inpatient telepsychiatry opinion/experience

[nexus73]

I'm seeing fluctuating use of telehealth in the inpatient setting around me. One local health system went all in on telehealth about 4 years ago for C/L and ED and now seem to be backtracking, hiring in person doctors to run the service instead. I've heard rumors the telepsych consults ranged from adequate to grossly unhelpful/bad.

Another local health system appears to be at the front end of the same experiment, expanding telepsych to ED and med/surg currently. So we'll see if it works out for them.

I've also heard some places use telepsych to staff inpatient units as well.

I was curious about opinions on inpatient telepsych, what are people seeing, how is the quality, inpatient units run by telepsych only?

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[ObsequiousAplomb]

I have never once seen telepsych work well in the inpatient, CL, or ED environments. Maybe it works great somewhere. Just not where I've been.
A lot more people are still behind PHPs and IOPs with hybrid models. I don't know anything about how well that has worked out, but it seems interesting to me as another element of the "step-down" you get from inpatient to PHP to IOP to hybrid to OP.

 

[Celexa]

My opinion on tele for CL is it's about as useful as giving recs entirely based on the chart. Which is to say, for a small percentage of pts that's reasonable, and the majority, a pile of nonsense.

 

[Liquid8]

One of my patients was admitted to a place where this kind of thing occurred and found it extremely unsettling, describing that they saw the doctor on a computer screen which was wheeled around the ward and stating it was like something out of a bad science fiction movie. It certainly doesn't scream therapeutic environment.

 

[calvnandhobbs68]

Can't say I've seen inpatient but I've shared my experiences with telepsych to the ED in residency. Basically had a contract service that was terrible, would recommend admission for everyone with a borderline useless note.

I think a major problem with these services (besides the lack of theraputic relationship at all as mentioned above or any knowledge of how the local system works) is the total lack of accountability when they're contracted out from outside the system. It's different if you have your own system docs doing telepsych to satellite hospitals or the ED overnight or something but for a total outside agency or outside hire who doesn't do anything except telepsych, what incentive do they have except to do the thing that opens them up to the least liability? So they recommend admission or staying in the hospital for every dumb thing and have no blowback from it because they never have to encounter the people they're dumping on all the time.

 

[splik]

My opinion on tele for CL is it's about as useful as giving recs entirely based on the chart. Which is to say, for a small percentage of pts that's reasonable, and the majority, a pile of nonsense.

I disagree. I did telehealth consults in addition to in person for over 5 yrs, and also piloted an econsult service (where we did chart review consults for inpatients) and there is a big difference. Of course, it depends on the consult (and I could do 95% consults without seeing the patient in actuality but mostly saw the pt). Painful evaluating delirium over telehealth, as well as neurocognitive disorders and catatonia. You can miss subtle signs of psychosis as well. However you can do a decent capacity eval, risk assessment, evaluation of depression, demoralization and a bunch of other things perfectly well via telehealth.

And even if you would make the same recs without seeing the patient, you won't have the same credibility if you haven't seen the pt. Of course, you have less credibility over telehealth than you do if you meet the patient in person.

I also did telephone consults when that became billable.

One nice thing about telehealth is you can log off when the patient gets abusive/starts throwing things!

Once the nurses put me in the wrong room. The patient responded affirmatively when I asked "are you x?" at the beginning, but looked more and more confused as I asked about the chip the surgeon had implanted in her that was picking up everyone's thoughts. When I asked the pt's name, it was a completely different pt!

 

[When is graduation again?]

My experience with ED telepsych was a travesty. I had a schizoaffective patient locked in a dark room in medical ED for 3 weeks with minimal visitation and no t.v or distractions. He was a treatment non-compliant clozaril patient, but when he was on meds functioned pretty well. I couldn't reach the telepsych docs directly, so I left messages they ignored. He was severely psychotic, but all they did was give him invega 3mg for the 1st 2 weeks, while loading him up with benzos, sertraline, and Depakote. After over 2 weeks, they finally increased the invega to 6mg which did nothing. I quit that job a month ago, so idk how that saga ended, but I hope his family sues that hospital for negligence.

 

[comp1]

It works okay some places, not okay others. It's dramatically increased access to care for people throughout the country. There are no psychiatrists or PMHNPs in much of the country, including places with hospitals. The places that are backtracking are fortunate to be located where they have that option.

 

[calvnandhobbs68]

It works okay some places, not okay others. It's dramatically increased access to care for people throughout the country. There are no psychiatrists or PMHNPs in much of the country, including places with hospitals. The places that are backtracking are fortunate to be located where they have that option.

I think there's a real slippery slope to the argument that "some of X is better than none of X", not the least of which is the assumption that the two "Xs" are equivalent. Again, this "access" argument without real quality control is the same argument that got us into the NP situation.

 

[comp1]

Fortunately there are no NPs either in these under-resourced areas to haunt the dreams of psychiatrists. /s One good thing about telehealth is that your hiring pool can be much, much broader (the whole country for federal employment). A skilled manager should, ideally, be able to select better telehealth providers than what is necessarily immediately available within driving distance. Access is extremely important. It's at least the first step to quality control and good care. You definitely can't have either without access.

 

[calvnandhobbs68]

Fortunately there are no NPs either in these under-resourced areas to haunt the dreams of psychiatrists. /s One good thing about telehealth is that your hiring pool can be much, much broader (the whole country for federal employment). A skilled manager should, ideally, be able to select better telehealth providers than what is necessarily immediately available within driving distance. Access is extremely important. It's at least the first step to quality control and good care. You definitely can't have either without access.

Again, this is all fine and dandy but is also an idealized world where, for instance, there aren't huge telemed companies back by private equity firms pushing their product to "improve access" everywhere.

As one example, there was just an article in AP about how school districts are signing multi-million dollar contracts with online tele-therapy companies because they "can't get any school counselors"....but part of the problem are the school counselors don't want to work for the school district because they can go do completely virtual with these telemed companies. Okay, cool, no problem, free market, except now you have school districts basically paying a middle man (the telemed company) to connect them with a service rather than working on ways to recruit this service directly to the school.

 

[Wilf]

We use a few teledocs here at the hospital I work at, and overall it is definitely subpar. There are so many subtle things we see when evaluating a patient in person that are not appreciated enough. It seems unfair to the patient that they go their whole stay without ever seeing a psychiatrist in person. The nurses also hate it.