Geriatric Telepsychiatry A Clinician’s Guide

Shilpa Srinivasan · Juliet Glover James G. Bouknight Editors

Geriatric Telepsychiatry

A Clinician’s Guide


Geriatric Telepsychiatry


Shilpa Srinivasan • Juliet Glover James G. Bouknight


Geriatric Telepsychiatry A Clinician’s Guide


Shilpa Srinivasan, MD Department of Neuropsychiatry

and Behavioral Science University of South Carolina

School of Medicine Columbia, SC, USA

James G. Bouknight, MD Department of Neuropsychiatry

and Behavioral Science University of South Carolina

School of Medicine Columbia, SC, USA

ISBN 978-3-319-51489-5

DOI 10.1007/978-3-319-51491-8

Juliet Glover, MD

Department of Neuropsychiatry

and Behavioral Science University of South Carolina

Library of Congress Control Number: 2017931963

© Springer International Publishing AG 2017

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School of Medicine Columbia, SC, USA

ISBN 978-3-319-51491-8




As the American, and indeed worldwide, population continues to age, innovative methods of addressing healthcare needs are critical. From a practical perspective, older adults with mental illness and/or substance use disorders often present in primary care settings, which are under-resourced. In such set- tings, managing healthcare needs of individuals with compli- cated age-related medical and mental health conditions are challenged by limited time and limited provider training. Stigma, lack of information about services, and limited trans- portation to services remain major barriers to mental health- care access and utilization among older adults. However, the volume of the current geriatric psychiatry workforce is insufficient to meet the mental healthcare needs of the aging population. The growing older adult demographic and the concomitant increase in older adults with mental illness high- light the critical need for expanding access to mental health- care in this population. One way to meet this growing need is geriatric telepsychiatry.

Telepsychiatry has the potential to not only increase access to mental healthcare for underserved older adults but also decrease cost of providing care. Furthermore, outcomes are equivalent to in-person care with regard to symptom improve- ment and treatment adherence. Patient and provider satisfac- tion is generally high even in geriatric populations. Through their own clinical experience and research, the editors and chapter authors have reviewed the body of extant literature showing that clinical care, education, and research through


vi Preface

telepsychiatry have the potential to improve access to care and train future workforce in geriatric psychiatry. This is cer- tainly timely given the increase in our aging population, prevalence of Alzheimer’s disease, and dearth of geriatric psychiatry providers.

This book is divided into three parts (background, clinical applications, and practical considerations) encompassing eight chapters:

Chapter 1 Introduction: A Primer and Overview of the Tele- psychiatry Consultative Process

Chapter 2 Overview of Telepsychiatry in Geriatrics: Applica- tion of Telepsychiatry in Geriatric Mental Healthcare

Chapter 3 The Economics of Geriatric Telepsychiatry: Focus on Costs and Benefits of a Geriatric Telepsychiatry Service

Chapter 4 Geriatric Telepsychiatry in Academic Settings: Aca- demic Implications of Geriatric Telepsychiatry Within Graduate Medical Education Programs

Chapter 5 Administration of New Telepsychiatry Programs in Public Psychiatry: Highlights Exemplar State Programs Utilizing Telepsychiatry in Rural Healthcare Settings

Chapter 6 Telemental Health in VA Systems: Summarizes VHA Telepsychiatry Contributions to Veterans Mental Health

Chapter 7 Scope of Telepsychiatry in Clinical Settings: Com- prehensive Review of Reliability and Cost-Effectiveness of Telepsychiatry in Geriatrics

Chapter 8 Technology Applications and Implications for Implementation: Technical Overview to Successfully Implement a Geriatric Telepsychiatry Program

Geriatric Telepsychiatry: A Clinician’s Guide endeavors to provide healthcare providers with an overview of telepsy- chiatry and its application and cost-effectiveness in the field of geriatric psychiatry. Public and federal programs using telepsychiatry are presented, and technological implications are highlighted. Recognizing the impact of training the


clinical workforce to meet the mental healthcare needs of the older adult population, this book also includes application of geriatric telepsychiatry in academic training programs. The editors hope that readers will be able to utilize this book as a resource either to develop telepsychiatry programs within their institutions/practice settings or bolster existing services through learning about applications across diverse settings showcased by chapter authors.

The editors are sincerely grateful to all our chapter authors who provide mental healthcare to older adults across diverse and interdisciplinary clinical settings. Most importantly, this book is dedicated to our patients and their families, who inspire and motivate us daily.

Columbia, SC, USA Shilpa Srinivasan Juliet Glover James G. Bouknight

Preface vii


Part I Background

1 Introduction to Telepsychiatry…………………………….. 3 Juliet Glover, Shilpa Srinivasan,

and James G. Bouknight

2 Overview of Telepsychiatry in Geriatrics …………….. 11 Juliet Glover

3 The Economics of Geriatric Telepsychiatry…………. 27 James G. Bouknight

Part II Clinical Applications

4 Geriatric Telepsychiatry in Academic Settings…….. 55 Shilpa Srinivasan, Ashley Blackmon Jones,

and Donald Hilty

5 Administration of New Telepsychiatry

Programs in Public Psychiatry

and Applications in Geriatrics …………………………….. 99 Mridul Mazumder and Brenda Ratliff

6 Geriatric Telemental Health

in the United States Department of Veterans

Affairs ………………………………………………………………… 123 Taya Varteresian, Alexander Threlfall,

and Paul Kirwin



x Contents

Part III Practical Considerations

7 Scope of Telepsychiatry in Clinical Settings ………… 137 Meera Narasimhan

8 Technology Applications in Geriatric

Telepsychiatry and Implications

for Implementation …………………………………………….. 151 Suzanne M. Hardeman

Index………………………………………………………………………….. 163


James G. Bouknight Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, SC, USA

Juliet Glover Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, SC, USA

Suzanne M. Hardeman Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, SC, USA

Donald Hilty Department of Psychiatry, Keck School of Medicine, Los Angeles, CA, USA

Ashley Blackmon Jones Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, SC, USA

Paul Kirwin Integrated Care, VA Connecticut Healthcare System, Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA

Mridul Mazumder Department of Behavioral Health, Tallahassee Memorial Hospital, Tallahassee, FL, USA

Meera Narasimhan Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, SC, USA

Brenda Ratliff Aiken Barnwell Mental Health Center, Aiken, SC, USA



xii Contributors

Shilpa Srinivasan Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, SC, USA

Alexander Threlfall Brookwood Health Center, Santa Rosa Community Health Centers, University of California, San Francisco, CA, USA

Taya Varteresian Los Angeles County Department of Mental Health, University of California Irvine, Los Angeles, CA, USA

Part I Background


Chapter 1

Introduction to Telepsychiatry

Juliet Glover, Shilpa Srinivasan, and James G. Bouknight

1.1 Introduction

Technology is ever present in today’s society. It penetrates multiple aspects of daily life. There has been a rise in tech- nological applications to the practice of medicine, and tele- psychiatry represents one aspect of this growth. It carries the possibility of increasing access to mental healthcare for the underserved. It holds the potential to erase geographic barriers while allowing for greater time efficiency. This chapter will provide background information on telepsy- chiatry, its history, and the telepsychiatry consultative process.

J. Glover, MD (*) • S. Srinivasan, MD • J.G. Bouknight, MD Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine,

Columbia, SC, USA


© Springer International Publishing AG 2017 3 S. Srinivasan et al. (eds.), Geriatric Telepsychiatry,

DOI 10.1007/978-3-319-51491-8_1

4 J. Glover et al.

1.2 Defining Telepsychiatry

In order to understand the origin and application of telepsy- chiatry, it is important to become familiar with the following nomenclature:

– Telemedicine

– Telehealth

– Telemental health/Telepsychiatry.

The American Telemedicine Association (ATA) defines telemedicine as “..the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status.” Services provided via telemedicine range from primary care, specialist referral services, and remote patient monitoring to consumer medical and health information and continuing medical/health profes- sional education. Benefits of telemedicine include improved access to care, cost efficiency, improved quality of care and, as a rapidly growing modality, is driven by patient demand [1].

While sometimes used interchangeably, telehealth is the broader application of technology to deliver virtual health, medical, and education services. Definitions of telehealth vary from state and federal perspectives. As defined by the federal Health Resources and Services Administration (HRSA), telehealth is “The use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration” [2].

Telehealth has four areas of application:

1. Live video (synchronous):

Also referred to as “real-time,” this modality involves live, two-way interaction between a patient and a healthcare pro- vider using audiovisual telecommunications technology and may serve as a substitute for an in-person encounter when the latter is not feasible.

2. Asynchronous (Store-and-forward):

Recorded patient health history (for example, pre-recorded videos and digital images such as X-rays and photos) is


1. Introduction to Telepsychiatry 5

relayed through a secure electronic communications system to a healthcare practitioner, usually a specialist, who uses the information to evaluate the case or render a service asynchro- nously, or outside of a real-time/live encounter. In contrast to a real-time interaction, this service provides access to data after it has been collected, and involves communication tools such as secure email. Store-and-forward technologies are commonly used in certain medical specialties including radiol- ogy, pathology, dermatology, and ophthalmology. Medicare and Medicaid reimbursement for telehealth services using asynchronous technologies are restricted to certain states [3].

3. Remote patient monitoring (RPM):

Personal health and medical data is collected in one loca- tion via electronic communication technologies and transmit- ted to a healthcare provider in a different location. Healthcare data for a patient can be longitudinally tracked once care is transferred (e.g., upon discharge or placement) with the potential to reduce readmission rates.

4. Mobile health (mHealth):

Mobile health includes healthcare, public health practices, and education supported by mobile communication devices such as cell phones, tablet computers, and other mobile devices. Applications can include messaging that promotes healthy behavior, for example, wide-scale alerts about disease outbreaks.

As illustrated in Fig. 1.1, telemedicine falls under the over- arching umbrella of telehealth. Similarly, within telemedicine, telemental health refers to the use of telemedicine to provide mental health and substance abuse services remotely [4]. By spe- cifically applying telemedicine to the field of psychiatry, telepsy- chiatry utilizes live interactive videoconferencing technology to provide psychiatric assessment and treatment at a distance [5].

1.3 Brief History of Telepsychiatry

The application of two-way interactive videoconferencing to psychiatry dates back to the 1950s. In 1956, Wittson and Dutton described their experience at the Nebraska Psychiatric

6 J. Glover et al.


Telemedicine Telepsychiatry

Fig. 1.1 This figure gives a pictorial representation of the relation- ship between telepsychiatry, telemedicine, and telehealth. Telepsychiatry represents the application of telemedicine to psychi- atric care while telemedicine sits under the umbrella term of tele- health

Institute where closed-circuit television was utilized primar- ily as a teaching tool. The equipment employed included an audiovisual system consisting of three cameras, three 17-inch monitor-receivers in a control room, a receiver-projector in an auditorium, and a six-by-seven foot projection screen also in an auditorium. The entire system costs approximately $18,000 and in order to function, required a full-time elec- tronics technician, a part-time television programming coor- dinator, and a part-time medical electronics consultant. The equipment was used mainly to provide demonstrations to trainees in psychiatry but also served other purposes includ- ing allowing nursing staff to monitor patients remotely [6].

In 1961, this same system was applied to providing group psychotherapy at the Nebraska Psychiatric Institute. Patients were gathered in a group room and arranged in a V forma- tion to allow unencumbered view of the television by all patients. A camera was mounted atop the television provid- ing the therapist a fixed view of the group. The authors report


1. Introduction to Telepsychiatry 7

that participants appeared interested and voiced no major concerns. They demonstrated successful use of this medium to provide group psychotherapy with one exception; one group containing three individuals with anti-social behavior resorted to whispering in an attempt to exclude the therapist from group discussions [7].

In 1971, Solow et al. described their experience with two- way closed circuit television at Dartmouth Medical School in Hanover, New Hampshire. Here, psychiatrists at the aca- demic medical center provided psychiatric consultations to residents of Claremont, New Hampshire, a town of approxi- mately 13,000 residents located in a rural county 26 miles from the academic center. This program was designed to provide access to psychiatric care as there were no psychia- trists and only 21 family physicians in the entire county. Almost 200 remote consultations were successfully com- pleted, each lasting about 50 min [8].

Despite application of two-way television to psychiatric care as far back as the 1950s, the term telepsychiatry was not coined until 1973. At this time, Dwyer employed this term to describe the use of interactive television at Massachusetts General Hospital to provide psychiatric consultations to Logan International Airport Medical Station. One of the benefits of this assessment and treatment modality was elimi- nation of travel time, allowing increased access to a greater number of patients. Patients from a variety of settings were assessed including consultations with probation officers charged with care of troubled youth, junior high school stu- dents, and inmates in correctional settings. The system also facilitated staff meetings between the two locations [9].

From the 1980s onward, technological advancements allowed for continued growth of telepsychiatry. These advancements included improvements in image and sound quality. Communication lag time between the provider and patient diminished and allowed for greater ease in rapport development. Freestanding encrypted videoconferencing units and software were developed, with continued decrease in cost over time. Advancements were made in high speed

8 J. Glover et al.

telecommunication and internet connections [10]. The American Telemedicine Association, an international organi- zation dedicated to promoting the use of telemedicine ser- vices, was established in 1993 and continues to advocate for the integration of telemedicine in the modern healthcare system [1]. By 1999, Medicare began to reimburse for tele- medicine services, albeit with some limitations [11]. Moving into the twenty-first century, telepsychiatry and telemedicine in general continue to grow. Current data on the exact num- ber of telepsychiatry programs in the USA is limited. A 2005 survey identified 116 telemedicine programs while a 1995 survey identified 50 programs specifically offering telepsy- chiatry services [12].

Telepsychiatry is currently being used to successfully pro- vide care to patients in a variety of settings. This treatment modality can be applied to the care of children and adoles- cents, geriatric patients, veterans, and prisoners. It has been employed in various settings to include outpatient primary care offices, emergency departments, nursing homes, schools, and forensic institutions. It can facilitate and help coordinate patient care when used for treatment team meetings, involun- tary commitment hearings, and other staff meetings. Beyond patient care, it can also serve educational purposes including allowing for supervision of trainees, patient/family education, and education of other mental health and primary care pro- viders [13, 14].

1.4 Conclusion

Telepsychiatry holds a specific niche within the broader field of telemedicine. Its use dates back almost 60 years and has con- tinued to grow. Various aspects must be considered in imple- menting a telepsychiatry program including equipment choice, assessment setting, and overall consultative process. Irrespective of these details, this treatment modality can be applied to the care of various types of patients in a multitude of settings. The remainder of this text will focus primarily on the application of telepsychiatry to the care of geriatric patients.


1. Introduction to Telepsychiatry 9


1. telemedicine#.V9Xh2UuEyag. Accessed 11 Sept 2016.

2. Center for Connected Health Policy. The National Telehealth Policy Resource Center. Accessed 11 Sept 2016.

3. Telehealth Resource Center Telehealth Reimbursement. http:// Sheet%20Telehealth%20Reimbursement%20V3%20FINAL. pdf. Accessed 11 Sept 2016.

4. Hilty DM, Marks SL, Urness D, Yellowlees PM, Nesbitt TS. Clinical and educational telepsychiatry applications: a review. Can J Psychiatry. 2004;49(1):12–23.

5. Shore JH. Telepsychiatry: videoconferencing in the delivery of psychiatric care. Am J Psychiatry. 2013;170:256–62.

6. Wittson C, Dutton R. A new tool in psychiatric education. Ment Hosp. 1956;7(9):11–4.

7. Wittson CL, Affleck DC. Two-way television in group therapy. Ment Hosp. 1961;12:22–3.

8. Solow C, Weiss RJ, Bergen BJ, Sanborn CJ. 24-Hour psychiatric consultation via TV. Amer J Psychiatry. 1971;127(12):1684–7.

9. Dwyer TF. Telepsychiatry: psychiatric consultation by interactive

television. Am J. Psychiatry. 1973;130(8):865–9.

10. Grady B. Promises and limitations of telepsychiatry in rural

adult mental health care. World Psychiatry. 2012;11(3):199–201.

11. Accessed 25 Sept 2015.

12. Myers K, Cain S. Practice parameter for telepsychiatry with chil-

dren and adolescents. J Am Acad Child Adolesc Psychiatry.


13.Hilty DM, Luo JS, Morache C, Marcelo DA, Nesbitt

TS. Telepsychiatry an overview for psychiatrist. CNS Drugs.


14. Hilty DM, Ferrer DC, Parish MB, Johnston B, Callahan EJ,

Yellowlees PM. The effectiveness of telemental health: a 2103 review. Telemed J E Health. 2013;19(6):444–54. doi:10.1089/ tmj.2013.0075.

Chapter 2

Overview of Telepsychiatry in Geriatrics

Juliet Glover

2.1 Introduction

Telepsychiatry, the application of two-way interactive video- conferencing to patient care, is a burgeoning aspect of the practice of modern medicine. The manner in which healthcare is delivered in the twenty-first century continues to evolve. Similarly, the demographics of the USA is changing and nowhere are these changes more evident than in the continued increase in the aging population. In order to meet the growing healthcare needs of the geriatric population, novel healthcare delivery modalities need to be explored and implemented. Telepsychiatry is a unique service delivery method that can be employed to meet the mental health care needs of older adults.

2.2 Demographic Changes and Telepsychiatry

The American population is aging. In 2014, there were over 46 million Americans age 65 and over, representing 14.5% of the US population. This number is projected to increase to

J. Glover, MD (*)

Department of Neuropsychiatry and Behavioral Science, University of South Carolina, School of Medicine, Columbia, SC, USA


© Springer International Publishing AG 2017 11 S. Srinivasan et al. (eds.), Geriatric Telepsychiatry,

DOI 10.1007/978-3-319-51491-8_2



J. Glover

Population Growth by Age

Age 65

Age 75

Age 85


100,000,000.00 90,000,000.00 80,000,000.00 70,000,000.00 60,000,000.00 50,000,000.00 40,000,000.00 30,000,000.00 20,000,000.00 10,000,000.00


Year 2014

Year 2030

Year 2050

Fig. 2.1 Graph depicting geriatric population growth by age group. Source:

88 million by the year 2050, increasing the proportion of older Americans to 22% [1] (Fig. 2.1). In addition, not only is the geriatric population as whole increasing, but the propor- tion of individuals classified as the oldest old, age 85 years and over, is also growing. By the year 2050, 4.8% of the US population will be over the age of 85, more than double the population in 2014 [1].

As the population continues to age, more healthcare pro- fessionals will be required. Mental illness is prevalent in this population. Depression symptoms are present in up to 25% [2] and anxiety in over 50% [3] of individuals age 60 and over. An estimated 5.2 million Americans suffer from major neuro- cognitive disorder due to Alzheimer Disease [4] with up to 60% exhibiting associated psychiatric and behavioral symp- toms [5]. These mental health disorders often require the expertise of geriatric psychiatrists. In 2010, there were approx- imately 1700 geriatric psychiatrists in the USA, roughly 1 per

2. Overview of Telepsychiatry in Geriatrics 13

10,000 adults age 75 and older ( Geriatric telepsychiatry represents one avenue to increasing access to specialized geriatric psychiatry care.

Access to care can be a significant barrier to obtaining mental healthcare for many Americans. Access can be further limited for those individuals residing in less populated or rural areas. The United States Office of Management and Budget defines a metropolitan area as an area with a population of 50,000 or more residents. A micropolitan area consists of 10,000–50,000 residents [1]. The 2010 US Census Brief on older Americans found 3.4 million individuals age 65 and over reside in non-metropolitan or micropolitan areas, represent- ing 17.2% of the total rural population. In comparison, older adults make up 12.8% of the metropolitan and micropolitan population [6]. Although a majority of the geriatric population resides in more populated areas, a significant number are in geographical areas that are often plagued with limited resources, and lack of access to specialized health care. This geographic distribution further highlights the need for innova- tive methods to improve access to care for the elderly.

Another potential barrier to mental healthcare access can be residence in a long term care facility. Of the 40.3 million individuals comprising the geriatric population in 2010, 1.3 million or 3.1% resided in skilled nursing facilities. The proportion of nursing home residents increases with age from 0.9% for individuals age 65–74 years to 10.4% for those age 85–94 [7]. As the proportion of the oldest-old continues to increase, the nursing home population is predicted to increase as well. This increase is likely to lead to increased demand for mental health care. Current estimates of the prevalence of mental health disorders in nursing home settings vary with diagnosis (Table 2.1). Data from the National Nursing Home Survey (NNHS) estimates approximately 50% of nursing home residents have a chronic mental illness or dementia [7]. Furthermore, it is estimated that up to 80% of nursing home residents with mental illness do not receive necessary mental health care compared to 58% of community dwelling older adults [7]. Geriatric telepsychiatry is one way to address this unmet healthcare need of the nursing home population.

14 J. Glover

Table 2.1 Prevalence estimates of psychiatric disorders in nursing homes


Behavioral and psychological symptoms of dementia

Neurocognitive disorder

Anxiety symptoms

Depressive symptoms Schizophreniaa

Major depressive disorder Posttraumatic stress disordera Alcohol use disordera

Drug use disordera Anxiety disordersb

Prevalence (%) 78








6 6

This table summarizes the prevalence of psychiatric disorders in nursing home residents

a2006 prevalence estimates from Department of Veterans Affairs nursing home residents (N = 11,150)

bAnxiety disorders include generalized anxiety disorder, panic disor- der, and phobic disorders


1. Seitz D, Purandare N, Conn D. Prevalence of psychiatric disorders among older adults in long-term care homes: a systematic review. Int Pscyhogeriatr. 2010 Nov; 22(7):1025–39

2. Smalbrugge M, Pot AM, Jongenelis K, Beekman ATF, Eefsting JA. Prevalence and correlates of anxiety among nursing home patient. J Affect Disorder. 2005 Oct; 88(2):145–53

3. Lemke SP, Schaefer JA. Recent changes in the prevalence of psy- chiatric disorders among VA nursing home residents. Psychiatr Serv. 2010 April; 61(4):356–63

2.3 Cost Considerations

The need for increased access to mental health care for the aging population is evident. In attempting to meet this need, potential solutions must be cost effective in order to be sus- tainable. There are several factors that affect the cost of pro- viding care by telepsychiatry. While economic considerations

2. Overview of Telepsychiatry in Geriatrics 15

will be examined in greater detail in later chapters, a brief overview is provided here.

In order to be sustainable, the cost of providing telepsychi- atric care must be offset by savings. Direct costs include cost of audiovisual conferencing hardware and software technolo- gies, installation/setup fess, and other supply costs. (Technological requirements will be reviewed in a later chap- ter.) Fixed costs factor in staff salaries and wages as well as other administrative expenses. There are also variable expenses to include data transmission fees and costs associ- ated with equipment maintenance [8]. Due to these expenses, earlier studies found telepsychiatry to be cost ineffective. In 1998, Werner et al. compared the cost of a face-to-face com- munity mental health medication management visit to remote care. Two remote care options were examined—(1) university based telepsychiatry consultation to a rural community men- tal health clinic and (2) other rural site based telepsychiatry consultation to rural community mental health clinic. Results revealed two to three fold higher costs per visit for telepsychi- atric care ($244/visit for other rural site based telepsychiatry visit, $179 for university based telepsychiatry visit, and $78.50 for in-person community mental health center visit) [9].

In contrast to these earlier findings, more recent studies have found that care by telepsychiatry leads to overall decrease in total costs due mainly to savings in travel costs. Compared to telepsychiatry, face-to-face psychiatric evaluations to remote sites require not only travel and accommodation expenses for the physician, but often times, higher compensation due to travel requirements. In 2007, O’Reilly et al. found that the average cost of telepsychiatric care was 10% less per patient and 16% less per visit compared to in-person care [10]. In 2010, Rabinowitz et al. examined the cost associated with 278 nurs- ing home telepsychiatry consultations and found personnel cost savings of over $30,000 and physician savings of over $80,000 when compared to face-to-face care [11]. One poten- tial explanation for the differences between earlier and recent findings with regard to cost is an overall decrease in cost of technology and remote communication. In fact, in 2011

16 J. Glover

Doolittle et al. found that since 1995, there has been a 70% decrease in cost per patient in providing telemedicine care. This decrease was attributed to both decreased technology costs and increased number of patient visits [12]. These figures support the notion of telepsychiatry as cost effective method of meeting the increasing mental health care demands of the growing geriatric population.

2.4 Clinical Applications of Telepsychiatry to Geriatric Mental Health Care

Telepsychiatry has the potential to increase access to special- ized mental health care while decreasing costs. Equally important are its accuracy and effectiveness in providing a means by which patients can be evaluated and treated. Telepsychiatry has been applied to patients in multiple differ- ent settings to include outpatient general medical clinics, hospital emergency departments, nursing and group homes, hospice facilities, rural facilities, and forensics/correctional settings. Several models of consultative services can be employed and may vary based on the clinical setting.

1. In the traditional or replacement model, the psychiatrist serves as the primary provider of mental health care with limited communication with the referring primary care provider.

2. In the consultation care model, the primary care provider retains the primary role even as it pertains to mental health care but seeks consultations from the psychiatrist.

3. The third model, the collaborative care model, consists of joint provision of mental health care by the primary care physician and the psychiatrist with frequent communica- tion between both providers [13].

Furthermore, the telepsychiatry interaction can be either

synchronous or asynchronous. Synchronous evaluations involve communication between the patient and the psychia- trist that occurs at the same time, typically via two-way video-


2. Overview of Telepsychiatry in Geriatrics 17

conferencing, chat, or telephone. Asynchronous encounters, also known as store-and-forward, consist of the psychiatrist reviewing pre-recorded interactions between the patient and primary care provider. The psychiatrist then formulates a diagnosis, treatment plan, and provides the primary care pro- vider with treatment recommendations. Irrespective of the clinical setting or the consultation model employed, telepsy- chiatry has been demonstrated to be feasible, reliable, and equivalent to face-to-face care [8].

In 2013, Conn et al. described a 7-year experience of utiliz- ing a university based telepsychiatry program to provide consultations to six rural communities in Canada. Almost 300 patients were evaluated and treated with the most common conditions encountered being dementia, depression, and mild cognitive impairment [14]. In 2001, Johnston and Jones reported on successful utilization of telepsychiatry to provide 71 consultations to 40 rural nursing home patients age 60–95. Again, the most frequently encountered diagnoses were dementia related behavioral disturbances and depressive disorders. The authors cited increased contact with patients and staff at the rural nursing facility, improved follow through of recommendations, and elimination of psychiatrist’s travel as the major advantages of the program [15].

Geriatric telepsychiatry is not only feasible, but also diag- nostically reliable. Telepsychiatry can be used to reliably diagnose various mental health disorders including mood disorders, panic disorder, and alcohol dependence [16]. Grob et al. conducted a study with residents of a Veterans Affairs nursing home examining in-person versus remote administra- tion of three screening tools—the Mini Mental State Examination (MMSE), Geriatric Depression Scale (GDS), and the Brief Psychiatric Rating Scale (BPRS). Results showed no significant differences between groups [17]. In 2004, Shores et al. found 100% agreement in initial diagnosis of dementia in residential care veterans who were assessed in-person versus by telepsychiatry [18]. Cullum et al. demon- strated that a battery of neuropsychological tests can be suc- cessfully administered to patients with cognitive impairment

18 J. Glover

via videoconferencing [19]. These findings demonstrate tele- psychiatry as an effective modality by which patients can be accurately assessed and diagnosed.

