2011 APA Gold Award: A Telepsychiatry Solution for Rural Eastern Texas

Burke Center, a community mental health center in rural eastern Texas, began offering a new approach for psychiatric emergency services through its mental health emergency center (MHEC) in December 2008. The breadth of services offered is more common to urban emergency facilities than to the rural area it serves. Telepsychiatry makes this possible. Burke Center MHEC is the first freestanding, rural comprehensive psychiatric emergency program in which psychiatric services are performed entirely by emergency telepsychiatrists, and it serves a population of 370,000 over 11,000 square miles.

Located in Lufkin, Texas, Burke Center MHEC comprises four components: the psychiatric emergency service; a 48-hour extended observation unit, which has eight beds and capacity for involuntary patients; a crisis residential unit with 16 beds for voluntary patients; and a mobile crisis outreach team for wrap-around services to patients in crisis. The program assists adults in crisis, either those brought to Burke Center under an emergency mental health warrant or persons who voluntarily walk in and request assistance. Among the services offered at Burke Center are mental health outpatient clinics, developmental disability programs, substance abuse treatment, and early childhood intervention.

Burke Center MHEC provides intensive psychiatric emergency care in a nonhospital setting. Program operations are led by a nurse manager and a program manager with around-the-clock teams of registered nurses and three mental health technicians. Licensed counselors, a licensed vocational nurse, and a case worker provide support from 7 a.m. to 11 p.m. daily, including weekends. These professionals, along with a psychiatrist available by videoconference, constitute the multidisciplinary treatment team that drives all care and clinical decisions.

Referrals to the center are made by law enforcement, hospital emergency departments, Burke Center outpatient mental health clinics, local public service agencies, judges, and community-based mobile crisis responders. Upon receiving a call, Burke Center staff use a triage protocol to validate that mental health emergency care is indicated and to rule out potential life-threatening medical comorbidities. Callers are subsequently given clearance for direct admission to the MHEC or are directed to medical clearance at a nearby hospital emergency department. Some referrals are best evaluated by sending a mobile crisis clinician into the community to conduct an evaluation.

Within 15 minutes of arrival at Burke Center, a patient is assessed by a registered nurse and a licensed counselor or social worker to determine appropriateness of admission. The patient is scheduled to see a psychiatrist within 30 minutes via videoconferencing regardless of the hour or day of the week. The psychiatrist is also available within five minutes by phone. These response times are maximums, and response by phone and videoconference is often much faster. This rapid psychiatric response allows for quick deescalation of psychiatric symptoms through the use of medications provided by the physicians and through psychological interventions provided by both the on-site staff and the telepsychiatrist. In addition, a wide array of medical issues can be treated by the emergency telepsychiatrists at Burke Center, including alcohol and drug detoxification, diabetes care, hypertension, thyroid disease, moderate infections, asthma, and nonacute seizure management, among other conditions.

In recognition of its innovative approachto bringing comprehensive psychiatric emergency services to rural communities in 12 counties of eastern Texas, the Burke Center Mental Health Emergency Center was selected to receive an APA Gold Achievement Award in the category of community-based programs. In the category of academic or institutionally based programs, the program selected for a Gold Award is described on page 1387.

Commitment to a respectful and pleasant environment

Burke Center MHEC has no seclusion rooms, and the program does not use restraint of any kind. All staff members receive extensive training to maintain a noncoercive environment. Burke Center has developed and rigorously tested a method for prevention and management of aggressive behaviors. Staff members are trained with Burke Center's fundamental texts and noncoercive techniques, including verbal deescalation of agitated patients and psychosocial interventions, such as problem solving and using compromise requests to communicate with patients.

All treatment planning is done with patients, families, and significant others. Family counseling is considered a key feature in crisis intervention and is part of each treatment plan where indicated. Burke Center MHEC has two peer counselors, and consumers and families are part of the Burke Center's Rural East Texas Health Network advisory.

Milieu and good architectural design contribute to a calming physical environment. The facility is pleasant and modern, and patients say that they prefer receiving care in this noninstitutional setting compared with most inpatient settings.

In regularly administered surveys, patients rate satisfaction with psychiatric telemedicine as high to very high. In fact, there have been only four departures against medical advice since the program was opened.

Providing comprehensive, innovative care

Burke Center MHEC offers a comprehensive approach to care and is innovative in many areas. For example, its registered nurses use telephone screening to assist persons throughout the region and to triage psychiatric emergencies for admission to the center. By using telemedicine, emergency psychiatrists are always available to this large rural region, and response times are typically shorter than emergency programs with on-site psychiatrists. Burke Center MHEC has a contractual arrangement with an emergency telepsychiatry company that provides access to 16 psychiatrists and one advanced practice nurse; they are located throughout the state, and one psychiatrist is Texas licensed and lives in Colorado.

Although the center is free standing, it retains the capacity for moderately intensive medical treatment provided by emergency psychiatrists, and it has the capacity to accommodate both voluntary and involuntary admissions. Burke Center MHEC offers a nonhospital, noninstitutional setting that was designed to be more attractive to patients and families than psychiatric hospitals or medical emergency departments, and it offers an environment without seclusion or restraints and with treatment modalities that support noncoercive interventions and the highest levels of verbal deescalation.

Texas' redesign of crisis management

Burke Center MHEC applies standards of care developed in 2005 by the Texas Department of State Health Services (DSHS) Crisis Redesign. These state standards were developed from guidelines introduced by the American Association for Emergency Psychiatry in conjunction with a statewide medical director's consortium. The program operates under the auspices of Texas DSHS, which regularly audits MHECs against state standards. Key regional stakeholders also regularly meet to monitor MHEC operations, including meetings with local emergency departments to ensure safe and speedy transfers of care.

