Silver and Bronze Achievement Awards

As in many states, the emergency departments of South Carolina are routinely overcrowded, with many of the patients in need of emergency psychiatric care. Mental health treatment is delayed when emergencies occur outside psychiatrists' standard business hours and if the emergency facility is in a rural location. Consequently, costly psychiatric inpatient admissions increase, and emergency departments have less capacity to tend to general medical emergencies. In March 2009, the state's Department of Mental Health launched an initiative to alleviate the overcrowding of psychiatric patients in South Carolina emergency departments and improve access to psychiatrists via telepsychiatry. The overarching goal of this initiative is to ensure that every one of South Carolina's 65 emergency departments can reach an available psychiatrist whenever needed.

The Statewide Telepsychiatry Initiative is unique in the United States in that it is a collaborative effort of public, academic, and private partners. The South Carolina Department of Mental Health is the lead agency, and collaborators include hospital emergency departments throughout the state, the University of South Carolina School of Medicine's Department of Neuropsychiatry and Behavioral Science, the South Carolina Hospital Association, the South Carolina Department of Health and Human Services, and the South Carolina Office of Research and Statistics. The Duke Endowment has provided substantial funding, awarding $3.7 million for the project launch and a subsequent $2.5 million. The National Institute of Mental Health has granted $1.05 million in additional funds to study the outcomes of the project.

As of 2011, telepsychiatry consults are available around the clock to emergency departments of 22 hospitals (rural and urban) in South Carolina, with three more awaiting telepsychiatry equipment and nine others in the contractual stage. A total of 8,068 patients have been served since March 2009. This initiative has improved and increased the quality and timeliness of triage, mental health assessment, and initial treatment of patients; reduced the number of individuals and length of stay in emergency departments; and allowed hospitals to direct critical personnel and financial resources to other needs. Electronic health records enable a seamless flow of information about the patient's history. The initiative also provides emergency facilities with access to a larger pool of psychiatrists for consultation than is available without technological connectivity and addresses the physician and psychiatrist shortages in the state.

In recognition of its innovative, collaborative approach to improving access, affordability, and quality of mental health care, the Statewide Telepsychiatry Initiative of the South Carolina Department of Mental Health, in partnership with the University of South Carolina School of Medicine, both in Columbia, was selected to receive APA's Silver Achievement Award for 2011.

Six full-time telepsychiatrists and one part-time telepsychiatrist are available and supervised by a lead psychiatrist. The initiative also has a program director, program coordinator, fiscal technician, and two information resource consultants and a programmer. In addition, three faculty members of Emory University and the University of Pennsylvania and a staff person from the South Carolina Office of Research and Statistics provide support in connection with the grant.

The telepsychiatrist provides assessment and recommendations for initial treatment and works closely with the emergency department physician in identifying resources within the community to guide the patient to follow-up care. The state's Department of Mental Health oversees the community mental health centers in the state, which are considered “receiver sites” for referrals after emergency treatment and discharge. Linkage to these community resources is crucial to many patients in reducing rehospitalization and to improving the quality of life for patients and their families.

The telepsychiatry process is as follows: an emergency department contacts a telepsychiatrist and forwards clinical notes and documents. The psychiatrist reviews the notes and the electronic medical record, then assesses the patient by videoconference. The equipment displays a high-definition image on a 26-inch screen with zoom-in capabilities so that the psychiatrist can carefully observe the patient. When the assessment is complete, the psychiatrist transmits a signed consultation recommendation. The patient's record is stored in a state-of-the-art database, and the record and the psychiatrist's recommendation are sent to the emergency department and to the local mental health center. Every telepsychiatry patient completes a survey, as does a family member if available. The emergency department physician and telepsychiatrist team involves families whenever possible, talking with them in person or by phone and with or without the patient. When the patient is ready for discharge, the team summarizes steps the family has agreed to take to help their family member get follow-up outpatient services, such as encouraging the patient to go to self-help group meetings, supervising medications and monitoring symptoms, and making the home a weapons-free environment.

