Using Continuous Quality Improvement to Design and Implement a Telepsychiatry Program in Rural Illinois

Access to behavioral health services continue to be limited across the United States, particularly in rural areas where approximately 75% of communities lack access to mental health clinicians, despite reporting consistently higher rates of mental illness compared with their nonrural counterparts (1, 2). Illinois is no exception, with fewer psychiatrists per person and a higher proportion of individuals living in areas with a behavioral health shortage (38%) compared with the national average (30%) (3).

It is in this context that OSF HealthCare (OSF), a large, integrated health system that serves individuals across Illinois and Michigan, was facing a twofold challenge in the care delivery process that needed to be addressed: wait times had climbed to six months because of the limited pool of psychiatrists in rural Illinois, and primary care providers (PCPs) had become increasingly challenged to respond to the growing psychiatric needs of their patients.

OSF staff members at multiple levels had observed how the lack of psychiatric services had adversely affected their facilities, their staff, and the well-being of local communities. This firsthand awareness compelled these individuals to organize a more formal team to improve access to evidence-based psychiatric treatment for these patients in both the specialty and primary care spaces. Concurrently, OSF was noticing financial implications associated with these unmet psychiatric needs, such as increased emergency care costs, acute hospitalizations, and comorbid medical conditions.

Because of the overwhelming clinical and financial implications of poor access to psychiatric care, the OSF team created a working group to address this problem and improve the care delivery process. The working group consisted of representatives from several different teams at OSF, including system-level and local behavioral health services leaders, as well as data analytics, telehealth, and provider teams. Although there were many moving parts to implementation, the common goal of the working group was to provide care to the most vulnerable populations, from mission-driven and financially conscious perspectives.

The working group’s first task was to utilize available metrics on volume to understand more precisely the program components needed to increase psychiatric access. As it was difficult and costly to recruit additional on-site psychiatric providers, the working group identified telepsychiatry—the use of videoconferencing and other information and communication technologies to provide behavioral health services remotely—as a potentially cost-effective alternative to in-person care. The working group reviewed the published literature that demonstrated that telepsychiatry has been successfully implemented in different settings to provide direct patient care and consultation services and found clinical outcomes comparable with those of face-to-face care (4, 5). Evidence from direct care settings indicated that telepsychiatry also has the capacity to improve patient satisfaction and enhance provider education and communication, especially in rural settings (6, 7). Additionally, case and policy reports have shown that asynchronous telepsychiatry consultation programs significantly expanded access to mental health services and reduced cost of care (3, 8).

Although the literature provided some orientation to the nature of telepsychiatry, the OSF team ultimately chose to collaborate with Regroup, a Chicago-based telepsychiatry company that provides behavioral health services remotely, to aid in customizing and implementing program components. Regroup and OSF’s working group agreed on a multimodal, multisite program, using a combination of direct care and consultation telepsychiatry services. Telepsychiatry can take many forms; however, this program aimed to address OSF’s specific set of needs by incorporating both types of services for adult patients, with the overarching goal of improving systemwide access to psychiatric services in a cost-effective manner (a figure showing a diagram of the telepsychiatry program structure is available as an online supplement to this article) (4, 5).

Implementation Challenges

To achieve expanded psychiatric access for both specialty and primary care patients, OSF and Regroup had to confront several complexities associated with OSF’s existing models of care delivery, including how to organize the clinical and financial aspects of this multimodal program. In this aspect, it was especially useful to have a telepsychiatry partner such as Regroup, who had the flexibility to help design and implement a program that could address these different types of patients’ needs.

Assessing financial feasibility.

Although cost reduction was not the primary goal, the program had to be somewhat cost-effective to ensure long-term sustainability. Consequently, the number of telepsychiatry hours and overall design was estimated on the basis of multiple considerations, including cost, estimated reimbursement rates, and projected utilization by patients. Reimbursement for direct care telepsychiatry services and for ancillary services contributed directly to the financial sustainability of this multimodal program. OSF anticipated further that nonreimbursed costs of the service would be balanced by the additional value of increasing patient retention and satisfaction by decreasing wait times for psychiatric assessment and consultation and by enhancing the capacity of psychiatrists and PCPs to address complex health and behavioral health needs.

Organizing initial program structure.

