AMA STEPS Forward® podcast
Return on Health Part 2: Telepsychiatry
Dec 2, 2023
Featured topic and speakers
In 2021, the AMA, in collaboration with Manatt Health, released case studies featuring organizations that are measuring the value of their virtual care programs as part of the Return on Health Framework. Two years later, we’re checking in on the progress.
In this episode, Robert Findling, MD, of Virginia Commonwealth University Health shares how their telepsychiatry program has improved patient satisfaction, mental health care access and more.
- Explore this case study.
- Discuss on the Physician Innovation Network.
- Explore the Return on Health Framework.
Speaker
- Robert Findling, MD, Virginia Commonwealth University Health
Host
-
Stacy Lloyd, MPH, director of digital health and operations, American Medical Association
Listen to the episode on the go on Apple Podcasts, Spotify or anywhere podcasts are available.
Transcript
Speaker: Hello, and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.
Lloyd: Welcome back to the STEPS Forward® podcast. My name is Stacy Lloyd, and I am the director of digital health here at the AMA. I’m back with the AMA’s Return on Health framework, which helps health systems and practices measure the value of virtual care programs within their organizations. To bring the framework to life, we collaborated with various health organizations to gather case studies on their virtual care programs to better understand how they’re measuring value, and after two years, we’re checking in on the progress.
So our next guest is Dr. Findling from Virginia Commonwealth University Health. We worked with him on our original case study back in 2021, and we’re excited to have him here to give us an update. So welcome and thank you for being with us today.
Dr. Findling: Thank you for having me. It’s a real pleasure to be back. A lot’s gone on in the last two years.
Lloyd: Awesome. So to get us started, could you set the stage for our audience? Tell us a little bit about yourself, your role at VCU Health, any existing digital medicine and telehealth efforts that you’re working on, and then specifically, touch a little bit on the program that was part of the case study, which is your telepsychiatry program.
Dr. Findling: To start off, my name is Robert Findling. I am a practicing child and adolescent psychiatrist, but my role here at the University in our health system is I’m the chair of the department of psychiatry. So I have the privilege of overseeing a department that takes care of the behavioral health needs of children, adolescents, adults and elders, but we also have a particular emphasis on taking care of folks who suffer from substance abuse disorders as well. And so I’ve got the privilege, as department chair, of overseeing these multiple programs.
Lloyd: All right. So when we first highlighted the telepsychiatry program in 2021, it was really a program that was primarily built out of the need to provide remote care during the pandemic, which I think a lot of virtual care programs at that time, that’s how they really got started, right? So how has this kind of played out since the program launched, what has the growth of the program looked like, and/or how has it evolved since you first started it back in 2020?
Dr. Findling: Well, to your point, a point of great pride for us is we went from almost an exclusively in-person, outpatient series of programs to predominantly greater than 90% telehealth, mostly video telehealth, within about four days. And we really hit the gas. And the reason for that was our patients needed us. And we really had to stop on a dime and throw things together quickly. And as you’d imagine, there were all kinds of learning curves that came with that, just the practical aspects of managing this, particularly regarding areas about remaining connected.
Also, as you’d imagine, some of our patients are at risk of being in harm’s way, and how do you ensure their safety while you do all this? And so we were learning very quickly on the fly. Ultimately, when we last spoke, we were kind of developing at least enough experience that we were comfortable with what we were doing and most of the major challenges of just implementing this had been ironed out.
But in the last two years, we’ve had lots of new challenges as things evolve. And I think it’s those challenges that I believe have been essential to having us continue to succeed in serving the patients we’re privileged to care for.
Lloyd: What are some of those challenges that maybe you weren’t experiencing so much at the very beginning, but as you settled in and tried to look to potentially scale and/or think about this as maybe a longer-term program since the public health emergency lasted a lot longer, what were some of those challenges?
And do you still face them today with the coming of the end of the PHE that happened recently? How do you think about that, or what are some of those challenges?
Dr. Findling: The first thing to do is put this into context. The direct impact of the virus has waned, but for psychiatry, the emergency continues. The impact of COVID continues unabated and unrelenting simply because COVID was and remains a disaster. And every time there’s a disaster, even if the insult, the acute damage, is done, the psychological, emotional aftermath continues.
And so we anticipate that COVID, for us, will remain at this awful fevered pitch for at least the next three to five years. And let’s be clear, at the same time as you’d imagine, the demand for behavioral health services has gone up drastically, and the creation of new providers doesn’t happen overnight. So within that backdrop of too much to do, not enough people to do it, has been really something that we’ve grappled with and that we have continued to try to chip away at. But it’s going to be unrelenting and we don’t anticipate it changing.
From behavioral health perspective, the concern is, as the world shifts away some of its attention from COVID, we’re still here, our patients are still here. And I worry, personally, that that change in attention is going to kind of leave our patients not quite the focus of attention that they deserve. And the things that we treat are not only disabling, they’re lethal. And there’s new evidence that just came out not so long ago about higher rates of suicide in young people at younger ages. It’s likely to be ever worsening for years to come.
So within that context, there were also some practical challenges. Got a new electronic health record. It was a challenge and it remained an obstacle for a while. You finally learn one system, you finally got it kind of figured out, and then another system happens. And people were starting to get frustrated just because the rules of engagement and operation changed. And that was a speed bump that we negotiated, not without a substantial amount of dedication and effort.
