Physicians leverage telehealth as a learning tool in mental health care
Family medicine residents sharpened their skills in behavioral health care by working with other medical professionals via telehealth, researchers wrote.
Additionally, findings from a second paper supported the use of telehealth as a training tool to improve mental health care in rural primary care settings.
Alexander Kowalski, DO, medical director at Rowan Family Medicine in New Jersey, told Healio Primary Care that family medicine residents and patients at his institution have “benefited greatly from the input of a behavioral health professional” during the past 5 years.
“The challenge was creating a way to do this via telemedicine, which was new to our practice and program,” he said.
The solution, Kowalski and colleagues wrote in Annals of Family Medicine, includes the following:
- The resident, without other health care professionals’ help, conducts a full evaluation of the patient via telehealth.
- The resident creates a virtual room by conferencing in a family medicine attending physician, who provides guidance on medication management. A clinical psychologist offers recommendations on behavioral interventions. Both nonresidents also discuss psychosocial stressors.
- Other faculty members enter the virtual room to help the resident implement the patient’s management plan and, if needed, assess the patient further.
- After the visit’s conclusion, the resident, attending physician and psychologist discuss the patient encounter and the resident’s comfort in managing complex situations.
“The biggest barrier was navigating technology issues and was solved with a simple solution of utilizing the conference call feature of personal cell phones to connect and discuss cases in real-time,” Kowalski said, adding that the model could easily work in rural areas.
Across the country in rural Washington, Morhaf Al Achkar, MD, PhD, a family physician in the department of family medicine at the University of Washington, and colleagues investigated the feasibility of a collaborative care model that included regular systematic case reviews by a consulting psychiatrist that were conducted remotely, and whether this strategy could eventually improve the skill sets of primary care providers in managing the mental health care of their patients.
“An important principle of traditional specialty consultation is to disseminate authoritative clinical knowledge to the referring clinician and medical community,” they wrote. “We hypothesized that over time, the collaborative care model serves as a training and workforce development strategy, a potentially important benefit.”
Given the shortage of rural primary care personnel with expertise in team care for patients with common mental health disorders, the researchers said “building the workforce for this population is a national priority.”
Achkar and colleagues interviewed 17 employees — nine case managers, four primary care physicians, three consulting psychiatrists and one medical assistant — who participated in webinars and learned the collaborative care model via the Advancing Integration Mental Health Solutions (AIMS) Center of the University of Washington approximately 2 years before being interviewed.
Based on the interviews:
- PCPs became more capable of diagnosing mental illnesses, engaging with patients and developing treatment plans.
- Psychiatrists embraced their role as teachers and became less condescending to PCPs.
- Medical assistants learned to screen for mental illness and talk to affected patients.
- Receptionists and billers became more proficient in their respective duties.
“Participants’ feedback supported the view that telepsychiatric case review-based consultation enhanced skills of diverse clinical team members over time,” Achkar and colleagues added.
References:
- Advancing Integration Mental Health Solutions (AIMS) Center of the University of Washington. Implementation Guide. https://aims.uw.edu/collaborative-care/implementation-guide. Accessed Oct. 6, 2020.
Perspective
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It is the duty of the PCP to know and understand their patient as a whole person — their physical, mental, emotional and social characteristics. It is through this mechanism that a PCP can truly care for patients.
Mental health is an integral part of one’s overall health. We know that those with a serious mental illness are more than twice as likely to develop a chronic disease such as cardiovascular or metabolic disease. In addition, patients with chronic illness experience depression and anxiety at a higher rate than the general population, and unemployment rates are higher amongst those with mental illness. Because one in five adults in the United States experiences mental illness each year, it is critical that PCPs be able to address patients’ mental health needs.
The COVID-19 pandemic has further highlighted this need. With isolation and fear, the pandemic has created and exacerbated mental illness. Finding creative ways to give patients access to mental health resources they need is vital. That is exactly what Kowalski and colleagues describe in their initiative to bring medication management and behavioral interventions virtually to patients. A telehealth opportunity like this eliminates many barriers to mental health treatment by providing easier access to treatment. However, there are potential barriers. Patients may feel intimidated having three providers present in the follow-up virtual room, two of whom they do not know. Logistics may interfere with seamless implementation. If the precepting physician and psychologist are precepting multiple residents it may significantly prolong the encounter.
A collaborative care model, such as the one described by Achkar and colleagues, will be essential moving forward to extend the reach of existing psychiatric resources, as there will be an estimated 12% deficit in the psychiatry workforce by 2025. A staggering 60% of adults with mental illness did not receive mental health services in the last year. Their model integrates behavioral health into a rural primary care office via remote case review based psychiatric consultations and care management and psychotherapy with a behavioral health care manager. In its most pure implementation, this model achieves the Quadruple Aim of bringing better outcomes, improving clinician and patient experience and lowering system costs. This system offers a safety net for patients and uses validated measurement tools to help guide treatment and improve outcomes. Continuous learning occurs not only for the PCP but also the care manager, medical assistants and psychiatrist. However, there are limitations to their study. As these researchers noted, only successful practices were interviewed, omitting valuable identification of common barriers. In addition, the AIMS model is complex and would require an upfront investment of time and money to find appropriate staff and to implement. Verifying insurance payment and potential costs to patients also needs consideration, as does the fact that staff turnover may hamper the model’s perpetuation, further increasing physician and staff burnout.
References
Katon WJ. Dialogues Clin Neurosci. 2011; 13(1):7-23.
National Alliance on Mental Health. “60% of adults with mental illness did not receive mental health services in the last year.” https://www.nami.org/nami/media/namimedia/infographics/generalmhfacts.pdf. Accessed Oct. 7, 2020.
National Alliance on Mental Health. “Mental health by the numbers.” https://www.nami.org/mhstats. Accessed Oct. 7, 2020.
National Institutes of Mental Health. “One in five U.S. adults experience mental illness each year, it is critical that PCPs be able to address mental health needs.” https://www.nimh.nih.gov/health/statistics/mental-illness.shtml. Accessed Oct. 7, 2020.
National Alliance on Mental Health. “Unemployment rates are also higher amongst those with mental illness.” https://www.nami.org/mhstats. Accessed Oct. 7, 2020.
HHS. “There will be an estimated 12% deficit in the psychiatry workforce by 2025.” https://bhw.hrsa.gov/sites/default/files/bhw/health-workforceanalysis/research/projections/behavioral-health2013-2025.pdf. Accessed Oct. 7, 2020.
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