School-based telehealth brings psychiatry to rural Georgia

During Sherrie Williams’ time in private practice as a social worker in Georgia, there was such a shortage of child and adolescent psychiatrists that many children she saw who had more severe problems or problems that may have required medication could not access needed treatment.

There were a number of reasons: “First, there aren’t many psychiatrists who specialize in children and adolescents,” she said, noting that waiting lists can be six to eight months long. Specialists tend to cluster in urban areas, while travel from rural areas of the state— sometimes requiring an overnight stay—can prove near impossible for many working parents. And, among those fortunate enough to schedule an initial consultation, many could not manage the monthly time and expense needed for ongoing treatment, said Williams, who is telehealth liaison and school-based telehealth specialist for the Georgia Partnership for TeleHealth.

“I could provide the therapy, but not the psychiatry,” she said. “Some children need a higher level of care.”

When Williams started working in the Ware County public school system, she continued to seek a better solution. With the help of grants, Williams found one, introducing a school-based health clinic with a telemedicine capability. “I was able to call the Georgia Partnership for TeleHealth and they were able to locate a psychiatrist,” she said. No longer did it matter that the psychiatrist was located in the Atlanta area, which was a 4½-hour drive from the county, in the extreme southeast corner of the state.

“Now the parents only have to come to the school,” Williams said.

Parents who are not able to take their children to far-away appointments on a monthly basis, or even for an initial evaluation, are not neglectful, according to Williams. “One single mom was only allowed so many days off per year, or she would lose her job,” she said. Just one visit with the Atlanta psychiatrist would mean at least two days away from work, hours behind the wheel, plus the cost of an overnight hotel stay—a proposition that was out-of-reach for the mom and for many working people like her. A sampling of parents participating in the telemedicine program found that, for each telemedicine doctor visit, each is saving 124 miles of driving—and significant lost time at work, Williams reported.

Lynn Rivers, nurse coordinator with the Ware County school district, says the program is making psychiatry available to children who otherwise just would not get it, and that involving the school is an important part of the process. “It’s helpful for staff to have a better understanding” of the child, she said. And she agreed that the most important part —helping parents connect with a psychiatrist without having to make the overnight trips to Atlanta—is key. “We do have a child psychiatrist locally, but in more severe cases of autism, we would want them to connect with a specialist,” she said.

“There aren’t enough child and adolescent psychiatrists to fill the need—their caseloads are already full,” Williams said. “We are looking outside of Georgia to contract with psychiatrists who are licensed in the state.”

Savings

Bringing telemedicine to the school resulted in a cost savings for the small (13-bed) local hospital, said Williams. The year after telemedicine was instituted, there was a 27% decrease in the number of children showing up at the emergency room, resulting in a $354,000 savings to state Medicaid (most of the patients in the area are covered by Medicaid). While not all of these visits were for mental health problems, some of the most difficult and costly ER cases involve children having suicidal thoughts or making suicide attempts.

The reach of the telehealth care relationship extends beyond school hours, too. “If a child becomes out of control during the evening hours, parents often don’t know what to do,” said Williams. The care relationships established through telehealth provide an additional resource to parents, since participating psychiatrists often provide an on-call phone number. Of course, if help is not available by phone, parents can bring their child to an emergency room for evaluation and possible transfer to a psychiatric hospital.

With school-aged children, some diagnoses are “as simple as ADHD,” said Williams, noting that many times, primary care pediatricians will provide the treatment and prescribe the medications. “But frequently, pediatricians are more comfortable with a psychiatric consult to make sure that is the correct diagnosis, and to adjust the medication,” she said. Psychiatrists can also rule out conditions, and recommend other tests, such as genetic tests, she added.

Autism spectrum disorders are more tricky, noted Williams. And for these, the school often turns to Felissa Goldstein, M.D., a child and adolescent psychiatrist at the Marcus Autism Center in Atlanta. “We need 10 of her,” said Williams. “She can’t accept any new telemedicine patients because she is so overwhelmed.”

Setting up services

Typically, a telemedicine evaluation is arranged for a child when the school and the family “know that something may not be okay,” said Williams. “We need psychiatrists who can work with the team —the teacher, the parent, me, the school nurse, the principal —everyone involved would be there while the child is being evaluated.”

“Telemedicine is not inexpensive,” said Williams. But, she added, enough organizations recognize its value to provide funding for school-based telemedicine projects. “The National Assembly on School Based Health Care is a wonderful resource,” she said, saying the school received some grants from the Washington, D.C.-based organization. In addition, some grants came from the urban health initiative from Emory School of Medicine in Atlanta.

The Healthcare Georgia Foundation also pitched in, providing startup money for the purchase of equipment and necessary staffing. And the federal Health Resources and Services Administration (HRSA) offers school-based health capital grants for up to $500,000 that can help with everything from high-end equipment “down to the most basic things like thermometers,” she said. Finally, in Georgia, an organization called Family Connection, with chapters in each county—can help build community partnerships, she said.

Equipment

Two of the companies that offer complete telemedicine “carts”—complete with monitors and cameras—are Cisco and Polycom. To carts like these, the Georgia Partnership for TeleHealth builds on additional equipment, typically including 3M Littman stethoscopes with Bluetooth, and an ENT scope from Robinson, said Williams. “With those two scopes you can do a complete examination,” she said. “You don’t necessarily need the ENT scope, but it’s recommended in case the psychiatrist wants to look in the ears, nose, or throat.”

The telehealth cart is located and used at the patient’s location; this is the “originating” site. At the remote or receiving site, the physician requires only internet access, a computer, a monitor, and access to the necessary software—typically the stethoscope software and a video software package like Cisco Jabber or Vidyo, explained Williams. Under the remote control of the physician, the camera at the originating site can pan, tilt, and zoom, enabling the physician to observe and follow the child as needed. “Children tend to move around,” said Williams.

For many children, especially those with autism, Williams believes that telemedicine is actually less intimidating than a face-to-face meeting with a clinician. “What I have seen is that as soon as the doctor comes on camera, the child makes eye contact,” she said. The child feels safe because the physician is “on TV,” she said. In addition, there is a picture display on the bottom of the monitor, and the child can see what is being transmitted to the doctor. “They really enjoy seeing themselves on TV,” she noted.

Medicaid

Insurance companies doing business in the state of Georgia are required to reimburse telemedicine visits at the same rate as they would for in-person visits under a law passed in 2005, said Williams. “I don’t know the exact rate” for the psychiatric evaluations, she said, “but I know Georgia Medicaid does pay.” Until recently, the only person who got paid was the psychiatrist. But just last month, Georgia Medicaid starting paying the originating site as well. “It’s not a lot – just $20 a session,” says Williams.
Rivers, the nurse in the school district, is pleased that the school can bill Medicaid for the on-site visit.

“There is,” she said, “a monthly fee that has to be paid” for maintenance of the equipment. The payments do help.

“We’re very excited about it,” said Williams of the Medicaid approval. “Medicaid recognizes that we are keeping children out of the emergency room, and that’s why they are paying.”