Launching this statewide project was not without obstacles. Emergency department physicians are sometimes apprehensive about the effectiveness of practices conducted at a distance instead of in person. Concerns have been raised about patient management, qualifications of telepsychiatrists, and the potential for competing responsibilities between emergency physician and telepsychiatrist. A DVD that explains the videoconferencing system, the training and credentials of the telepsychiatrists, and the goal of collaborative treatment helps allay concerns, and site visits by the project leadership team provide opportunities to discuss and resolve concerns with emergency department staff. Although there was some initial concern about how patients would react to assessment by teleconference, this format has not been problematic.

The project team has contacted schools of medicine throughout the state to recruit potential telepsychiatrists, and DVDs are used for recruitment as well as training. The recruitment DVD discusses advantages and disadvantages (such as isolation and working nights, weekends, and holidays) of being a telepsychiatrist, explains how the system works, and explains privileges and credentialing requirements for different hospitals and availability of the lead psychiatrist. Once recruited, telepsychiatrists are required to complete six hours of clinical review on training DVDs, which are supplemented with handouts, before they begin seeing telepsychiatry patients. The training lectures on the DVDs have been prepared by University of South Carolina School of Medicine faculty and cover child and adolescent psychiatry, adult psychiatry, geriatric psychiatry, addiction psychiatry, risk assessment, and legal issues. Peer review is conducted every two weeks for the telepsychiatrist's first three months; the lead psychiatrist meets with other physicians to discuss the consultation, diagnosis, and treatment recommendations.

Many chief executives wondered whether the costs of the technology infrastructure of telepsychiatry and electronic records would result in a net loss, despite the project's aims to reduce the number of admissions, reduce hospitalization costs, reduce length of stay, and increase outpatient mental health follow-up care. The University of South Carolina School of Medicine has been studying this project's clinical, policy, and financial implications. Its findings indicate that the technological costs are offset by reductions in length of stay and ultimately show cost savings.

In fact, the research data show that telepsychiatry is significantly improving the quality of emergency psychiatric care while significantly reducing costs associated with wait times, hospital stays, and health care utilization. In a comparison of emergency departments with telepsychiatry and those without, wait times for a psychiatric consultation have in many cases been reduced from days to hours. For example, a typical situation is that a person will come in for emergency treatment on a weekend, when a psychiatrist is not normally available. The patient may need to stay two or three days before receiving the necessary mental health assessment. With telepsychiatry, this wait time decreases to an average of four to five hours.

With the efficient triaging by telepsychiatrists, admission rates for their patients was 10%, compared with 18% for patients receiving standard emergency care. The average length of stay was four days for the telepsychiatry group versus five days for the control group. Considering that a hospital stay costs $2,000–$2,500 per day, the savings are substantial. The proportion of patients receiving outpatient follow-up care was 51% within 30 days of emergency telepsychiatry treatment and 62% within 90 days of emergency telepsychiatry treatment, compared with 28% and 37%, respectively, for a control group of patients receiving standard emergency care. Psychiatric readmissions within 30 and 90 days of an emergency visit are being analyzed.

In addition to these impressive outcomes, the technological improvements resulting from the Statewide Telepsychiatry Initiative are helping the Department of Mental Health capture precise quantitative data on the diagnosis of mental disorders, substance use disorders, and co-occurring disorders.

A stakeholders group meets quarterly to share experiences, resolve issues, and plan for expansion to other emergency departments. For example, an area for improvement was to create a uniform credentialing application for recruiting telepsychiatrists that could be used across hospitals in the state. Participants in these quarterly meetings include hospital administrators, health care providers, researchers, and information technology staff. In addition, personnel from prospective emergency departments that want to learn more about telepsychiatry are welcome to attend. With this success, additional hospitals have signed up for the telepsychiatry initiative. The team is also studying contextual factors that will allow the program to be disseminated to other states.

In 2001 a cluster of suicides among young members of the White Mountain Apache Tribe alarmed the tribal council. Determined to respond swiftly, the council took the unprecedented step of requiring every tribal member living on the Fort Apache Reservation to report any instance of suicidal behavior to a central data registry.

Mandated reporting and surveillance are the key elements of the White Mountain Apache Suicide Surveillance and Prevention System, which is now regarded as a cutting-edge public health model for suicide prevention. In 2004, the Johns Hopkins Center for American Indian Health (CAIH) joined forces with the White Mountain Apache Tribe to more systematically collect surveillance data and extend the reach of existing mental health services on the reservation. The database, now fully computerized, is analyzed regularly to detect trends and design prevention and treatment strategies.

