Designing an Academic-Community Telepsychiatry Partnership to Provide Inpatient and Outpatient Services in a Critical Access Hospital

“Critical access hospital” is a federal designation that conveys certain reimbursement benefits to hospitals that have 25 or fewer acute inpatient beds, staff a 24/7 emergency room, are located at least 35 miles from another hospital, and maintain a short (≤96 hours) stay for acute care patients. The majority of Washington State’s counties are classified as rural. As such, there are 39 critical access hospitals in Washington State, and these institutions serve a vital role.

Critical access hospitals periodically admit patients who need weeks of intravenous antibiotics for infections associated with intravenous opioid use. This type of protracted stay can provide a unique challenge because critical access hospitals are designed for short stays and do not usually have access to psychiatry consultations. However, hospitalizations of this type also represent an opportunity for critical access hospitals to have a long-term, positive impact on patients in their community who have opioid use disorders.

Although every county in Washington State has an unmet need for outpatient psychiatric prescribers (1), the geographic disparity in dispersion of these providers is stark, with far more providers per capita located in the state’s urban areas. Moreover, opioid prescribing rates in Washington State are higher in rural counties (2), and prescribing rates tend to correlate with community rates of opioid use disorders (3). Critical access hospitals and primary care clinics are often the only resource for mental health care in many areas of Washington State.

The University of Washington (UW) School of Medicine in Seattle provides staff for several medical centers in Washington State, but these facilities are all congregated in Seattle and its large metropolitan area. UW has a large psychiatry residency program, consultation-liaison psychiatry fellowship, and addiction psychiatry fellowship. Thus, the UW has a responsibility to develop novel programs that reach beyond Seattle and deliver psychiatric care to rural counties. UW has long-standing programs that provide inpatient consultations via televideo to unaffiliated, rural hospitals as well as expertise in implementing and staffing integrated care programs via televideo at rural primary care clinics. However, the UW had never developed a telepsychiatry program to provide consultation to the medical wards of a critical access hospital. Additionally, we knew of no telepsychiatry program that combines inpatient consultations, an addictions service, nursing home case reviews, and outpatient integrated care programs to deliver comprehensive services to a critical access hospital and its affiliated outpatient facilities.

Delivery of Comprehensive Services to a Critical Access Hospital

Dayton, Washington, with a population of about 2,500, is part of Columbia County, a county with about 4,000 residents located over 250 miles from Seattle. Dayton General Hospital (DGH) is a critical access hospital with a nursing home on its campus. DGH also operates two primary care clinics. There are, however, no psychiatrists in Columbia Country. After contacting the Washington State Hospital Association regarding resources on collaborative care models, the Columbia County Health System (CCHS) was referred to the UW’s Advanced Integrated Mental Health Solutions program. These conversations yielded the idea of creating a comprehensive psychiatry service via a unique community-academic partnership.

Through a process of prospective planning, the elements of the service quickly took shape. In the outpatient setting, a pragmatic combination of approaches—including the collaborative care model (CCM) (4), telepsychiatry, and peer-to-peer consultation—was strategically developed to expand access to integrated behavioral and addictions treatment for community-dwelling patients served at the two DGH-affiliated outpatient clinics. This model allows a single UW psychiatrist to influence the care of a much larger panel of patients in 1 day than would be possible in a colocated model. General inpatient consultations, addictions-specific consultations, and nursing home reviews are part of the same comprehensive service, and each service was initiated within months of each other as staffing, credentialing, and privileging were completed.

The CCM model.

Prior to the start of the partnership, access to psychotherapy and psychosocial support at the DGH-affiliated clinics was provided by the director of behavioral health integration and coordination, an on-site, licensed, and independent clinical social worker. With the advent of the CCHS-UW partnership, the social worker underwent further training and expanded his role to include providing population-based management and functioning as a behavioral health consultant (BHC) within the CCM. In the past 2 months, the program added a second full-time BHC to manage the increased caseload.

The work of the BHCs is supported by use of a clinical registry (AIMS Center Caseload Tracker registry [https://aims.uw.edu/resource-library/aims-caseload-tracker]) and weekly, video-based consultation with a UW psychiatrist. Leveraging universal behavioral health screening (mainly with the Patient Health Questionnaire–9 and the Generalized Anxiety Disorder seven-item scale [GAD-7]) and referrals initiated by a primary care physician (PCP), the BHC works within the CCM to identify, engage, assess, and enroll patients. To facilitate this program, the BHC obtains consent from and empanels appropriate patients, schedules appointments (initially twice monthly), and enters patient data into the clinic’s registry. Using the registry, the BHC and consulting psychiatrist can continuously monitor a population while making adjustments in the intensity and content of interventions. The BHC and psychiatrist meet weekly for 1 hour of video-based consultation during which treatment recommendations are made for new patients as well as for existing patients who are not showing expected clinical improvement.

Based on these reviews, assessments and treatment recommendations are entered directly by the psychiatrist into the electronic health record and forwarded to the primary care provider and other relevant staff. In this way, each patient’s progress is reviewed every 5 to 8 weeks, depending upon the proportion of new cases to follow-up cases. Both the BHC and the psychiatrist help to maintain the registry, which facilitates shared patient care, enables quality improvement projects, and supports billing with CCM codes (5). Each full-time, embedded BHC requires 3 hours per week of psychiatric consultant time (1 hour of direct weekly consultation plus an additional 2 hours for chart review, documentation, and direct consultant-to-PCP phone-based consultation) in order to ensure that a dynamic panel of patients with moderate to severe symptomatology is intensively monitored and treated.