Furthermore, telepsychiatric care produces outcomes equivalent to in-person care. O’Reilly et al. examined reduc- tion in Brief Symptom Inventory scores in a general adult population assessed in-person versus remotely. Outcomes were equivalent for both groups [10]. Similar results were found when comparing treatment of depressed veterans in- person versus remotely, with comparable reductions in scores on the Hamilton Depression Rating Scale and Beck Depression Inventory. In addition, there is equivalent compliance in keep- ing appointments and adhering to medications [20].

Another outcome of interest when telepsychiatry is employed is its potential impact on overall resource utilization. The application of telemedicine to the care of geriatric nursing home patients can allow for more patients to be served with shorter follow-up intervals [21]. This can lead to downstream effects on the healthcare system as a whole including up to 10% decrease in emergency department visits and acute hospi- talizations [21]. This benefit to the healthcare system holds true for telepsychiatry as well. Lyketsos et al. found approximately 50% decrease in acute hospitalizations with overall fewer days in the hospital when geriatric nursing home patients with dementia had access to telepsychiatric assessment and treat- ment [22]. As the aging population continues to grow, efficient use of limited resources must remain a priority.

2.5 Telepsychiatry and Patient/Provider Satisfaction

Patient satisfaction with medical care is often examined as one marker of quality care. Equally important is the satisfac- tion level of clinical staff to include the referring clinician and the psychiatrist providing telepsychiatric care. Careful atten- tion to factors affecting satisfaction levels can reveal poten- tial areas for future growth and improvement.

2. Overview of Telepsychiatry in Geriatrics 19 2.5.1 Patient Satisfaction

Patient satisfaction with telemedicine in general and specifi- cally with telepsychiatry has been examined in the literature. A systematic review of 32 studies found teleconsultations to be generally acceptable to patients [23]. In comparing tele- psychiatric consultations to telemedicine consultations in other specialties, Callahan et al. examined four aspects of patient satisfaction: ability to speak freely, probability of utilizing telemedicine in the future, perceived experience of telemedicine staff, and preference for telemedicine visit ver- sus in-person visit. Results showed no significant differences in patient satisfaction for mental health compared to non- mental health telemedicine care. More importantly, a major- ity of patients rated telemedicine care superior to in-person care [24]. Other studies focusing on telepsychiatry have found similar results with high patient satisfaction as well as appointment adherence [13, 25].

The acceptability of telepsychiatry by geriatric patients warrants special attention. One may expect older patients who may be less familiar with audiovisual technology to be apprehensive about utilizing this technology to receive psy- chiatric care. In 2000, Rohland et al. examined the acceptabil- ity of telepsychiatry to a rural population and found older adults and those enrolled in Medicare to be less willing to endorse telepsychiatric care [26]. Rowe et al. examined this further and found patients age 50 and over had higher prefer- ence for in-person visits compared to their younger adult counterparts. Despite this finding, 67% of patients age 60 and above still reported no preference between telepsychiatric and in-person visits and cited no difference in quality [27].

There are several potential determinants of patient satis- faction with telepsychiatric services. These include demo- graphic factors, state dependent factors, technological factors, and social/environmental factors [13]. Demographic determi- nants of patient satisfaction include age and gender. While older patients may prefer in-person visits, increased exposure to telepsychiatry can serve as a mitigating factor. Patients

20 J. Glover

with a greater number of telepsychiatric sessions are more likely to have positive views of their experience. Gender may also play a role with one study showing females to be more accepting of remote care than males [27]. State dependent factors take into account the patient’s current health status. Patients who perceive themselves to be in good health are more accepting of telepsychiatry than those with perceived fair or poor health (79% vs 21%) [26]. Technological issues such as poor image quality and interruptions in transmission can negatively impact patient satisfaction. Lastly, social/envi- ronmental factors such as the effects of telepsychiatric ser- vices in decreasing costs, travel time, and wait time for patients can lead to higher satisfaction and more positive perception of telepsychiatry [13].

2.5.2 Provider Satisfaction

Provider satisfaction with telepsychiatry has been evaluated to a lesser degree than patient satisfaction. Some studies sug- gest high satisfaction from referring primary care physicians [13, 14]. Rural primary care providers tend to self-report higher satisfaction than urban or suburban providers, likely due to limited access to in-person psychiatric consultations [13]. Less is known regarding satisfaction of telepyschiatrists. Factors reported to negatively influence psychiatrists’ views of remote care include poor image and sound quality, unex- pected transmission interruptions, and other technological issues. In addition, some have expressed concerns over the ability to develop meaningful rapport and relationships with patients [13, 28, 29]. In a randomized study consisting of 40 patients, Stevens et al. examined patient and psychiatrist satis- faction with the rapport/therapeutic alliance developed during the interview process. Patients were randomized to either in- person or remote care and two scales were employed to assess satisfaction: the California Psychotherapy Alliance Scale and the Interview Satisfaction Scale. Results showed no difference in patient satisfaction for in-person and remote care on both

2. Overview of Telepsychiatry in Geriatrics 21

assessment tools. However, there was a statistically significant difference in favor of face-to-face care with the psychiatrists’ version of the Interview Satisfaction Scale. Despite this differ- ence and preference for in-person care, psychiatrists were overall satisfied with telepsychiatric care [30]. Future studies in this area may help elucidate factors that can be addressed to further increase provider satisfaction.

2.6 Challenges in Geriatric Telepsychiatry Implementation

There are various challenges associated with geriatric tele- psychiatry of which one must be cognizant. These can be categorized as patient related and administrative challenges. It is important to recognize and anticipate these so that they can be appropriately addressed to allow seamless provision of care.

2.6.1 Patient Related Challenges

Patient related issues include normal physiological changes that occur with age that may make care via videoconferenc- ing more difficult. Loss of visual acuity and hearing impair- ment are two aspects of aging that can interfere with patient–physician communication and limit the ability to provide care by telepsychiatry. These factors can be antici- pated and addressed in several ways. Ensuring that patients have/use corrective lenses and hearing aids during the psychi- atric assessment is vital. The assessment setting should be well lit with either plain or non-distracting background. Ambient and extraneous noises should be minimized as much as possible. If these measures are insufficient to over- come hearing impairment, amplified microphones may be utilized [28, 31, 32].

A second patient related factor to consider is the presence of cognitive impairment that can affect the reliability of the

22 J. Glover

history obtained. In providing care to older adults, a collat- eral informant is often necessary [31]. Collateral informants can be spouses, adult children, home caregivers, or nursing staff in cases where the patient resides in a facility. The pres- ence of an additional person during the telepsychiatry visit not only aids the psychiatrist in obtaining an accurate history but can also help patients feel more comfortable. Rowe et al. found that a majority of patients (56%) age 60 and above felt more at ease during the telepsychiatry assessment when an additional clinician (nurse, therapist, or case manager) was present [27]. Furthermore, an additional clinician present with the patient can assist with operation of videoconferenc- ing equipment and any technical difficulties that may occur at the remote site. Remote site clinicians can subsequently ensure that psychiatric recommendations are appropriately implemented [31].

Lastly, as is the case with face-to-face patient encounters, psychiatrists may be faced with unanticipated or emergency situations during a telepsychiatry visit. Examples of this might include patients who are suicidal or violent, acutely psychotic, intoxicated, or require involuntary inpatient hospi- talization. Emergency protocols should be in place to address these issues. Clinicians familiar with these protocols must be present at the remote site to assist the consulting telepsychia- trist in implementing the necessary procedures. These situa- tions may be anxiety provoking for the consulting psychiatrists due to potential for perceived lack of control resulting from providing care from a distance. Familiarity with safety proto- cols can help ease this anxiety and ensure patient and staff safety [32].

2.6.2 Administrative Challenges

Administrative and reimbursement issues can be complex and have been addressed in more detail elsewhere in this book. Telepsychiatrists must ensure that they hold the appro- priate medical licenses and privileges to evaluate patients at the remote site. This may require obtaining out-of-state


Overview of Telepsychiatry in Geriatrics 23 Medicare Coverage for Telemedicine Services

Medicare Part B? Patient in Rural Area?

Patient located in one of the following:

Yes Yes Yes

No Service Not Covered

No Service Not Covered

No Service Not Covered Service Covered

1. Doctor’s office/hospital

2. Critical access hospital

3. Rural health clinic

4. Federally qualified health center

5. Hospital-based or critical access hospital dialysis facility

6. Skilled nursing facility

7. Community mental health center

Fig. 2.2 This figure demonstrates eligibility requirements for Medicare coverage of telemedicine services. Source:

medical licenses if patients are located in states different from that of the treating psychiatrist. In addition, the psy- chiatrist must ensure proper credentialing in all remote sites where patients will be evaluated. This process can be cumber- some. The psychiatrist also needs to be mindful of confiden- tiality issues with regard to videoconferencing encryption requirements as well as medical record ownership and stor- age regulations [32]. Reimbursement for services rendered can pose further challenges. Medicaid reimbursement for telepsychiatric services varies by state. While Medicare Part B reimburses for telepsychiatric services, there are some limi- tations (Fig. 2.2) [33]. These administrative issues will be reviewed in further details in subsequent chapters.

2.7 Conclusion

In summary, as the US aging population continues to increase, geriatric telepsychiatry remains one avenue to meet the men- tal health care needs of older adults. It has the potential to increase access to specialized mental health care as well as

24 J. Glover

decrease overall healthcare costs. It has been demonstrated to be feasible and diagnostically reliable. Furthermore, out- comes are equivalent to in-person care. While some patients and physicians alike may be apprehensive about utilizing telepsychiatric services, the literature has shown overall high levels of satisfaction. While these favorable aspects of implementing geriatric telepsychiatry are encouraging, chal- lenges unique to serving geriatric patients from a distance remain. They require diligent awareness and preparation in order to allow for successful application of this innovative treatment modality to the care of older adults.


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depression. Am J Geriatr Psychiatry. 2012;10:1–15.

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disease facts and figures. Alzheimers Dement. 2013;9(2):208–45.

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lar health study. JAMA. 2002;288(12):1475–83.

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of mental health care for nursing home residents: a literature review. Med Care Res Rev. 2010;67(6):627–56. doi:10.1177/ 1077558710362538.

8. Hilty DM, Ferrer DC, Parish MB, Johnston B, Callahan EJ, Yellowlees PM. The effectiveness of telemental health: a 2103 review. Telemed J E Health. 2013;19(6):444–54. doi:10.1089/ tmj.2013.0075.

9. Werner A, Anderson LE. Rural telepsychiatry is economically unsupportable: the concorde crashes in a cornfield. Psychiatr Serv. 1998;49(10):1287–90.


2. Overview of Telepsychiatry in Geriatrics 25

10. O’Reilly R, Bishop J, Maddox K, Hutchinson L, Fisman M, Takhar J. Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial. Psychiatr Serv. 2007;58(6):836–43.

11. Rabinowitz T, Murphy KM, Amour JL, Ricci MA, Caputo MP, Newhouse PA. Benefits of a telepsychiatry consultation service for rural nursing home residents. Telemed J E Health. 2010;16(1):34–40. doi:10.1089/tmj.2009.0088.

12. Doolittle GC, Spaulding AO, Williams AR. The decreasing cost of telemedicine and telehealth. Telemed J E Health. 2011;17(9):671–6. doi:10.1089/tmj.2011.0033.

13.Hilty DM, Luo JS, Morache C, Marcelo DA, Nesbitt TS. Telepsychiatry an overview for psychiatrist. CNS Drugs. 2002;16(8):527–48.

14. Conn DK, Madan R, Lam J, Patterson T, Skirten S. Program evaluation of a telepsychiatry service for older adults connecting a university-affiliated geriatric center to a rural psychogeriatric outreach service in Northwest Ontario. Canada Int Psychogeriatr. 2013;25(11):1795–800. doi:10.1017/S104161021300118X.

15. Johnston D, Jones BN. Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol. 2001;14(2):72–5.

16. Ruskin PE, Reed S, Kumar R, Kling MA, Siegel E, Mitchell R, et al. Reliability and acceptability of psychiatric diagnosis via telecommunication and audiovisual technology. Psychiatr Serv. 1998;49(8):1086–8.

17. Grob P, Weintraub D, Sayles D, Raskin A, Ruskin P. Psychiatric assessment of a nursing home population using audiovisual tele- communication. J Geriatr Psychiatry Neurol. 2001;14(2):63–5.

18. Shores MM, Ryan-Dykes P, Williams RM, Mamerto B, Sadak T, Pascualy M, et al. Identifying undiagnosed dementia in residen- tial care veterans: comparing telemedicine to in-person clinical examination. Int J Geriatr Psychiatry. 2001;19:101–8.

19. Cullum CM, Weiner MF, Gehrmann HR, Hynan LS. Feasibility of telecognitive assessment in dementia. Assessment. 2006;13(4): 385–90.

20. Ruskin PE, Silver-Aylaian M, Kling MA, Reed SA, Bradham DD, Hebel JR, et al. Treatment outcomes in depression: com- parison of remote treatment through telepsychiatry to in-person treatment. Am J Psychiatry. 2004;161(8):1471–6.

21. Hui E, Woo J, Hjelm M, Zhang YT, Tsui HT. Telemedicine: a pilot study in nursing home residents. Gerontology. 2001;47:82–7.

26 J. Glover

22. Lyketsos CG, Roques C, Hovanec L, Jones BN. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol. 2011;14:76–9.

23. Mair F, Whitten P. Systematic review of studies of patient satis- faction with telemedicine. BMJ. 2000;320:1517–20.

24. Callahan EJ, Hilty DM, Nesbitt TS. Patient satisfaction with tele- medicine consultations in primary care: comparison of ratings of medical and mental health applications. Telemed J. 1998;4(4): 363–9.

25. Leigh H, Cruz H, Mallios R. Telepsychiatry appointments in a continuing care setting: kept, cancelled and no-shows. J Telemed Telecare. 2009;15(6):286–9. doi:10.1258/jtt.2009.090305.

26. Rohland BM, Saleh SS, Rohrer JE, Romitti PA. Acceptability of telepsychiatry to a rural population. Psychiatr Serv. 2000;51(5): 672–4.

27. Rowe N, Gibson S, Morley S, Krupinski EA. Ten-year experience of a private nonprofit telepsychiatry service. Telemed J E Health. 2008;14(10):1078–86. doi:10.1089/tmj.2008.0037.

28. Jones RM, Leonard S, Birmingham L. Setting up a telepsychiatry service. Psychiatr Bull. 2006;30:464–7.

29. Jones BN 3rd. Telepsychiatry and geriatric care. Curr Psychiatry Rep 2001; 3:29–36.

30. Stevens A, Doidge N, Goldbloom D, Voore P, Farewell J. Pilot study of televideo psychiatric assessments in an underserviced community. Am J Psychiatry. 1999;156(5):783–5.

31. Jones 3rd BN, Ruskin PE. Telemedicine and geriatric psychiatry: directions for future research and policy. J Geriatr Psychiatry Neurol. 2001;14(2):59–62.

32. Shore JH. Telepsychiatry: videoconferencing in the delivery of psychiatric care. Am J Psychiatry. 2013;170(3):256–62.

33. Accessed 23 Sept 2015.

Chapter 3

The Economics of Geriatric Telepsychiatry

James G. Bouknight

3.1 Introduction

While the advantages of offering medical treatment via vid- eoconferencing remotely may be multiple, sustainability can- not occur unless a program can show financial advantages. Geriatric telepsychiatry shows promise for the elderly because of the characteristics of aged patients including problems with ambulation, transportation, crowded sched- ules for medical appointments, and difficulty in adapting to a typical office setting. The elderly patients that will be treated by psychiatrists in the next 30–40 years vary dramati- cally from the elderly in the twentieth century. The Baby Boomer geriatric patient is more likely to lack family sup- port, have issues with substance abuse, live longer, and have a higher rate of incarceration in jails and penal institutions [1]. These changing characteristics of the elderly make geri- atric telepsychiatry an economically viable option for the delivery of psychiatric care to the elderly. This chapter will focus on the benefits and costs of a geriatric telepsychiatry service.

J.G. Bouknight, MD (*)

Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, SC, USA


© Springer International Publishing AG 2017 27 S. Srinivasan et al. (eds.), Geriatric Telepsychiatry,

DOI 10.1007/978-3-319-51491-8_3

28 J.G. Bouknight

3.2 Legal Requirements

Medicare has specific requirements for telepsychiatry which include the originating site of the service, the practitioners who are allowed to offer telepsychiatry services, the type of services offered, and the Current Procedural Terminology (CPT) codes used to bill for the services (DHHS). Most pri- vate insurers use Medicare as a guide for reimbursement. The originating sites of telepsychiatry services must be one of the following:

• Physician or practitioner’s office

• Hospital

• Critical Access Hospital (a designation given to certain

rural hospitals)

• Rural Health Clinic

• Federally Qualified Health Center

• Hospital-based renal dialysis center

• Skilled nursing facility

• Community mental health center.

From a reimbursement perspective, Medicare also speci- fies which practitioner may offer telepsychiatry services. These include:

• Physicians

• Nurse practitioners

• Physician’s assistants

• Nurse-midwives

• Clinical nurse specialists

• Certified registered nurse anesthetists

• Clinical psychologist

• Social workers (with some exceptions)

• Registered dietitians or nutrition professionals.

With few exceptions, the services offered must permit real- time interaction between the patient and the practitioner. There are a number of CPT Codes (Current Procedural Terminology Codes) that can be used to bill for telepsychia- try services [2]. Table 3.1 details those presently used.

3. The Economics of Geriatric Telepsychiatry 29 Table 3.1 Telehealth CPT codes [2]

CY 2016 Medicare Telehealth Services

Telehealth consultations, emergency department, or initial inpatient

Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs Office or other outpatient visits Subsequent hospital care services, with the limitation of one telehealth visit every 3 days Subsequent nursing facility care services, with the limitation of one telehealth visit every 30 days Individual and group kidney disease education services Individual and group diabetes self-management training services, with a minimum of

1 h of in-person instruction to

be furnished in the initial year training period to ensure effective injection training

Individual and group health

and behavior assessment and intervention

Individual psychotherapy

Telehealth pharmacologic management

Psychiatric diagnostic interview examination

End-Stage Renal Disease (ESRD)-related services included in the monthly capitation payment

Healthcare Common Procedure Coding System (HCPCS)/CPT code

HCPCS codes G0425–G0427

HCPCS codes G0406–G0408

CPT codes 99201–99215 CPT codes 99231–99233

CPT codes 99307–99310

HCPCS codes G0420 and G0421

HCPCS codes G0108 and G0109

CPT codes 96150–96154

CPT codes 90832–90834 and 90836–90838

HCPCS code G0459

CPT codes 90791 and 90792

CPT codes 90951, 90952, 90954, 90955, 90957, 90958, 90960, and 90961


30 J.G. Bouknight Table 3.1 (continued)

CY 2016 Medicare Telehealth Services

End-Stage Renal Disease (ESRD)-related services for

home dialysis per full month, for patients younger than 2 years of

age to include monitoring for the adequacy of nutrition, assessment

of growth and development, and counseling of parents (effective

for services furnished on and after January 1, 2016)

End-Stage Renal Disease (ESRD)- related services for home dialysis per full month, for patients 2–11 years

of age to include monitoring for the adequacy of nutrition, assessment

of growth and development, and counseling of parents (effective

for services furnished on and after January 1, 2016)

End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients 12–19 years of age to include monitoring for the adequacy of nutrition, assessment of growth

and development, and counseling

of parents (effective for services furnished on and after January 1, 2016)

End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients 20 years of age and older (effective for services furnished on and after January 1, 2016)

Individual and group medical nutrition therapy

Healthcare Common Procedure Coding System (HCPCS)/CPT code

CPT code 90963

CPT code 90964

CPT code 90965

CPT code 90966

HCPCS code G0270 and CPT codes 97802–97804


3. The Economics of Geriatric Telepsychiatry 31 Table 3.1 (continued)

CY 2016 Medicare Telehealth Services

Neurobehavioral status examination

Smoking cessation services

Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services

Annual alcohol misuse screening, 15 min

Brief face-to-face behavioral counseling for alcohol misuse,

15 min

Annual depression screening,

15 min

High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training, and guidance on how to change sexual behavior; performed semi-annually, 30 min Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 min

Face-to-face behavioral counseling for obesity, 15 min

Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge) Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge)

Healthcare Common Procedure Coding System (HCPCS)/CPT code

CPT code 96116

HCPCS codes G0436 and G0437 and CPT codes 99406 and 99407

HCPCS codes G0396 and G0397

HCPCS code G0442 HCPCS code G0443

HCPCS code G0444 HCPCS code G0445

HCPCS code G0446

HCPCS code G0447 CPT code 99495

CPT code 99496


32 J.G. Bouknight Table 3.1 (continued)

CY 2016 Medicare Telehealth Services


Family psychotherapy (without the patient present)

Family psychotherapy (conjoint psychotherapy) (with patient present)

Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour

Prolonged service in the office or other outpatient setting requiring direct patient contact beyond

the usual service; each additional 30 min

Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service; first hour (list separately in addition to code for inpatient evaluation and management service) (effective for services furnished on and after January 1, 2016)

Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service; each additional 30 min (list separately in addition to code for prolonged service) (effective for services furnished on and after January 1, 2016)

Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) first visit

Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) subsequent visit

Healthcare Common Procedure Coding System (HCPCS)/CPT code

CPT codes 90845 CPT code 90846

CPT code 90847 CPT code 99354

CPT code 99355

CPT code 99356

CPT code 99357

HCPCS code G0438 HCPCS code G0439

3. The Economics of Geriatric Telepsychiatry 33

Unless the services provided meet the requirements of Centers for Medicare and Medicaid Services (CMS) and third party payers, there can be no economic justification for offering telepsychiatry services to the geriatric population. The most expensive method of offering services would be one which does not meet all of the requirements of appropri- ate care. It is important to remember that “Utilizing tele- medicine does not alter the standard of care to which the physician will be held – it is the same standard of care that would apply if the patient was in the physician’s office or facility” [3]. The physicians who participate in the program must also be certain that they are meeting the requirements of their state medical boards. Many healthcare systems cross state lines and in sparsely populated states there may be an inadequate population in one state to support a geriatric tele- psychiatry program. It is, however, important to remember that most state medical boards expect practitioners offering services within a state to possess a license from that state. The Veterans Administration (VA) hospitals and clinics are an exception since VA physicians need to be licensed in only one state to practice throughout the VA system. If the physician is offering services within a healthcare system whether for inpatients, outpatients, or patients in the emergency room, the psychiatrist will need to be credentialed by not only the organization providing the service but also the organization in which the patient is being served. This can be an enor- mously time-consuming process since each organization needs separate documentation which is usually repetitive. One option available in some locations is “privileging by proxy.” This system which has been approved by CMS allows the healthcare system receiving telepsychiatry services to credential the psychiatrist by relying on the credentialing process of the healthcare system from which the services originate [4]. Utilizing this credentialing system significantly decreases the time, effort, and cost involved in applying for credentials in multiple healthcare systems. Note that this sys- tem does not negate the need for the psychiatrist to acquire and maintain a license in each state in which he or she

34 J.G. Bouknight

practices telepsychiatry. There is growing acceptance of telemedicine and telepsychiatry including an endorsement by the American Medical Association (AMA) which supported the bipartisan Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act to expand the use of telemedicine to achieve quality care for patients. The bill reflects the AMA’s belief that the appro- priate use of telemedicine can greatly improve access to qual- ity care while maintaining patient safety.

As noted by AMA President, Steven J. Stack, MD, “this legislation has the potential to remove barriers to new health care delivery models that promote coordinated and patient- centered care. Importantly, the bill aims to maintain high standards whether a patient is seeing a physician in an office or via telemedicine” ( [5]).

3.3 Benefits

The benefits of a geriatric telepsychiatry program include economic benefits and intangible benefits that do not lend themselves to valuation in dollars. At present there are about 40,000 psychiatrists in the USA but there is a shortage of at least 10,000 psychiatrists with even a more serious shortage of geriatric psychiatrists. To compound the prob- lem, the average age for currently practicing psychiatrist is around 56 years old so our nation is headed for an even more profound shortage of psychiatrists just as the Baby Boomer Generation reaches retirement age. Due to the shortage of geriatric psychiatrists in the USA, the options available to patients are often telepsychiatry or no care at all. Those patients who receive psychiatric care from their primary care providers face significant problems: up to about 50% of patients are under-diagnosed and under-treated by primary care providers [6].

There are no accurate estimates of the costs to the nation and to mentally ill patients for inadequate treatment or for- going treatment for mental illness. Simply having the avail- ability of psychiatric care constitutes an intangible benefit to

3. The Economics of Geriatric Telepsychiatry 35

patients. Because the patient and the physician do not need to be present at the same location, situations in which trans- porting either the patient or the physician is difficult make geriatric telepsychiatry more economically viable.

Patients who live in rural areas or are geographically iso- lated do present viable opportunities for cost savings by tele- psychiatry. Patients with debilitating physical illnesses may also be difficult and expensive to transport to a physician’s office or clinic. Rehabilitation facility patients face pain and the possibility of injury during transport. Likewise, nursing home and assisted living facilities who care for patients with Neurocognitive Disorders find transport a challenging prop- osition. A patient with cognitive and behavioral issues could wander away from the transport personnel or become com- bative. Ambulance rides for physician appointments are expensive and can be difficult to schedule. Other geriatric patient populations make interactions challenging. A larger number of geriatric patients are incarcerated for a variety of reasons explored later in this chapter. Although deinstitu- tionalization has decimated the long term psychiatric inpa- tient population, some patients remain in long term psychiatric facilities either because of their mental illness or, in some cases, because they are considered dangerous sex offenders.

In general, physician home visits are prohibitively expen- sive so when face-to-face time with the physician is arranged, most psychiatry clinics insist that the patients travel. The costs to the patient are not trivial. Many geriatric patients either cannot drive because of mental or physical issues or lack modes of transport. Some geriatric patients are immunocom- promised so that travel to a healthcare provider and being exposed to others in a waiting room would place them in danger. Although some patients may qualify for Medicaid transport, many do not, so alternative means of transport would need to be arranged. Some patients are not safe to travel alone so the costs to serve these patients would include either a hired escort or a family member who would be unable to work during that time. Many families simply cannot afford to miss work to provide for their loved one.

