BY: TODD LAWLEY and DAVID LOPEZ, MD
The land of opportunity beckons different generations to different locations. Engineers and miners rushed to California in the 1840s and 50s to find gold, and then to South Dakota, Colorado and Utah in the 1870s in pursuit of more gold and other minerals. As energy became more critical to the American economy, workers moved to dig for coal in Pennsylvania and West Virginia at the end of the 19th century, then for oil in Texas and Oklahoma in the first half of the 20th century.
Our need for fuel hasn't lessened. The Alaskan pipeline induced thousands of skilled and unskilled workers to move to that state in the 1970s. Today, the newest boomtowns for the oil industry are in western North Dakota, particularly in Williston and Dickinson, located in the state's northwest and southwest quadrants, respectively.
By 2015, Dickinson's population will have almost doubled its 2011 numbers. As of October 2014, Williston is the fastest-growing city in the country. Available housing and city services can't keep pace in either location. Both Dickinson and Williston rank in the top 10 most expensive places in the U.S. for housing — along with such cities as New York, Los Angeles, San Diego and Chicago. High wages paired with a dearth of recreational offerings plus limited options for merchandise and services have resulted in epidemic figures for substance abuse, domestic abuse, prostitution, violence, anxiety disorder and depression in Williston and Dickinson. Workers for jobs outside the oil business are at such a premium that a local McDonald's is offering $20 an hour plus a signing bonus. Especially worrisome is the need for health care in general and specialized medical services in particular in areas where there are neither enough facilities nor health care professionals to meet the growing population's needs.
Catholic Health Initiatives (CHI), one of the largest Catholic health ministries in the country, has 105 hospitals in 18 states across the nation. CHI's Fargo division is using telemedicine to respond to health care needs in western North Dakota. While it is attending to the rapidly growing rural population in the traditional specialties of medical-surgical care, obstetrics and gynecology, cardiac and stroke care, oncology, and emergency medicine, it has determined the community's most critical need is mental health services.
Operated out of the Fargo division offices in the Red River Valley, on the state's eastern border, telemedicine efforts throughout the region are getting impetus from a pilot program at CHI St. Joseph's Health, a 25-bed, rural critical access hospital in Dickinson that now has full-time mental health support for the emergency department as well as a virtual outpatient clinic in full operation.
Williston's Mercy Medical Center, also a 25-bed, rural critical access hospital that is part of CHI, is in operation with ED mental health services. Plans call for outpatient behavioral telehealth services to be available there later in 2015.
The partnership accomplishing this innovative pilot is between CHI and Psychiatry Networks, a combination that leverages the opportunities of technology with the power of faith. Psychiatry Networks, a secular, for-profit company interested in technology's health care possibilities, takes an entrepreneurial approach to bringing good business practices to underserved communities and attracting like-minded physicians to its provider network of more than 100 MDs, DOs, PhDs and PsyDs.
The CHI health care ministry's mission is to treat the patient — in mind, body and spirit —with innovation and compassion in pursuing new avenues of care. According to Chris Jones, vice president for strategy and business development in CHI's Fargo division, the number of ED visits in the two towns skyrocketed in 2011. In addition to the usual accidents, injuries and serious illnesses that already were stressing the small local hospitals, there were increasing incidents of suicide attempts, domestic abuse, substance abuse, depression and violent psychotic episodes.
"Too often, ambulances were delivering people to jail or care centers a hundred miles away because there weren't enough beds or health care practitioners available in the small, rural hospitals," Jones explained.
In 2012, CHI-Fargo and Psychiatry Networks applied for a telehealth network grant from the Health Resource Service Administration (HRSA), part of the U.S. Department of Health and Human Services. According to the grant abstract, the CHI-Fargo Division Tele-Behavioral Health Network will serve 12 spoke sites, all community-based, nonprofit hospitals, throughout North Dakota and Minnesota.
The project coordination hub is the CHI-Fargo Division, with Psychiatry Networks serving as the clinical services hub. The 12 spoke sites are all rural and lack qualified psychiatrists, or psychiatric-certified physicians' assistants or nurse practitioners, for adults as well as adolescents. Patient diagnostic codes indicate dementia, psychosis, anxiety states, alcohol and substance abuse and depressive disorders across the region. Family or emergency practitioners are tasked with diagnosing and managing mental health events, particularly in the emergency departments. The service area contains 151,535 residents in 17,000 square miles.
Awarded in September 2013, the CHI-Fargo Division Tele-Behavioral Health Network grant funded the purchase of dedicated mobile Tele-Psych carts with 22-inch monitors, laptops, keyboards, speakers, high-definition webcams and microphones, along with money for travel, implementation and administrative costs.
As the CHI-Fargo Division and Psychiatry Networks prepared their grant application, they set priorities for their mutual goals:
- Improve access to services in CHI-Fargo's seven hospitals in North Dakota locations, beginning with the Dickinson and Williston sites, and its five hospitals in Minnesota
- Improve the quality of care for vulnerable persons in a rapidly changing community
- Reduce the sense of stigma for those needing and receiving care
- Reduce the costs of care for individuals and providers
They fleshed out each goal with realistic strategies that took into account factors of population, providers and geography. For example, there are only 87 licensed psychiatrists in the entire state of North Dakota, and about half of them are located in the Red River Valley. That means a person experiencing a mental health crisis might need to travel as far as 200 miles to be evaluated and treated by a licensed provider. Creating a new model of mental health care delivery for Dickinson and Williston would have to align clinical, operational and technological excellence simultaneously.