For some individuals enrolled in the CCM program, the diagnostic picture may remain uncertain and treatment options may be particularly complex. The psychiatrist sets aside 2 hours per week for direct telepsychiatry with patients such as these, wherein the patient is scheduled for a 25- to 50-minute appointment at the clinic. The BHC joins the patient and teleconsultant for the last 5 to 10 minutes of the encounter to review the diagnostic impressions and the treatment recommendations.

The same UW psychiatrist reviews the medical records for patients at the DGH-affiliated nursing home and participates in a monthly, interdisciplinary case review with nursing home physicians and staff.

Staffing the medical wards.

To staff the medical wards at DGH, psychiatry attending physicians on the UW Medical Center (UWMC) psychiatry consultation-liaison service are available to provide “curbside” consults to DGH hospitalists from 9 a.m. to 5 p.m. on weekdays. In addition, a UWMC consultation-liaison psychiatrist protects 1 hour every weekday, and the addictions-trained psychiatrist protects 1 hour per week, for direct patient care consultations via televideo with hospitalized DGH patients. There is no weekend, holiday, or after-hours availability. The telepsychiatry service uses HIPAA-compliant Zoom software for video conferencing. DGH uses a laptop computer with a built-in camera and microphone, which is wheeled around on a small cart. The consultations are initiated by DGH hospitalists, who directly page the UWMC psychiatrist to discuss the case. The DGH social worker then logs into the Zoom conferencing system, wheels the computer cart into the patient’s room, and stays for the duration of the patient’s conversation with the psychiatrist. The addictions-trained psychiatrist is also available to participate in multidisciplinary patient care meetings with DGH staff via video conference. The addictions-trained psychiatrist is the same physician who delivers all of the outpatient care via the CCM in the DGH-affiliated clinics, which allowed for continuity of care for several patients with substance use issues who transitioned from inpatient to outpatient care.

Staffing, Billing, and Managing Caseloads

Credentialing and privileging are the processes of confirming the licensure and performance of health care providers as well as defining the scope of practice. In order for UW psychiatrists to be able to see patients at the rural hospital and its affiliated clinics, they must undergo the same credentialing and privileging processes as the physicians who provide care in person at the facilities. These processes are not quick and involve significant paperwork and expense, but they cannot be avoided unless the rural hospital and clinics rewrite their bylaws and consent to indemnify the risk of the academic center’s credentialing processes. As part of the implementation of the program, DGH was designated by the UW as a site of practice, which ensures that the UW physician practice plan covers the malpractice insurance for the psychiatrists for both indirect and direct consultation.

UW assigns billing to the rural facilities so that patients do not have to separately register with the UWMC prior to being seen by UW providers. However, this means that DGH administrative staff must credential and enroll the UW psychiatrists in the health insurance programs with which DGH contracts. The DGH-UW agreement is organized such that DGH pays an hourly rate for UWMC psychiatrist time but keeps the billing reimbursement from the visits.

The UWMC psychiatrists were provided training for DGH’s electronic health record and are thus able to log in remotely to review the record prior to talking with the patient as well as directly document notes at the conclusion of patient interviews. UWMC psychiatrists do not write orders or prescribe medication, deferring to the primary hospitalist or outpatient provider.

DGH has an average total inpatient census of eight patients. Over the first 3 months of the telepsychiatry program, only one inpatient psychiatry consultation was requested per month. However, over the past 2 months, the inpatient psychiatry service has done seven consultations. Of the patients seen so far, half have had an active substance use disorder, with one case referred to the addictions-trained psychiatrist for an additional (inpatient) follow-up visit. Questions of decisional capacity, often in the setting of dementia or delirium, have also been a common reason for inpatient consultation requests. All of the inpatient psychiatric consultations have been conducted within 1 business day of the request.

In the outpatient setting, the clinics’ director of behavioral health integration and coordination was able to obtain consent from and enroll many of his existing patients in the new CCM program for enhanced, population-based care. Consequently, as BHC, his panel rapidly increased to 75 patients over the first 3 months of the service. In spite of the initial, rapid panel growth, the BHC maintained care episode follow-up rates of over 90%. Nearly all of the BHC visits are conducted in person, although phone encounters have been used to facilitate access and sustain engagement. To create a second CCM panel for the second BHC, CCHS doubled the amount of weekly outpatient UW psychiatrist time that it purchased. Currently, 112 patients are enrolled in CCM. The consultant psychiatrist and each BHC meet for 1 hour each week for consultation, with an average weekly case review rate of four to six patients per BHC. At any given time, approximately 80% of the enrolled patients have undergone a formal psychiatric case review, including nearly all those with moderate or high PHQ-9 and GAD-7 scores. Psychotropic case reviews, which involve a conference call between the UW psychiatrist and the nursing home physicians and staff, have occurred monthly since the inception of the telepsychiatry program.

Conclusions

Critical access hospitals are a vital part of health care delivery in the United States, although, by definition, they are located remotely from academic medical centers. Leveraging integrated care models, telehealth technology, and partnerships with academic medical centers can enable the development of sophisticated inpatient and outpatient models of psychiatric service delivery in rural counties.