36 J.G. Bouknight

Extremely remote areas offer the best example of the ben- efits of telepsychiatry to the elderly. In a study published in the Journal of Telemedicine and Telecare in 2006, Jacqueline Harley described the provision of telepsychiatry services to the island of Jersey, which is a part of the United Kingdom but lies 160 km south of the British coast. The island had primary and secondary mental health services but no access to specialist psychiatrists for either patient care or for educa- tional presentations to the island medical community. In this study, a monitor was placed on a “rollabout system” on the island connected with equipment in a conference room at Bethlem Royal Hospital in South London. Of note, this is Europe’s oldest institution to specialize in the treatment of mental illness (established 1330) and is the origin of the term “bedlam.” In a 6-month period there were five patient con- sultations and six presentations carried out. The cost of these 11 services was £3483.06 which included the capital costs of the equipment, call charges, and line rental. The estimate for offering the same services by transporting the patient to the mainland with an escort was £12,975.00. “The threshold at which videoconferencing became cheaper than travel was between five and six telemedicine episodes per year…” [7]. Another pilot telepsychiatry project in rural Alberta, Canada found that the average cost savings per consultation was $210 per patient for patients who would otherwise need to travel. Based on this pilot project, the Alberta Mental Health Board expanded the telepsychiatry network to cover the province with 21 receiver sites [8].

A path breaking use of telepsychiatry services was employed in a war zone to treat service men and women with Acute Stress Disorder and Posttraumatic Stress Disorder. Few places are more remote than the terrain surrounding the Taliban strongholds in Afghanistan. Pelton et al. used Prolonged Exposure (PE) therapy to treat service members who had been involved in combat. Their approach included therapy sessions, the first half of which were traditional face- to-face with the second half composed of therapy via video- conferencing. The treatment protocol consisted of 8–12 90-min sessions focusing on psychoeducation about common

3. The Economics of Geriatric Telepsychiatry 37

emotional reactions to trauma and treatment rationale; repeated visualization of traumatic memories (imaginal exposure); in-vivo exposure to avoided situations; and thera- peutic processing and discussion [9]. This study demonstrates the usefulness of telepsychiatry in even the most difficult situations where treatment would otherwise be unavailable. The economic benefits of rapid treatment of Acute Stress Disorder within a combat zone would include decreased “downtime” for the soldier, decreased incidence of Posttraumatic Stress Disorder (PTSD) and, potentially, decreased future treatment and disability costs.

Emphasizing the economic benefits of telehealth services is the Northern Periphery Programme (NPP). The NPP is composed of Greenland, Iceland, Faroe Islands, Ireland, Northern Ireland, Scotland, Norway, Sweden, and Finland. While most of the countries have urban centers with ready access to psychiatric and other health services, there are also very remote areas of all of these countries that are subject to harsh weather conditions. Currently there is a project called the Transnational Telemedicine Solutions which has as its goal the provision of telehealth services to the NP. Among the projects proposed is the provision of emer- gency psychiatric services for adults and children in these regions [10].

Savings in office space are also an important savings offered by telepsychiatry. For the provider, little other than a chair and a monitor with audio capabilities is needed. If the care is offered to a patient’s home, the office cost would be minimized but there may be added equipment and staff costs. Our experience is that most geriatric telepsychiatry services are offered in the primary care setting with no extra space devoted to telepsychiatry because the equipment takes little space. The provision of a safe environment for the interview- ing psychiatrist may also be a benefit of remote treatment. A patient who may be too violent to interview face-to-face may be safely evaluated by telepsychiatry. Gun ownership is a controversial topic in American politics but the treating psy- chiatrist must always be cognizant of the need to evaluate for

38 J.G. Bouknight

risks. The attitudes of rural residents toward gun ownership may vary significantly from those of urban providers of tele- psychiatry services. The telepsychiatrist must be cognizant of this difference in attitudes and avoid imposing their values on patients who may possess firearms while always keeping the patient’s safety a top priority [11].

Another potential advantage of telepsychiatry is that patients with easily communicable diseases could be evalu- ated without the need for the physician to take precautions. The recent Ebola outbreak in Africa and cases in the USA demonstrate the need for strict precautions to prevent infec- tion [12]. In South America, there has been an outbreak of the Zika virus which would place the children of female psy- chiatrists at risk if they were exposed during pregnancy. The savings in the time and equipment spent to ensure the safety of the psychiatrist is obvious but the emotional benefit of being able to evaluate a patient without fear is less easy to measure.

Geriatric telepsychiatry can increase the frequency and duration of psychiatric treatment over that offered by tradi- tional face-to-face treatment. For some patients, telepsychia- try may be the only way in which they can receive treatment. In a 2013 publication, Morland et al. examined the cost effec- tiveness of clinical video-teleconferencing (CVT) to a popu- lation of Veterans suffering from posttraumatic stress disorder (PTSD). Of the approximately eight million Veterans who use the Veterans Affairs healthcare system in the USA, 3.3 million reside in rural areas where mental healthcare is not readily available. In this study of 74 male Veterans on the Hawaiian Islands of Maui and the Big Island of Hawaii, the geographic distances are significant and travel costs (by air) are sizeable. The study concluded that the mean cost of a treatment session by telepsychiatry was $79 while the mean cost for an in-person encounter was $792. Results indicated CVT was superior to in-person care especially when consid- ering challenges to Veterans accessing mental health services, making CVT a “cost-reducing” modality of mental health service delivery [13].

3. The Economics of Geriatric Telepsychiatry 39

Among the complications of determining the cost effectiveness of delivering mental health services by telepsy- chiatry is that more patients are likely to be served. While this increases the cost of service provision which is easily deter- mined, the societal benefits of improved mental health can be more difficult to measure. Estimating the added cost of delaying mental health services is a daunting task. In the most severe cases, patients may harm themselves or others due to untreated mental illness. While placing an economic value on the loss of life is impossible, human lives have value that does not easily lend itself to dollar estimations. Crudely stated, patients who die because of mental illness no longer cost society but a civil society certainly places value on the life and well being of its citizens.

3.4 The Implications of an Aging Population

As the Baby Boomer generation ages, the number of frail elderly in nursing homes and other long term care facilities can be expected to rise dramatically (Fig. 3.1). Because trans- porting the frail elderly can be physically stressful to the patient, expensive and difficult to arrange logistically, geriatric telepsychiatry services seem an ideal solution. The older the population, the more likely they are to require services of either a skilled nursing facility or an intensive assisted living residence.

The older the individual, the more likely that nursing home placement will be necessary to supply their care needs. Many assisted living facilities offer comprehensive services but there are legal limitations on the patients who are appro- priate for assisted living. In most situations, patients must be able to leave a facility unassisted if there is a fire or other emergency. This does not necessarily mean that the patient must be able to ambulate but they must be able to propel themselves using assistive devices if necessary (wheel chairs, walkers, and canes). Figure 3.2 illustrates the relationship of

40 J.G. Bouknight 30

25 20 15 10



2010 2030 2050

Fig. 3.1 Elderly adults as a share of all adults age 18 or older, 2010–2050. Source: Congressional Budget Office tabulations based on population projections reported in The 2012 Long-Term Budget Outlook (June 2012) [14],










Ages 85 or Older Ages 75 to 84 Ages 65 to 74

Percent of Adult 18 years or older

Nursing Home Residential Care





Percent of adult over age 65

14 12 10

8 6 4 2

1 0 0.3

Ages 65-74

Ages 75-84

Ages 85 or Older

Fig. 3.2 Rates of institutionalization among elderly people, by age, 2010. Source: Congressional Budget Office based on data from Medicare Current Beneficiary Survey, Access to Care 2010 [15]

3. The Economics of Geriatric Telepsychiatry 41

Fig. 3.3 Emergency room visits among nursing home residents, 2004. Source: CDC/NCHS, Nursing Home Survey, 2004

age with residential needs for the elderly. Many facilities offer primary care but relatively few offer geriatric psychiatry ser- vices in the nursing home or assisted living facility.

Each day over 500,000 individuals with mental illnesses are housed in skilled nursing facilities. Prior to the deinstitu- tionalization of the mentally ill, these patients were cared for in state mental hospitals. Nursing homes were not designed to treat mental illness so some of the specialized needs of the elderly mentally ill likely go unmet. Using results of the 2004 National Nursing Home Survey, Grabowski et al. highlighted challenges such as limited staff training in skills to manage mentally ill patients, many facilities use hospital emergency rooms when a mentally ill patient decompensates, refuses medications, or becomes agitated (Fig. 3.3) [16, 17].

3.5 Implications for Older Adults and the Criminal Justice System

The opportunity to provide psychiatric services to the elderly incarcerated population may be the most effective use of telepsychiatry services [18]. In the USA about half of the inmates in correctional institutions have a mental illness. “Inmates in correctional facilities have long received sub- standard health care, including mental health care” [19].


42 J.G. Bouknight

Prison facilities are often located in rural areas without men- tal health providers. Many psychiatrists are reluctant to par- ticipate in prison work because of the potential danger involved. Physicians have been attacked and taken hostage in these institutions. In addition, the time involved to provide for security in these institutions takes away from the productive time of physicians. Passing through metal detec- tors, emptying pockets, and allowing possessions and bodies to be searched is a tedious process. Most prisons will not allow any type of communication device within the prison which puts the physician out of touch in emergency situations involving patients not imprisoned. In fact, having no emer- gency communication available may violate some state laws and hospital bylaws. Evaluating and treating convicted felons brings with it contact with patients who have personality dis- orders that can make treatment a challenge. Manipulation and fabrication are regular in this environment. The goal of many incarcerated individuals is release and they may see the physician as a pathway to release either through an escape or by feigning a medical illness. While many inmates find ways to manipulate the treatment relationship to their benefit, telepsychiatry can provide some useful barriers.

The scope of the geriatric prison population reflects the general population trends of the Western world: the geriatric segment of the population is the fastest growing. Between 2007 and 2010 the number of sentenced state and federal prisoners who are 65 or older increased by 63 percent, while the sentenced prison population grew by 0.7%. This trend in the over 65 prison population will continue because the growth in state and federal prisoners 55 or older grew by 282 percent from 1995 to 2010 while the total number of prison- ers grew by 42% during the same period [1]. Figure 3.4 illus- trates similar trends from 2009 to 2013.

Some reasons for the growing number of older inmates are:

1. Long sentences. Prisoners with long sentences are more likely to grow old behind bars than prisoners serving short sentences. A significant percentage of prisoners age 55 or older were incarcerated with long sentences.








Inmate Population Percentage of

80% 70% 60% 50% 40% 30% 20% 10%



The Economics of Geriatric Telepsychiatry 43

50-54 55-59

60-64 65-69 70-74

Age Cohorts

75-79 80+

Fig. 3.4 Percentage change in population of aging inmates from FY2009 to FY 2013. BOP population snapshots from “The Impact of an Aging Inmate Population on the Federal Bureau of Prisons,” Evaluation and Inspections Division, Bureau of Prisons, May 2015 [20]

2. Life sentences. The imposition of life sentences, a particu- larly extreme form of long sentence, has increased.

3. Older age of offenders. More people are entering prison for crimes committed after age 55 than in years past.

4. Early release. Correctional and parole officials often have little legal authority to release old and infirm prisoners before their sentence expires and such authority as exists is exercised infrequently.

While the “Three Strikes” law was enacted to ensure that

repeat felons are not released, it also resulted in an increase in the geriatric population within the US prison system. For example, in California, the average age of a “third-strike” offender entering the prison system is 36 years. These offend- ers have a minimum of 25 years to serve their sentence before the possibility of their release, which effectively creates a situ- ation of aging in place within the prison system [21]. Several states have laws that prohibit parole for any life sentences. Adding to the imprisoned elderly is that the number of older

44 J.G. Bouknight

persons arrested is rising, likely because of the aging of the US population [1].

The prevalence of mental illnesses including substance abuse in inmates within correctional facilities in the USA has been estimated at greater than 50%. There is considerable variation in estimates depending on the database and the assumptions made. There seems to be no accurate estimate of those convicted of crimes who are hospitalized for their men- tal illness which likely biases the estimates to under reflect the prevalence mental illness among the incarcerated popula- tion [22]. The reason for the high number of mentally ill is in part the unintended consequence of the last act signed by President Kennedy, a well-known advocate for the mentally ill. The Community Mental Health Act of 1963 accelerated the movement of “deinstitutionalization,” a move to dis- charge the mentally ill from state mental institutions and return them to their communities. The changes that resulted from this act were dramatic. From 1955 to 1998 the number of occupants of state and county mental hospitals dropped from about 558,000 to less than 60,000. Where did the mentally ill go? The original plan was to shift funding to com- munity outpatient mental health centers which were funded by the Mental Health Systems Act of 1980 but this act was repealed early in the Reagan administration. Many of the mentally ill became homeless. Others became involved in the corrections system which is why a 2015 The Atlantic magazine article referred to Chicago’s Cook County jail as “America’s largest mental hospital” [23]. As the aged prison population grows, the incidence of dementia will likewise increase. Although there are no reliable estimates of dementia in the incarcerated population, about 13% of individuals older than 65 have some degree of dementia which may be their primary psychiatric diagnosis or dementia may be comorbid with other mental illnesses [24]. The number of prisoners with Major Neurocognitive Disorders is expected to increase more rapidly than in the general population because of the “health and environmental risk factors associated with pro- longed imprisonment” [25]. Inmates with dementia place other strains on the system in addition to their medical costs.

3. The Economics of Geriatric Telepsychiatry 45

Incarcerated individuals with neurocognitive disorders, by definition, have poor judgment and are vulnerable to exploi- tation by other inmates. They need a special observation level to prevent harm to themselves and harm from others. Patients with neurocognitive disorders also need special accommoda- tions for dietary needs since these patients may eat or drink nonfood materials. Transportation can be a particular chal- lenge since careful supervision is essential to guard the health of inmates with neurocognitive disorders.

The costs of providing medical care to aging inmates are substantially higher than for younger ones. In an issue paper completed for the Michigan State Senate, Angelotti and Wycoff used data from 34 states to estimate the per capita cost of medical care for inmates. As expected, the costs are directly proportional to the age of the inmate. An inmate younger than 20 was projected to have an annual health care cost of $2200 while an inmate over 80 had an estimated annual health care cost of $40,000 (all in 2009 dollars) [26]. In general, the prisons are responsible for providing medical care for inmates. Medicare and Medicaid (except in very lim- ited circumstances) do not cover medical expenses for prison inmates [1]. All penal institutions must provide medical care to all prisoners. This was established when the US Supreme Court ruled in Estelle v. Gamble that ignoring a prisoner’s serious medical needs can amount to cruel and unusual pun- ishment, noting that “[a]n inmate must rely on prison authori- ties to treat his medical needs; if the authorities fail to do so, those needs will not be met. In the worst cases, such a failure may actually produce physical torture or a lingering death [.] … In less serious cases, denial of medical care may result in pain and suffering which no one suggests would serve any penological purpose” [27].

In summary, the geriatric population in state and local prisons and in jails presents a special opportunity for geriat- ric telepsychiatry to provide needed medical care for these elderly prisoners without compromising the safety of provid- ers or placing undue costs upon an already overburdened prison and jail system. Telepsychiatry systems are safe,

46 J.G. Bouknight

effective, and easily accessible. Most telepsychiatry operations involve either governmental bodies or estab- lished healthcare systems but there is also a growing com- mercial sector that offers telepsychiatry services. This new delivery system provides mental health treatment from psy- chiatrists and psychologists at rates roughly comparable to office visit costs [28].

3.6 Costs

In order to maintain an ongoing system of geriatric telepsy- chiatry care, the costs of the system must be covered. There are many determinants of the costs of the geriatric telepsy- chiatry system of care. Other variables influencing the eco- nomics of telepsychiatry include hardware/equipment, infrastructure, healthcare provider remuneration, and other costs. These factors are explored in the following section.

3.7 Equipment

The technologies which can provide geriatric telepsychiatry services are varied. The key quality of all telepsychiatry tech- nologies is security. Patient data must be kept secure not only because of the patient–physician relationship but also to conform to federal and state laws. The equipment may be either purchased or leased. With the rapidly changing techno- logical environment, many providers find that leasing allows them to upgrade more frequently so that they can provide state-of-the-art care. Likewise, there are a variety of methods to achieve connectivity from encrypted internet access to dedicated phone lines. All costs are subject to the carrier involved. Telepsychiatry services can be transmitted in a number of different ways. These include encrypted internet connections, major broadband networks, high-speed telecom- munications lines which allow dedicated secure connections, patient monitoring centers which receive transmissions from at-home devices, and single-line telephone and video lines [29].

3. The Economics of Geriatric Telepsychiatry 47

Just as there are a variety of methods to transmit patient—physician interactions, there is also a variety of equipment that can be utilized. The equipment can range from a simple, encrypted internet connection through a com- puter to equipment that establishes a dedicated communica- tion from one site to another. The cost of the equipment and software varies with the sophistication of the connection and with the competitive nature of the market in the areas in which telepsychiatry services are offered. With encrypted internet connections, the desktop computer used in provid- ing geriatric telepsychiatry services can also be utilized for other needs offsetting the cost. Due to the rapidly changing economic environment, dollar estimates for equipment con- tinue to vary.

3.7.1 Infrastructure

A geriatric telepsychiatry practice requires little space. Most telepsychiatry is offered in a clinic, emergency room, or pri- mary care provider’s office without the need to construct a special room to accommodate these services. The patients simply need to have a camera, display, microphone, and speaker available which take relatively little space and can easily be mounted on a mobile unit so that it can be stored when not in use and easily moved from room to room if needed.

3.7.2 Physician Salaries

In general, physicians are paid on an hourly rate or per patient seen. Because there is no office overhead for the phy- sician and most of the other costs are paid by the hiring entity, per hour payments are typically much lower than typical psychiatry office rates. Malpractice insurance is usually also provided by the hiring entity. The physician is typically responsible for maintaining his state license and certifications

48 J.G. Bouknight

to allow for the prescribing of medications. Payment of as low as $150 per hour for a board certified psychiatrist is offered by some organizations ( [30]).

3.8 Conclusion

The economic benefits of telepsychiatry will be the driving force in offering these valuable services to the geriatric popu- lation. The current technological, regulatory, and reimburse- ment environment is rapidly changing making concrete projections of the benefits of geriatric telepsychiatry difficult to estimate. Several generalities appear to determine the eco- nomic benefit of this method of offering psychiatric care to the geriatric population:

1. The more debilitated the patient, the more it will cost to transport them to a psychiatrist. This makes offering psy- chiatric care in a nursing home or assisted living facility much more beneficial.

2. The further the distance either the patient or the provider must travel to receive/provide care, the more cost effective geriatric telepsychiatry becomes. This is particularly evi- dent in remote parts of the planet.

3. Because a geriatric telepsychiatry program requires there be an investment in equipment, support staff, and some form of data transmission service, the larger the volume of patients receiving the care, the more cost effective [31]. This is because the fixed costs of the program are spread over a larger volume of patients thereby decreasing the fixed cost per patient.

4. Certain populations may be particularly appropriate for care that is not face-to-face. These would include the jail and prison population and those who might be infectious.

5. While the geriatric population is growing, the number of geriatric psychiatrists is not commensurately expanding.

Telepsychiatry makes it possible for providers to render care

to a larger number of patients which may ease the shortage

3. The Economics of Geriatric Telepsychiatry 49

of geriatric psychiatrists over the next few decades. This approach to providing care is effective and economic. It takes advantage of the technological advances of the twenty-first century and applies them to care for the older adult.


1. Fellner J, Vinck P. Old behind bars: the aging prison population in the United States. Human Rights Watch; 2012.

2. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Medicare Learning Network. Website; 2016. Accessed 7 July 2016.

3. Professional Risk Management Services, Inc, (PRMS). Introduction to Telepsychiatry Newsletter; 2015, p. 3.

4. Centers for Medicare and Medicaid Services. Revised Appendix A: Interpretive Guidelines for Hospitals, and Revised Appendix W, Interpretive Guidelines for Critical Access Hospitals, in CMS Manual, Publication 100-07, 482(a)(8), Baltimore, MD; 2011.


6. Bashshur RL, Shannon GW, Bashshur N, Yellowlees PM. The empirical evidence for telemedicine interventions in mental dis- orders. Telemed J E Health. 2016;22(2):87.

7. Harley J. Economic evaluation of a tertiary telepsychiatry ser- vice to an island. J Telemed Telecare. 2006;12(7):354–7.

8. Hailey D, Jennett P. The need for economic evaluation of tele- medicine to evolve: the experience in Alberta, Canada. Telemed J E Health. 2004;10(1):71–6.

9. Pelton D, Wangelin B, Tuerk P. Utilizing telehealth to support treatment of acute stress disorder in a theater of war: prolonged exposure via clinical videoconferencing. Telemed. J E Health. 2015;21(5):382–7.

10. Casey M, Hayes PS, Heaney D, Dowie L, ÓLaighin G, Matero M, Hun S, Knarvik U, Alrutz K, Eadie L, Glynn LG. Implementing transnational telemedicine solutions: a connected health project in rural and remote areas of six Northern Periphery countries: series on European collaborative projects. Eur J Gen Pract. 2013;19(1):52–8.

11. Shore JH. Telepsychiatry: videoconferencing in the delivery of psychiatric care. Am J Psychiatry. 2013;170(3):256–62.

50 J.G. Bouknight

12. Sun L, Dennis B. Why Zika is ‘much more insidious, cunning and evil’ than Ebola. The Washington Post; 2016. http://www.washington- Accessed 11 May 2016.

13. Morland LA, Raab M, Mackintosh MA, Rosen CS, Dismuke CE, Greene CJ, Frueh BC. Telemedicine: a cost-reducing means of delivering psychotherapy to rural combat veterans with PTSD. Telemed J E Health. 2013;19(10):754–9.

14. Congressional Budget Office tabulations based on population projections reported in The 2012 Long-Term Budget Outlook; 2012.

15. Congressional Budget Office based on data from Medicare Current Beneficiary Survey, Access to Care files; 2010.

16. Grabowski DC, Aschbrenner KA, Feng Z, Mor V. Mental illness in nursing homes: variations across states. Health Aff. 2009;28(3):689–700.

17. Jones AL, Dwyer LL, Bercovitz AR, Strahan GW. The National Nursing Home Survey: 2004 overview. Vital Health Stat. 2009;13(167):1–55. Data from the national health survey

18. Langan PA. America’s soaring prison population. Science. 1991;251(5001):1568–73.

19. Deslich SA, Thistlethwaite T, Coustasse A. Telepsychiatry in cor- rectional facilities: using technology to improve access and decrease costs of mental health care in underserved populations. Perm J. 2013;17(3):80.

20. Office of the Inspector General. U.S. Department of Justice.The Impact of an Aging Inmate Population on the Federal Bureau of Prisons 2015.

21. King RS, Mauer M. Aging behind bars: “three strikes” seven years later. Sentencing Project; 2001.

22. Sarteschi CM. Mentally ill offenders involved with the US crimi- nal justice system. Sage Open. 2013;3(3):2158244013497029.

23. Ford M. America’s Largest Mental Hospital is a Jail. (2015).

largest-mental-hospital-is-a-jail/395012/. Accessed 11 Apr 2016.

24. Maschi T, Kwak J, Ko E, Morrissey MB. Forget me not: Dementia

in prison. Gerontologist. 2012;52(4):441–51.

25. Wilson J, Barboza S. The looming challenge of dementia in pris-

ons. Correct Care. 2010;24(2):10–3.

26. Angelotti S, Wycoff S. Michigan’s prison health care: costs in

context. Michigan Senate Fiscal Agency; 2010.

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27. American Civil Liberties Union. prisoners-rights/medical-and-mental-health-care

28. Rosman K.. As a Startup Founder, It Pays to Have Dr. Phil as Your Dad; 2016. Accessed 3 Mar 2016.

29. Health Information Technology and Great Plains Telehealth Resource and Assistance Center. Telehealth Start-Up and Resource Guide, Version 1.1; 2014. p. 5–6.

30. Accessed 6 May 2016.

31. Chakrabarti S. Usefulness of telepsychiatry: a critical evaluation of videoconferencing-based approaches. World J. Psychiatry.

2015;5(3):286–304. doi:10.5498/wjp.v5.i3.286.


Part II Clinical Applications

Chapter 4

Geriatric Telepsychiatry

in Academic Settings

Shilpa Srinivasan, Ashley Blackmon Jones, and Donald Hilty

4.1 Introduction

As the population of older adults in the USA continues to burgeon, with a projected increase from 40.3 million individ- uals over age 65 in the year 2010 to 72.1 million by the year 2030 and over 80 million by the year 2050, the number of older adults with mental illness is also projected to rise com- mensurately (US Census Bureau; [1, 71]). The Institute of Medicine (IOM) report, Retooling for an Aging America: Building the Health Care Workforce, released in 2008 [2], cast

S. Srinivasan, MD (*)

Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, 3555 Harden Street Extension, Suite 301, Columbia, SC 29203, USA


A.B. Jones

Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine,

3555 Harden Street Extension, Suite 141, Columbia,

SC 29203, USA


D. Hilty

Department of Psychiatry, Keck School of Medicine,

2250 Alcazar Street, Suite 2200, Los Angeles, CA 90089, USA e-mail:

© Springer International Publishing AG 2017 55 S. Srinivasan et al. (eds.), Geriatric Telepsychiatry,

DOI 10.1007/978-3-319-51491-8_4

56 S. Srinivasan et al.

a spotlight on the pressing need to expand and fortify the health care workforce to meet critical needs of the aging population. Following a congressional mandate in 2009, the IOM committee on the Mental Health Workforce for Geriatric Populations was assembled and generated the 2012 report—The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? [3]. These reports highlight the mental health and substance use (MH/SU) conditions in older adults, with prevalence estimates ranging from 14 to 20% of the overall population. While serious mental illness (SMI) such as schizophrenia and bipolar disorder is less prevalent, depressive disorders and major neurocognitive disorder (dementia)- and related behavioral and psychiatric symptoms are increasingly common in older adults. Given the prevalence of chronic physical health conditions in the elderly, the MH/SU needs are often first encountered in the context of primary care settings, which are under-resourced, both in terms of time and professional training. Stigma in seeking mental health care, lack of information about ser- vices, and limited transportation to services remain major barriers to mental health care access and utilization among older adults. [4–6].

In light of the demographic transitions of a growing older adult population and the critical need to meet their mental health needs, healthcare providers with geriatric training and/ or expertise have come under scrutiny. Both allopathic and osteopathic psychiatry residency program governing bodies stipulate the inclusion of exposure to geriatric psychiatry clinical experiences as part of residency training. The former requires “one month FTE (Full Time Equivalent) of orga- nized experience focused on the specific competencies in areas that are unique to the care of the elderly” [7], whereas this timeframe is not specified for osteopathic psychiatry pro- grams [8].

