How it all began

There are not a large number of individuals who are both hearing impaired and additionally have a mental illness, but they are located all over the State. BHDD Office of Mental Health was and still is fortunate to employ an excellent psychiatrist who is also fluent in American Sign Language. However, it was very inefficient for her and the agency for her to see all hearing impaired patients face-to-face. She would have to spend hours traveling rather than seeing patients. The solution was to use telemedicine technology to enable her to remotely assess and treat BHDD Office of Mental Health hearing impaired patients at whichever BHDD Office of Mental Health Community Mental Health Center was providing services to that patient. All this was possible not just because of telehealth videoconferencing technology, but because BHDD Office of Mental Health is one of only a few integrated public mental health systems in the 50 states and 8 territories. The agency directly operates the State’s psychiatric hospitals as well as the States network of Community Mental Health Centers. BHDD Office of Mental Health has 17 Community Mental Health Centers (CMHCs) most with multi-county service areas. Combined, the CMHCs and their associated clinics provide 60 outpatient treatment sites, covering all 46 counties in the State, enabling most patients to receive mental health services close to where they live. All 17 Centers use a common Electronic Medical Record (EMR), which enables the psychiatrist to view the patient’s medical record, and enter notes and write prescriptions from where the psychiatrist is located, even when communicating with a patient at a Mental Health Center miles away.

Following the success of the Deaf Services program, BHDD Office of Mental Health launched the Emergency Department (ED) Telepsychiatry Program.

The two largest programs are the Emergency Department Telepsychiatry Program and the Community Telepsychiatry Program.

The Emergency Department Telepsychiatry Program provides comprehensive evaluations to participating hospitals. The Community Telepsychiatry Program provides treatment services to patients at BHDD Office of Mental Health’s community mental health centers and mental health clinics.

Like many states, the emergency departments in South Carolina’s hospitals see a large number of patients experiencing a behavioral health crisis. Due to a shortage of psychiatrists, especially in rural areas of the State, patients may wait days in an emergency department for a psychiatric assessment and recommended treatment. Beyond the adverse impact on the patients themselves, the cost to South Carolina hospitals of dozens of behavioral health patients waiting days for an assessment and appropriate treatment in their emergency departments is serious, especially for smaller hospitals.

In the spring of 2007, BHDD Office of Mental Health State Director John H. Magill met with staff from The Duke Endowment (TDE), located in Charlotte, NC to explore whether TDE would be willing to assist BHDD Office of Mental Health in addressing this difficult issue. The Duke Endowment is a foundation that funds projects in North and South Carolina, and health is one of the areas in which it specializes. In a collaboration of historic significance, the Department of Behavioral Health and Developmental Disabilities (BHDD) Office of Mental Health partnered with The Duke Endowment to create in December 2007 an innovative solution to the overcrowding of psychiatric patients in local hospital emergency departments. The solution was called “Partners in Behavioral Health Emergency Services.” Informally, it is referred to as the “BHDD Office of Mental Health Emergency Department Telepsychiatry Consultation Program.” It is a cutting-edge statewide service delivery model that provides remote access for emergency departments in South Carolina to psychiatrists whenever a psychiatric consultation is required. With on-going program evaluation from the University of South Carolina, School of Medicine, early financial support from the South Carolina Department of Public Health and Human Services, and initial program support from the South Carolina Hospital Association, the Program is a critical component to meeting the increased demand on emergency departments to treat psychiatric and co-occurring disorder patients. The approach is to impact the demand for services at the service-delivery point with a product that will augment the limited resources available in the emergency departments. The solution is the BHDD Office of Mental Health Emergency Department Telepsychiatry Program.

The project’s goal is to increase the quality and timeliness of psychiatric assessment and initial treatment of patients in community hospital emergency departments. Timely psychiatric evaluation provides Emergency Department staff with treatment recommendations that can often reduce the patients’ length of stay in emergency rooms, to the benefit of both the patients and the participating hospitals. The means selected to reach that goal is to make a psychiatric comprehensive evaluation available Statewide from a BHDD Office of Mental Health psychiatrist by using innovative high definition (HD) video technology.

