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Telepsychiatry in the Emergency Department Setting Improving Care for Vulnerable Populations in Rural Communities
Institute on Psychiatric Services
Washington, DC
October 7, 2016 Sonia Tyutyulkova, MD
Conflict of Interest Disclosure
No financial or intellectual conflicts of interest
Acknowledgements
Roanoke-Chowan Triage Team Greg Riley, RN, Program Director Behavioral Health Marvalette Bradley, RN, Nurse Triage Supervisor Louisa Ayafor, MD Stephanie Hill, MD Rich Rutz, NP Kevin Stewart, RN Shannon Pittman, RN William "Bill" Lidster, RN Rhonda Flythe, RN Marci Martin, RN Jennifer Anderson, RN
Data Analytics Team
Michael Barnes, Performance Improvement Coordinator Stephanie Plumb-Maxwell, RHIA, MBA
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Dec-11 Apr-12 Jul-12 Oct-12 Jan-13 May-13 Aug-13 Nov-13 Mar-14 Jun-14 Sep-14 Dec-14 Apr-15 Jul-15 Oct-15 Jan-16 May-16 Aug-16
ED LOS
Telepsychiatry consult (NC-STeP)
Daily Leadership Huddle Discontinue Telepsychiatry Consult Pilot Tele-team
Improvement Initiatives 2012 - 2016 Regional Emergency Departments Vidant Health
Data Analysis
Source of data – EPIC EHR
Data Sample. 60, 242 ED visits with ICD-9 and ICD-10 diagnostic code related to mental health, substance abuse, intellectual disabilities diagnosis, and behavioral health related problems.
Timeframe. January 1, 2012 through June 30, 2016
Data Analysis Behavioral vs medical reason for visit Length of stay for admitted and discharged patients Length of stay by reason for visit and ED discharge diagnosis Median vs average length of stay
Vidant Health System Overview
A regional health system serving 1.4 million people in 29 counties in eastern North Carolina
Vidant Health System Overview
Eight hospitals, physician practices, home health, hospice, wellness centers, ACO, CIN
Regional ED Services for Behavioral Health Patients
Telepsychiatry Consult 8AM-6PM, 7 days/week
Evaluation by a psychiatrist
NC-STeP – North Carolina state subsidized program established in 2013
Placement service 8AM-6PM, 7 days/week
Placement for involuntary patients in need of an inpatient bed
After hours outreach 6:30PM to 7AM
ED LOS Trends Regional EDs 2012 - 2015
2012 2013 2014 2015
Inpt Unit, Low Telepsych Utilizer 8.97 9.90 8.69 11.87
Inpt Unit, High Telepsych Utilizer 17.57 17.99 18.43 25.11
Inpt Unit, Nurse Triage 8.26 7.85 8.56 9.31
No Inpt Unit, High Telepsych Utilizers 14.52 17.40 19.14 23.82
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ED LOS
Roanoke Chowan Hospital ED Triage Team
24/7 service
Collaborative team staffed by dedicated RNs, LCSW from inpatient psychiatric unit and a psychiatrist on call
Initial assessment by RN, presents to psychiatrist for disposition decision and treatment recommendation
Patient placement, coordination of care
ED Nurse Triage Team Rapid Improvement Event July 2015
ED Nurse Triage Team Rapid Improvement Event July 2015
Gaps Root Cause
Incomplete referral Information Lack of communication
Inconsistent presentation to provider No standard process
Inconsistent admission acceptance No clearly defined acceptance criteria
Inconsistent referral documentation No standardization for referral
documentation
Inconsistence among providers Lack of standard presentation
ED Nurse Triage Team Rapid Improvement Event July 2015
Solution (If We...): Expected Outcome (Then We Expect...):
Better communication with our referral resources
Complete referral information the first time
Standard procedure for presenting information to the
providers Consistent information to make decision
Clearly defined acceptance criteria
