Leveraging Telepsychiatry for Population Health

Synchronous telepsychiatry has become part of the mental health care landscape. Multiple studies have documented its ability to improve access to care for diverse patients in multiple settings and to improve the quality of that care. Patients are highly satisfied with their care, outcomes appear as good as comparable interventions delivered in person and can be superior to care available in patients’ home communities. Perhaps equally appealing to the telepsychiatrists is the opportunity to reach new populations without time away from the office and family. Studies addressing the cost effectiveness of telepsychiatry and the return on investment are in progress. Clearly, telepsychiatry is the wave of the future—a future that has already arrived.

While telepsychiatry addresses inequities in access to and quality of care, it maintains the traditional structure of "one-patient-one-doctor" model of care. It redistributes the workforce. To build capacity in communities, telepsychiatry must be integrated into population models of care. Project ECHO® (Extension for Community Health care Outcomes) is one approach to the integration of telepsychiatry into population-based mental health care.

The mission of Project ECHO® is to expand the capacity to provide best practice care for common and complex disorders in rural and underserved areas, and to monitor outcomes. Project ECHO® builds on existing technology to create virtual learning collaboratives that promote evidenced-based best practices utilizing case-based learning to master complexity. It is breaking down the walls between specialty and primary care using a "hub and spoke" model that links specialist teams at an academic 'hub' with primary care clinicians at multiple spoke communities. Together, they participate in weekly teleECHO™ clinics, combined with mentoring and patient case presentations.

During teleECHO clinics, primary care clinicians present patient cases to the specialist teams and to each other, discuss new developments relating to their patients, and determine treatment. In the process, they establish a supportive network for one another. Specialists serve as mentors and colleagues, sharing their knowledge and expertise with primary care clinicians. Essentially, ECHO® creates ongoing learning communities in which primary care clinicians receive support and develop the skills they need to treat a particular condition. As a result, they can provide comprehensive, best-practice care to their patients with mental health care needs.

Project ECHO® and comparable programs can change the mental health care landscape. A single specialist can reach multiple primary care providers who manage their patients' mental health care needs. Consequently, capacity is built in the community by strengthening primary providers' skills. Access increases, and the provision of evidence-based care to more patients improves the mental health of the community. A secondary benefit to primary providers is the potential for participation in such programs to contribute to their Maintenance of Certification.

Project ECHO® has an emerging evidence base indicating its ability to enhance workforce capacity in medical specialties as well as to influence provider behavior, patient outcomes, and health care costs1. There are now over 250 Project ECHO® across the United States, Europe, Africa, Asia, and South America. Programs have focused on physical health but there is a growing emphasis on behavioral and mental health including addictions, depression, geriatric mental health, and child mental health. Project ECHO® for mental health may expand to include other professionals involved in patient care—for example psychologists, social workers, case managers, even school staff or community workers.

Developing a Project ECHO® program relies on partnerships. Starting with providers and sites that have an established trusting relationship with the psychiatrist may be most feasible and productive. In person visits to the sites to solicit and provide feedback helps to optimize program development and retention. Major medical centers with outreach to regional sites are especially well suited to building partnerships that reach diverse populations and facilitate payment mechanisms. Grants and contracts often fund initial program development.

Establishing a Project ECHO® program involves administrative supports. Although usual telehealth videoconferencing technologies are used, technical supports remain available for unforeseen difficulties in connecting multiple sites. A scheduler coordinates the participants across sites and a staff is identified as the facilitator. It takes a team to provide comprehensive, evidence-based, population mental health care.

Project Lessons Learned

Project ECHO® moves knowledge, not patients. Everyone is a teacher and a learner. The hub and spoke network model creates a learning loop. Primary care providers have learning experiences that they share with colleagues. Specialist psychiatrists appreciate the larger picture of the health care needs of patients with mental health problems and challenges in meeting their needs in the home communities. Going forward, collaborations should focus on developing practical tools for managing patients' mental health care and identifying patient resources. Practice management information, such as billing codes, is needed to make such programs sustainable. Performance improvement components should be integrated into ECHO® programs to ensure quality collaboration and improved patient outcomes, particularly for emerging ECHO-Psychiatry programs.

Project ECHO® is one example of how telepsychiatry may be leveraged to build and disseminate models of care that overcome barriers to patients receiving evidence-based mental health care. On a broader systems level, it integrates physical and psychiatric care and redefines a role for psychiatrists.

Learn About Project ECHO®

About the Author

Kathleen Myers MD, MPH, MS, FAACAP, FATA
Member, APA Committee on Telepsychiatry
Professor of Psychiatry and Behavioral Sciences, University of Washington
Director, Telepsychiatry Service, Seattle Children's Hospital
Co-Chair, Telepsychiatry Committee, American Academy of Child and Adolescent Psychiatry

Dr. Myers has conducted research demonstrating the effectiveness of telepsychiatry in community-based samples and has led development of practice guidelines for telepsychiatry with children and adolescents.

References

  1. Arora S, Thornton K, Murata G, et al. Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers. 2011; N Engl J Med. 2011; 364:2199-2207.
  2. Katzman JG, Comerci G, Boyle JF. Innovative Telementoring for Pain Management: Project ECHO Pain. Journal of Continuing Education in the Health Professions. 2015; 35(3):176-184.
  3. Mehrotraa K, Chanda P, Bandawara M, et al. Effectiveness of NIMHANS ECHO blended tele-mentoring model on Integrated Mental Health and Addiction for counsellors in rural and underserved districts of Chhattisgarh, India. Asian Journal of Psychiatry. 2018; 36:123-127.
  4. Zhou C, Crawford A, Serhal E, Kurdyak P. The Impact of Project ECHO on Participant and Patient Outcomes: A Systematic Review. Academic Medicine. 2016; 91(10):1439–1461.

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