With the grant from TDE, BHDD Office of Mental Health developed an implementation plan. BHDD Office of Mental Health searched for best practices in other states but did not find one. So BHDD Office of Mental Health staff created its own. They looked at other states, researched current technology options available in terms of cost value ratio and applied a good bit of local creativity. BHDD Office of Mental Health secured some vendor input and put out a bid for the program’s equipment. AVI Group was selected to install Polycom equipment. The state-of-the-art high definition video/audio equipment selected allows BHDD Office of Mental Health psychiatrists to see, speak with and evaluate the patients in real time, as well as speak to Emergency Department staff. The high-tech wireless video cart functions on a secure network meeting all privacy standards.

The first wireless video cart was activated in a hospital emergency department on March 29, 2009. The patient sees the psychiatrist on a 26-inch high definition flat screen located on a wireless HD mobile practitioner cart in the privacy of the patient’s room. The distant BHDD Office of Mental Health psychiatrist, in real time, views the patient on a desktop system from their office. With the clarity of a high definition picture and with pan, tilt and zoom cameras that the doctor can manipulate remotely, bringing minute visual elements, such as eye contact, pupil dilation or tics, into view, as well as clear audio, the psychiatrist conducts an assessment with the quality of a “face to face” encounter, just as in the doctor’s office.

The unique application of modern technology allows both the urban and rural emergency department patient and his/her doctor to participate in a psychiatric session described to be nearly as personal as a “face to face” encounter. This ground breaking program is an excellent way to provide critical psychiatric care in rural areas of South Carolina where there is a long standing shortage of psychiatrists and other mental health professionals.

A typical assessment between the psychiatrist and the patient may take some 20-30 minutes. Hospital medical professionals are allowed to participate in the assessment process with the patient’s approval. Prior to the video exchange, the psychiatrist secures and reviews available medical record information including laboratory results from the hospital. The assessment is concluded with written recommendations made to the patient’s physician in the hospital. Recommendations may range from psychiatric medication, individual and/or family counseling, discharge to a specific community referral for continuing treatment, or transfer to a longer-term psychiatric bed for inpatient treatment.

When the assessment is concluded, the psychiatrist completes an electronic medical record with treatment recommendations, affixes an electronic signature and sends a confidential copy to the local hospital for inclusion in the patient’s medical record. A copy also goes to the nearest BHDD Office of Mental Health mental health center for follow up care.

The benefits were immediate. With videoconference-based behavioral assessments, 31% of the patients assessed were being discharged from the hospital and returned to their families and to their lives on the same day they were assessed, cutting lengths of stay substantially. For those patients who can be safely discharged from the emergency room, but who are in need of aftercare at a mental health center, the BHDD Office of Mental Health psychiatrist supplies the patient and Emergency Department staff with information about the local mental health center and other local resources, reducing the risk of a future crisis. The mental health center is able to immediately access the electronic medical record of the psychiatrist’s assessment and recommendations.  For those patients who are retained, treatment recommendations from the consulting psychiatrists generally improved the quality of care they receive.

Twenty-four hospitals across the state are currently participating in the BHDD Office of Mental Health ED Telepsychiatry Program. Being a fairly small state, the program has made a substantial impact.

• It is the first of its kind nationally.
• The Program began in December 2007.
• There are five primary goals of the program. In summary, they are as follows: have the patient receive a quality psychiatric assessment as soon as possible, initiate medication and/or other treatment as prescribed, reduce the length of stay in the hospital, accrue savings to the hospital wherever possible and propose comprehensive discharge planning for continued aftercare in the community.
• An R01 Grant awarded to the University of South Carolina, School of Medicine has demonstrated that this unique program has improved access, affordability, and provided quality care to citizens of the state with mental illness.