Standardized process, better communication, clear data collection and will decrease
repetition and reduce wait time for patient and staff
Standardized presentation process
Consistent acceptance /denial rate amongst providers based on providing the same data to
every provider, every time
Current State - Outcomes ALOS Behavioral Health Reason for ED Visit
Hospital ALOS in h (FY15) ALOS in h (FY14)
Bertie 25.03 20.51
Chowan 21.44 23.81
Edgecombe 27.77 23.31
Outer Banks 15.11 13.84
Duplin 18.43 14.41
RCH 8.93 8.05
Pilot Expansion of Triage Tele-team – Results
2012 2013 2014 2015 2016
BRT 12.69012346 17.30140562 20.94503817 20.17114286 10.9165
CHO 11.31659808 18.45624143 22.73681086 22.52842409 16.1245045
HET 9.773857302 15.29848856 22.05704182 24.97737048 19.3045809
RCH 6.417151163 7.324983498 7.647149123 9.22530253 9.18064877
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BRT CHO HET RCH
Pilot Expansion of Triage Tele-team - Results
Site ED LOS in hours 2015
ED LOS in hours 2016
% Change
BRT (test site) 20.17 10.92 - 45.86 %
CHO (test site)
22.53 16.13 - 28.41 %
HET (test site) 24.98 19.3 - 22.74 %
RCH (Nurse Triage Team Originating Site)
9.23 9.18
ED LOS Pilot Expansion of Triage Tele-team
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FY15 IVC Jan-Mar 16 IVC
BER 45 14.38
CHO 43 19.15
EDGE 40 23.92
ED L
OS
BER
CHO
EDGE
ED LOS for IVC Patients
Change in LWOT and AMA Discharges in 2016 Compared to 2015
Variance from Baseline (%)
Nurse Triage Tele-Team Pilot Sites
- 23.52
Control Site - Discontinued Tele-psychiatry Consult
- 14.30
ED LOS Pilot Expansion of Tele-team – Controls
2012 2013 2014 2015 2016
Inpt Unit, Low Telepsych Utilizer 8.97 9.90 8.69 11.87 10.52
No Inpt Unit, High Telepsych Utilizers 14.52 17.40 19.14 23.82 19.18
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ED LOS
Discontinue telepsychiatry consult
ED LOS Pilot Expansion of Tele-team – Controls
2012 2013 2014 2015 2016
Inpt Unit, Low Telepsych Utilizer 8.97 9.90 8.69 11.87 10.52
Inpt Unit, High Telepsych Utilizer 17.57 17.99 18.43 25.11 23.76
No Inpt Unit, High Telepsych Utilizers 14.52 17.40 19.14 23.82 19.18
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ED LOS
Site continued telepsychiatry consult
System-wide Daily Leadership Huddle
Goal – alignment, accountability for results Metric of success – decreased ED LOS 7 days/week, 9:15AM Led by the Regional Medical Director All sites participate Program Directors/Nurse Managers, Medical Directors
System-wide Daily Leadership Huddle
Goal – alignment, accountability for results Metric of success – decreased ED LOS 7 days/week, 9:15AM Led by the Regional Medical Director All sites participate Program Directors/Nurse Managers, Medical Directors
Effect of Huddle on ED LOS
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ED LOS Comparison January – June 2015 vs 2016
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BRT CHO HET BFT DUP OBH RCH
2015 2016
Pilot Sites All Other Sites
Change in ED LOS for Pilot vs All Other Sites January-June 2016
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Pilot sites All Other Sites
42%
19.86%
% IMPROVEMENT
Service Models Comparison
Service Elements Tele-psychiatry Consult Nurse Triage Tele-Team
Basis for decision-making Psychiatric Interview Record, RN triage assessment
Type of service Consult Consult
Visit structure Videoconferencing Videoconferencing
Care coordination Absent Embedded
Management Centralized, state entity Decentralized to end-user
Service model Fragmented, multiple
services
Collaborative team model
Funding Provider billing, public funds,
contract fees
Hospital funded
In Conclusion
In Conclusion
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