A suicide prevention team staffed by five Apache community mental health specialists validates every reported incident, assesses risk for future self-injury, and helps individuals connect with suitable treatment. Johns Hopkins partners deliver technical expertise by training the Apache community mental health specialists in mental health diagnosis and intervention. Case-by-case consultation to the team is provided by a Johns Hopkins psychiatrist, psychologist, or social worker. A public health expert on the CAIH staff manages the partnership and helps to monitor the quality of data collected through weekly conference calls with Apache community mental health specialists. An Apache program director reports results on a quarterly basis to the Apache tribal council and the health board.

The surveillance data have substantiated alarming rates of suicide morbidity and mortality among the tribe's youngest members. More than half of the 15,500 residents of the 1.6 million acre reservation, located in east-central Arizona, are younger than 25. Between 2001 and 2006, the death rate by suicide for Apaches ages 15 to 24 was 13 times the U.S. average and six times the rate for American Indians and Alaska Natives. But in a sign of the community's increased awareness of the program, reports to the registry have increased significantly, from 127 in 2001 to 543 in 2010, and many are self-referrals and anonymous referrals by family members. The percentage of residents of the reservation linked to treatment rose from 15% to 32% between 2007 and 2010.

In recognition of its effective and culturally respectful partnership among Apache community mental health specialists, university medical and technical support, and tribal leadership to report, assess, and intervene in suicidal and self-injurious behaviors by members of an autonomous American Indian population at risk for suicide, the White Mountain Apache Suicide Surveillance and Prevention System is the recipient of APA's 2011 Bronze Achievement Award.

Prevention and treatment efforts reflect both traditional Apache modes of healing as well as Western treatment of mental disorders. Preventive efforts have included community-based prayer walks to increase awareness of suicide, community education workshops, a comprehensive multidisciplinary media campaign, and the work of a community advisory board comprising key tribal leaders and stakeholders. Elders teach Apache traditions and culture to children at school, and gatekeepers of at-risk youths receive Applied Suicide Intervention Skills Training (ASIST) led by certified Apache ASIST trainers. Technical empowerment workshops help Indian Health Service hospital staff to identify and refer those at risk.

The programs New Hope and Re-Embracing Life are designed specifically to prevent repeat suicide attempts by educating youths and their families about strategies for coping with family conflicts, a key precipitant of self-injurious behavior. Immediately after a suicide attempt, Apache community mental health specialists meet with the youth and the family to view a locally produced DVD featuring a cast of American Indians about an Apache teenager who attempted suicide. The video includes commentary by well-known Apache elders, who convey the seriousness of a suicide attempt, emphasize traditional Apache beliefs about the sacredness of life, and explain treatment resources. Apache community mental health specialists work with the youth and family to develop a safety plan, connect them to mental health services, and provide follow-up to ensure that youths engage and participate in treatment. Many youths and families also enroll in Re-embracing Life, a nine-week course taught by Apache community mental health specialists that covers conflict resolution, emotion regulation, communication, and coping and problem-solving skills.

The White Mountain Apache Tribe has received support for the program from the National Institutes of Health Native American Research Centers for Health and MACRO International as well as renewable grants from the Substance Abuse and Mental Health Services Administration. The use of Apache community mental health specialists to provide assessment and clinical care in lieu of more expensive clinical professionals is a cost-effective option to stretch that funding. Their cultural background and experience living in the community they serve taps local human resources and extends the reach of mental health care available on the reservation.

The comprehensive, community-based approach to prevention and treatment developed by the White Mountain Apache Suicide and Prevention System is now regarded as a model for other tribal communities. It regularly responds to requests for assistance with replicating the surveillance and prevention system and provides, free of charge, copyrighted forms developed for intake, follow-up, and death by suicide. In addition, through its unique emphasis on data collection and analysis, it has been successful in identifying characteristics of individuals who engage in nonsuicidal self-injury, such as cutting and binge drinking. In doing so, it is helping to fill a gap in research on suicide prevention and treatment in other American Indian communities, where suicide rates are similarly high but clinical resources scant.