Since its inception and recognition as an accredited sub- specialty by the American Board of Medical Specialties (ABMS) in 1991, additional post-residency training in geriat- ric psychiatry has been offered, which entails the completion of a one-year fellowship where the focus is on the diagnosis

4. Geriatric Telepsychiatry in Academic Settings 57

and treatment of mental health conditions in older adults. Despite the availability of fellowship positions, the number of fellowship trained physicians has declined over the years. The 10-year period between 2001 and 2011 saw a 50% reduction in the number of general psychiatry graduates pursuing sub- specialty geriatric psychiatry fellowship training. Similarly, the number of geriatric psychiatrists maintaining specialty certification has decreased over time, with only 47% of geri- atric psychiatrists in 2011 maintaining or recertifying in geri- atric psychiatry [9, 10]. Of note, during the same ten-year period, medical student interest in pursuing psychiatry resi- dency training increased by almost 20% [11].

To put it in another perspective, Figs. 4.1 and 4.2 illustrate the number (and projected number) of geriatric psychiatrists per 10,000 older adults (age 75 and above) in the USA. These numbers clearly delineate the inadequate volume of the cur- rent geriatric psychiatry workforce to meet the mental healthcare needs of the aging population. As a consequence, there is an unequivocal requirement for improved access to specialized psychiatric care for this patient population.

Telepsychiatry, the provision of mental health/psychiatric care via live-two way videoconferencing, is one way to bridge the looming gap between available specialty trained providers

3000 2500 2000 1500 1000

500 0

Geriatric Psychiatrists

2000 2010

2030 2050

Fig. 4.1 Projected numbers of geriatric psychiatrists in the united states. Source (Adapted from [12])

58 S. Srinivasan et al.

1.6 1.4 1.2

1 0.8 0.6 0.4 0.2 0

Fig. 4.2 Geriatric psychiatrists/10,000 population ≥age 75. Source (Adapted from [12])

and the population in need of services. The foundation and history of telepsychiatry has been extensively covered in Chaps. 1 and 2 and includes the effectiveness of telepsychiatry in geriatric populations. However, training future psychia- trists and geriatric psychiatrists via a structured, well-defined evidence-based curriculum in telepsychiatry remains an area of development. This chapter will review the extant literature describing the prevalence of telepsychiatry in psychiatry training programs; discuss factors promoting telepsychiatry incorporation in clinical curricula and implementation, as well as barriers to effective implementation. This chapter will also inform discussion of telepsychiatry in light of ACGME milestones and competency-based assessments. Lastly, a sum- mary of geriatric telepsychiatry outcome studies from the current literature will be provided which can be used as refer- ence material when developing a geriatric telepsychiatry cur- ricular experience for psychiatry training programs.

Geriatric psychiatrists/ 10,000 population ≥ age 75

Geriatric Psychiatrists/ 10000 popula􏰀on age ≥ 75

2000 2010

2030 2050


4. Geriatric Telepsychiatry in Academic Settings 59

4.2 Approach to Training: Adding

to Residency Education Foundation and Putting Telepsychiatry in Context

Telepsychiatry has been integrated into clinical care with edu- cational components being facilitated by the release of tele- psychiatric competencies [70] including the first telemedicine competencies based on Accreditation Council of Graduate Medical Education milestones movement [13] and the Royal College of Physicians and Surgeons of Canada clinician com- petency movement [14]. The competencies provide outcomes mainly in the form of skills, with suggested teaching, supervi- sory, and program evaluation steps. As has been outlined in several publications, few programs have a formal telepsychia- try curriculum, while others feature an informal telepsychiatry experience, including telepsychiatry approaches to child and adolescent care [15–17]. While it has been shown that residents and training directors have an interest in telepsychiatry, cer- tain misconceptions are evident. In a survey of training direc- tors and residents conducted by Hilty et al., 39% of respondents felt that certain cultures will be less accepting of telepsychiatry care. 36% expressed concern that non-verbal cues are missed, and 33% of respondents noted privacy is a problem. Furthermore, over a third of respondents felt telepsychiatry is not as effective as in-person care [18]. It is therefore evident that training should address competencies that are:

1. Technical

2. Collaborative/interprofessional 3. Administrative [19, 20].

4.3 Telepsychiatry in Residency Training Programs: Considerations for Curriculum Development

As has been discussed elsewhere in this book, given the increasing popularity of telepsychiatry initiatives, more emphasis is likely to be placed on exposure and training

60 S. Srinivasan et al.

during residency. Currently the Accreditation Council for Graduate Medical Education (ACGME) does not require residents to train in telepsychiatry, nor do the accrediting bodies in Canada, Australia, New Zealand, and the United Kingdom [19]. Though telepsychiatry experiences are not presently an ACGME requirement, there are several studies that investigate the prevalence of telepsychiatry exposure in training programs, resident and program interest in telepsy- chiatry, and model curricula. A 2015 article by Hoffman and Kane published data from surveyed psychiatry residency programs, with 46 respondents. Twelve programs (26.1%) reported having telepsychiatry curricula and 21 (45.7%) pro- grams involved their residents either formally or informally in telepsychiatry experiences. 84.4% of the responding pro- grams reported an interest in receiving a sample telepsychia- try curriculum [16]. In a national survey of psychiatry trainees published in 2013, 19% reported direct patient care experi- ences in telepsychiatry and 21% were offered didactic exposure. Only 18% of psychiatry residents and fellows reported providing direct patient care through telepsychiatry. However, 72% of the respondents were “interested” or “very interested” in telepsychiatry [15]. This data suggests a signifi- cant difference between interest (from residents and pro- grams) and actual clinical exposure to telepsychiatry for residents.

The ability to create a telepsychiatry experience may vary by program, given the support provided by the institution, availability of knowledgeable faculty, and the organizational framework of the training program [19]. Just as other facets of training programs evolve, telepsychiatry experiences will likely change, especially with technological advancements [19]. Given the scope of telepsychiatry to meet the ongoing mental health needs of the aging population and continued interest in clinical and educational exposure to telepsychia- try in psychiatric training programs, expansion of the num- ber of programs offering telepsychiatry exposure and increasing the number of residents trained in telepsychiatry is a logical next step.

4. Geriatric Telepsychiatry in Academic Settings 61 4.3.1 Learning and Demonstration

of Competency

There are a few publications that detail residency program telepsychiatry curricula, which are variable between pro- grams [19, 21]. An experience in telepsychiatry offers several benefits for trainees within a psychiatric residency program. The practice of telepsychiatry provides the opportunity for residents to learn and demonstrate competency in all of the ACGME competencies (which are common across psychia- try subspecialties) and many of the milestones (Table 4.1).

Most of the competencies are broad-based skills, applica- ble to all rotations and experiences in psychiatric residency training, including geriatric psychiatry. There has been an increase in dialogue geared towards creating specific objec- tives and competencies related to telepsychiatry. Both the American Medical Association and American Telemedicine Association have established guidelines and recommendations for telehealth [22]. In a 2015 article, Sunderji and colleagues presented three areas of skill development for residents using telepsychiatry: technical skills, administrative skills, and col- laborative skills [19]. A 2016 study by Crawford and col- leagues gathered data from interviews of faculty and residents to recommend telepsychiatry-specific skills for competency and presented recommendations for teaching and learning methods. They identified “technical skills; assessment skills; relational skills and communication; collaborative and inter- professional skills; administrative skills; medico-legal skills; community psychiatry and community-specific knowledge; cultural psychiatry skills, including knowledge of indigenous culture; and, knowledge of health systems” [23]. In the cur- rent system, most residents will be able to demonstrate all of the ACGME competencies when being evaluated by a super- visor on a telepsychiatry rotation. The creation of telepsychi- atry-specific, evidence-based competencies may be an important future direction, particularly in geriatric psychiatry training.

62 S. Srinivasan et al.

Table 4.1 ACGME core competencies ACGME competencies

Patient care

Medical knowledge

Practice-based learning and improvement

Systems-based practice

Interpersonal and communi- cation skills


“Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.”

“Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care.”

“Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.”

“Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.”

“Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration

with patients, their families, and health professionals.”

“Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.” Common Program Requirements for Psychiatry

4.3.2 Enhancement of Diversity in Patient Care

and Learning

For trainees, telepsychiatry can provide diversity in case exposure by treating patients who are not directly located in the community of their program. Telepsychiatry has

4. Geriatric Telepsychiatry in Academic Settings 63

applications across a wide array of patient populations including adults, children and adolescents, geriatrics, veter- ans, college students, nursing home residents, and patients with developmental disabilities [19, 21, 24, 68]. Experience in the core competency of systems-based practice (SBP) is obtained by working in a different system of care outside of the home institution and through utilization of community resources unique to the specific geographical area of the patient. Telepsychiatry has been employed to provide con- sultations to patients in diverse locations including emer- gency rooms, outpatient settings (public and private), inpatient hospitals (psychiatric and non-psychiatric), foren- sic facilities, primary care offices, nursing homes, rural areas, residential centers, and more [15, 19, 21, 24, 25, 58]. ACGME further expands the goals of systems-based practice to include delivering health care services in various settings, advocating for quality care, and working in a team to improve patient assessment, care, and safety ( Psychiatry residents are involved in consultation and col- laboration with other providers and staff and documenting the care they provide, which affords the opportunity to dis- play competency in Interpersonal and Communication Skills. Practice-based learning and improvement also incorporates a goal for learning from the use of information technology, which residents develop by not just documenting encoun- ters, but utilizing the telepsychiatry equipment. Patient care and professionalism are important competencies to assess throughout training experiences, and telepsychiatry is no exception. Residents may also learn ethical and medico- legal issues that are unique to telepsychiatry [19, 21].

Telepsychiatry offers an opportunity for attending psychi- atrists to work with residents when they are not physically located in the same area, which diversifies teaching faculty. This is particularly important for programs in which geriatric psychiatry faculty may be under-represented. This not only provides the resident an opportunity to observe and learn skills from the teaching psychiatrist, but also provides the faculty an opportunity to teach, which may not be available


64 S. Srinivasan et al.

where they are located. Residents learn new technological skills, are exposed to different psychiatric practice models, gain the flexibility in navigating systems, and a greater under- standing of the applicability of a biological–psychological– social/spiritual/cultural model across treatment venues. Increased Interest and Recruitment in Telepsychiatry

An additional significant benefit for patients, residents, and employers is the potential for clinical experiences in telepsychiatry to positively influence career selection. This results in having more psychiatrists providing care via tele- health and therefore increases access to care for patients. Given the shortage of geriatric psychiatrists discussed in the introduction, telepsychiatry has the potential to make a sig- nificant impact on access to mental health care for older adults. If residents have a model for utilizing telepsychiatry as part of their practice, receive mentorship in this arena, and experience the positive benefits of telepsychiatry, it could impact resident decisions regarding future career and prac- tice. Reports in the literature highlight that clinical rotations are one of the influential factors on geriatric psychiatry sub- specialty choice [26, 27]. After curriculum exposure to tele- psychiatry, many residents reported increased overall interest and an increased interest in participating in telepsychiatry in the future [15, 21]. In one study, 90% of the residents agreed with a statement about their telepsychiatry experience increasing their interest in future participation [21]. Another study found that 72% of residents and fellows were inter- ested in telepsychiatry after having direct clinical exposure, but only 29% reported plans to utilize telepsychiatry after training [15]. A study by Chung-Do and colleagues in Hawaii reported that after a 6–12 month telepsychiatry experience, 73% of the 11 trainees went on to use telepsychiatry in their career and practice in rural areas [25]. Given the evidence, it is reasonable to consider that resident telepsychiatry experi- ences may at a minimum increase interest and potentially influence career choices.

4. Geriatric Telepsychiatry in Academic Settings 65 Resident Feedback

When creating a telepsychiatry curriculum, it is important to review feedback provided by residents who have been through a telepsychiatry experience in their training pro- gram. There are few telepsychiatry curricula that have been evaluated in the literature, with a paucity of data for geriatric psychiatry specific experiences. However, examples in the literature include a study describing resident feedback after performing telepsychiatry child and adolescent consultations at the University of Toronto. Nearly 100% of residents were in agreement that their telepsychiatry exposure was “enjoy- able” and “interesting.” Residents reported feeling personally “rewarded” in providing care that improves patient access to mental health services, found benefits in working with a team, and appreciated obtaining insights into other cultures as well as ethical issues that are specific to telepsychiatry. Residents also provided feedback on the involvement of the supervising faculty, reporting that they appreciated being able to discuss the case and literature with attending faculty [21]. Residents participating in a telepsychiatry rotation at the Veterans Administration Medical Center in California provided posi- tive feedback about using instant messaging for communica- tions between the resident, supervising psychiatrist, and a “Telehealth Clinical Technician” [28]. They found it helpful to obtain quick supervision without interrupting the patient care appointment. In this study, a brief elective experience in telepsychiatry received positive feedback and subsequently became incorporated into the rotation requirements [28]. In another survey of residents and fellows, 77% of respondents believed telepsychiatry was an important part of training and 51% felt that direct patient care via telepsychiatry should be required. This survey did not find a correlation between the interest level after exposure to telepsychiatry and the num- ber of patient care hours on a telepsychiatry experience [15]. Taken together, the data suggests that any exposure to tele- psychiatry can increase resident interest.

66 S. Srinivasan et al.

Based on resident feedback in the literature, there are several aspects of a telepsychiatry experience that programs should consider when developing a telepsychiatry curriculum.

1. Introduce unique aspects to telepsychiatry, such as tech- nology and patient care related topics. This could also include discussion about technology support [21].

2. Enhance resident knowledge of current literature describ- ing telepsychiatry studies and outcomes in older adults (Table 4.2) as well as comparative literature on the effec- tiveness of telepsychiatry vs. in-person care [19, 22, 24]. This is important because, despite the increase in interest from residents after a telepsychiatry clinical experience, one survey found that 40% still did not agree that using telepsychiatry as a treatment modality was equal to an in- person encounter [15].

3. Provide patient background information and/or access to medical records prior to the encounters [21].

4. Include a follow-up discussion at the completion of the ses- sion to enhance the learning experience [21].

5. Allow residents to be active participants instead of observ- ers in the clinical encounter [19, 21].

6. Provide opportunities for residents to observe a telepsychiatry-based clinical interview demonstration by teaching faculty [21].

4.4 Implementation: Making It Work

4.4.1 Communication and Presence

A host of factors affect perception of the telepsychiatry visit and communication by participants [47]. This is particularly relevant when considering implementation for geriatric patient care. The presence of others in the room (e.g., family members, nurses, and tele-coordinators) is important. Many patients feel they are being videotaped when they are not—a big deterrent to disclosure and spontaneity. Other important

4. Geriatric Telepsychiatry in Academic Settings 67


Description Technology Table 4.2 Summary of telepsychiatric clinical/outcome studies with older adult patients Location N Study

Able to provide care sooner and staff felt


satisfied; caregiver

2 years: CDR, SBT,

distress reduced;


improved patient


learning curve; some

1 year

savings in costs

psychiatrist’s time Satisfaction high; efficient use of


Descriptive study



hospitalization rate compared to past

TP = in-person; nurses

Prospective over


South Korea



Nursing home Jones [29]

Satisfaction high with

Prospective over




Tang et al. [31]


Case reports


Descriptive study:








Lee et al. [30]

Johnston et al.

Lyketsos et al.




S. Srinivasan et al.




N Location


Satisfaction high;

Pilot study: DCM


24 USA




Descriptive study:



Yeung et al.

high; significant


improvement in 6/9


Nearly equal, with

TP vs. in-person:

Coaxial cable

15, medical USA

Montani et al.

0.95 correlation; all

MMSE, clock

TP as reliable as

In-person (twice)


24, medical USA

Menon et al.

between providers and

staff good

Cost and time savings

Descriptive study


106 USA



exceeded the start-up

preferred in-person,


vs. in-person/video:







Table 4.2 (continued)

et al. [34]

et al. [36]




4. Geriatric Telepsychiatry in Academic Settings 69


TP as reliable as


0.9 and GDS 0.78



Nearly equal with

TP vs. in-person:


0.8 correlation for


only 0.48 for clock

drawing, digit span

screen; helped with

depression with

Equal, with MMSE

TP vs. in-person:


TP equal to in-person

TP vs. in-person:



16, veterans


High correlations (> 0.60) for all, though

96.6% completed the

Screening for



118, home

Turvey et al.


triage and treatment







vs. in-person/video: In-person (twice) Description BPRS, MMSE,


DSM-IV, clock

TP vs. in-person:


MMSE, clock







27, veterans

Grob et al.[39]




20, primary



20, community


33, primary



Saligari et al.

Shores et al.



Loh et al. [42]

Cullum et al.


S. Srinivasan et al.

Dementia Scale, CGI-I Clinical Global Impressions-Improvement Scale, MMSE Mini-Mental State Examination,

Reprinted with permission from [67]





For severe depression, all patients improved to mild depression No significant

differences in TP

vs. in-person test


Clinical Dementia Rating, SBT Short Blessed Test, BDS Blessed

TP Telepsychiatry, KBS Kilobits per second, CDR

DCM Depression Care Management module, PHQ-2 Patient Health Questionnaire-2, HDRS Hamilton depression

Descriptive: DCM,



English, and Spanish

TP vs. in-person neurocognitive testing in Spanish

rating scale, GDS-15 Geriatric Depression Scale-15, BPRS Brief Psychiatric Rating Scale

DSL, 512


22, rural

Vahia et al.


19, home N Table 4.2 (continued) Sheeran et al.





4. Geriatric Telepsychiatry in Academic Settings 71

clues to the patient’s problems are evidenced before they appear on video: the time and behavior of the patient’s arrival; conversations and other interactions with the tele- medicine coordinator; and initial anxiety and distraction due to the equipment and/or self-conscious seeing oneself on the screen (if that exists).

A critical variable in communication is telemedicine’s ability to simulate real-time experiences, at least in terms of image and interaction. A speed of transmission of 384 KBS suffices for most everything; the technology must be ade- quate for the clinical task at hand (e.g., have staff come for an emergently suicidal patient; use a primary care physician (PCP), nurse, or physician extender to evaluate for tremor). A concept that bears on communication is presence, defined as “ … the fact or condition of being at the specified or understood place” [48]. The physical, virtual, and imaginal environments affect presence. In a physical environment, informational cues may be incorporated into conversation without conscious awareness (e.g., a patient walks in a reti- cent way). Participants in the virtual environment created by telemedicine may not realize all cues in the physical environ- ment—so being observant and listening carefully may be more important [47, 48]. Videoconferencing provides “enough” of the physical environment to facilitate decision- making one-on-one and a “social presence” for participants to share a virtual space, get to know one another, and discuss complex issues [49].

4.4.2 Adapting Telepsychiatry: The Approach and Specifics Related to Patient Care and Other Competencies

The challenge of meaningful assessment of learner compe- tence has stimulated interest in the Dreyfus and Dreyfus Model, a framework for assessing skill acquisition that describes developmental stages beginning with novice and progressing through advanced beginner, competent, profi-

72 S. Srinivasan et al.

cient, expert, and master [50]. Although many educators have adopted this model, a lack of consensus about its adaptation to clinical medicine has been documented [51]. Hilty et al. developed telepsychiatry competencies aligned along ACGME domains of patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills and com- munication [13, 52]. Key telepsychiatry competencies were defined by using milestone levels with the Dreyfus model:

– Level 1—novice (medical student) –> novice resident

– Level 2—advanced beginner (first-year resident) –> sec-

ond year resident

– Level 3—competent (senior resident)

– Level 4—proficient (beyond Milestones; above average

graduating resident, fellow and/or attending)

– Level 5—expert (beyond Milestones; intuitive problem-

solver who exceeds principle-based solutions) [50].

This was further simplified to three levels: Novice or Advanced Beginner (e.g., advanced medical student, early resident, or other trainees); Competent/Proficient (e.g., advanced resident, graduating resident, faculty, attending, or interdisciplinary team member); and Expert (e.g., advanced faculty, attending, or interdisciplinary team member). The fol- lowing suggestions or examples may be considered to incor- porate a competency-based approach to telepsychiatry training (Table 4.3):

• Informed consent: verbal or written, depending on the state; option not to continue with the telepsychiatry evalu- ation is discussed.

• Contextualized history if less familiar with the location (e.g., aware of geographic and cultural specificity for Native Americans).

• Privacy and confidentiality expectations are similar to in- person but be aware of pitfalls with technologies (e.g., cel- lular phones are not private; Gmail is not HIPAA compliant).

Table 4.3 Telepsychiatry (TP) competencies related to patient care, system- and practice-based learning, professionalism,

communication, knowledge, and technology

(e.g., advanced faculty/attending/

(e.g., advanced resident/graduating

(e.g., advanced

interdisciplinary team member)


medical student,

Recognizes potential informed

consent problems (e.g., lack of

capacity) and seeks collateral

Conducts in-depth, well-paced,


and concise interview; adapts

interview to patient age

Assesses devices for functionality

Identifies and manages problem(s) with

Determines best appropriate assessment adjustments based on

the setting (in-person vs. TP) Readily utilizes nursing and/ or ancillary staff or family as historian when relevant


4. Geriatric Telepsychiatry in Academic Settings 73



advanced beginner


interdisciplinary team member)

early resident, other trainees)

Patient care

Obtains informed consent for telehealth

Obtains standard


(checks state regulations to see if form


needed; discusses option not to perform Obtains contextualized history (e.g., telepsychiatry encounter)

is aware of geographic and cultural

Adjusts interview to technological and




Requests devices to augment hearing


Novice or





patient needs/preferences

Builds trust and





S. Srinivasan et al.



Synthesizes information

Assesses risks for suicide/harm to

(including risk vs. protective

factors and obtains key

Ensures identification of significant

collateral information)

exam findings (e.g., movement

Administers tools contextually for non-reproducible task at (e.g., substitutes score item


staff to complete or do part of PE/

screening tools


Teaches staff/others how to do

parts of PE/neurologic exam

and trouble-shoot PE/

neurologic exam problems

at the remote end


adjustments (e.g., uses remote site


disorders; intoxication/withdrawal)

Examines and administers tools with

neurologic exam)

Table 4.3 (continued)

Novice or

advanced beginner and protective Stratifies risk

factors based on

epidemiology (e.g.,

suicide, homicide


(e.g., MMSE)


Ascertains need

for in-person

physical exam





and physical


prioritization and anticipates barriers to treatment plan Tailors recommendations to implementation

adults, cultural specificity, and

Follows in-person medication


Provides succinct summary to

interdisciplinary team and other


Formulates plan for calls and


Follows up with

changes the process); terminates

recommendations: considers safety and adherence factors;

monitoring; aware of legal and jurisdictional issues related to



Formulates BPS outline with

Formulates in-depth BPS outline with


(BPS) outline

available resources for older

continuum (levels of care)

patient preference

recommendations (i.e., reviews


or other providers succinctly

Selects “best” mode: e-mail,

telephone, or other (and if it

For medication

plan for follow-up and




in providing summary and

medical decision-

making on safety, need for treatment,


PCP or TP by


attention to medical and behavioral

Provides summary to patient and family Demonstrates awareness of treatment

applicable, provides specific instructions

for PCP to initiate, titrate, and

Follows up with PCP by TP or phone

Management and Treatment Planning

4. Geriatric Telepsychiatry in Academic Settings 75

Novice or Expert

Area/topic advanced beginner Competent/proficient

Engages patient, referring doctor

options, side effects, and alternatives if


and other

video if disruptive to patient care


S. Srinivasan et al.



asynchronous notes

diagnosis, and codes

telemedicine standards

translation of principles to video and

basic regulations

Provides sufficient detail to

Generates initial/revised draft for

allow implementation of plan

primary or other specialty care with Complex EHR (e.g., Cerner, Epic) modification for TP consultation

Documents final time spent,

Identifies diagnoses for billing

Learns why billing


Considers health advocacy issues

related to billing; access to care

Practices within in-person and

Is aware of regulations and learns

Learns in-person

Privacy and

phones are not private; Gmail

encrypted differently

over time and within local Utilizes phone, e-mail, and context/resources

Is aware of pitfalls with

adjunct regulations, if applicable



technologies (e.g., cellular

Is aware that technologies are

is not HIPAA compliant)

advanced beginner Electronic Health rudimentary Record (EHR) Drafts TP note hard copy or Novice or Table 4.3 (continued) Documentation


is important

and how it is



issues )



and communities:

language fluency,

Considers one’s culture, values,

behaviors, and



CM in-person care


Adjusts interview based on patient

Considers diversity

Demonstrates language fluency: double culture and preference checks/confirms

Elicits cultural meaning of illness/


Demonstrates awareness of social

determinants that may affect interest

in, use of, and experience with

Demonstrates time management when

Uses the


using an interpreter and incorporates



medical interpreter > family)

Clarifies and amplifies communication

Clearly communi


Cultural, diversity,

and social

determinants of


4. Geriatric Telepsychiatry in Academic Settings 77

Novice or Expert

Area/topic advanced beginner Competent/proficient

Follows cultural formulation

Ascertains and inquires if

Adjusts interview, assessment,


Learns how social determinants affect

in-person care if critical need

dimensions during interpreted

culture affects using TP (general exploration) or explanation of


relationship in context of culture, values, behaviors, and preferences


Assesses verbal and non-verbal


patient preference (e.g., professional/

Trouble-shoots communication


of patients, families,



cates with patient,

family, and healthcare

Considers patient–doctor

and treatment per social determinants; considers



S. Srinivasan et al.



Establishes and maintains

Demonstrates thoughtful

care, if applicable

Serves as IPE provider and



Uses individual consult as an

relationships with communities

integration of in-person and TP

within community

Supports interdisciplinary team


demonstrates familiarity with IPE


care (e.g., care coordinators—

Engages providers with unclear


needs and adapts consult and note


perspective of

opportunity for building ongoing


Integrates indirect care (e.g., case

or chart review) into practice

Visits community in-person before TP Identifies relevant resources and needs (if applicable)

Works with interprofessional team and

Participates and

Begins to teach within IPE

different roles;

Understands the referring provider’s

MS-SBP Novice or Area/topic advanced beginner Table 4.3 (continued) Systems-based practice

Participates and

Outreach to



works effectively

(IPE) and team



consultation from

referring provider’s








primary care

Practices and serves as role Practices and serves as role model model

Learns about rural access, epidemiology,

finances, and other

knowledge of rural

to TP system practice

Demonstrates facility with

models of consultation,

Demonstrates flexibility to structure practices style with


Rural health

health basics

(e.g., veterans/





of systematic



Care models

knowledge of

4. Geriatric Telepsychiatry in Academic Settings 79

Novice or Expert

Area/topic advanced beginner Competent/proficient

Recognizes differences and adapts assessment and management approaches accordingly

Demonstrates differences among knowledge of

Demonstrates facility with traditional

referral to psychiatry, consultation care,



special populations


in-person, TP care,

and consulting TP

care are

Adjusts risk and its management

Identifies problems and stratifies risk



integrated, stepped, and hybrid


Begins to demonstrate understanding of

collaborative care

and TP



80 S. Srinivasan et al.

Table 4.3 (continued)

Novice or

knowledge of in-person regulations




advanced beginner


(e.g., veterans affairs)

Considers ways that the


Practices within telemedicine

Demonstrates awareness of similarities/



regulations either from state-to-

differences between in-person and

state or within unique systems

telemedicine regulations

Considers range of evaluation

Demonstrates knowledge of basic



approaches and uses results for

evaluation strategies for TP outcomes

patient satisfaction

QI or to inform practice

physician role can impact policy

Considers how technology can address and also contribute to health equity

and advocacy through technology

Demonstrates leadership in

Serves as role model and gives


clinical practice and teaching/learning

receptiveness to


as applied to



and differences

telemedicine care

model (medico-

between states



legal issues

Identifies issues



related to access



using technology

behavior consistent

ethical behavior


and health equity

Engages within interprofessional

Serves as role model


Integrity and

Novice or Expert

Area/topic advanced beginner Competent/proficient

Provides feedback on scope and

Practices within scope(s)

boundary issues; trouble-shoots


Practices with adjustments and

customization to telepsychiatric


Analyzes QI options, selects, and


Provides context and next steps

Covers history, evidence-

Covers relevance, history, and evidence-

based, and incorporates clinical



of scope issues Becomes aware TP care, and TP of in-person,


consultation MS-PrBLI Practice-based learning



basics of in-person knowledge of

participate in QI Participates and

Learns how to contributes


Covers relevance

4. Geriatric Telepsychiatry in Academic Settings 81

Demonstrates awareness that

in-person and telepsychiatric care have


Applies QI information to cases and


Organizes and furthers


and history

Teaching and




82 S. Srinivasan et al.



advanced beginner


Uses humor to actively engage

Takes steps to actively engage and put

patient at ease

Identifies differences

subsequent TP encounters

Demonstrates ways to express

and continuous, iterative

Modification: assesses if non-


and put patient at ease with TP Analyzes outcome of each visit encounter

and customizes adjustments for


Demonstrates pre-visit planning

sensory barriers exist (e.g., room


Expects and plans for differences in

Identifies barriers and implements

Considers incorporating third party by

Identifies remote site layout problems

Acts as observer

Remote site


Modification: hearing aid/amplification

ease of establishing rapport

replacement behavior


Recognizes non-

verbal limitations

and possible solutions to optimize



Table 4.3 (continued)

Novice or

between TP and in-person care Tries to project

15% more (voice/


(e.g., offering a

tissue, handshake)


Adapt to



Optimizes hardware, software,

Performs basic trouble-shooting (e.g., Operates hardware, software, and re-boot system; call for assistance) Competent/proficient accessories

operations on near end and advice on far end prn

Optimizes use of multiple


(for enhancement and avoiding and accessories based on context Manages all trouble-shooting distraction)

Abbreviations: TP Telepsychiatry, CM based on submission for CanMEDS TP competencies, MS US Milestones; consis- tent with non-TP, regular competencies of the Accreditation Council of Graduate Medical Education (ACGME) (PC

patient care, K medical knowledge, PrBLI practice-based learning and improvement, SBP systems-based practice, P professionalism, IPSC interpersonal skills and communication, MS-PC milestones patient care), PE physical examina-


Geriatric Telepsychiatry in Academic Settings 83

Novice or

camera, and prn familiarity with microphone,

CM Technology operation


how multiple

technologies (e.g., primary

and secondary


advanced beginner Demonstrates


Operates use of multiple technologies

2nd camera

camera) are used

tion, PCP primary care provider, QI quality improvement


84 S. Srinivasan et al.

• Language/interpreter ability is more of an issue with tele- psychiatry, as inputting a professional (rather than a con- venient family member) is easier [53].