Direct care services, which included psychiatric evaluations and medication management appointments, would be delivered via synchronous videoconferencing, using a collaborative approach that emphasizes the integration of the telepsychiatrist into the in-person treatment team to enhance care coordination and continuity of care.

Once direct care services were outlined, OSF had to consider what type of consultations they wanted to offer to PCPs and how they would measure satisfaction with and utilization of the consultations. Synchronous consultations, also referred to as “live consults,” consisted of a member of the primary care team (e.g., PCP, imbedded psychotherapist, or case manager) presenting cases to the telepsychiatrist, who would provide guidance on diagnosis and treatment. Asynchronous consultations, or “e-consults,” included consultation requests and questions sent through the electronic health record (EHR) by the PCP. For these e-consults, the telepsychiatrist would perform a chart review and deliver feedback in the form of a consultation note with an assessment, rationale, and recommendations; the e-question service was designed for clinical questions not requiring a comprehensive chart review. OSF started with the live consults. The e-consults were added later to give PCPs the full range of support, with an eye toward tracking which lines of service earned greater utilization by, and satisfaction from, PCPs.

Licensing and training.

Next, OSF had to consider how to obtain new telepsychiatrists and train in-person staff on new workflows associated with telepsychiatry. Licensing, credentialing, and privileging physicians are lengthy processes that contribute to delays in program deployment. However, OSF was able to benefit from utilizing Regroup’s broad network of telepsychiatrists, many of whom were already licensed in Illinois. The telepsychiatrists providing services to OSF sites were selected on the basis of an extensive screening, vetting, and matching process that Regroup uses. This process assessed for the psychiatrists’ education, training, and certification, as well as clinical experience, professionalism, experience with telepsychiatry, available hours, and technical competency. Additionally, OSF trained in-person staff on the use of videoconferencing and other technologies to ensure integration of the new telepsychiatry services into the in-person treatment teams.

Ensuring clinical quality in implementation.

OSF also had to develop clinical oversight for both aspects of this program, including supervising telepsychiatrists and developing quality improvement metrics for services. Planned clinical oversight included support from both Regroup and OSF medical directors in supervising telepsychiatrists and reviewing challenging cases. Peer reviews were conducted on a regular basis to assess for quality of care and documentation.

Selecting patients for telepsychiatry services.

In the final stages of implementation before deployment, OSF had to develop an effective referral management process, wherein patients could be appropriately identified as candidates for telepsychiatry services. Patients were screened on the basis of diagnosis, severity of symptoms, and willingness to engage in virtual visits. For example, OSF prioritized keeping actively psychotic patients and those at higher risk for hospitalization with in-person providers to maintain continuity of care. OSF also queried patients on their comfort level with telepsychiatry to best meet their preferences and needs while also conveying to patients that wait times would be significantly shorter for telepsychiatry appointments. Regroup also helped guide site-specific approaches to educate patients effectively on telepsychiatry policies and procedures.

The working group recognized that this earlier phase of the program would not reflect a perfect implementation model. However, with the pressing need to expand access to care, along with the extensive research, planning, and training conducted by OSF and Regroup, the group was confident that the program could be successfully implemented. Working group members also understood and intended for the program to undergo further refinement, as guided by ongoing data collected to monitor utilization, provider satisfaction, patient satisfaction, and cost.

Program Components and Adjustments

Direct care services.

Direct care services were initially provided by three telepsychiatrists for up to 24 hours per week at a psychiatric clinic in the Saint Elizabeth Medical Center CHOICES outpatient department in Ottawa, Illinois, and at a satellite clinic of this department. These telepsychiatry services supplemented existing psychiatry services that were available onsite. Because of fluctuation in staffing, competing clinical responsibilities, and turnover, these onsite services have been provided by a mean of 2.5 full-time equivalent (FTE) psychiatrists and one FTE advanced practice nurse.

Consultation services.

Consultation services were provided by three telepsychiatrists for up to five hours per week at eight ambulatory primary care clinics across Illinois. Live consults were completed via weekly, prescheduled videoconferencing sessions, whereas e-consults, including both e-consult and e-question services initially, were completed throughout the week, depending on the availability of the psychiatrists.

Improving utilization.