As of October 10, 2018:

• The Program is being utilized by 24 hospitals.
• The Program provides approximately 570 comprehensive evaluations per month.
• The Program has 17 telepsychiatrists in full- and part-time capacities.
• The Program operates approximately 18 hours a day, 7 days a week, including holidays.

The results demonstrate:

• Higher follow-up and retention of patients seen with the telepsychiatry group compared to controls in an outpatient setting.
• Shorter lengths of stay.
• Fewer inpatient admissions.
• Total charges at encounter level for the index emergency department visit including subsequent inpatient admission that were significantly lower for the telepsychiatry group.

The South Carolina General Assembly has provided more than $11 million in State Appropriations since inception to support the Program.

The Duke Endowment has provided more than $9 million in grant funds since inception to support the Program.

BHDD Office of Mental Health’s ED Telepsychiatry Program has far exceeded the Agency’s early expectations in terms of both its capacity and its successful outcomes, winning the following awards:

• (2011) The American Psychiatric Association awarded BHDD Office of Mental Health and the Department of Neuropsychiatry and Behavioral Science of the USC School of Medicine the Psychiatric Services Achievement Award, Silver Medal, for its Statewide Emergency Department Telepsychiatry Consultation program.
• (2012) BHDD Office of Mental Health Emergency Department Telepsychiatry Consultation Program received the South Carolina Office of Rural Health’s Annual Award.
• (2015) The Ash Center for Democratic Governance and Innovation at the John F. Kennedy School of Government of Harvard University recognized BHDD Office of Mental Health’s Telepsychiatry Consultation Program as part of its 2015 Bright Ideas program, honoring government programs that are at the forefront in innovative action.
• (2015) the Program was recognized as a Statewide Telehealth Program of Excellence at the 4th Annual Telehealth Summit.

While the high definition video/voice telemedicine technology is central to the Program’s ability to provide services remotely to hospital Emergency Departments around the State, a key to the Program’s success has again been the agency’s network of Community Mental Health Centers and common Electronic Medical Record (EMR). Prior to the video exchange, the psychiatrist secures and reviews available medical record information, which includes information from the hospital. But the BHDD Office of Mental Health psychiatrist also has access to the BHDD Office of Mental Health EMR, which may contain information about prior treatment episodes for that same patient. The BHDD Office of Mental Health telepsychiatrists also have access to the State’s electronic health database which contains a history of any past hospitalizations for that patient in any one of the State’s hospitals, and some of its outpatient clinics. The system, known as the SC Health Information Exchange, or SCHIEx, may provide information about past treatment of the patient in a non-BHDD Office of Mental Health hospital. In many cases, the BHDD Office of Mental Health psychiatrist can actually provide medical history information about the patient to the Emergency Department about which they were previously unaware.

The connection between the BHDD Office of Mental Health telepsychiatrists and the BHDD Office of Mental Health Mental Health Centers has been valuable for another reason. For those patients who can be safely discharged from the emergency room, but who are in need of aftercare at a mental health center, the BHDD Office of Mental Health psychiatrist supplies the patient and Emergency Department staff with information about the local mental health center and other local resources, reducing the risk of a future crisis. The Mental Health Center is able to immediately access the electronic medical record of the psychiatrist’s assessment and recommendations, ensuring a smooth transition of care from the ED to the Center.