• Adapting to the technology involves several dimensions: project self 15% more (voice/animation) and use replacement behaviors for offering a tissue or shaking hands on greeting.

• Familiarity with microphone, camera and when needed, a 2nd camera is helpful. Pursuant to the technical skill level of the clinician further optimization of hardware, software, and accessories may be based on context (rather than depending on technical assistance or coordinators). Far end control of cameras and equipment minimizes depen- dence on remote site patient and staff.

• A geriatric patient evaluation by telepsychiatry could fur- ther include a spouse, an adult child, or caregiver who participates in the evaluation in-person or via telephone.

4.4.3 Teaching and Supervision

The following case example illustrates a competency-based approach to training learners in geriatric telepsychiatry.

John Smith, a 71-year-old widowed man, lives with his daughter and son-in-law in the rural Southwest. Mr. Smith’s daughter asked his primary care physician (PCP) for a psy- chiatry referral because she was concerned that Mr. Smith had expressed suicidal thoughts. Given the limited access to mental health services in their region, Mr. Smith’s PCP sought geriatric telepsychiatry services provided via the affili- ated regional medical center. More recently Mr. Smith has withdrawn socially and spends much of his time in his room. His daughter notes he has not participated in family activities, and has told family members he is a “burden to everyone” and that they would be “better off without him.” During the telepsychiatry evaluation, Mr. Smith is in a room alone, wear- ing a hat that obscures his face from view, and avoids looking directly at the monitor.

4. Geriatric Telepsychiatry in Academic Settings 85 Questions to facilitate the teaching of competencies

before starting or early on:

1. What is the referral source asking the telepsychiatrist to do? What is needed? What might they need from the tele- psychiatrist that they are not aware of?

2. What protocols need to be established before the telepsy- chiatry assessment, given that the patient might present with acute safety risks at the time of the assessment? Who will need to be informed/engaged at that time? What legal mechanisms are needed to ensure the patient’s safety? What local resources/services are available in the event of acute safety issues?

3. What can be done to engage him, given that he may be a somewhat reluctant participant?

4. What can the telepsychiatrist do to improve his/her ability to see the patient on screen?

At the mid-point, Mr. Smith has warmed to the encounter,

having taken his hat off, is looking more directly into the camera, and answering questions more readily. He said that he began feeling down 3 years prior, shortly after the death of his wife, following which he moved in with his daughter and son-in-law for financial reasons. He endorsed most symptoms of depression, but specifically denied ever thinking about suicide.

Questions further into the clinical assessment might include:

1. What can the telepsychiatrist do further to assess Mr. Smith’s suicide risk? Competencies relate to patient care (assessment and physical examination) and systems-based practice (safety).

2. In what ways does Mr. Smith’s cultural background affect: The assessment of his suicidal risk? The assessment of his mental status? The assessment of issues in his personal his- tory that relate to why he has developed depression? What can be done to incorporate this understanding of diversity into the assessment? Competences relate to systems-based practice (special populations) and communication (cul- tural, diversity, and social determinants of health).

86 S. Srinivasan et al.

4.4.4 Geriatric Telepsychiatry Specifics

A good geriatric mental health history not only includes the patient’s point-of-view, but also collateral information from all other stakeholders and medical providers—largely depen- dent on where the patient generally resides and is cared for (e.g., home, family and caregiver, nursing home, staff, and others). Cognition, pain severity, physical/other limitations, and environmental factors that may affect assessment are important to understand. Screening of geriatric patients via self-report questionnaires or clinician rated instruments is virtually the same as for in-person assessments, e.g., Patient Health Questionnaire—9 items, Geriatric Depression Scale— 30 items [54, 55].

As part of providing telepsychiatry training, the logistics of conducting a geriatric psychiatry evaluation via telepsychia- try should be covered. There are some important additional items to keep in mind when using telepsychiatry with older adults, including:

• Pre-visit event summary: An accounting of general events and the patient’s attitude, comments, complaints, sources of information, and clinician observations (e.g., olfactory/ vision/hearing limitations, gait/balance problems, other) need to be communicated before the patient enters the room.

• The clinical examination, in general: this may require staff assistance (often a nurse facilitator) to complete, particu- larly if a patient is delirious, combative, or agitated, has a low level of formal education, or suffers from aphasia, poor hearing, or vision impairment.

• Cognitive examination: may require item substitution if clock drawing or sentence writing cannot be uploaded to see or held visually in the camera; again staff are better in assisting here so as to not answer questions for the patient.

• Physical examination: camera control at the far end enables easy wide angle, close-up, and focused viewing to detect tremors, micrographia, and other abnormalities but

4. Geriatric Telepsychiatry in Academic Settings 87

staff may need to be trained to check for extrapyramidal

side effects (EPS) like cogwheel rigidity.

• Encouraging family member(s) to attend in general and

when there is significant cognitive impairment can pro- mote patient acceptance. Families are very welcoming of telepsychiatry interventions and are grateful for the extra time and effort put forth to facilitate a telepsychiatry encounter [36].

• It is recommended that most or all telepsychiatry encoun- ters for nursing home residents or elders in similar envi- ronments include a member of the social work staff to give input on family of origin, family dynamics, and past family and social history [36].

4.5 Geriatric Telepsychiatry Program Options: Potential Prototypes

for Academic Engagement

Example 1.

Resident and fellow learners may be incorporated into exist- ing academic geriatric telepsychiatry programs and/or gain clinical experience in geriatric telepsychiatry through com- munity psychiatry rotations. One such experience offered at the University of South Carolina School of Medicine is a geriatric telepsychiatry consultative evaluation model wherein consultations are provided to a rural PACE (Program for All-Inclusive Care of the Elderly). In this model, residents and fellows review records from the requesting facility, obtain a clinical history from patients and collaterals (family members, PACE staff including nursing and social work, and referring PCP), conduct psychiatric evaluations of geriatric patients, review laboratory and neuroimaging results via real- time access to the remote facility’s electronic medical record, and formulate diagnostic impressions followed by develop- ment of a clinical plan of care, all under the supervision of geriatric psychiatry faculty.

88 S. Srinivasan et al. Example 2.

Geriatric telepsychiatry services can combine low and high intensity models. The following clinical vignette is an example highlighting teaching aspects to clinical telepsychiatry care. The telepsychiatric competencies that are pertinent are patient care (PC), interpersonal skills and communication (IPSC), practice-based learning (PBL), system-based practice (SBP) and, although not an official ACGME competency per se, tech- nology (T). The vignette below highlights two particular dimensions: (1) Days 1 and 3 show the consultation role to the PCP—a SBP competency and (2) Day 30 is the assessment of the patient (the other competencies mentioned above).

Day 0, A PCP called a hospital from a skilled nursing facil- ity about a 71-year-old Caucasian woman, with depression, dyslipidemia, and new onset psychosis (i.e., auditory and visual hallucinations). Current medications were venlafaxine extended release (ER) 75 mg in the morning and temazepam 15 mg at bedtime.

The PCP was considering a psychiatric admission. An alternative would be taking the patient by ambulance to a facility nearby that had a synchronous telepsychiatry unit, but there would be a one-month delay for an opening in the schedule. There were no local psychiatrists in the city of 25,000 and the nearest in-person option was 2 h away but with a greater delay in appointment time.

Day 1, Telephone consultation with an academic telepsy- chiatrist. The telepsychiatrist and general psychiatry resident received the consultation request. The psychiatry resident obtained preliminary information from the PCP who was unaware of any recent acute medical problems. The resident pursued inquiry to establish a differential diagnosis. While the PCP was initially unsure of the potential for bipolar disorder, not having considered or inquired about it; he did not recall severe persisting insomnia and mood swings. After case discus- sion with the supervising attending telepsychiatrist, a prelimi- nary treatment plan was developed, entailing the following:

1. Continue venlafaxine

2. Replace temazepam with olanzapine (Zyprexa Zydis)

5 mg HS

4. Geriatric Telepsychiatry in Academic Settings 89

3. Hold off on the psychiatric admission (it was unclear if beds were available)

4. Exclude medical etiologies by work-up (e.g., a metabolic panel, Complete Blood Count (CBC), Thyroid Stimulating Hormone (TSH) level, Vitamin B12 level, and Rapid Plasma Reagin (RPR))

5. Schedule a follow-up appointment in the PCP’s office within the week.

Day 3, PCP office: The PCP noted that there were no wax-

ing and waning mental status changes. The patient and his wife denied racing thoughts, restlessness, decreased need for sleep, and impulsivity such as spending sprees associated with mood elevations of a week’s duration. The auditory hallucina- tions were diminished, but the depression, ruminations, and hopelessness persisted in the absence of suicidal ideation. Initial laboratory work-up was unremarkable. A 5-minute re- consultation by phone to the telepsychiatrist and psychiatry resident led to the following recommendations:

1. Raising the venlafaxine extended release dose to 150 mg

2. Continuing the olanzapine, and/or

3. Follow-up telepsychiatry visit in 2 weeks for a consultative


It was recommended that a nurse from the PCP’s office be

present during the telepsychiatry consultation.

Day 30, Telepsychiatry 60-minute evaluation: At this time, the telepsychiatrist and the resident who was still on service saw the patient. The resident obtained an interim clinical his- tory as well as past psychiatric histories. The patient was about “two-thirds” better in terms of his mood, but he was still not “back to normal” and his enjoyment, drive, and energy remained low; the latter had not changed with olan- zapine. The resident directed the PCP’s nurse to perform an AIMS evaluation during the consultation visit to assess extra- pyramidal symptoms as a side effect of olanzapine, and observed this assessment being performed. Consultation sug- gestions included:

90 S. Srinivasan et al.

1. Raise the venlafaxine to 225 mg; or

2. Add bupropion sustained release 150 mg in the morning

for residual depressive symptoms 3. Continue olanzapine.

Analysis: The telephone consultation prevented an unnec- essary medical or psychiatric hospitalization, used a low intensity intervention, and helped the PCP increase self- efficacy in decision-making (e.g., prescribing antipsychotic medications). The PCP gained trust in the consultant and that type of relationship. Models of telepsychiatry care may be combined with models of in-person care to forge intensity of care interventions, based on technology complexity, specialist time, and service delivery model care [56, 57, 69, 70].

Example 3. Telepsychiatry utility for collaborative, stepped and integrated care.

Academic health centers are uniquely positioned to use the consultation care model to primary care or nursing homes, as one end of a continuum of increasing access and providing case-based PCP education and technical assistance to PCPs (e.g., prescribing medication). Videoconferencing, secure e-mail, and telephone interventions have been used to link psychiatric specialists at academic health centers with rural underserved areas [58]. Indeed, provider knowledge, skills, and complexity of questions improve over time [59], particu- larly in rural PCPs [60].

More robust models are disease management for depres- sion by telepsychiatry [61], collaborative care for Post- Traumatic Stress Disorder (PTSD) and depression [62, 63], and potentially stepped care [18]. In the disease management study, geriatric patients stayed enrolled longer than another demographic group—this discounts the presumption that older patients may not like to use technology. Integrated care models are increasingly being adopted [18, 62] and compe- tencies have been spelled out for residents and the psychiat- ric consultant for integrated care [64–66]. These focused on knowledge, individualized treatment plans mental and medi- cal illness, oral/written communication, training/supervision, collaboration, and leadership within clinical teams [66].

4. Geriatric Telepsychiatry in Academic Settings 91 4.6 Conclusions

Psychiatry training programs, trainees, faculty, and patients have the potential to benefit greatly from implementation of an effective and appropriately designed telepsychiatry curricu- lum. Not all institutions currently have infrastructure to be able to implement such programs, but the extant literature suggests that there is a large interest in gaining exposure to telepsychiatry particularly among trainees [15, 16]. Creation of a new telepsychiatry program should focus on providing qual- ity care and assuring sustainability [47]. Whether a telepsychia- try program is being established with the plan for trainee involvement or residents are incorporated into an existing opportunity, there are several facets to consider. For the resi- dency training program, striking a balance between obligations for service and education can be difficult at times. Finding a way for the resident to maintain autonomy and be an active provider in the patient’s care as well as receive support in the form of medical information, technology support, and case discussion may be a way to begin balancing clinical and educa- tional demands [21]. Providing necessary support for residents to be able to deliver excellent evidence-based patient care via telepsychiatry is an important part of curriculum development [19]. Currently, most of the literature focuses on telepsychiatry program evaluations based on resident experience or satisfac- tion, and not on the learning needs of the resident [19]. In the future it would be beneficial to fortify this volume of informa- tion by including other outcomes or effects of resident training in telepsychiatry. Based on recent publications, there is an additional need to expand literature regarding specific objec- tives and competencies for telepsychiatry, particularly in geri- atric patient care settings [19, 23]. These possibilities make it an exciting time to be a psychiatrist!

Key Points

1. A psychiatry resident or geriatric fellow involved in pro- viding direct patient care with telepsychiatry can be evalu-

92 S. Srinivasan et al.

ated on all of the ACGME core competencies, and many of

the milestones.

2. Possible benefits to the resident from participation in a

telepsychiatry curriculum:

– Exposure to unique systems of care and patient populations

– Exposure to additional teaching faculty

– Learn unique ethical and medico-legal issues related to


– Opportunity to work within a treatment team and col-

laborate in care

– Enhanced telepsychiatry and technical skills

3. Data suggests the existence of a gap between resident interest in telepsychiatry and exposure to telepsychiatry in training.

4. Residents may be more likely to participate in telepsychia- try as a part of their career, if they have clinical experience during residency training.

5. Residents have provided positive feedback regarding their participation in existing telepsychiatry curricula.


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Chapter 5

Administration of New Telepsychiatry Programs

in Public Psychiatry

and Applications in Geriatrics Mridul Mazumder and Brenda Ratliff

5.1 Introduction

Older adults (especially those living in rural areas) face chal- lenges in accessing health care that can include transporta- tion, financial difficulty, and provider shortages. Seventy percent of older adults with anxiety and depression do not seek care. Barriers to care include the following [1]:

1. Practical reasons

a. Cost (58.4%)

b. Don’t know where to go (49.6%).

2. Personal beliefs

a. Should not need help (80%)

b. Mistrust of mental health providers (41.9%).

M. Mazumder (*)

Department of Behavioral Health, Tallahassee Memorial Hospital, 1616 Physician’s Drive, Tallahassee, FL 32308, USA


B. Ratliff

Aiken Barnwell Mental Health Center,

1135 Gregg Highway, Aiken, SC 29801, USA e-mail:

© Springer International Publishing AG 2017 99 S. Srinivasan et al. (eds.), Geriatric Telepsychiatry,

DOI 10.1007/978-3-319-51491-8_5

100 M. Mazumder and B. Ratliff 3. Stigma

a. Embarrassed to talk about the problem (39.8%) b. What will others think (39.8%).

The physical and mental health of patients suffers when these barriers are not circumvented. Unnecessary hospital- izations, increased mortality and morbidity, and reduced quality of life are the likely outcomes [2]. Furthermore, communication issues and limited collateral information can result in suboptimal outcomes whether in person or by telemedicine.

Telemedicine is rapidly growing as a vehicle to provide clinical services. The number of telemedicine programs in the USA grew over 200% between 1995 and 2005, increas- ing from 50 to 116 programs [3]. The first step in implement- ing a geriatric telepsychiatry program is conducting a needs assessment to determine the specific clinical needs of the community, and then develop mission statements/goals for the project. Providers and administrators should be com- fortable describing the scope of the program and specifi- cally how telepsychiatry will be incorporated into existing service delivery systems. Brief presentations to clinicians and organizations who will interact with the proposed tele- psychiatry program can aid in providing a clear description of the role this technological initiative will play in the com- munity in addressing the mental healthcare needs of older adults [4]. Engagement of healthcare providers and poten- tial referral sources can help build momentum and excite- ment regarding the possibilities of a new telepsychiatry service. From a patient perspective, it is important to iden- tify the appropriateness of patients for videoconferencing applications, which can minimize patient, families, and pro- vider frustration. Poor experiences increase reluctance for future telepsychiatric care [5].

5. Administration of New Telepsychiatry Programs… 101

5.1.1 Establishing a New Telepsychiatry Service

Several factors must be considered when developing a new geriatric telepsychiatry service. These include:

• Funding

• Certification • Staffing

These specific areas are examined in more detail below. Funding

Prior to the implementation of any clinical service, funding must be secured. Model telepsychiatry programs in the USA are funded by a variety of sources. In the public psychiatry sector, some examples include the Burke Center Mental Health Emergency Center (MHEC) in rural eastern Texas, an emergency telepsychiatry program funded by a combination of state funds, local matching funds from regional hospitals, and other sources [19]. Another is the South Carolina Department of Mental Health (SCDMH) Telepsychiatry Consultation Program, which commenced in 2009 with initial funding from the Duke Endowment [6].

Federal grants are another potential funding source . A description of the planned service and expected outcomes must be prepared. Answers to the following questions will be a large part of the funding request and will define the project:

1. Will this be a new freestanding program, a new service within an existing outpatient program or a new service in a hospital, nursing home, rehabilitation, or residential facility?

2. Who will comprise the population to be served (community- dwelling elderly vs. institutionalized)?

3. What specific services will be offered (consultative evalua- tions vs. longitudinal management)?

4. Where will the providers be located?

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5. Where will patients receiving the services be located?

6. What specific outcomes will be used to measure success? 7. Will the services being provided be billed? Certification

Adding a new service to an existing facility such as an outpa- tient clinic, rehabilitation facility, hospital, or nursing home requires written policies/guidelines specific to the new ser- vices. Policies already in existence may require revision to ensure there are no conflicts. New policies should not only address issues related to clinical services, but also how service delivery and technology will interface. Health Insurance Portability and Accountability Act (HIPAA) compliance, patient confidentiality, encryption, and informed consent are examples of aspects of telepsychiatric care that require spe- cific policies that may differ from those used for face-to-face care. In developing these new guidelines, some areas to address will be evident early on while others surface as imple- mentation occurs including equipment selection, information technology (IT) services, electronic medical record (EMR) availability, and service delivery site requirements. Allowing flexibility for future modifications can prevent these new policies from limiting necessary changes as the program matures.

Certifying agencies can provide some insight in developing program policies and guidelines. Two certifying agencies are The Joint Commission and the Commission on Accreditation of Rehabilitation Facilities (CARF). The Joint Commission is an independent non-profit organization that accredits health- care organizations by providing specific standards that must be met in order to obtain certification [7]. CARF is another independent non-profit organization that accredits entities providing human services including aging services, behavioral health, and medical rehabilitation [8]. Both of these certifying organizations provide guides that can be used in the process of developing administrative policies for a new telepsychiatry program.

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For freestanding projects, the federal and state govern- ment guidelines must be followed to ensure compliance with HIPPA and other laws [9]. After these requirements are met, decisions must be made regarding whether certification will be sought and if so, which certifying entity will be used. Familiarity with the requirements of the selected certifying entity is essential from program inception. If the decision is made not to seek certification initially, it may be helpful still to use guidelines from a certifying entity to facilitate imple- mentation. Certification status may affect whether services are billable to third party payers thereby significantly influ- encing viability of new programs. Staffing

Staffing needs require administrative forethought and over- sight. Provision of trained staff represents a significant amount of initial and on-going cost of providing telepsychiat- ric care. Staffing cost can vary by level of training, relative amount of patient contact time by highly trained staff versus other support staff, and the telepsychiatry model employed. In 2012, Butler and Yellowlees compared cost of asynchro- nous versus synchronous telepsychiatric care and found staff marginal cost of US$68.18 and $107.50, respectively [10]. Outlining program function and determination of staffing needs helps not only with managing the budget but reduces service delivery frustration that may occur if one area is over-staffed and another under-staffed. The following are staffing positions essential to successful delivery of geriatric telepsychiatry services.

Program Director

An experienced program director is vital. The role of director includes setting timelines, developing organizational and work flow guidelines, and spearheading staffing require- ments. A hiring plan should be developed early including identifying necessary staffing needs by job title, advertising, interviewing, salary offers, and hiring schedules. Staffing


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qualities important in providing telepsychiatric care include openness to new methods of service delivery; desire to learn new skills, and attitudes regarding the effectiveness and qual- ity of care that can be provided remotely. Once the program is operational, a director is necessary for typical duties such as hiring, training and supervising staff, managing the budget, ensuring that data needed for outcome measures are gener- ated and maintaining adherence to program policies. These program director duties occur in the context of rapidly chang- ing technology, requiring an effective director to support the staff and keep the program competitive.

Clinical Staff

Clinical staff may include the psychiatrist, psychotherapist, or nurse. Providing care remotely may require more time than the same service delivered in person. Butler and Yellowlees found that telepsychiatric care took 94–110 min of total staff (psychiatrist and other support staff) time versus 80 min for in-person care [10]. The Mental Health Emergency Care- Rural Access Program in Australia investigated the time efficiency of providing remote care and found mean time for telephone triage along with video assessment was 126 min, with 47 min spent in clinical care [11]. Assessment of older adults may require more time due to sensory or cognitive impairments that necessitate additional time to interview collateral informants. Allowing extra time for patient evalua- tions, especially at program inception, allows staff and patients alike to become familiar with new technologies and procedures.

Support Staff

Support staff including social workers, case managers, and others in administrative roles are important irrespective of the setting of care. For facilities already in operation, sharing telepsychiatry positions with employees providing in-person care may be feasible. However, careful consideration of duties and time constraints is necessary in order to allot

5. Administration of New Telepsychiatry Programs… 105

adequate time to the telepsychiatry program. Inclusion of support staff in planning meetings and technical training will facilitate knowledge about telepsychiatry and the concept of remote service delivery. As support staff are often at the frontline of initial patient encounters, it is important that they are knowledgeable and comfortable communicating with patients and families regarding telehealth service provision.

Transport and Other Staff

Additional personnel may be required to provide remote care to geriatric patients or those in facilities such as rehabili- tation or long-term care facilities. Staff may be required to transport the patient or to assist the patient to an appropriate visual position for the telepsychiatric evaluation. Patients must be positioned to be able to best see and hear the service provider on a monitor. When care is provided to patients in facilities, roommates if present, may need to be moved to another location to ensure confidentiality. Patient transporta- tion requires additional support staff. Geriatric patients may have vision or hearing impairments that may further increase staffing needs to ensure successful clinical encounters.

Information Technology and Electronic Medical Record Support

IT and EMR support dedicated to the telepsychiatry pro- gram are essential. If telepsychiatry is being added to a facil- ity where IT and EMR personnel are already in place and additional staff will not be hired, having a small number of technicians assigned specifically to the telepsychiatry pro- gram will facilitate resolution of technical issues unique to the program. Prompt availability of technicians is critical to address technical difficulties during the clinical encounter that if not addressed, may require additional staffing time to set the patient up for services later. For example, a patient in a long-term care facility may have to be moved back to his/ her room then transported back at a later time if technical difficulties are not able to be resolved quickly. This requires

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additional transport staff and may be disruptive to patients leading to increased agitation or pain in debilitated patients. If clinical services are available after regular business hours, IT and EMR coverage must be arranged. Decisions as to whether the parent agency maintains IT and EMR staff in the building around the clock or if technicians will be on call for issues that arise after-hours must be considered. If on-call, factors such as time to respond, working from home to iden- tify/address problems, and reimbursement for on-call cover- age must be delineated.

Most staffing positions will require training prior to pro- gram implementation to include general training about tele- psychiatry, technology, program policies, safety, and confidentiality. Technology allows staff to be located in indi- vidual work areas located some distance away from each other and from where the service is being delivered to a patient. Mental health providers are generally used to work- ing within a treatment team framework. Telepsychiatry can be isolating, causing a sense of detachment from the program as a whole. One way to combat this is to foster staff engage- ment via joint meetings and trainings. Encouraging staff to communicate and consult with each other using the technology at hand, setting up meetings that allow employees to attend from multiple locations interacting with each other in real time, and arranging interdisciplinary treatment teams can be useful techniques [12].

