HealthResources limited:One ASL-fluent psychiatristEight ASL-fluent
clinicians2CLAS MANDATES - Language Access Standards 5-8.
Standard 5Offer language assistance to individuals who have
limited English proficiency and/or other communication needs, at no
cost to them, to facilitate timely access to all health care and
services.
LANGUAGE MATTERS!Language assistance strategiesHealth care
organizations should use a wide spectrum of strategies for
overcoming linguistic barriers to health care: Use of bilingual
providers/staff.Bilingual/bicultural community health workers.
Interpreters (onsite and telephone). Hidden costs of not bridging
language barriersMisuse of expensive bilingual staff.Misdiagnosis,
expensive extra-testing, re-visits.Non-compliance.Potential
liability linked to medical errorsLonger hospital stays.More
complications.Lower satisfaction rate.Misuse of expensive Emergency
Services.Unpaid bills due to lack of proper communication and
mishandling of the insurance/financial status of the
clients.Standard 6 Inform all individuals of the availability of
language assistance services clearly and in their preferred
language, verbally and in writing.
Standard 7Organizations must assure the competence of language
assistance provided to those with limited English proficiency by
interpreters and bilingual staff.
Bilingual Staff And Interpreter Services Failure to interpret
accurately, because of lack of understanding of particular words
and idioms, often leads to both patients and providers trying to
guess what questions are being asked and at the answers given.
Ineffective communication can:compromise diagnosis and treatment
inadvertently breech confidentialityIncrease liabilityBilingual
Staff And Interpreter Services Effective communication is central
for access and outcomes.Never Rely on Crash Courses or Survival
Language Courses pose a threat, because clinicians overestimate
their fluency.Never allow family, friends, and other untrained,
ad-hoc persons to act as an interpreterNever allow minors to act as
interpreters. Legal ConsiderationsAmericans with Disabilities
ActTitle VI of the Civil Rights ActSection 504 of the
Rehabilitation Act of 1973Tugg v. Towey 864 F. Supp. 1201 (S.D.
Fla., 1994)Belton v. Georgia 10-CV-0583-RWS (N.D. Ga., 2014)Deaf
& Hard of Hearing ServicesHuman ResourcesASL Fluent
PsychiatristTwo Regional Teams of Therapists and
ParaprofessionalsStatewide Interpreter Coordinator and
Interpreters
Deaf & Hard of Hearing ServicesTechnical ResourcesStarted
tele-medicine use in 1996Polycom RealPresence Desktop on
laptopsSeparate monitors availableInternal network between 17
centers with 63 officesTelemedicine connection with 25 EDsSingle
EMR across all clinic sites, with remote access
Deaf & Hard of Hearing ServicesCultural ResourcesHigh degree
of acceptance of new technologyVisually oriented
communityAccustomed to use of video communicationService delivery
mix of in-person and virtualDriven by:Client preference Clinical
appropriatenessEfficient use of resourcesResults in:Improved client
satisfactionIncreased availability of servicesReduced costsNormally
done in-personScheduled intakes and
assessmentsCommunication/psychological assessmentsAppointments
within 20 miles of regional officesForensic AssessmentsCompetency
examsInsanity determinationPsychological testingViolation of
testing protocolAbuse investigationsVictim interviews
Normally done virtuallyRoutine medication
checksUrgent/unscheduled psychiatric assessmentsEmergency
appointments away from regional officesEmergency interpreting
appointmentsIt depends.Routine counseling appointmentsScheduled
interpreting appointments
How do you decide which to use?There is not a definitive answer
to this question. It will require weighing several variablesThese
variables include:Time sensitivityLength of assignmentNature of
assignmentRoutine vs. unusualForm critical vs. content
criticalClient factorsLinguistic featuresTechnological
comfort19Time sensitivity of assignmentUrgent vs.
scheduledEmergency Room vs. Mental Health ClinicDistant vs.
localNot only time but also expenseUrgentScheduled20Length of
assignmentKnow your break-even pointFor clinical services, the cost
of that person being on the road and unavailable to bill, compared
to providing services which may not be billable For interpreting,
the number of minutes when the total cost of VRI equals the minimum
hourly fee plus travel required of in-person interpreting.
Short/DistantExtended/Local21Type of assignmentRoutineClient and
clinician familiar with each otherExpectations from both sides
clear and well-definedContent emphasis vs. form emphasis20%
Content80% FormIn Mental Health, form is often the critical
element, especially in assessmentContentForm22Client
factorsLinguistic featuresDegree of dysfluencyASL fluencyPsychotic
featuresAbility/willingness to stay within camera
requirementsTechnological comfortFamiliarity with videophone and
computersPsychotic processFluent Dysfluent23Remote or
In-Person?UrgentScheduledShort/DistantExtended/LocalRemoteIn
PersonContentFormFluent DysfluentBarriersInsurance & Billing
RestrictionsTechnological limitationsPrimarily bandwidthClient
concerns/resistanceNow lets put theory into practiceThe following
case vignettes are typical mental health situationsUsing the
variables from the earlier slides, assess their appropriateness for
telemedicine useNo right answers 26Repeat Psychiatric Checkup15
minute appointment, 2 hours awayStable medicationAssessment of side
effects and medication
responseUrgentScheduledShort/DistantExtended/LocalRemoteIn
PersonContentFormFluent Dysfluent27Intake AppointmentScheduled at
mental health center (MHC) an hour away, two hour appointmentClient
is new to mental health centerAssessment includes paperwork and
interviewsUrgentScheduledShort/DistantExtended/LocalRemoteIn
PersonContentFormFluent Dysfluent28Emergency Room Visit Client
brought in by police, disoriented and agitatedIt is 10:00 pm Friday
night, 2 hours before a live interpreter can arriveGoal of
assessment is retain or discharge, not
treatmentUrgentScheduledShort/DistantExtended/LocalRemoteIn
PersonContentFormFluent Dysfluent29Thank You!Roger C. Williams,
LMSW, Q-MHI-S, NAD-5, [email protected]
Voice803-807-2701 VideoPhone863-230-4429 Text/Cell 30