• The tremendous success of the ED Consultation Program led BHDD Office of Mental Health to expand its telepsychiatry services to include community-based telepsychiatry.
• The Community Telepsychiatry Program started because of the need for full spectrum community mental health services in rural areas across the state.
• Built on the success of the BHDD Office of Mental Health Emergency Department Telepsychiatry Consultation Program, BHDD Office of Mental Health has equipped its community mental health centers and mental health clinics to provide psychiatric treatment services to its patients via Telepsychiatry.
• The Program began in August 2013.
• The Program is currently deployed in 17 community mental health centers and 43 mental health clinics.
• The Program provides approximately 1,600 treatment services per month.
• The Program has 42 telepsychiatrists in full- and part-time capacities.
• Many BHDD Office of Mental Health community mental health centers operate mental health clinics in rural counties that are distant from the main center. For example, Beckman Center for Mental Health Services’ catchment area covers seven counties. The use of telepsychiatry within catchment networks allows psychiatrists based at the main center to serve outlying satellite clinics without having to travel to those locations. This technology provides patients in need of mental healthcare both scheduled and urgent access to psychiatric services.
• BHDD Office of Mental Health has also recruited agency psychiatrists to supplement catchment areas experiencing a shortage of available psychiatric time by utilizing telepsychiatry. These psychiatrists are located in a central geographic location and provide telepsychiatry services from that central location to locations across the state.
• Services are provided to child, adolescent, and adult patients.
• Recruiting psychiatrists is challenging in many locations, especially rural areas. Driving to remote rural clinics consumes valuable time better spent serving patients.

The South Carolina General Assembly has provided more than $2 million in State Appropriations since inception to support the program.

How BHDD Office of Mental Health leadership continues to look for opportunities to use Telemedicine technology

On May 1, 2017, the Assessment Mobile Crisis (AMC) team at Charleston Dorchester Mental Health Center (CBHDD Office of Mental HealthC) began a Telehealth Pilot Project with Charleston County EMS (CCEMS). Funded by an MUSC Telehealth Grant, the pilot project was created in an effort to appropriately divert behavioral health patients from local Emergency Departments and hospitals. CCEMS uses the telehealth technology on all 911 calls which are identified as psychiatric in nature. It first sends a staffed ambulance to evaluate the individual for medical needs for emergency transport. If there are no medical concerns, a CCEMS supervisor, with the telehealth equipment, is dispatched to the scene. At this time, the ambulance is able to leave the scene, returning to service for other calls. AMC is contacted by the supervisor, and they establish a video connection using HIPAA compliant software called Vidyo. The AMC clinicians are able to use this platform to gather information from police, EMS, the patient, and any friends/family on scene. AMC staff provide a full emergency mental health assessment, and coordinate the linking of the patient to the appropriate level of care. Possible dispositions include: follow-up with outpatient treatment; admission to the Tri-County Crisis Stabilization Center; inpatient treatment (voluntary and involuntary); and/or a link to treatment for substance use disorders.

Prior to this pilot project, CCEMS only called AMC 4-5 times a year, due to its need to quickly return the ambulance to service for other emergency calls in the community. CCEMS reports transporting most of the behavioral health patients to the ED as a result of its need to quickly complete the call. Using telehealth assessments has significantly decreased the amount of time needed to complete the intervention, and has allowed for the ambulance to quickly return to service without transporting to the ED. In the first 3 months of the project, CCEMS called AMC 163 times. Of these 163 calls, 51% were diverted from an ED. Also, due to AMC helping patients use their natural support systems to access care, only 29% of all of the calls required EMS transport to an ED. The estimated cost savings for the healthcare system in the first 3 months (cost of ambulance transport and a basic ED visit) was approximately $206,600.

BHDD Office of Mental Health’s Telepsychiatry Programs now comprise the Deaf Services Telepsychiatry Program, Emergency Department Telepsychiatry Program, Community Telepsychiatry Program, EMS Telehealth Pilot Project, and Inpatient Services Telepsychiatry Program.

Future plans for BHDD Office of Mental Health’s Telepsychiatry Programs include:

• Continued expansion of the Emergency Department Telepsychiatry Program
• Continued expansion of the Inpatient Services Telepsychiatry Program
• Alignment of services with primary care providers
• Implementation of a telepsychiatry component into the BHDD Office of Mental Health School Mental Health Program
• Continued recruitment of ED telepsychiatrists
• Deployment of physician extenders to provide telehealth services