5.1.2 Logistics of New Geriatric Telepsychiatry Programming: Technologic and Other Considerations

Beginning in the 1950s, pioneering work in telepsychiatry began at Nebraska’s Psychiatric Institute [13]. Subsequent to their work, other thoughtful implementations helped to expand access to patients of all ages and backgrounds. While technology can broaden access and improve efficiency, it can- not compensate for all obstacles public psychiatry patients

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face including affordability, compliance, and availability of the support system to implement a treatment plan.

The following technical factors should be considered when implementing a telepsychiatry service in public settings: Hardware

There are a range of offerings, and thought in selecting plat- forms with compatibility, ease of use, reliability, availability of vendor/other support, and cost are among the metrics for consideration. IBM, Cisco, iRobot, and other companies are vying for market share of an industry projected to be US$30 billion dollar plus by 2020 [14]. SCDMH’s telepsychiatry pro- gram funded by The Duke Endowment (TDE) has standard- ized connections between the remote providers and the emergency departments with equipment from Polycom [22]. Minimizing the variety of equipment (each usually has its own interface and control schema) lessens learning time enhancing ease of utilization significantly for users and sup- port staff. Reliable Data Connections

Poor connection quality and delays can add to the frustra- tions of patients, especially those in crisis, and this can decrease willingness towards telepsychiatric use in the future [5]. Dedicated connections can offer stable bandwidth versus other connection offerings when traffic volume is high. Furthermore, guaranteed bandwidth escapes the penchant of providers throttling connections thereby reducing call drop- outs or disruptions in quality that can distract both provider and patient, compromise rapport, and interrupt interview flow. High quality connections allow providers to visualize subtle movements (e.g., extrapyramidal symptoms) or lesions on the skin (e.g., evidence of self-injury).

108 M. Mazumder and B. Ratliff Security

Although firewalls and direct (non-internet) connections can be part of excellent first line security measures, they are not invulnerable. In general, vigilance towards privacy, encryp- tion, network monitoring, and other precautions are para- mount in protecting consumers. HIPAA compliance, federal, and state based regulations are among the security and integrity standards, which can help guide implementation.

In some cases, mental health visits and records are treated with security beyond that employed for other health care encounters. For example, not all health care staff can access psychiatric documents in the electronic medical record, espe- cially due to the sensitive material comprising psychiatric interviews. Advanced Encryption Standard (AES) is an NIST (National Institutes of Standards and Technology) encryption cipher and H323 is a standard that addresses the control and connection of video sessions. H323 allows for standardization of information flow and control through different types of packet networks [22]. Resources and Protocol for Emergencies

Examples of emergency protocols include a process for invol- untary commitment and/or duty to warn or protect. These may include mobilizing onsite staff at the patient’s location and/or incorporating family members for emergency plans. A program may handle this situation by placing the onus on the emergency department (ED) to arrange for these, maintain- ing the telepsychiatry service in a classic consultation role. Often the ED physician, case manager, nurse, or other staff will complete commitment papers and if indicated contact or warn other parties. Part of the evaluation may consist of ask- ing the patient if family can be contacted to collect collateral information and/or help establish a safety plan. Other situa- tions, such as providing services to patients in their homes or in facilities without established emergency protocols, may be

5. Administration of New Telepsychiatry Programs… 109 important areas to address during the planning process prior

to implementation. Support Staff

Persons familiar with videoconferencing equipment set up, establishing the proper connection, troubleshooting equip- ment, and calling network providers to maintain appropriate upgrade of service are necessary. Staff, both onsite and remote, should be familiar with equipment operation, as well as when to contact telecom service providers. Technological issues can compromise patient care, as well as frustrate the psychiatrist and the emergency department staff. In some rural settings, these telepsychiatry services may not be regu- larly used. This can lead to training problems in having staff from the various shifts trained to set up the equipment. Subsequently, there could be reduced productivity and patient contact time as the provider is guiding someone on equipment use rather than seeing patients. One potential way to address staff training is to employ the videoconferencing equipment for training purposes. Documentation of Services

Many healthcare organizations now operate with an elec- tronic medical record. When adding on telepsychiatry ser- vices, required elements of documentation must be established then reviewed against the existing EMR to determine if modifications are required. For example, documentation for every service should identify that the service was provided via telemedicine and indicate that the patient provided informed consent specific to the service delivery method. Information for informed consent may be provided by the clinician or by administrative staff. Some geriatric patients may not be able to consent and mechanisms to address this issue should be discussed with legal advisors in formulating informed consent policies. In many situations, verbal consent by either the patient or the power of attorney/family member

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may be sufficient. When remote services are provided on an on-going basis such as a geriatric psychiatry outpatient pro- gram, a written consent may be obtained at the first encoun- ter [15]. The EMR should contain elements that allow for time efficient documentation of these aspects of the patient encounter.

Local IT support and equipment provider support are imperative to troubleshoot technical issues. Existing facilities may have plans in place on how to handle documentation when EMR is unavailable. However, these may not meet the needs of a telepsychiatry program, which relies more heavily on technology. Careful review of contingency plans for docu- mentation when EMR is unavailable will allow for develop- ment of alternative means of documentation that is applicable to a telepsychiatry program. One option is to have paper forms similar to the EMR that can be completed, signed, dated, timed, and then faxed to the remote location awaiting psychiatric recommendations. Consent

Providers should be aware of proper informed consent and differences between traditional face-to-face versus via tele- mental health.There are several approaches towards informed consent. These include giving patients the choice of non- participation, addressing doctor–patient confidentiality, and assuring the session will not be recorded and will be carried over secure communications connections. Staff Privileges

Addition of telepsychiatry care to an existing institution will require establishment of criteria for privileges in telepsychia- try. Each proposed service to be provided remotely will require clear descriptions of the services and locations to which services will be rendered. Psychiatrists that provide care to patients in multiple remote sites are required to have privileges at each site where the patient is located. An alter-

5. Administration of New Telepsychiatry Programs… 111

native is privileging by proxy, an option that allows the psy- chiatrist to be credentialed at multiple remote sites if appropriate privileges are granted by the organization in which the telepsychiatry service originates [16]. Familiarization with the process of adding new privileges can expedite the implementation process. Peer Review and Professional Practice Reporting

Certified healthcare organizations may be required by the certifying entity to undergo professional practice evaluation and reporting [7]. This typically incorporates peer review, which serves to monitor clinical performance. Decisions to be made related to implementing a peer review program include:

• Who will develop/set questions for a tool by which records will be peer reviewed?

• Will peer review contain both clinical questions and ques- tions related to telepsychiatry?

• Will existing tools be appropriate for use by a telepsychia- try service?

• How often will peer review be conducted?

• Who will conduct the peer review—someone of similar

training or another professional?

• What kind of relationship will the reviewer have with the

telepsychiatry program?

• How will records for review be selected?

• What is the allowable threshold for number of charts not

meeting predetermined standards?

• What is the remediation process for clinician not meeting

predetermined standards?

• Who is responsible for ensuring that peer review is con-

ducted according to program guidelines?

• Who can access peer review results?

• Who reviews results of the peer review and completes

practice evaluation forms?

Attention to these aspects of peer review and professional practice reporting can aid in retaining certification. Peer

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review can also serve to ensure that older adults are receiving quality care remotely that meets similar standards as in- person care. Tracking

Satisfaction Surveys

Many programs examine the satisfaction levels of those who are served and those who interface with the program to identify potential issues and growth areas. There are several groups with differing exposure to a telepsychiatry program, and each can provide unique perspectives in evaluating the program. Table 5.1 summarizes sample survey questions that can be posed to staff that interface with a telepsychiatry program.

Patient satisfaction can be difficult to obtain. Patients who are involuntarily committed to an inpatient facility due to safety concerns may report low satisfaction. Patients with

Table 5.1 Sample satisfaction survey questions

Role Referring physicians

Technical staff

Administrative staff

Sample survey questions

1. Was your consultation question adequately


2. Were treatment recommendations clear? 3. Were interactions with remote staff

positive and efficient?

1. Was adequate time allotted for equipment setup?

2. Was the set up process complicated or confusing?

3. Was IT support readily available?

1. Were interactions with remote providers pleasant?

2. Were responsibilities clearly identified? 3. Were administrative steps for

requesting consultations and receiving recommendations efficient?

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neurocognitive disorders, delirium, agitation, or psychosis may not be able to appropriately answer satisfaction survey questions. Furthermore, surveying only those patients who are cognitively intact enough to understand the service and those who willingly accept treatment recommendations skews results. One alternative is to have nursing staff answer questions such as whether the patient displayed understand- ing of the remote nature of the evaluation, interacted ade- quately with the provider, and demonstrated understanding of recommendations [17]. Other Factors

These include environmental and patient-specific factors. Environmental factors include ambient lighting, noise, session privacy, and room set up. Patient-specific factors such as vision or hearing impairment may affect suitability for tele- psychiatry based evaluation and management. In emergen- cies, glasses and/or hearing aids may not accompany the patient. To compensate, increased volume on the equipment’s speakers can exceed the typical sound attenuation (materials like walls/doors and the distance between other patients) of the evaluation area. These factors can compromise privacy. Emergency departments also often have very high levels of background noise, which can further obscure communication. When the vision-impaired patient cannot see the provider well, they may also lose non-verbal communication such as gestures (e.g., nods) facilitating continued discussion or rap- port building. This may also make verbal communication more difficult as the provider’s lips cannot be read. In such circumstances, enhanced efforts on the part of the telepsy- chiatrist to clarify and encourage verbal response to ques- tions may be necessary to compensate for these barriers.

Program Outcomes

Various outcome measures can be gathered to assess the suc- cess of a geriatric telepsychiatry program. These may include:

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• Number of patient encounters by a provider over a given time period

• Time from consultation request to patient evaluation

• Number of patient transfers to higher level of care pre-

and post-implementation of telepsychiatry services.

Outcome measure data can be easily accessible and gath- ered from the EMR. Statisticians then analyze and generate outcome reports that can inform future directions of the program.

5.2 Ethical Considerations

Sabin and Skimming identified the following challenges to telepsychiatry services, particularly from an ethical perspective [23].

1. Providing competent, safe care

2. Ensuring informed consent

3. Promoting privacy and confidentiality

4. Managing boundaries

5. Encouraging continuity of care

6. Addressing health equity.

No matter how robust the technology, patient encounters

and resulting outcomes require well-trained and diligent providers.

As there are varieties of mental illnesses faced by the elderly, as well as different settings and levels of care, so there are numerous opportunities for implementation and inter- vention via conventional, telemedicine, or combinations thereof. Yellowlees mentions the only contraindications from the patient’s perspective are “a refusal to take part, or current actual physical violence towards the self or others” [18]. There are some varieties of psychotic symptoms including referential thinking, which may limit or perhaps even make videoconferencing counter-therapeutic. Patients reluctant to engage in face-to-face encounters may refuse telepsychiatric

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assessment. An example is a patient on a psychiatric unit who was chronically concerned that she was being filmed. This inpatient refused to appear before a camera and feared there were hidden cameras continuously surveilling her actions. She required in-person assessment for these reasons.

Occasionally individuals express chagrin at not having face-to-face encounters; however, some may later become cooperative and allow evaluation when it is explained that they may not be able to leave the emergency department without an interview. Other patients view telepsychiatry from a more positive perspective.Apart from timesavings, increased access, and many benefits addressed elsewhere in this book, there are additional advantages. As noted by Yellowlees, dur- ing telepsychiatry connections, patients “feel more in control during video consultations, and can, if they wish, literally switch off the doctor at their end and leave the consultation without any physical embarrassment or loss of face.” Further, “the online relationship, in most situations, tends to be more egalitarian than that which occurs in-person” [18].

5.3 Hybrid Care

Traditional healthcare with its commute, waiting room, and de rigueur interaction can be viewed as “outmoded and inconvenient” [18]. Telehealth solutions mirror the ease and immediacy of other goods and services of the present day, particularly in the developed world.

The hybrid model often has one component at the primary care provider’s (PCP) office. Initially the patient (and some- times family) are interviewed followed by a joint feedback session with the PCP. At the time with PCP present, the tele- psychiatrist instructs the patient to tell the PCP “what their diagnosis is, and what the proposed treatment plans are.” “This is a powerful approach that shifts the locus of care away from the telepsychiatrist, as the distant expert, and back fully to patient and the PCP. It also ensures the patient understood the consultation findings” [18].

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5.3.1 Telepsychiatry in Emergency Departments

Patients seeking mental health services in emergency depart- ments (particularly in rural areas) often do not receive care from psychiatrists. Telemedicine is an elegant way to bring specialist access to remote areas and improve support and collaboration with emergency department (ED) staff. Some of these implementations have been successful and attained American Psychiatric Association (APA) Achievement Awards. Two such programs, one in Texas and the other in South Carolina, will be described.

Lufkin County Texas’s Burke Center received the 2011 APA Gold Achievement Award for its psychiatric receiving facility featuring a comprehensive range of services not usu- ally available in rural settings. Burke Center Mental Health Emergency Center (MHEC) serves 12 East Texas counties and utilizes telemedicine. Staff onsite include mental health technicians, nurses, caseworkers, and counselors, while psy- chiatrists are available by either video or phone. Typically, psychiatric consultation is available via video (within 30 min- utes) or via phone (usually in 5 minutes). In addition to emer- gency services and outpatient services, both crisis and voluntary beds are available. In contrast to needing medical clearance via all-purpose emergency departments as a gate- way step preceding emergency psychiatric services, MHEC’s services can directly be accessed and if necessary, a medically unstable patient can be redirected to a local emergency department. The psychiatrists of the MHEC treat many com- mon medical comorbidities (including asthma, “moderate” infections, diabetes, and hypertension) while simultaneously addressing the mental health component(s).

Benefits of this program are noteworthy. Patients evalu- ated at the Burke Center often avoid lengthy stays in emer- gency departments after medical clearance. The average time in the emergency department has decreased to 3.9 hours. Most of the medical illnesses are addressed in-house, and about 10% of patients are directed to emergency depart- ments for acute conditions requiring that level of care [19].

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The burden on law enforcement is likewise eased with lower number of ED visits and shorter time spent waiting with patients.

South Carolina Department of Mental Health (SCDMH) began a project funded by the Duke Endowment grant to provide psychiatric consultation to patients presenting to rural emergency departments [24]. While numerous consulta- tions are generated from the non-geriatric adult population, evaluations requested for the geriatric population were rare in the SCDMH telepsychiatry program. SCDMH telepsychi- atry process starts after the emergency physician initiates a consultation and then notes, labs, contact information for families/guardians/nursing homes, and other information are uploaded for review by the psychiatrist operating remotely. Typically, these documents are reviewed and nursing staff called prior to setting up the equipment to connect with the patient.

After the patient interview and contact with collateral sources, the psychiatrist provides a consultation report to the emergency department. The report does not initiate orders and serves in the manner of the classic consultation model providing recommendations. These may include commitment for danger to self or others due to mental illness or substance use disorders. Other consultation recommendations would include therapy and/or medication changes for either inpa- tient or outpatient settings. Recommendations for additional labs/medical workup may be another component of the con- sult. At times, the emergency department is asked to warn a potential victim and/or for the police to be contacted. In cases of suspected child or elder abuse, the primary provider is given direction to contact the appropriate social services department.

Obtaining adequate collateral information (at times, geri- atric and other patients are poor historians) is frequently difficult. Sometimes nursing home staff or family member(s) will bring the patient to the emergency department and then leave. Thus, in the emergency department, medically fragile and/or delirious patients may be interviewed alone. At times,

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a staff member serves as an “interpreter” to help convey the message/question from the remote provide to a hearing or other sensory impaired patient. Sometimes it may help if there is a staff member gently touching or otherwise provid- ing cues to awaken a sleepy or otherwise unfocused patient. The telepsychiatry provider often must contact the nursing home after the interview (especially in cases with poor histo- rians) and try to find a staff member familiar with the patient, and/or contact a family member as well. Family and/or nurs- ing home staff may be harder to reach, especially when con- sultations occur at night.

Hearing impairment can be a significant obstacle but loud volume settings on the videoconferencing equipment can violate privacy in the emergency department (ED). Furthermore, even if telepsychiatry equipment cannot ade- quately amplify sound or be positioned close enough to the patient for adequate contact, nurses or other staff could serve as an “interpreter.” In cases with delirious patients, the encounter is often brief with recommendations weighted towards medical workup more so than psychopharmacology or other interventions under the auspices of mental health providers.

Other potentially frustrating issues for the telepsychiatrist include lack of a clear reason for the psychiatric consultation. Sometimes the question might be “does this patient have dementia?” This can be difficult to ascertain as some patients may have overlapping medical illness or other stress, includ- ing the chaos of the ED, which can result in a poorer cogni- tive performance than true baseline.

Though the SCDMH telepsychiatry service averaged 12 consults a day during 2014, there were surprisingly few con- sultations in the geriatric age bracket. Out of more than 4000 consults, only 102 pertained to elderly patients. Reasons for this discrepancy may be multifactorial- geriatric patients presenting to EDs were medically ill and higher priority may have been given to addressing medical illness as the etiology of the mental health symptoms. Another possibility could be that the psychiatric consultation was postponed to a medical inpatient setting rather than within the ED itself.

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SCDMH results may not be representative of other pro- grams. 2009 census data from the Administration on Aging shows South Carolina ranking number 18 nationally for greatest percent of residents aged 65 plus. Despite this rank- ing, relatively few geriatric ED psychiatric consults were seen in 2014. However, The Duke Endowment (TDE) program partners with rural emergency departments, and fewer patients 65 and older would be seen due to geographic distri- bution as “Most persons 65+ lived in metropolitan areas in 2014 (80%)” [20].

Of the 102 individuals evaluated in rural South Carolina EDs via telepsychiatry, 20 received outpatient management whereas the remainder received recommendations for fur- ther medical workup. The remainder either received a recom- mendation for involuntary commitment (more commonly) or were admitted voluntarily (infrequently).

Tang et al. examined mental health services provided to older adults at an urban emergency room in Missouri. Of 54,047 patient visits, 3886 of these were elderly and only 95 of this subset were evaluated for a primary mental health issue. Some patients had more than one emergency department presentation leading to a total of 138 patient visits [21]. Patients seen were 42% Caucasian, 52% African-American, and 1% Hispanic. One difference noticed among this small study: Caucasians were much more likely to receive psychiat- ric consultation (32.1%) versus African-Americans (8.6%). The authors posit that this difference may be partially explained by a lower likelihood of Caucasians to present with delirium perhaps due to better access to medical care. Further, decreased access to health care and greater comor- bidity burden in non-Caucasians may lead to more frequent delirium presentations versus other groups.

Gender differences were also noted. 66.3% (of total men- tal health visits) were by women whose mean age was 75.5 years. Of the elderly patients, 47% came from a nursing home and 45% were from home unaccompanied by family. Sixteen percent of patients were accompanied by family and 3% arrived via police or from jail. The most common presenting diagnoses were delirium (85%), anxiety disorder (23%), and

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mood disorders (17%). Psychosis was 6% and dementia was 2%. Though delirium was the most common diagnosis, most patients arriving in the emergency department with delirium did not receive a psychiatric consult. Many of the delirium based presentations (48.2%) were dispositioned to inpatient medicine admission (most not having a prior psychiatric consultation) and only 2.4% of delirium visits received psy- chiatric admission [21].

Administration of an emergency department based geriat- ric telepsychiatry program can be complex irrespective of urban or rural setting. The programs in Texas, South Carolina, and Missouri all demonstrate feasibility of telepsychiatry in addressing public sector mental health care needs. While pro- viding care to older adults utilizing this treatment modality may incur additional challenges, these can often be addressed and accommodations made to serve this growing segment of the population.

5.4 Summary

Since the 1950s, teleconferencing health care applications are increasing and serving broader populations. Geriatric patients, including those with severe and persistent mental illness, are a subgroup with great need for expansion to current offer- ings. Fortunately, the nature of psychiatric assessments allows for utilization and adaptation of technology to provide remote care. Administration of a new telepsychiatry program requires careful planning and coordination with various enti- ties. These include funding sources, certifying agencies, clini- cal staff, and technical staff. Once a program is operational, administration then further involves steps to ensure not only satisfaction with the service but outcome measures necessary for long-term program viability. Greater awareness, perhaps in part by more exposure in the medical literature, may help increase deployment of such services. Telepsychiatry is a use- ful technology that can bring services to underserved areas, save time for both provider and patient, and provide quality care that is equivalent to traditional interventions.

5. Administration of New Telepsychiatry Programs… 121 References

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3. Myers K, Cain S. Practice parameters for telepsychiatry with children and adolescents. J Am Acad Child Adolesc Psychiatry.


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white space spectrum to practice telemedicine: a promising tech- nology to enhance broadband internet connectivity within healthcare facilities in rural regions of developing countries. J Telemed Telecare. 2016;22(4):260–3.

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10. Butler TN, Yellowlees P. Cost analysis of store-and-forward tele- psychiatry as a consultation model for primary care. Telemed J E Health. 2012;18(1):74–8.

11. Saurman E, Lyle D, Kirby S, Roberts R. Assessing program effi- ciency: a time and motion study of the Mental Health Emergencyy Care-Rural Access Program in NSW Australia. Int. J. Environ. Res. Public Health. 2015;11:7678–89.

12. Kaliebe KE. The future of psychiatric collaboration in federally qualified health Centers. Psychiatr Serv. 2016;67(8):827–9.

13. Deslich S, Stec B. Telepsychiatry in the 21st century: transform- ing healthcare with technology. Perspect Health Inf Manag [Internet]. 2013;10 Available from: pmc/articles/pmc3709879/

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15. Recupero P, Fisher JC. Resource Document on Telepsychiatry and Related Technologies in Clinical Psychiatry. 2014. American Psychiatric Association.

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17. Bashshur RL, Shannon GW, Bashshur N, Yellowlees PM. The empirical evidence for telemedicine interventions in mental dis- orders. Telemed J E Health. 2016;22(2):87–113.

18. Yellowlees P, Burke MM, Marks SL, Hilty DM, Shore JH. Emergency telepsychiatry. J Telemed Telecare. 2008; 14(6):277–81.

19. Burke Center Mental Health Emergency Center, Lukin Texas. A telepsychiatry solution for rural eastern Texas. Psychiatr Serv. 2011;62(11):1384–6.

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21. Tang S, Patel P, Khubchandani J, Grossberg GT. The psychogeri- atric patient in the emergency room: focus on management and disposition. ISRN Psychiatry. 2014;2014:1–5.

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23. Sabin JE, Skimming K. A framework of ethics for telepsychiatry practice. Int Rev Psychiatry. 2015;27(6):490–5.

24. Narasimhan M, Druss BG, Hockenberry JM, Royer J, Weiss P, Glick G, et al. Impact of a telepsychiatry program at emergency departments statewide on the quality, utilization, and costs of mental health services. Psychiatric Serv. 2015;66(11):1167–72.

Chapter 6

Geriatric Telemental Health in the United States Department of Veterans Affairs

Taya Varteresian, Alexander Threlfall, and Paul Kirwin

The Veterans Health Administration (VHA) defines tele- health as: “The wider application of care and case manage- ment principles to the delivery of health care services using health informatics, disease management and telehealth tech- nologies to facilitate access to care and improve the health of designated individuals and populations with the intent of providing the right care in the right place at the right time” [1]. For well over a decade, the VHA has worked to mitigate deficits in access to care by harnessing advances in technol- ogy to provide specialty care to underserved areas, especially those geographically isolated from major medical centers.

T. Varteresian (*)

Los Angeles County Department of Mental Health, University of California Irvine, 550 S. Vermont Ave., 6th Floor, Los Angeles, CA 90020, USA


A. Threlfall

Brookwood Health Center, Santa Rosa Community Health Centers, University of California, San Francisco, CA, USA


Integrated Care, VA Connecticut Healthcare System, Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA

© Springer International Publishing AG 2017 123 S. Srinivasan et al. (eds.), Geriatric Telepsychiatry,

DOI 10.1007/978-3-319-51491-8_6

124 T. Varteresian et al.

The Veterans Health Administration (VHA) has estab- lished itself as a national leader in the development of tele- mental health, which has enabled the VHA to provide access to high quality psychiatric care for rural Veterans. Telemental health is typically delivered from the parent medical center (VAMC) to its Community Based Outpatient Clinics (CBOCs) often nested in rural, hard to reach areas. Since 2003, the VHA has performed close to 1,830,000 telemental health encounters [2].

In 2010 the VHA established a National Telemental Health Center (NTMHC) to provide expert consultation to providers across the national VHA system. Out of the 380,000 telemen- tal health visits to more than 122,000 Veterans in FY15, the NTMHC provided 13,000 consultations to approximately 3,900 Veterans in over 100 sites in 31 states. These NTMHC providers include experts in geriatrics and affective, anxiety, psychotic, and substance abuse disorders [2].

Much of the existing telemental health literature is based primarily on experiences within the VHA, signifying the importance of the VHA model to inform the field on best practices for telemental health. Years of VHA implementa- tion experience have prepared this healthcare system to uti- lize rapidly advancing technology to create novel ways to improve access to care for the growing elderly Veteran popu- lation. Over the next decade, Veterans over age 60 will repre- sent more than 50% of the total Veteran population [3]. Telehealth has special relevance for this geriatric population, as medical and psychiatric care for older adults is often lim- ited due to difficulties with transportation to a medical center or clinic environment.

In FY 2015, the VHA provided 9,700 Veterans telemental health services to their home, reflecting a steady growth in the VHAs efforts to improve access to health care for vulner- able populations, such as frail elderly Veterans [2]. Home- based telemental health care is especially important for homebound older adults who are unable to attend traditional hospital or CBOC clinics due to complex neuropsychiatric and medical illnesses, which make transportation challenging

6. Geriatric Telemental Health… 125

or impossible. This modality also contributes to provider effi- ciency reducing the need for time-consuming in-person home visitations [4]. A study of behavioral activation therapy for major depression found that evidence-based psychotherapy can be delivered, without modification, via home-based tele- mental health, and that this method can overcome barriers to care associated with distance from and difficulty with atten- dance at in-person sessions in older adults [5].

By providing Veterans access to mental health services through telehealth, the VHA has decreased psychiatric hos- pitalizations for patients receiving telemental health services by 32% within approximately 6 months of initiating treat- ment [2]. Similar reductions in hospitalization rates (24.2%) from 2006 to 2010 were observed across all age groups, including those ≥65yo (~18.4% or ~18,000 Veterans) in an earlier large, observational, nationwide study [6].