A little more than a year after the three-year grant was awarded, big changes are in evidence. Because all CHI hospitals in western North Dakota are small critical-access facilities, emergency departments have been the transition point from the practice of defensive medicine to the trajectory of evaluation, referral and treatment in the form of telepsychiatry. Psychiatry Networks guarantees a response within an hour of referral or follow-up; a licensed professional is available 24 hours a day, 7 days a week.
Lopez, a practicing psychiatrist who is co-owner of Psychiatry Networks, handles many of the interactions himself. Others are handled by network psychiatrists who may be located in distant parts of the country but have been properly credentialed for practice in North Dakota. Using the COWs (Carts on Wheels), most patients begin their treatment with a psychiatrist in real time on the same day as the incident that landed them in the ED.
Daniel Sheps, DO, a hospitalist on staff at St. Joseph's Hospital in Dickinson, is grateful for the telepsych services. "Many patients who are working in the oil fields struggle with psychiatric issues, in addition to active medical problems," he said. "They are frequently separated from their families while working in North Dakota. Dr. Lopez and the staff of Psychiatry Networks help provide a healing bridge and support that gives patients the strength they need to move forward. They are often treated on the night of admission with a treatment plan that incorporates medical, nursing and spiritual care aspects. This holistic approach is well received by patients."
Such arrangements not only achieve the goal of accessibility, but they improve the timeliness of care as well as decrease costs to patient, hospital system and the community as a whole. For example, what once could have been an extended episode involving a night in jail, a day of evaluations and a lengthy transfer by ambulance or police car to a municipality with a mental health facility — accompanied by multiple copays for the patient, duplicative processing by the hospitals and financial strain on city services — has been streamlined to immediate care and the option of ongoing treatment at St. Joseph's virtual outpatient clinic in Dickinson.
According to Robert Riddick, MD, a surgeon at St. Joseph's, patient access to mental health services is allowing him and other medical specialists to operate with an assurance that patients are receiving all the services they need.
"It is immensely helpful to know that my patients have convenient access and quality options for mental health care. The telepsych service fills a much-needed gap in patient care in this community," he said.
To be sure, hospital staff had some early reservations about how a telemedicine approach to mental health care might be received. Patients, however, have responded enthusiastically, partly because telemedicine enhances confidentiality and privacy surrounding their treatment and helps them avoid embarrassment or stigma. Once a patient in the emergency room has been stabilized and can be directed to the outpatient clinic for mental health services, he or she walks into the same building that expectant mothers, elderly heart patients and teens getting their annual health exams enter. There is no mental health building or designated office that could feed speculation about who is spotted there. In the clinic, the nurses who work with the telepsychiatrists uphold strict parameters of privacy and confidentiality. Patients are alone when they engage with the psychiatrist via equipment in a consultation room.
Most patients report that the flexibility of the clinic, the anonymity of the setting and their own proficiency with the technology give them a level of comfort and control they wouldn't have in other situations. Rather than judging a telemedicine approach as a second-best or compromise option, they tend to describe it as excellent care that adjusts to their circumstances and needs. The fact that it is convenient, local, timely and cost-efficient is hugely important to them.
Provider satisfaction matches patient satisfaction. The team of doctors, nurses, technicians and administrators involved in the telepsych pilot is excited about the early success and optimistic about growing the opportunity for tele-behavioral health services not only in the Dickinson and Williston communities, but also in the system's 10 other facilities by August 2016. There is nothing naïve about that ambition: the careful planning, selective team building, measurable accountability, frequent communication, expectation of high technological standards and commitment to patient-centered care that brought about the first year's success will be applied just as rigorously to the next two years' work.
A look at the numbers confirms that the individual patient responses and provider enthusiasm indicate a trend for increasing use of the services and growing confidence in the program. There were a total of 75 telepsych visits in the first year of operation (including the pilot phase). In the first six months of the telepsych services funded by the grant, there were 284 patients in the ED given mental health diagnoses resulting in 36 virtual ED visits; in the second six months, the number of ED patients given mental health diagnoses was 277, with 21 virtual visits.
St. Joseph's Hospital in Dickinson traced 44 of the mental health patients who consulted with Psychiatry Networks, and the data showed a 54 percent decrease in ED visits. Many of those patients are being managed in the outpatient virtual clinic, which logged over 315 virtual visits between September 2013 and August 2014. According to the figures recorded for grant reporting and CHI's department of strategy and business development, patients who had a virtual visit with a psychiatrist more often received the care they needed in a timely manner and were stabilized first by consulting with the doctors and nurses on staff and then by their consult with Lopez. In addition to better and timelier care, in most cases the patient did not have to be transferred out of the community. That saved health care dollars as well as county dollars, since the nearest mental health facility is 99 miles away.
Those figures, combined with projected population growth and the plan to develop services in all 12 regional hospitals in North Dakota and Minnesota by 2016, have CHI estimating that they will be serving more than 2,100 individuals a year. The extension of the project from its pilot in Dickinson to all other sites in just three years will include inpatient care, ED services and the addition of outpatient tele-clinic services based on each site's needs.
The successful partnership between CHI-Fargo and Psychiatry Networks is an example of how innovation, collaboration and faith in the healing ministry can provide important behavioral health services to communities in a committed and strategic way.
TODD LAWLEY is director of strategy and business development for the CHI-Fargo Division, Fargo, N.D.
DAVID LOPEZ is a licensed psychiatrist and president and CEO of Psychiatry Networks, Fargo, N.D.
- This project is supported by grant number H2ARH26031 from the Office for the Advancement of Telehealth, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Md.
Copyright © 2015 by the Catholic Health Association of the United States
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