As this early phase of the program rolled out, some components worked well and were easily adopted from the beginning; however, others required modifications, as guided by the initial data that OSF collected on utilization and satisfaction rates. For example, the e-consult services encountered lower utilization during the early stages of implementation, likely related to limited awareness and adoption of the service among PCPs. This lower initial utilization may be attributed to PCP perspectives on, and discomfort with, managing psychiatric conditions within primary care settings, challenges in changing physician behavior, and geographic variations in availability of psychiatric services at different sites.

Several approaches were used to improve the overall utilization of the service, including disseminating information across the OSF HealthCare system on the availability of the e-consult service, having OSF HealthCare’s behavioral health directors educate providers about the service, and engaging regional and local leadership to promote the service. OSF also trained PCPs on sending e-consults through the EHR, wording consultation questions, and other telepsychiatry-related factors at workshops such as the educational session on telepsychiatry at the 2018 Annual OSF HealthCare Behavioral Health Conference.

Refining services.

Eventually, as the e-consult services became more popular, four of the five initial hours dedicated for live consults were replaced with dedicated e-consult hours. Additionally, the e-question service was discontinued because only one question had been submitted in six months. As discussed further in the next section, these changes ultimately yielded more successful results for OSF, from both financial and clinical quality improvement perspectives.

Results and Recommendations

Ongoing analysis of the data that OSF collected in the first 2 years of this program revealed that this program has successfully and sustainably improved access to psychiatric services and support for PCPs.

In terms of direct care telepsychiatry services, 1,031 outpatient direct care visits were completed with 333 unique patients between November 2017 and January 2019. Patient satisfaction was measured using the results of 227 self-administered surveys that patients completed immediately after their appointments in January–December 2018. Approximately 91% of respondents strongly agreed or agreed that they felt heard, understood, and supported by their provider in session. About 84% strongly liked or liked having their appointments over live video. Wait times during this period decreased an estimated 75%, from approximately six months to six weeks. For patients who required or preferred in-person psychiatry, the availability of telepsychiatry still cut wait time in half. Thus, a mere 24 hours per week of this telepsychiatry program has reduced wait times for all OSF’s patients seeking psychiatric care.

In terms of e-consults, the data collected across 2018 reveal that PCPs at OSF requested 20 to 25 e-consults per month that served to decrease, delay, or mitigate the need for a referral to direct care, be it in-person psychiatry or telepsychiatry. Eighty-three percent of these e-consults were completed by telepsychiatrists within 24 hours, indicating a highly responsive and accessible level of support for PCPs. Additionally, results from a monthly survey of all PCPs who used the e-consult service indicated that 91% of providers (N=29) were very satisfied with the response time of the consulting telepsychiatrists. Ninety-seven percent of PCPs also reported that e-consults either always or sometimes offered sufficient support. Finally, 91% of PCPs reported that they followed the telepsychiatrist’s recommendations from the e-consult. In parallel to the self-report survey, a review of 127 charts from January to December 2018 showed that OSF providers took documented action on 86% of cases after an e-consult. The actual percentage is likely closer to the 91% reported by PCPs, as treatment changes after e-consults may not always be documented.

With regard to billing, reimbursement rates for direct care consultations are comparable to in-person rates. Moreover, between November 2017 and January 2018, 41 of these direct care cases were referred for laboratory testing or additional reimbursable ancillary services, which contributed to program revenue. Although live consults and e-consults are still not billable at this time, the value of improving access to behavioral health services has—as anticipated—offset any potential added costs of telepsychiatry consultation services from OSF’s perspective.

This program evaluation reveals that, although it is well established that telepsychiatry can enhance access to behavioral health services, the formal planning, thoughtful implementation, and ongoing evaluation of these telepsychiatry program components are critical to the success and sustainability of the program. The multimodal, multisite program discussed here has helped OSF meet their systemwide objectives by improving access to care and enhancing their behavioral health integration into primary care in an efficient and cost-effective manner. The program has managed to achieve this with less than one FTE telepsychiatrist (24 hours per week direct care services, five hours per week consultation) because of the thoughtful anticipation of implementation challenges and data-driven modifications. Given the similar challenges that other rural health care systems are facing, this telepsychiatry program may help to guide the implementation and long-term success of similar programs through an approach rooted in implementation science and continuous quality improvement.