Burke Center staff expedite access to psychiatric resources for law enforcement and other first responders. Since the Crisis Redesign, there is no longer a conventional practice that all mental health emergencies must pass through a local hospital emergency department. Mental health patients no longer linger in hospital emergency departments for many hours while waiting for a psychiatric bed to become available somewhere in the state of Texas. Likewise, law enforcement officers are no longer waiting long hours with the patient to be medically cleared or for a psychiatric hospital bed to be found, and officers spend less time transporting clients to remote inpatient hospitals, often hours away and sometimes on the other side of the state. If an individual under a mental health warrant needs to be directly admitted to a psychiatric hospital, the center is now able to conduct the transport, using its own vehicle and utilizing off-duty officers under contract for the task.

To ensure effectiveness and continuous improvement, Burke Center MHEC has an internal director of quality management. Program effectiveness is measured against Texas DSHS performance standards and internally identified standards. Auditing these standards is done internally and by state auditors. Quality improvement is a primary and ongoing function of Burke Center's management team. The center is accredited by the Joint Commission and follows those standards with a three-year evaluation cycle.

Overcoming obstacles and extending resources

The single biggest challenge in implementing Burke Center MHEC was bringing together a diverse group of stakeholders to understand and address the commonalities faced in helping patients in psychiatric crisis. By working cooperatively, regional stakeholders greatly increased the likelihood of accomplishing the construction and implementation of this MHEC.

In 2006, Burke Center obtained a federal Health Resources and Services Administration grant, which led to the early development of the regional stakeholder network and some rather modest goals. In 2007 an opportunity arose when the Texas legislature dedicated funding to improve the ailing state mental health crisis system. A percentage of those funds was earmarked for special projects in crisis response, contingent upon a 25% local match to what would be provided by the state. Since the Burke Center had developed an organized network of key stakeholders within the region, the mental health authority was ideally positioned to rally allies to bring the needed funds to bear to achieve something significant. This state funding, along with the local matching funds, enabled the establishment of the Burke Center MHEC and full implementation of comprehensive psychiatric services.

Communication between the local mental health authority, law enforcement, judges, magistrates, and hospital emergency departments is the best that it has ever been in the Burke Center catchment area. With what is now a strong collaborative relationship, the 12 counties and eight general hospitals for the region provide the 25% financial match to the state funds for this project. With a 2011 budget of $2.3 million, Burke Center MHEC receives $1.5 million from state crisis project funds and $375,000 from local matches from counties and hospitals in the region, and the remaining funds come from other sources and earned revenues.

Outcomes and contributions

Before Burke Center MHEC opened, the first stop for all mental health emergencies was a hospital emergency department for medical clearance and transitioning to the next level of care, which took an average of 9.2 hours. One out of every 19 emergency visits resulted in medical-surgical hospital admission because of a lack of psychiatric beds.

Burke Center MHEC has treated over 3,000 persons since it opened in 2008, or 88 persons per month on average, with only 15% of patients having to be transitioned to a higher level of care (hospital-based psychiatric care). The center is providing psychiatric care that would have previously resulted in an inpatient referral. Of the 662 calls to Burke Center from medical facilities in a ten-month period ending June 30, 2011, only 16% were denied admission for medical reasons and level of care needed. Analysis of admissions to Burke Center's locked unit shows that only 30% needed to be sent to hospitals, whereas in the past that figure would have been 100%. Since its opening, Burke Center has had to request medical clearance for only 10% of its emergencies, and the average stay in a hospital emergency department has been reduced to 3.9 hours. Medical-surgical hospital admissions have been eliminated for psychiatric admissions.

Burke Center MHEC is an important source of relief to medical emergency departments throughout the region of eastern Texas, helping to decompress facilities that are usually overcrowded with psychiatric emergency patients. At the state level, Burke Center MHEC has reduced the utilization of state hospital resources by 32% and has exceeded the Texas DSHS performance expectations. Burke Center MHEC is increasingly singled out by DSHS as a viable and recommended model for other regions of the state. Similarly, state legislators, judges, and law enforcement are speaking out about the need for more facilities throughout the state that are based on the Burke Center model.

Burke Center MHEC is unaware of any similar rural, comprehensive psychiatric emergency service that is providing 100% of the psychiatric care via telemedicine. After nearly three years, telemedicine has been proven to work in an emergency treatment setting with no significant shortcomings and no “sentinel events.” Prompt access to psychiatric care via telemedicine 24/7 has proven very efficacious. Such prompt psychiatric service is rarely seen in most inpatient treatment programs. Telepsychiatry is a viable solution to many locales around the country that face shortages in psychiatrists, particularly a federally recognized medical and psychiatric shortage area such as the Burke Center region.

Burke Center representatives have been asked to speak at numerous meetings to present its MHEC model. Some of these meetings include the National Council for Community Behavioral Healthcare 40th National Meeting in 2009, the International Crisis Intervention Team Conference in 2010, and the American Telemedicine Association Meetings in 2011.

Burke Center MHEC is featured as a novel telepsychiatry program in the Handbook of Community Psychiatry, to be published this fall by Springer Verlag for the American Association of Community Psychiatrists.

For more information, contact David Cozadd, Burke Center MHEC, 105 Mayo Place, Lufkin, TX 75901 (e-mail: davidc@burke-center.org).