6.1 Applications in Veteran Geriatric Telemental Health

Much of the VHA’s research on the effectiveness of tele- mental health services has centered on providing PTSD treatment to combat Veterans, many of whom are Vietnam Veterans. It is well known that Veterans with PTSD suffer a higher degree of comorbid cardiovascular disease, diabe- tes, gastrointestinal ulcer disease, dementia, and overall mortality that their age matched cohort [7, 8], thus research in telemental health services for PTSD is ostensibly geriat- ric in nature given that a large proportion of Veterans enrolled in these studies are 55 years old and older [9, 10]. From 2009 to 2011, the VHA studied the impact of a tele- mental health-based collaborative care model to rural CBOCs in Arkansas, Louisiana, and California showing a significant increase in referral to evidence-based treatment for PTSD and subsequent improvement in PTSD symp- toms compared to care as usual for individuals with a mean age of 52.2 ± 13.8 years [9].

126 T. Varteresian et al.

The VHA has also investigated the utility of telemental health services in a variety of diagnostic and/or treatment paradigms related to the treatment of PTSD. In a study with a similar demographic distribution to Fortney et al., research- ers investigated the non-inferiority of a 12 week telemental health group for anger management in rural Veterans with PTSD (70% Vietnam Veterans) compared to an equivalent in-person group from 2005 to 2008 and confirmed that both were similarly efficacious in reducing anger symptoms [10]. This study helps validate the efficacy of telehealth treatment to more remote CBOCs to conduct group therapy. Using telemental health, a clinic can create a group via videotele- conferencing, either by combining multiple sites in real time or by referring them to an established group at an affiliated VAMC or CBOC.

Another study of Veterans focused on those over age 60, comparing the efficacy of a more rudimentary form of tele- mental health, telephone-based therapy, using CBT versus non-directive supportive treatment for GAD. This study con- firmed and supported the use of an evidence-based therapy (CBT) for older Veterans using just a telephone call [11], lending credibility to more advanced forms of telemental health technology.

Other studies have shown effective and accurate assess- ment and management of cognitive impairment via telemen- tal health. A study of older Veterans living in a residential care environment demonstrated telemental health accuracy in the diagnosis of dementia, which compared favorably to in-person evaluations [12]. Several non-VHA studies have examined the utility of telemental health technology to administer neurocognitive assessments. Vahia et al. adminis- tered a comprehensive battery of tests to Latino patients via telemental health and showed equivalent results between the telehealth and in-person groups [13]. Cognitive assessment research in China demonstrated comparable results for tele- mental health and in-person testing for individuals with mild cognitive impairment or mild dementia [14]. Another study showed that brief neurocognitive screening tests in geriatric

6. Geriatric Telemental Health… 127

psychiatry outpatient clinics compared favorably to face-to- face evaluations [15].

Although multiple studies have validated the delivery of telemental health to individuals suffering from cognitive dis- orders, cognitive impairment may impact the patient’s famil- iarity and tolerability of the technology creating a higher dependency on the in-person assistance or caregiver help [16]. The application and feasibility of a model that includes onsite help was established in a small pilot by Barton and colleagues [17] where Veterans residing near a CBOC, but over 300 miles from the San Francisco VAMC Memory Disorders Clinic, were offered assessment and treatment rec- ommendations using a traditional multidisciplinary team approach (including social work counseling/education, neu- ropsychological assessment by a neuropsychologist, and com- plete medical exam by the geropsychiatrist) via videoteleconferencing, with the assistance of a local clinician (RN) trained to help conduct the examination.

6.2 Benefits of Telemental Health for Veteran Patients

Telemental health helps address psychiatric provider short- ages across the VHA system and provides increased access to mental health care for patients in remote areas. VHA national data collection shows that telemental health reduces inpatient hospitalizations and promotes medication adherence. Patients receiving telemental health services had a 32% decrease in psychiatric hospitalization in the first 6 months after initiating telemental health treatment, suggesting that access to tele- mental health improves the quality and outcomes of mental health treatment [2]. In addition, delivering telemental health to Veterans in their homes is now provided by multiple pro- vider disciplines within the VHA. This shows extraordinary promise for home bound or institutionally bound elder Veterans when transportation to medical facilities is onerous or impossible for routine appointments. Various treatments

128 T. Varteresian et al.

are employed, including: individual, group, and family psycho- therapy, as well as pharmacotherapy. [2]

Consummate with the VHA’s efforts to reach Veterans liv- ing in remote areas, the VA has initiated efforts to reach remote Native American and Alaska Native Veteran popula- tions. The Tribal Veterans Representative (TVR) training program has reached numerous Native American popula- tions with very limited access to traditionally supplied medi- cal care [18]. This program underscores the importance of innovative telehealth efforts to reach remote populations devoid of mental health services. In general, VHA providers like using telehealth, and endorse the advantages of reaching remote populations, such as those served in the CBOCs. [12, 14, 19–23].

Patient satisfaction surveys support the use of telehealth for mental health assessment and treatment. VHA patient satisfaction surveys demonstrate impressive overall satisfac- tion with the telemental health modality: 94% satisfaction with office-based telemental health services and 89% satis- faction for home-based telemental health services [2]. Some patients actually prefer the videoconferencing modality and the increasing availability of health related phone apps for tracking critical health data, such as hours of sleep, blood pressure, or depression scores. A recent study of individuals over the age of 60 years old demonstrated that patients show a strong interest in using smart phones or mobile applications in order to track their mental health symptoms [24]. The VHA has pioneered encrypted software to ensure the protec- tion of Veterans’ information to enhance patient trust and satisfaction with this modality of treatment.

6.3 Benefits of Telemental Health for Providers

Many health care professionals are drawn to the VHA out of a sense of service and mission; to serve those who served. Taking care of vulnerable populations is part of that calling.

6. Geriatric Telemental Health… 129

Telemental health extends that principle to rural populations where access to health care is inadequate or inconsistent at best. Most VHA medical centers are attached to major medi- cal schools, enhancing the VHA core missions of providing clinical care, promoting education, and encouraging research. VHA telehealth is able to draw on the expertise of local medical school faculty to provide expert care and consulta- tion to other mental health and/or primary care providers. Telehealth expands the academic and clinical missions of the VHA and gives providers and trainees novel experiences in providing direct care and expert consultation to underserved populations in remote areas.

6.4 Teaching Telemental Health

The VHA provides significant training stipends for health care providers nationally. In FY 2012, the VHA provided training for 37,104 physician residents; 25,102 medical resi- dents; 32,349 nursing students; 1579 physician associate stu- dents; 24,260 “other specialties”; for a total of 116,794 training stipends [25]. The VA already encourages training in tele- health as a central part of physician and allied health profes- sional’s curriculum. [26]. In 2003 the VHA medical center in Denver pioneered a telehealth training program for psychia- try residents. [27]. The program provided access to mental health care to underserved rural areas, and novel training opportunities for psychiatry residents. Over four years, the program logged over 1,078 telemental health encounters, primarily for PTSD, but also for a variety of mental health diagnoses. The Denver program developed a full telemental health curriculum for psychiatry residents, including adminis- trative issues in telemental health, managing of psychiatric emergencies, understanding the impact of videoconferencing on clinical interactions, and modification of clinical style for videoconferencing. The Denver program serves as a model curriculum for other psychiatry training programs [27].

US psychiatry residents are eager to learn how to use telehealth, in greater numbers than available training

130 T. Varteresian et al.

opportunities. [28]. A study from Toronto, looked at a small sample (N = 16) of residents and faculty in attempts to define “core components” in telemental health. The investigators identified eight essential components for telemental health: technical skills, assessment skills, medico-legal practices, com- munication skills, collaborator, manager, advocate for the community, and advocate for the health system. Perceived benefits for providers included: helping patients in under- served areas, learning about different patient populations, and helping the practitioners in these underserved areas [29]. Telehealth offers unique opportunities to train providers to serve those at the margins of traditional health care. Positive exposure to telemental health in training programs is essen- tial to prepare residents for an emerging, key element in the delivery of mental health care.

6.5 Limitations of Telemental Health

Exam room space for patients and the technological exper- tise to facilitate the clinical interview remain challenging for the VHA telehealth system. Telemental health is not space neutral. While this modality improves access to care, space and equipment is required for both patient and provider. In most CBOC settings, space is at an absolute premium, so accommodating exam room space for patients presents a constant challenge. Provider-home-based telemental health or “smart” phone app technologies alleviate crushing space needs and facilitate access to care. Device security issues and implementation strategies remain a high priority for VHA where patient privacy and security concerns remain preeminent.

Providers and administrators outside the VHA system have cautioned that having a geographic distance between provider and patient jeopardizes the mental health treatment team approach [30]. Having components of the treatment team present with the patient, i.e., social work and/or nursing, helps mitigate this concern. This approach enhances

6. Geriatric Telemental Health… 131

communication among members of the treatment team and promotes continuity of care.

Despite VHA’s robust telehealth efforts nationally and advancing technological improvements, technical difficulties still arise, such as connection failures or lag times in real time transmissions of the interview process. The VHA has employed a bevy of telehealth technicians to assist with set- ting up the logistics of the visits and to address technological glitches in when they arise. Provider expertise with the equip- ment is critical, but easily attainable through formal training. Angle of videoteleconferencing equipment to maximize eye contact is important, as are adequate explanations from tele- health technician and provider about possible technical glitches, such as voice and motion lag times [27].

Implementing telehealth in the world’s largest health care organization comes with significant capital investment. The VHA has invested heavily in this technology with the convic- tion that this form of treatment improves access and decreases more expensive traditional treatment. Enrolled VHA tele- mental health patients are hospitalized less frequently and utilize less days in the hospital [31]. Some argue that this is simply an elaborate redistribution of clinical resources “tele- psychiatry redistributes resources but not necessarily create them” [32]. Any clinical intervention takes time and resources to implement, yet the net savings to the system are promising and improvements in patient access to mental health care are impressive. [2].

In the future, using technology such as mobile apps, may surpass infrastructure space limitations to assist the VHA in delivering more efficient and effective care. These novel mobile applications may improve patient compliance and improve patient engagement in treatment [33]. Home-based technologies, such as encrypted iPads, reach patients where they live, saving on space, and transportation time/costs. Home-based telemedicine is growing within the VHA and can involve a Veteran peer who helps facilitate the applica- tions within the Veteran’s home or alternative place of resi- dence, i.e., group home, assisted living facility, or other long

132 T. Varteresian et al.

term care facilities. This modality will expand in the future as access to this encrypted technology improves and our public partners in healthcare become more familiar with the value of telemental health in improving outcomes.

6.6 Conclusions

Telemental health is a growing field delivering critical mental health services to rural, isolated, and ethnically diverse popu- lations. The VHA leads the nation in pioneering this novel technology to expand access to vulnerable and remotely located populations. As a leader, the VHA model serves as a blueprint for the design and implementation of telemental health interventions in the private sector.


1. About VA Telehealth Services. Retrieved from http://www.tele-

2. Telemental Health in the Department of Veteran Affairs, Fact Sheet, Office of Public Affairs and Medial Relations, Department of Veterans Affairs, Washington D.C., February 2016

3. National Center for Veterans Analysis and Statistics, 2014. Table 1L: VETPOP2014 Living Veterans by Age Group, Gender, 2013–2043. Available at: Population.asp (last accessed April 14, 2016).

4. Shah A. Home visits by psychiatrists. BMJ. 1992;304:780.

5. Egede LE, Frueh CB, Richardson LK, Acierno R, Mauldin PD, Knapp RG, et al. Rationale and design: telepsychology service delivery for depressed elderly Veterans. Trials. 2009;


6. Godleski L, Darkins A, Peters J. Outcomes of 98,609

U.S. Department of Veterans Affairs Patients Enrolled in Telemental Health Services, 2006–2010. Psychiatr Serv. 2012; 63:383–5.

7. Lohr JB, Palmer BW, Eidt CA, Aailaboyina S, Mausbach BT, et al. Is PTSD associated with premature senescence? a reivew of the literature. Am J Geriatr Psychiatry. 2015;23:709–25.

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8. Beristianos MH, Yaffe K, Cohen B, Byers AL. PTSD and risk of incident cardiovascular disease in aging veterans. Am J Geriatr Psychiatry. 2016;24:192–200.

9. Fortney JC, Pyne JM, Kimbrell TA, Hudson TJ, Robinson DE, Schneider R, et al. Telemedicine-based collaborative care for posttraumatic stress disorder a randomized clinical trial. JAMA Psychiatry. 2015;72(1):58–67.

10. Morland LA, Greene CJ, Rosen CS, Foy D, Reilly P, Shore J, et al. Telemedicine for anger management for rural population of veterans with PTSD: a randomized non-inferiority trail. J Clin Psychiatry. 2010;71(7):855–63.

11. Brenes GA, Danhauer SC, Lyles MF, Hogan PE, Miller ME. Telephone-delivered cognitive behavioral therapy and telephone-delivered nondirective supportive therapy for rural older adults with generalized anxiety disorder a randomized clinical trial. JAMA Psychiatry. 2015;72(10):1012–20.

12. Shores MM, Ryan-Dykes P, Williams RM, Mamerto B, Sadak T, Pascualy M, et al. Identifying undiagnosed dementia in residen- tial care Veterans: comparing telemedicine to in-person clinical examination. Int J of Geriatr Psychiatry. 2004;19:101–8.

13. Vahia IV, Ng B, Camacho A, Cardenas V, Cherner M, Depp CA, et al. Telepsychiatry for neurocognitive testing in older rural Latino adults. Am J Geritr Psychiatry. 2015;23:666–70.

14. Poon P, Hui E, Sai D, Kwok T, Woo J. Cognitive interventions for community dwelling older persons with memory problems: tele- medicine verses face-to-face treatment. Int J Geriatr Psychiatry. 2005;20(3):285–6.

15. Grosch MC, Weiner MF, Hynan LS, Shore J, Cullum MC. Video teleconference-based neurocognitive screening in geropsychia- try. Psychiatry Res. 2015;225(3):734–5.

16. Brignell M, Wootton R, Gray L. The application of telemedicine to geriatric medicine. Age Ageing. 2007;36:369–74.

17. Barton C, Morris R, Rothlind J, Yaffe K. Video-telemedicine in a memory disorders clinic: evaluation and management of rural elders with cognitive impairment. Telemed e-Health. 2011;17(10):789–93.

18. Kaufman LJ, Richardson WJ, Floyd J, Shore J. Tribal Veterans representative (TVR) training program: the effect of community outreach workers on American Indian and Alaska Native Veterans access to and utilization of the Veterans Health Administration. J Commun Health. 2014;39:990–6.

19. Jameson JP, Farmer MS, Head KJ, Fortney J, Teal CR. VA community mental health service providers’ utilization of and

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attitudes toward telemental health care: the gatekeeper’s per-

spective. J Rural Health. 2011;27:425–32.

20. Nesbitt TS, Hilty DM, Kuenneth CA, Siefkin A. Development of

a telemedicine program. Western J Med. 2000;173:169–74.

21. Hilty DM, Urness D, Yellowlees PM, Nesbitt TS. Clinical and educational telepsychiatry applications: a review. Can

J Psychiatry. 2004;49(1):12–23.

22. Hilty DM, Yellowlees PM, Nesbitt TS. Evolution of telepsychia-

try to rural sites: changes over time in types of referral and in primary care providers’ knowledge, skills and satisfaction. Gen Hosp Psychiatry. 2006;28:367–73.

23. Greenwood J, Chamberlain C, Parker G. Evaluation of rural tele- psychiatry service. Australasian Psychiatry. 2004;12(3):269–72.

24. Torous J, Friedman R, Keshavan M. Smartphone ownership and

interest in mobile applications to monitor symptoms of mental

health conditions. JMIR mHealth and uHealth. 2014;2(3):e34.

25. Chang B. VA Funding for Graduate Medical Education [GME] WWAMI GME Summit, March 23, 2012, Office of Academic

Affiliations, VA Central Office, Washington D.C.

26. Shore JH, Thurman MT, Fujinami L, Brooks E, Nagamoto H. Resident, rural telepsychiatry service: training and improving

care for rural populations. Acad Psychiatry. 2011;35(4):252–5.

27. Shore J. The evolution and history of telepsychiatry and its impact on psychiatric care: current implications for psychiatrist and psy-

chiatric organizations. Int Rev Psychiatry. 2015;27(6):469–75.

28. Glover JA, Williams E, Hazlett LJ, Campbell N. Connecting to the future: telepsychiatry in post=graduate medical education.

Telemed J E-Health. 2013;19(6):474–9.

29. Crawford A, Sunderji N, Lopez J, Soklaridis S. Defining compe-

tencies for the practice of telepsychiatry through an assessment of resident learning needs. BioMed Central. 2016; doi:10.1186/ s12909-016-0529-0.

30. Kornbluh RA. Staying true to the mission: adapting telepsychia- try to a new environment. CNS Spectrums. 2014;19:482–3.

31. Godleski L, Cervone D, Vogel D, Rooney M. Home telemental health implementation and outcomes using electronic messag- ing. J Telemed Telecare. 2012;18(1):17–9.

32. Grady B. Promises and limitations of telepsychiatry in rural adult mental health care. World Psychiatry. 2013;11(3):199–201.

33. Shore JH, Aldag M, McVeigh FL, Hoover RL, Ciulla R, Fisher A. Review of mobile health technology for military mental health. Mil Med. 2014;179:865–78.

Part III Practical Considerations

Chapter 7

Scope of Telepsychiatry in Clinical Settings

Meera Narasimhan

7.1 Introduction

Mental disorders are a ubiquitous problem, with health sys- tems around the world grappling to address the “Mental Health Gap” created by growing numbers of mentally ill and extremely low numbers of mental health providers. Previous chapters in this book have described how, telepsychiatry has been shown to be a feasible alternative to effectively address the scarcity of mental health services. Mental health disor- ders are highly prevalent with epidemiological study esti- mates as high as 49% life time prevalence in the adult population [1]. The aging population across the world is on the rise. In 2006, almost 500 million people worldwide were 65 years of age and older. By 2030, that number is projected to increase to 1 billion or one in every eight of the world’s inhabitants, which is a 140% jump in developing countries by 2030 ([2]). This imposes social, economic, and medical chal- lenges to our society at a time when geriatric medical care is not universally available. There is a dearth of geriatric

M. Narasimhan (*)

Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine,

3555 Harden Street Extension, Suite 301, Columbia,

SC 29203, USA


© Springer International Publishing AG 2017 137 S. Srinivasan et al. (eds.), Geriatric Telepsychiatry,

DOI 10.1007/978-3-319-51491-8_7

138 M. Narasimhan

medical and psychiatric practitioners. This dearth is further magnified in rural communities resulting in a significant individual and societal burden.

Telepsychiatry offers a unique delivery platform to be able to address some of these challenges by improving access, shortage of providers while reducing costs on several fronts including unwarranted hospital admissions, effective triage, and hand off to outpatient care via expert availability in real- time [3]. It becomes imperative for healthcare providers to become familiar with the challenges in the field of telepsy- chiatry given the insurmountable mental health gap. This can only be addressed by increasing the number of geriatric psy- chiatry fellowships, strengthening and growing existing ones, and increasing psychiatric training at the under-graduate level. While many of these solutions have lengthy gestation periods, technological solutions like telepsychiatry can attempt to address the impending problems of unmet needs, scarce resources, provider shortage, and the urban–rural and tertiary–primary care divide. A perfect marriage of technol- ogy and mental health services in many settings and more so in the geriatric setting can be the panacea to health care sys- tem and to the citizens we serve.

This chapter attempts to provide a comprehensive litera- ture review that supports acceptable, reliable, and cost- effective application of telepsychiatry strategies in geriatrics. Telepsychiatry has proved useful in both clinical and non- clinical applications in geriatric medicine and psychiatry, in clinical care, distance learning, education, and research in various practice settings. Over the years synchronous and asynchronous telehealth has been used for consultation, diagnosis, management, psychotherapy, education, supervi- sion of medical professionals in rural and outreach areas, as well as for research purposes [4]. Clinical care settings can be broadly categorized as hospital work to include emergency department, inpatient care and consultation liaison psychia- try, community work that includes chronic disease manage- ment and disability management, office practice, integrated clinics, nursing home visits, home visits, and care planning.

7. Scope of Telepsychiatry in Clinical Settings 139 7.2 Inpatient and Emergency Room


Given the magnitude of mental illness in our communities, there is tremendous demand for geriatric care in clinical set- ting including inpatient, outpatient, and consultation liaison psychiatry. Consultation via telepsychiatry for hospital patients is becoming more acceptable in these settings and has been shown to improve clinical outcomes. Given the need for geri- atric providers, it has been a focus of more recent telehealth efforts. Offsite consultation for nursing home residents has been reported by geriatric teams since consultation work is a major component of hospital geriatric practice [4, 5]. Evidence from other specialties including radiology, neurology, neuro- surgery, geriatrics for effectively triaging admission using telehealth [6–8, 9] to nursing homes or inpatient beds has been reported, demonstrating that a larger proportion of patients can be managed without transfer- associated unnecessary costs. The likelihood of telepsychiatry use increases when the distances or potential for transfer is greater.

7.3 Emergency Evaluations

Telepsychiatry evaluations in emergency departments are offered across several programs in the United States of America (USA). These emergency evaluations require additional per- sonnel both for physical control of the environment and for patient safety. Managing psychiatric emergencies including suicidal/homicidal patients, or those suffering from dementia, agitation or acute psychosis by using experts who can provide recommendation to the ED teams has been shown to pro- mote cost-effectiveness, timely assessment, improvement in access to specialty and subspecialty services [10, 11]. In a study by Pallawala and Lun, telehealth services used to manage geri- atric patients at a remote site led to rapid decision making in the presence of acute emergencies, reducing unnecessary

140 M. Narasimhan

admissions and improving nursing skills in geriatric care [8]. This study also demonstrated that telehealth can result in effi- cient management, while contributing to professional develop- ment for nurses. Telehealth helps converge experts where there are multi providers providing case management in complex chronic disease management models. This allows for clinical treatment plans that include expert advice and a well-rounded patient care experience for the patient.

Telehealth services can improve the quality of life for elders with physical and mental impairments. Other studies evaluating the effectiveness of home telemonitoring have demonstrated reduction in the number of hospitalization and emergency department visits of elderly patients with mixed chronic disease [12]. Another study of homebound elderly provided videophone nursing care to measure changes in their functioning and demonstrated it to be an effective and alter- native care model that could be integrated into existing home- care services [13].

7.4 Nursing Home

Elderly in nursing homes, especially in rural communities, are an underserved population, at greater risk of isolation and suicides. This risk is further magnified by under recogni- tion and under diagnosis due to lack of specialized mental health services including provider access [14, 15]. Non- urgent consultations and advice from allied health practitio- ners have been reported from Australia where videoconference links to nursing homes were used [16]. The outcomes from five disciplines were reported in terms of user satisfaction and also adequacy of assessment. This enables clinical relationships between teams with clinicians from several disciplines working with hospital and nursing home staff resulting in enhanced clinical interaction and sup- port for the nursing home and hospital staff. The geriatric provider can work closely with nursing staff to help provide specialty service, interact, educate, train, and support nurses who often have very little mental health training. Elders

7. Scope of Telepsychiatry in Clinical Settings 141

appear to benefit from telehealth services and seem to be more accepting and satisfied by technology driven solutions to address some of their healthcare needs [17, 18].

7.5 Therapeutic Applications

of Telepsychiatry in Geriatric Ambulatory Care Settings

The practice of telepsychiatry in geriatrics is gaining popular- ity given the scarcity of geriatric psychiatrists. A consultative role that allows for clinical assessment and recommendation without ongoing management may be more practical to address the mental health gap given the enormous need and burden. There have been several studies and clinics that have successfully embedded specialists via telehealth. These stud- ies have reported improved outcomes, cost, and patient satisfaction levels [19, 20]. Telepsychiatry is an effective tool that has been used in those with mild cognitive impairment and dementias while it may have less of a utility in those with severe dementia and sensory impairments. Standardized rat- ing scales can be used via telehealth services both in clinical practice and research use of [21]. While a comprehensive geriatric assessment, including assessment of cognitive func- tion would offer valuable information for treatment planning, severely impaired cognition may pose a risk for patients who are unfamiliar with technology and may need skilled staff to help navigate the healthcare delivery via telehealth [21].

Telepsychiatry can be used for ongoing psychotherapy ses- sions either between the clinician and patient from the com- fort of their homes or in group sessions with the treating clinician and many participants [5].

Given the complexity of medical issues in the geriatric population and an emphasis on value-based care there is a need to manage chronic disease states in an efficient, inte- grated fashion that would help address the fragmentation that currently exists in the health care environment. This

142 M. Narasimhan

would provide improved satisfaction and health outcomes monitoring [22, 23] such as vital signs and blood glucose. These approaches could result in improvements in both physical and mental health parameters while resulting in cost-effective care and in chronic disease management. Video link to augment usual home care has been shown to be well accepted and cost-effective [24, 25], and can complement existing outreach and case management services.

Telepsychiatry has been utilized to deliver various modali- ties of psychotherapy including cognitive-behavior therapy, supportive therapy, group therapy for depression and anxiety disorders, and trauma focused therapy ([26, 27, 28]). Internet- based CBTs with online lessons and homework assignments have been conducted in patients with neurotic disorders [29, 30]. Neuropsychological assessments for cognitive evaluation and neurological tests such as abnormal involuntary move- ments have been carried out using telehealth [31, 32].

7.6 Education and Research

Telemedicine for distance learning purposes can occur between physicians, physician and patient, or physician trainee. It may also take place in a classroom setting where a preceptor is at one site and students are at other, multiple remote end user sites. It could be used for supervision, mentoring, continuing medical education programs for individuals within psychiatry, and across medical specialties [33]. A number of training pro- grams across the nation include telepsychiatry experiences for residents in various clinical settings [34]. Supervision can occur in real-time with the supervisor present via videoconferencing, or by the use of store and forward technology (asynchronous transmission of clinical information).

Telemedicine particularly lends itself to procuring effective and reliable research data from clinical populations. It allows for remote acquisition of assessment information, direct obser- vation, checking for inter-rater reliability, and scoring. It also allows for storing or archiving of data for later scoring and evaluation. This can occur in clinics, hospitals, nursing homes,

7. Scope of Telepsychiatry in Clinical Settings 143

home-based setting, schools, and forensic settings. Studies have demonstrated a high inter-rater reliability of the diagnostic assessment using telehealth [35, 36]. Telepsychiatry has been found to be a reliable alternative for diagnosis in geriatric population where studies [36, 37] found that subjective verbal reports were more reliable than visual observations when vid- eoconferencing was compared to face-to-face evaluation of geriatric patients. A meta-analysis found that agreement between in-person assessment and high-bandwidth telepsy- chiatry evaluation was excellent while that of in-person with low-bandwidth telepsychiatric assessment showed adequate, but somewhat lower agreement than the former [38].

