RESNA 27th International Annual Confence
Effectiveness of Telepsychiatry on Functional Status and Use of Health Resources For Veterans with Schizophrenia
Telepsychiatry has been found to be a reliable method of evaluation and a satisfactory method of service delivery. This study explored the effectiveness of telepsychiatry on functional status and health resource utilization for veterans with schizophrenia. Analysis of resource utilization indicated telepsychiatry had an impact on how participants utilized services. Functional areas were also impacted through the use of telepsychiatry. This is important in finding alternative solutions to providing mental health care in underserved populations.
Telepsychiatry, telehealth, telemedicine, schizophrenia, outcomes
The 1999 Surgeon General's Report states 1 in 5 Americans suffers from a mental illness every year (1). Despite the high incidence of mental illness, there are many barriers to obtaining treatment. One of those barriers is the lack of services available to consumers who reside in rural areas. Telepsychiatry, or providing mental health services remotely, offers the potential to reduce or eliminate this barrier. Telepsychiatry can save staff travel time, bring services to rural communities, and facilitate emergency treatment (2).
Research on telepsychiatry has focused on reliability of evaluation, the effects of high tech versus low tech equipment on the quality of the telepsychiatry experience, and patient satisfaction. Several studies document the reliability of telepsychiatry. High inter-rater reliability has been found in diagnosing clients comparing video consulting with face-to-face interviews (3). Several studies have reported on the reliability of telepsychiatry with different types of equipment. Good audio and video transmission is necessary for effective telepsychiatry consultations (4). A low bandwidth system (128 kbs) may produce motion echoes making it difficult to assess negative symptoms. Using a higher bandwidth system (384 kbs) considerably reduces motion echoes resulting in an experience similar to the live interview (5)(6). Several studies have addressed patient and staff satisfaction with telepsychiatry. Overall, patient satisfaction with telepsychiatry services has been found to be similar to in-person interviews (7). Often, people have to drive long distances or wait months to receive in-person sessions with a psychiatrist. It has been found patients prefer telepsychiatry services to waiting or traveling for a face-to-face interview (8).
Three studies have reported functional outcomes with the use of telepsychiatry. Two studies examined the change in Global Assessment of Functioning scores between a group that received telepsychiatry and a group that received in-person interviews and found no significant differences in GAF scores between the two groups (9)(10). A third study examined the use of telepsychiatry in discharging patients from an inpatient psychiatric hospital. Participants in the videoconferencing group had less frequent rehospitalizations, experienced fewer medication side effects, and had better treatment compliance (11).
The present study explored the effectiveness of telepsychiatry on functional status and health resource utilization for veterans with schizophrenia, and reports differences in outcome measures between an initial and 12-month follow-up.
This report focuses on the Gainesville Florida demonstration of the VISN-8 home telehealth program by the Veterans Health Administration, Veterans Video Network (VVN) which between 2000 and 2002 served 56 veterans with chronic mental illness, including posttraumatic stress disorder (PTSD), schizophrenia, depression, substance abuse, and personality disorders. Most participants, ranging in age from 32 to 82 years, also had chronic medical conditions, and lived in the North Florida and South Georgia area. Practitioners in the Veterans Health Administration referred patients to the project.
Telepsychiatry equipment included a computer with audio / video units for linking with 2 base stations monitored by care coordinators, one at a mental health center, the other at a community hospital. Care coordination services were provided at-home through the use of email and/or phone contact. Care coordinators provided an initial assessment (including an SF 36v), sent reminders about appointments and medications, reinforced providers' instructions, and education regarding their condition and treatment. Care coordinators maintained at least weekly contact with each patient in the program, and when problems were identified, a referral was made to the primary, or to a specialty care provider. The goal was to handle problems early and quickly to circumvent the need for more costly hospitalizations, or emergency room visits.
Service utilization declined significantly in the area of hospital admissions, from a 66 percent rehospitalization rate to a 46 percent rate - a 20 percent decline.
|
Baseline |
12-mo Post |
|---|---|---|
*Hospital Admissions |
66.07% |
46.43% |
Bed Days of Care |
7.7 |
6.1 |
ER Visits |
33.9% |
39.3% |
PC Visits |
78.6% |
85.7% |
Unscheduled PC clinic visits |
39.3% |
30.4% |
NH admissions |
8.9% |
1.8% |
| P <.05 PC = Primary Care; NH = Nursing home; ER = Emergency Room | ||
No significant differences in service utilization were found for bed days of care, emergency room visits, clinic visits, or nursing home bed days of care, although for the sample, with two exceptions, actual differences were in the expected direction (study participants averaged at the follow-up fewer bed days of care, unscheduled psychiatric clinic visits, nursing home admissions, and nursing home bed days of care). Patients in the study did have a somewhat higher number of emergency room visits and scheduled psychiatric clinic visits. The increase in scheduled psychiatric visits and emergency room visits is likely a reflection of more rapid response to patients' problems. Since the care coordinators did not themselves provide 24/7 services, they were backed up by the Veterans Health Administration's General 24 hour service (called Telecare), or some patients called 911.
Several sub-scores on the SF-36v also showed improvement from initial assessment to the 12-month follow-up assessment.
Scales |
N |
Initial Assessment |
12 Month Follow-up |
|---|---|---|---|
Physical Functioning |
43 |
52.6 (28.7) |
55.3 (29.5) |
*Role-Physical |
41 |
31.3 (28.1) |
44.7 (31.1) |
*Bodily Pain |
43 |
28.0 (26.6) |
37.9 (29.5) |
General Health |
43 |
31.2 (20.7) |
31.1 (19.9) |
***Vitality |
43 |
17.8 (15.4) |
27.8 (22.5) |
**Social Functioning |
43 |
23.5 (21.2) |
39.2 (29.6) |
*Role - Emotional |
43 |
32.2 (23.6) |
46.3 (25.8) |
Mental Health |
43 |
27.8 (18.7) |
37.7 (23.1) |
Physical Component Scale |
42 |
35.2 (11.6) |
36.3 (12.6) |
**Mental Component Scale |
42 |
23.9 (9.1) |
30.6 (12.5) |
| *p < .05; ** p < .01; ***p < .001 | |||
These included "Role-Physical”, "Bodily Pain," "Vitality," "Social Functioning," "Role-Emotional," and Mental Health Component Score. While the design of this clinical demonstration leaves many variables uncontrolled, these results suggest that patients in the care coordination program were faring significantly better with the program than they were before they entered it.
In summary, care coordination combined with a distance technology approach was evaluated over a 12-month period. Patients in the program decreased their use of expensive hospitalizations by 20 percent, and improved significantly on 6 of 10 sub scores of the SF-36. A more rigorously designed randomized controlled trial is needed to validate these initial findings.
William C. Mann, OTR, PhD,
University of Florida,
2107A Health
Professions Building,
Box 100164,
Gainesville, Fl 32610-0164,
Office Phone (352) 273-6883,
E-MAIL: wmann@hp.ufl.edu