Public-Academic Partnerships: The University of Hawai‘i Rural Health Collaboration: Partnerships to Provide Adult Telepsychiatry Services

The Department of Psychiatry established the University of Hawai‘i Rural Health Collaboration (UHRHC) ( 7 ) to increase rural access to behavioral health services across the state, primarily via telepsychiatry. The UHRHC has partnered with community health clinics on the islands of Maui, Molokai, and Hawai‘i. Direct patient care and consultation-liaison services are provided through two modalities: face to face and via videoteleconferencing. Services are provided to children, adolescents, and adults. The UHRHC uses a service-learning approach to workforce development, which allows universities to contribute to improved public health through structured trainee experiences in community settings. Such settings include publicly funded clinics, such as federally qualified rural community health centers and the State of Hawai‘i Department of Health, and private clinics that receive referrals via public and nonprofit institutions, such as from the State of Hawai‘i Adult Mental Health Services.

Our lessons are based on both anecdotal and empirical analyses from one of our adult specialty clinics. Not only is this information critical for improving services, it also is shaping community partnerships.

Before providing psychiatric services in a rural community (unnamed to protect confidentiality), the attending psychiatrist met with key stakeholders, such as mental health providers, case managers, and hospital personnel, to inform the development of the specialty clinic. This specialty clinic initially was conceived of as a freestanding psychiatric clinic colocated with but separate from the health clinic in which it is housed. The specialty clinic also offers care in cardiology and veterans' care, for example.

In addition to conducting an informal needs assessment of existing resources within the community, we wanted to assure stakeholders of our genuine interest in providing a service in their rural locale. This is an inherent concern of communities that engage with academic institutions because these institutions not only provide clinical services but also involve trainees (psychiatry fellows) in service delivery and conduct mental health research. We wanted to address community concerns about training and research, particularly because we were proposing to use a new technology in providing care—telemedicine. Finally, as in most of rural Hawai‘i, a majority of residents in this community are Native Hawaiian, the indigenous people of the Hawaiian Islands. Like other indigenous populations in the United States and around the world, Native Hawaiians have a history of being affected by colonialism and are aware of the potential for ethical breaches in medical and research practices, so assurance and clarity of our purpose and practice were key.

To fully understand the community's clinical issues, we conducted a small study of all psychiatric patients who were referred to a single rural psychiatric specialty clinic. Most patients had not received previous psychiatric care. The clinic was established in September 2006, so the study period represents the start-up phase of our nascent rural telehealth collaboration.

We conducted a retrospective medical record review using existing patient records. We received study approval from the Committee on Human Subjects at the University of Hawai‘i and the Research and Institutional Review Committee of the Queen's Medical Center.

Data were collected on referral source, demographic information, service encounter, patients' primary diagnoses ( ICD-9 code), and medications prescribed. During the ten-month study period, 39 patients were referred to the telepsychiatry specialty clinic from various sources, including a community health center, local hospital, private practice primary care provider, Native Hawaiian health care system, self or family, or off-island clinic. Of these patients, 18% (N=7) did not show up for their scheduled appointment and were excluded from these analyses. A total of 32 patients participated in the specialty clinic services. Just over half of the clients were women (N=17, 53%). Patients' ages ranged from 19 to 86, and over 60% (N=19) were aged 50 or older. These patients were ethnoculturally diverse, although not representative of the State of Hawai‘i's population: white or Euro-American (47%, N=15), Hawaiian (34%, N=11), Filipino-American (6%, N=2), other or undisclosed race-ethnicity (13%, N=4).

In the ten-month start-up period, 61 psychiatric service encounters were provided, of which 10% (N=6) were delivered via the videoteleconferencing technology and 90% (N=55) were face-to-face encounters at the rural specialty clinic site. Of the 32 patients, 16% (N=5) received one or more encounters via the videoteleconferencing modality. Services were scheduled primarily for the purpose of initial evaluations for eligibility for psychiatric services, second-opinion diagnoses, and medication monitoring. Clients had various primary diagnoses, most of which included depression (44%, N=14), substance use disorders (25%, N=8), schizoaffective disorders (19%, N=6), bipolar disorder (16%, N=5), posttraumatic stress disorder (9%, N=3), attention-deficit disorder or attention-deficit hyperactivity disorder (9%, N=3), and other diagnoses (22%, N=7). Medications were prescribed to 81% (N=26) of clients.

A goal of this service system research was to inform the UHRHC organizational development regarding capacity to provide mental health services in a rural community. Results indicate that this rural clinic has the potential to provide a variety of diagnostic and medication management opportunities, which is an essential aspect of academic psychiatry for the purpose of education and training. However, these analyses and other insights have provided several lessons as we refine and expand the UHRHC.

Our telehealth approach to eliminating rural mental health disparities began organically, with two attending psychiatrists committed to serving rural populations. Through their intuitive use of principles of practice in community participation in health, one psychiatrist has established and maintained a rural psychiatry specialty clinic for several years. Through needs assessments and by seeking patient referrals, the foundation for community collaboration was formed. As a result, the UHRHC has moved to a model in which telepsychiatry is the dominant service modality, with face-to-face site visits as a supplement and reinforcement. Parallel to these service activities, we conducted medical record reviews to understand the service's strengths and areas for improvement. This was a critical step in our organizational development, because the analyses indicated the need for an integrated service model as opposed to a freestanding specialty clinic. Therefore, we are structuring the UHRHC to become a sustainable integrated service that can meet a community's need for psychiatric services as well as the university's interests in workforce development.

Funding was provided by the National Center for Indigenous Hawaiian Behavioral Health, the National Center on Minority Health and Health Disparities, the State of Hawai‘i Department of Human Services, and the State of Hawai‘i Department of Health's Child and Adolescent Mental Health Services Division. The views expressed are those of the authors and do not reflect the position of the funders.

The authors report no competing interests.

The authors are affiliated with the Department of Psychiatry, John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Ala Moana Building, 18th Floor, 1441 Kapi'olani Blvd., Honolulu, HI 96814 (e-mail: [email protected]). Lisa B. Dixon, M.D., M.P.H., and Brian Hepburn, M.D., are editors of this column.