Studies have shown telepsychiatry to be a cost-effective delivery tool by minimizing travel time, reducing emergency room visits, hospitalization, time taken off from work [10, 39]. A number of factors need to be considered while determin- ing cost-effectiveness, including health outcomes, utilization, accessibility, quality, and needs for such services in the spe- cific population studied [40]. An increase in volume of tele- psychiatry can bring down costs especially of capital investment at the beginning and of continued maintenance costs. Some studies have demonstrated that to get to a “break-even” cost analysis, an average of seven consultations per week are required [41, 42]. Many studies do not calculate the cost benefits for the individual, their families, referring physicians, and health systems. In forensic settings it appears that clinical and educational applications of telepsychiatry are cost-effective in minimizing unnecessary transfers and hospitalization in management of the cases [39, 43]. Butler et al. found a 10% reduction in cost for those who had tele- psychiatry services compared to those who did not have it [44]. Further systematic studies are needed to evaluate the cost-effectiveness of telepsychiatry projects especially as it pertains to the elderly population.

Psychiatry is a specialty that relies on human interaction and observation of human behavior which warrants an important question: how does teleconsultations compare to face-to-face interviews. Systematic reviews have not shown significant differences in patient satisfaction with telehealth

144 M. Narasimhan

as a modality to deliver mental health services compared to face-to-face health care [43, 45, 46]. Shore et al. examined “usability of the technology,” “patient/provider interaction,” “cultural competence,” and overall satisfaction, which failed to demonstrate statistical difference on these measures com- pared to “in-person interview” [47].

Telepsychiatry applications in the elderly bring up legal and ethical issues including their role in emergency situations, privacy and confidentiality, primary responsibility, and secu- rity of data. As with telepsychiatry psychiatry application in other age groups, defining the duties and role of the specialist consultant, the primary care nurse practitioner or physician assuming the primary responsibility in emergency situations while providing support to the primary care providers, and developing administrative and emergency protocols is a criti- cal element [48]. Cloud-based secure connections both for the telepresence and the electronic medical records ensure privacy and confidentiality which are extremely important with necessary emphasis on data security, appropriate collec- tion and handling of user data, the protection of data from unauthorized access, and the safe storage of data [49, 50]. Most healthcare systems, especially in the USA, have com- prehensive data security protocols, use secure lines and serv- ers, encrypted software that deals with unauthorized tampering or interception and takes every measure to protect confidentiality and privacy [49]. Clear guidelines and recom- mendations covering ethical issues such as informed consent and confidentiality, use of technology, and procedures for conducting assessments are necessary.

7.7 Conclusions

Telepsychiatry service has enormous scope in geriatric set- tings to address clinical, educational, and research needs and objectives. Telepsychiatry holds tremendous potential to solve the problems of under recognition, access to care, and lack of trained manpower at the level of local communities especially in addressing the mental healthcare needs of the

7. Scope of Telepsychiatry in Clinical Settings 145

elderly population. In areas where there is dearth of and a need for geriatric expertise, telepsychiatry has the capacity to allow remote consultation allowing for a more comprehen- sive geriatric assessment and follow-up. It has been a chal- lenge to recruit geriatric psychiatrists in rural and communities. Telepsychiatry may help circumvent that problem. It is gener- ally well accepted by patients and allows for effectively estab- lishing therapeutic alliances. Telepsychiatry has greatly empowered patients, providers, programs, and communities. Educational use including didactics, case-based consultation, and supervisory initiatives are becoming more of the norm in today’s academic settings. Training more psychiatrists and primary care physicians also empowers them to deliver men- tal health services directly to the underserved elderly popula- tions, while providing support and supervision by specialists. These models also demonstrate that participating primary care physicians effectively transition from requesting assis- tance in diagnostic process to increased requests for assis- tance with developing or modifying management plans [16]. This allows for prudent use of human capital that is cost- effective both in the short term and more so in the long term to address the mental health needs in the elderly. Given the paucity of research studies using telepsychiatry in the elderly, there is an urgent need to have well-planned comparative studies assessing diagnostic reliability and cost-effectiveness in the geriatric population. Telepsychiatry can provide the same quality of face-to-face medical care and consultation among specialties while erasing distances, addressing short- age of expert providers, and can prove to be a cost-effective tool. Telehealth in geriatric population can lend itself to medical consultation within various clinical settings including home-based care, benefitting the overall health of patients while allowing for a rapid exchange of information and tech- niques in an integrated fashion while reducing fragmentation of care. It addresses issues pertaining to access to healthcare services, ensures continuity of care and optimal use of avail- able health resources. It behooves public, private academic health systems to work in partnership given the costs and benefits and the opportunities to optimize their resources.

146 M. Narasimhan References

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Chapter 8

Technology Applications in Geriatric Telepsychiatry and Implications

for Implementation

Suzanne M. Hardeman

8.1 Introduction

Video teleconferencing (VTC) is a communication technol- ogy that allows people at different locations to simultane- ously see and hear each other on a computer or television screen [1]. This capability has allowed healthcare to expand its reach to most any place around the world, creating the field of telemedicine. Advances in VTC technology and an expanding market of equipment and service providers have made telemedicine services both accessible and reasonably priced. Psychiatry has embraced telemedicine creating a growing telepsychiatry practice for both consultation and treatment across all ages. This chapter outlines basic informa- tion required for implementing a telepsychiatry program as well as specific needs of a geriatric telepsychiatry setup. Additional resources for detailed technical requirements, platform options, and product information are provided at the end of the chapter.

S.M. Hardeman (*)

Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine,

3555 Harden Street, Suite 301, Columbia, SC 29203, USA e-mail:

© Springer International Publishing AG 2017 151 S. Srinivasan et al. (eds.), Geriatric Telepsychiatry,

DOI 10.1007/978-3-319-51491-8_8

152 S.M. Hardeman

VTC can be used to join groups of people at different sites or as a point-to-point service limited to only two persons. This point-to-point service is ideal for telepsychiatry.Telepsychiatry, in basic terms, is a videoconference between a patient and healthcare provider in which both use a computer or tablet, a camera, a microphone, and secure high-bandwidth internet network access. This basic equipment is a far cry from the expensive videoconferencing technology (VTC) equipment of days-gone-by. Today’s providers can craft a reliable tele- psychiatry practice with minimal investment.

8.2 Technical Overview

There are two types of VTC: dedicated and desktop/laptop. These may also be distinguished as standards-based (organizational-based) and consumer-based. Dedicated standards-based systems are fixed in one location such as an auditorium or conference room and are usually supported by an organization. These systems, most often used for large group conferencing, are increasingly used for telemedicine consultations. Desktop/Laptop/Tablet systems (consumer- based) simply add VTC software programs and equipment (camera and microphone) to existing desktop/laptop setups. While desktops and laptops can be added to the standards- based organizational systems, these consumer-grade products are not always compatible with standards-based systems and organizations may limit consumer product access. This will be a basic consideration when planning telepsychiatry [2]. VTC is delivered over one of the three networks: H.320, H323, or SIP (Session Initiation Protocol). Voice and video signals are then compressed with a CODEC (coder-decoder) allowing the signals to be delivered in analog or digital formats. A CODEC is either a device or a computer software program that encodes the audio and video data on the user side, pack- ages it for transmission (streaming), and then decodes that audio and video data stream converting into the voice and images we see and hear on the receiving side.

8. Technology Applications in Geriatric Telepsychiatry… 153 8.3 Support

While the equipment is basic and familiar to most users, the behind-the-scene requirements are well beyond the expertise of most providers. For this reason, Information Technology (IT) and Health Information Technology (HIT) support are essential at every step of the setup and operation of a telepsy- chiatry program. IT and HIT not only provide support and troubleshooting, they ensure security, which is the highest priority in patient care delivery. Each endpoint (the VTC equipment) and end-user (the providers and patients) will require IT support for equipment, applications (software), and security. Dedicated IT support should be available dur- ing telepsychiatry sessions to troubleshoot problems and assist staff members. HIT specialists will be essential in sup- porting provider access to medical records. In smaller set- tings, IT, HIT, and security may be handled by a single department but in larger organizations, IT and HIT may be separate departments. For those wishing to begin a telepsy- chiatric practice and are not part of a larger organization with IT and HIT support, it will be essential to choose a service provider which offers IT support. Finally, manufacturer sup- port for the equipment may also be required and can be negotiated at the time of purchase.

8.4 Internet Connections

Telepsychiatry can be delivered through several different VTC methods: Internet Protocol lines called IP lines or via Integrated Services Digital Networks (ISDN) lines. IP lines utilize the worldwide web and ISDN lines utilize standard telephone lines. The majority of telemedicine is done over an IP line due to the cost associated with ISDN delivery. Information in this chapter is presented for IP delivery.

Telepsychiatry technology utilizes industry standard band- width networking. The American Telemedicine Association (ATA) recommends a minimum bandwidth of 384 Kbps in

154 S.M. Hardeman

both directions with a screen resolution set at a minimum of 640×360, and speed at 30 frames per second [3]. Equipment should never be connected to the internet without a firewall. Reliable connectivity, dependable bandwidth, and dedicated personnel to troubleshoot problems are central to successful telepsychiatry. Consultation with IT and HIT personnel is essential when planning and purchasing equipment since there is much behind the scene that users may have no knowledge of, especially security related.

8.5 Security Concerns

Security for telemedicine connections requires sophisticated network connections and firewall allowances as well as spe- cific software and network configurations to ensure clinical risk-management and is thus best handled by IT personnel skilled in network security. In larger organizations security is usually supported via videoconferencing services such as Polycom, Cisco, Vimeo or Jabber, or fee-for-service compa- nies which provide secure, high definition, Health Insurance Portability and Accountability Act (HIPAA) compliant, ser- vices, and support. Fee-for-service companies are viable options for smaller practices which may not be affiliated with larger organizations because most offer setup, secure connec- tions, and support. Security and encryption are required by all end-users. Please note that consumer services for the gen- eral population such as Skype© and FaceTime© do not offer the security levels needed for HIPAA compliance and should not be used for telemedicine.

8.5.1 Encryption, Firewalls, Gatekeepers

Encryption scrambles the videoconference transmission and can only be unscrambled at the receiving end with the appro- priate embedded software key. As an example, Polycom offers a 128-bit AES encryption. Gatekeeper units are used to manage VTC traffic by recognizing outside video systems

8. Technology Applications in Geriatric Telepsychiatry… 155

and routing incoming calls to their desirable destinations. Firewalls are used to block unauthorized communications between computers. Firewalls at each location must be con- figured to identify the incoming video traffic and allow that traffic to pass through the organizational firewall. Firewalls without gatekeepers must manually open designated ports to allow the video traffic to pass through. More detailed infor- mation on these and other security essentials can be found in the Resource Section.

8.6 Selecting a Videoteleconferencing Vendor

8.6.1 Vendors

With the rapid advances in technology and hence a wide range of videoconferencing capabilities, most any size organi- zation has feasible options for providing secure, HIPPA com- pliant telepsychiatry. Many larger organizations are already utilizing Polycom, Cisco, Vimeo or Jabber as VTC platforms making establishment of telepsychiatry a seamless process. For smaller organizations or private practitioner, there are a number of reputable providers with complete services for both monthly and hourly charges. Most require a joining fee and credentialing. Some companies are set up to charge patients prior to the visit making payment (minus fees) avail- able to the provider at the end of the session. Both the American Telemedicine Association and the National Telehealth Technology Assessment Resource Center offer information and reviews on such services and links to these sites are provided in the chapter resource section.

8.6.2 Collaboration Features

Most platforms have the capability for additional collabora- tion via text messaging, screen sharing, and document shar- ing, although some of these functions may not be operable on

156 S.M. Hardeman

tablets or other mobile devices. When choosing a platform, it is important to determine whether these functions might be helpful when consulting with the geriatric patient. Screen sharing can be used for patient teaching just as document sharing could be used to provide patient or family teaching materials.

8.6.3 Licenses

A licensing fee is usually associated with VTC software. Standards-based systems provide licenses at a cost determined by the organization. Consumer-based technology often offers lower cost licenses, but providers should be always mindful of the security offered by lesser costs services.

8.7 Interoperability of Systems

Endpoints refer to the equipment used at each VTC site. End-user refers to the people using the technology. Endpoints utilizing different VTC setups can be connected through a bridge provided by a gateway service. Gateways are essen- tially translation devices between differing audio and video formats. The bridge provides a secure connection for any user who has the bridge number and password. The bridge requires encryption but does not ensure complete security for the system outside the bridge [4]. As an example, the Cisco Telepresence 4505 MCU (Multi-Conferencing Unit) allows up to 12 High definition (720p) calls to participate in a single virtual video meeting. These calls can also connect at various speeds and video formats as long as the calls are SIP or H323 Standards based.

8.8 Equipment

The American Telemedicine Association outlines guidelines for best practices in telemedicine. The guidelines highlight the importance of device management software to provide

8. Technology Applications in Geriatric Telepsychiatry… 157

oversight of both devices and security software. The guidelines require that a backup plan that provides for alternate means of communication should a failure occur at the primary VTC site be in place and be communicated to both the patient and the referring site.

8.8.1 Computers

Telepsychiatry can be successfully delivered with basic desktop, laptop, or even tablet equipment. The VTC equipment supplier or individual service provider will provide informa- tion on computer requirements. Connectivity does not require highly sophisticated computers, but computers with current cameras, processors, and cameras will perform better in day- to-day practice. Whether the personal computer is used by provider or patient, ensure that a firewall and antivirus soft- ware are installed. Maintaining the computer and completing operating systems and VTC software updates will ensure compatibility across all connections. A Special Note about Mobile Devices

While mobile devices are growing in popularity and becom- ing ever more reliable as a means of VTC there are several essential considerations before using. First the devises need to be authenticated for access. Second, devices will need to have set timeout thresholds and third, they will need to have locator and wipe clean software in the event they are lost or stolen. Additionally, it is recommended that users be required to log off after each session to prevent unauthorized users from accessing an open session [5].

8.8.2 Cameras

Video cameras may be built into the desktop/laptop monitor. If there is no camera, a USB camera is easily added to the monitor. While many USB cameras are advertised as high

158 S.M. Hardeman

Fig. 8.1 Double monitor setup for computer

definition (HD), the computer must have the capability to maximize this function. Before selecting a camera, one is advised to speak with the platform or computer support personnel to ensure that the selected camera will give the highest quality video within the specifications of the desktop or laptop.

Some organizational standards-based telemedicine VTC setups allow the provider to pan and zoom the far-end cam- era to view patients and the room’s surroundings. Desktop, laptop, and tablet devices generally do not have this capabil- ity (see Fig. 8.1).

8.8.3 Software

Software will be dependent on the chosen platform and will be provided as part of the service purchase. In some cases, providers may be asked to download software from the inter- net. Caution must be exercised here to ensure that software is downloaded from reputable company sites and not alternate sites which may offer the download. Business or professional

8. Technology Applications in Geriatric Telepsychiatry… 159

editions of software are generally safer and more reliable. While these versions will carry a cost, they often offer addi- tional features including additional security features. The videoconferencing software should be able to adapt to chang- ing bandwidth environments without losing/dropping the connection.

8.9 Facilities Setup

Just as consideration is given to the facilities in which live office visits take place, consideration should be given to the telemedicine delivery setting. In addition to providing com- fort and privacy, the room should provide optimal lighting and acoustics and be able to accommodate the equipment. Supplementary lighting may be necessary, particularly in rooms that have fluorescent overhead lighting. Supplemental lighting, preferably incandescent, should be placed behind and above the computer screen to add light to the provider’s and patient’s faces. In rooms where light comes in through the window, the patient–provider should be situated facing the window and computers and cameras should be facing away from the window with natural light coming in over the computer monitor or screen if at all possible. Lighting coming directly over or behind the provider or patient casts shadows making it difficult to see the person. The background should be free of pictures and other items such as water bottles, books, and charts, which can distract attention from the inter- action. Soft grey tone backgrounds offer the best lighting options [6]. See Fig. 8.2.

8.10 Ready-Set-Launch

• Rehearse

• Telemedicine is a complex network of people and technol-

ogy that need to work together in a seamless fashion. Rehearsals bring providers and technologies together to

160 S.M. Hardeman

Fig. 8.2 Consideration should be given to the telemedicine delivery setting, including background and lighting

determine compatibility, test protocols, and work out staff procedures. Rehearsals will identify procedural and technology issues so that they can be addressed before patients are involved. During these sessions cameras and lighting will be adjusted to maximize quality of each. All personnel involved should participate in the rehearsal. Finally, several rehearsals may be required to solve all issues before the “go-live” patient encounter [7]. The checklist provided in section 8.12 provides a comprehen- sive list of the equipment and support needed to set up and launce a telemedicine program.

• Have a backup plan

• As noted above, the ATA guidelines outline the require-

ments for a backup plan for those times when equipment failure is inevitable. Backup equipment that is not used on a regular basis should be on a periodic testing plan with regularly scheduled maintenance to ensure that all soft- ware is up to date.

8. Technology Applications in Geriatric Telepsychiatry… 161 8.11 Checklist

□ Internet capacity

□ Computer (desktop)

□ Computer laptop

□ Tablet computer

□ Camera

□ Microphone

□ Mouse

□ IT support contact

□ Connectivity ports all open

□ Appropriate firewalls activated

□ Encryption in place

□ HIT support information

□ EMR access

□ VTC software and/or equipment

□ List of participant phone numbers

□ List of participant emails

□ Equipment operations instruction sheet

□ Equipment trouble Shooting Guide

□ Backup plan instructions

8.12 Essential Online Resources

The American Telemedicine Association offers information on all aspects of telemedicine and provides guidelines for technical aspects of telemedicine. Guidelines for tele-mental health practice and technology standards are provided. Buyer’s guides are also available.


Telehealth Resource Centers exist across the USA and serve to provide education and assistance to active telemedi- cine providers. Their services are generally free.


The National Telehealth Technology Assessment Resource Center offers a wide variety of information on technology and telehealth programs for both the novice and the IT

162 S.M. Hardeman

expert.“Toolkits” provide telehealth technology reviews, help users understand product uses, and offer technical guidelines for the IT expert.


Behavioral Health Innovations provides information and comparisons of services, vendors, and technology used in the provision of online behavioral health. The site contains reviews of HIPPA compliant platforms and up-to-date reviews of other mental health technologies. Staff is available to provide introductory webinars and guidance on technolo- gies that best suit the intended practice.



1. Center for Connected Health Policy. Video conferencing. Sacramento; 2016. conferencing.

2. Telehealth Technology Assessment Resource Center. Desktop video applications – overview. Anchorage; 2016. http://www.tele- desktop-video/technology-overview.

3. American Telemedicine Association. Core operational guidelines for telehealth services involving provider-patient interactions. Washington, DC; 2014. default-source/standards/core-operational-guidelines-for-telehealth- services.pdf?sfvrsn=6.

4. National Telehealth Technology Assessment Resource Center. Videoconferencing – technology overview. Anchorage; 2016. http://

5. American Telemedicine Association. Practice guidelines for live on-demand primary and urgent care. Washington, DC; 2016. primary-urgent-care-guidelines.pdf?sfvrsn=4.

6. Telehealth Resource Centers. Facilities at the provider site. 2016.


7. Telehealth Resource Centers. Pilot testing. 2016. http://www.tele-



Accreditation Council for Graduate Medical

Education (ACGME),

59, 60

ACGME core competencies, 62

Acute stress disorder, 36 Advanced Encryption Standard

(AES), 108

Aging Inmate Population, 43

Aging population, 39–41 American Psychiatric Association

(APA), 116 American Telemedicine

Association (ATA),

4, 153 Asynchronous, 4


Behavioral activation therapy, 125 Brief Psychiatric Rating Scale

(BPRS), 17

Cameras, 157

Centers for Medicare and

Medicaid Services (CMS), 33

Clinical care settings education and research,

telemedicine, 142 emergency evaluations,

139, 140

inpatient and emergency

room management, 139 nursing homes, 140

Clinical video-teleconferencing (CVT), 38

Cognitive assessment, 126 Cognitive-behavior therapy, 142 Commission on Accreditation of


Facilities (CARF), 102 Community Based Outpatient

Clinics (CBOCs), 124 Computers, 157

Consumer-based technology, 156 CPT. See Current Procedural

Terminology (CPT) CPT codes, 28

Creating Opportunities Now for Necessary and

Effective Care Technologies (CONNECT), 34

Criminal Justice System, 41–46 Current Procedural Terminology


© Springer International Publishing AG 2017

S. Srinivasan et al. (eds.), Geriatric Telepsychiatry, DOI 10.1007/978-3-319-51491-8


(CPT), 28

164 Index


Dreyfus Model, 71

Duke Endowment (TDE)

program, 107, 119


Electronic medical record (EMR), 102

Emergency departments, telepsychiatry

adequate collateral information, 117

administration, 120

Burke Center, 116 involuntary commitment, 119 issues, 118

labs/medical workup, 117 mental health providers, 118 MHEC’s services, 116 psychiatric consultation, 116,

118, 119 SCDMH telepsychiatry

process, 117 SCDMH telepsychiatry

service, 118 telemedicine, 116

videoconferencing equipment, 118

Emergency Evaluations, 139–140 Encryption, 154

End-Stage Renal Disease

(ESRD), 29

Firewalls, 155


Geriatric ambulatory care settings, 141

Geriatric Depression Scale (GDS), 17

Geriatric incarceration rates, 27 Geriatric psychiatry, 57

Geriatric telepsychiatry, 28–33, 46–48, 156–159


olanzapine, 89 PACE,87


treatment plan, 88, 89

administrative challenges, 22–23

benefits, 34–39 checklist, technical

requirements, 161 clinical applications, 16–18 clinical examination, 86 cognitive examination, 86 collaborative care, 90 consultation care model, 90 costs

considerations, 14–16 equipment, 46–48 infrastructure, 47 physician salaries, 47–48

demographic changes, 11–14 diagnostic reliability, 17 encryption, firewalls,

gatekeepers, 154–155 essential online resources,

161–162 facilities setup, 159

Geriatric Depression Scale, 86 graph, depicting geriatric

population growth, 12 internet connections, 153–154 interoperability of systems

cameras, 157–158 computers, 157 equipment, 156–159 software, 158–159

IT support, 153 legal requirements

CMS, 33

CPT, 28 reimbursement

perspective, 28 telehealth CPT codes, 29–32 telepsychiatry services, 28


older adults implications, 41–46

Patient Health Questionnaire, 86

patient related challenges, 21–22

physical examination, 86 prevalence of psychiatric

disorders, nursing

homes, 14 psychiatry evaluation, 86

psychiatric treatment, 38

(see also Telepsychiatry)

ready-set-launch, 159–160 security concerns, 154–155 therapeutic applications, 141 VTC, 152

Geriatric Telepsychiatry Programming,

112–113 consent, 110

documentation of services, 109–110

hardware, 107

outcomes, 113–114

peer review and professional

practice reporting,


reliable data connections, 107 resources and protocol for

emergencies, 108–109 security, 108

staff privileges, 110–111 support staff, 109 tracking

satisfaction surveys, 112–113

Group therapy, 126, 142


Health Information Technology (HIT), 153, 154

Health Insurance Portability and Accountability Act

(HIPAA), 102

Health Resources and Services Administration

(HRSA), 4 Healthcare Common Procedure

Coding System

(HCPCS) code, 29–32 Healthcare provider

remuneration, 46 Home-based telemental health

care, 124

Information Technology (IT), 153 Inpatient and Emergency Room

Management, 139 Institute of Medicine (IOM), 55

Integrated Services Digital Networks (ISDN), 153

Internet-based CBTs, 142 Interpersonal and Communication

Skills, 63

Mental health, 125

Mental Health Emergency

Center (MHEC),

101, 116

Mental Health Gap, 137, 138

MHEC. See Mental Health Emergency Center


Mini Mental State Examination

(MMSE), 17 Mobile health (mHealth), 5


National Nursing Home Survey (NNHS), 13

National Telehealth Technology

Assessment Resource

Center, 155 National Telemental Health

Center (NTMHC), 124



Index 165

166 Index

Neurocognitive disorders, 44 Northern Periphery Programme

(NPP), 37 Nursing Home, 140–141


Osteopathic psychiatry programs, 56, 57

Session Initiation Protocol (SIP), 152

Software, 158

South Carolina Department of

Mental Health

(SCDMH), 101, 117 Supportive therapy, 142


Teaching and learning methods, 61 Telehealth, 145

application, 4, 5 CPT codes, 29–32 definitions, 4 telemedicine, 5 VHA, 123

Telehealth CPT codes, 29–32 Telemedicine, 142

application, 18 ATA, 4

benefits, 4 definition, 4 delivery setting, 160 mental health, 5 psychiatry, 151 security, 154 services, 8 telepsychiatry, 6, 8 VTC setups, 158

Telepsychiatry (TP), 60–66, 138 child and adolescent care, 59 clinical/outcome studies, 67–70 clinical settings (see Clinical

care settings) communication, 66, 77


Patient satisfaction, 19–20 Personalized prevention plan of

service (PPPS), 32 Posttraumatic stress disorder

(PTSD), 36–38, 90 Primary care provider’s

(PCP), 115

Program for All-Inclusive Care

of the Elderly

(PACE), 87 Prolonged Exposure (PE)

therapy, 36 Provider satisfaction, 20–21

Psychiatric emergencies, 139 Psychiatry, 124, 127, 143 Public psychiatry

MHEC, 101


Remote patient monitoring (RPM), 5

Rollabout system, 36

competency-based approach, S 72,85

SCDMH. See South Carolina Department of Mental

Health (SCDMH) SCDMH telepsychiatry


program, 101 Security, 154

Serious mental illness (SMI), 56

cost-effective delivery tool, 143 definition, 4–5

demographic changes, 11–14 Dreyfus model, 72

geriatric mental health care, 16–18

geriatric populations, 58 geriatric settings, 144–145

history, 5–8

legal and ethical issues, 144 mental health disorders, 17 mental healthcare, 3

patient care, 73, 75, 76

patient satisfaction, 19 practice-based learning, 81 privacy and confidentiality, 144 professionalism, 80

provider satisfaction, 20, 21 psychiatric training

programs, 60 recruitment, 64

residency training programs ACGME competencies, 61 ACGME requirement, 60 feedback review, 65, 66 Patient Care and

Learning, 62–64 skill development, 61

synchronous evaluations, 16 systems-based practice, 78–80 teaching and supervision, 84, 85 technology operation, 82 telehealth, 4, 5

telemedicine, 4

telemental health, 4 Telepsychiatry Service, 103–105

certification, 102–103 ethical perspective, 114, 115 funding, 101–102


clinical staff, 104

IT and EMR support, 105 program director, 103–104 support staff, 104

transport and other staff, 105

Three Strikes law, 43

Tribal Veterans Representative

(TVR) training

program, 128 Two-way videoconferencing,


Veterans Administration (VA), 33 Veterans Health Administration

(VHA), 128–131 cognitive assessment, 126

dementia, 126 NTMHC, 124 patient satisfaction

surveys, 128

PTSD treatment, 125, 126

telehealth, 123 telemental health, 127

benefits, 128, 129 limitations, 130, 131 teaching, 129, 130

videoteleconferencing equipment, 131

Video teleconference (VTC)

camera, 152 collaboration features,

155–156 computer/tablet, 152

description, 151 licenses, 156

software programs, 152 types, 152

vendors, 155 Videoconferencing, 71, 128, 129


Index 167

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