Using Telepsychiatry With High-Risk Patients in Rural New York State

“People don’t think of New York as a place where we have to worry about telepsychiatry. We’ve got all these providers, because New York City has more psychiatrists per square mile than anyplace else in the world, but actually the majority of the state is a health shortage area,” said Rachel Zinns, MD, of the Maimonides Medical Center in Brooklyn, NY, in a presentation at the Annual Meeting of the American Psychiatry Association in San Diego.

Zinns said that the first outpatient clinic to introduce telepsychiatry in New York was a state hospital-run clinic upstate in Monticello in the Catskill Mountains. Zinns said, “It’s actually northern Appalachia, and it is in the poorest county in the entire state.”

Zinns is now the telepsychiatrist serving the clinic. In terms of scale, Zinns described the outpatient clinic as consisting of about 120 patients who receive approximately 1500 telepsychiatry visits per year. “This is a state hospital, so the level of acuity is very high. About half of the patients have substance-abuse disorders, about 30% to 40% have psychotic disorders, and about 20% to 30% have either bipolar or depressive disorders; 100% had serious trauma, and 25% of these had post-traumatic stress disorder [PTSD].”

In terms of operational outcomes, Zinns said, “Our rate of no-shows was about 10%, which is better than anywhere else in the state.”

Patient satisfaction with the program was also high. Continuing regarding the program’s success, Zinns showed clinical outcome data. “We had 12 different clinics in this system with roughly the same demographics and staffing, but we were the only one with telepsychiatry. Compared with the average of the other 11 clinics, ours had lower psychiatric hospitalization rates, 18.4% vs 23.1%; less than half the rate of emergency room [ER] visits, 6.1% vs 12.7%; much lower rates of suicide and violence, 5.1% vs 12.8%; and far fewer medical/surgical hospitalizations, 9.2% vs 16.3%.”

However, Zinns said that for her, the key significance of these positive results was that “telepsychiatry didn’t mess everything up.” Zinns stressed that the numbers of psychiatric hospitalizations in the system as a whole speaks to the level of acuity in these patients. “These are patients that would not be managed anywhere but in a state hospital. This is a particularly high-risk group of patients.”

Zinns covered operational issues that need to be addressed and implemented in a successful telepsychiatry program. These include having appropriate video conference equipment and room configuration, but also includes having the right team in place at the remote site.

“Recommendations include 1 full-time employee [FTE] as telepsychiatrist, 1 FTE as community mental health nurse [CMNH], 1 FTE as registered nurse [RN], 0.6 FTE for vocational counselor, 0.4 FTE for peer provider, and 1 FTE as social worker.” Required community resources include the availability of a mobile crisis team, primary care doctors, pharmacists, a residential program, and an acute-care hospital.

In conclusion, Zinns said that there have been few studies that have measured clinical outcomes, and even fewer that have looked at clinical outcomes in high-risk populations, such as in a state hospital system.

“Because of this lack of data, psychiatrists can be reluctant to treat suicidal or psychotic patients by means of telepsychiatry. The purpose of this talk was to present evidence of the effectiveness of telepsychiatry for such high-risk patients.”