And then as things changed, our patients’ expectations changed. So now we were able to offer patients options. Do you want to come in, or do you want to be telehealth? We really wanted to make sure it was telehealth and not just telephone health but with a visual component to it because ultimately, the goal was not to be more inflexible than necessary but to meet our patients where they were at.
Lloyd: That makes a lot of sense. I have a couple of things that I’m going to probably follow up on a little later related to the lack of providers and/or you can’t make new psychiatrists and support the influx of needs overnight. So we’ll get to that.
But I do appreciate where you sit within the health system and specialty-wise really are maybe even getting the brunt of the post-PHE effects, now that we’re beyond that, when people settle into what is now back to the old norm, maybe a new norm, but we just went through this monumental thing that’s going to really affect your patients and maybe cause a little bit more influx in your patient population in general.
So with that, as you likely recall, our framework looks at the following value streams: clinical outcomes, access to care, patient experience, clinician experience, financial impact, and then health equity across all of these value streams.
So when we developed the case study a few years back, VCU was fairly new-ish to doing this, as you mentioned, kind of stood this up in four days out of need. So a couple of things that you were measuring back then was access to care as measured by the number of visits, decreasing no-show rates, and increasing patient’s ability to actually be available for their appointments via this mode of delivery, and then a little bit around physician and patient experiences and/or relationships.
So would love an update on where those measures are and if there’re other things, now that we’re much further into this, that you have started to measure as a system or a department or a practice that has been impactful in the way that you look at the success of and the impact of the program.
Dr. Findling: The major benefits have basically matured and, for the most part, really been weaved into our entire ability to deliver outpatient care. If a patient needs to be seen in person, we can see them in person without the same challenges as before. If they don’t need to be seen in person, we can meet them where they live. If they want to come in because something is lost by being in a different room, we can do that.
But we’ve also allowed ourselves to remain available in a way that we weren’t before. We’re in Richmond. There are a lot of rural parts of Virginia, where access to care is sometimes geographically impeded, and that’s not unique to Virginia, but we know that there’s a discrepancy in access to care between rural parts of the country and less rural parts of the country as far as behavioral health care is concerned. So we were able to make a dent into that.
The other part of this certainly is we decided, rather than mandating patients needed to come in or weren’t allowed to come in unless there was some medical necessity that really needed a hands-on evaluation, we let the patients decide and it’s done a wonder. Our retention remains really robust. Our no-show rates remain remarkably low compared to historical precedent. It’s overall been a wonderful thing and we’re so lucky that we were able to do this. And it’s become just the way we do things.
Now, as the pandemic’s emergency has changed, certainly expectations about in-person care has changed, and we’re trying to meet that. And that comes with its own interesting challenges, not only for us, but for our patients.
Lloyd: Has tracking some of this impact of the program, specifically for the telepsychiatry, has it helped to gain additional buy-in for long-term use of this modality within the VCU health system and/or even beyond that in the state and policy space?
And then I guess my second question would be, even beyond continuing it in your department of psychiatry, has your experience and your department’s success in offering these services helped to expand that beyond other services and departments in the VCU system?
Dr. Findling: We’re lucky here. We were given the latitude and deference that you guys in behavioral health and psychiatry, you know your patients better than anybody. If it makes sense to you, have at it. And that’s a lovely privilege to not be, for lack of a better phrase, micromanaged. We were really given broad latitude. And again, I think that is a reflection of the respect that our department is given here. And again, you can see it. We’re retaining our patients, our no-show rates remain low.
We are meeting the needs of our patients, I would argue, perhaps better than ever before. And the patients who might not ever have been able to see us are grateful that they now have access that they might not have had previously. I mentioned rural locations, but some of our patients are infirm, and getting around is not easy. And there’re lots of data that many of the things we do are equally well-delivered virtually.
So from my perspective, it delivers the care patients benefit from. It offers an opportunity to reach people who might not otherwise be able to reach us, whether it’s geographic distance or other forms of access to transportation or infirmity. In many ways, it gave us an opportunity to treat the isolated and the vulnerable in a way that might not have been possible otherwise. So from my perspective, this has been a real opportunity.
But as the rules of engagement have been changed by regulations, now we have to adapt yet again. And the new adaptations come with their own challenges.
Lloyd: I said I was going to circle back a little bit to this in terms of thinking about provider shortages and physician shortages, but one thing that I really appreciated about what you said was that you give the option to patients, right, if they want to be seen in person. And I think sometimes when we talk about virtual care and telehealth, it’s, well, if it’s appropriate for telehealth, it should be done or it has to be done via telehealth. And I don’t think that’s the answer.
So I really appreciated that from your perspective and how you are thinking about it. It should be an option, right? And it should be something that a patient can choose if they want, if it’s appropriate to be seen that way. Or if they want to come in and that’s where they feel more comfortable, that’s great.
And I think it’s also a little bit of that from the physician perspective too, right, in terms of if you feel comfortable providing care that way and you feel like you can do it, great. If you prefer to see your patients in person, then that’s okay too. We just want this offering to be there, especially after so many years of it being there at this point, right, I feel like it would almost be more disruptive to completely pull it away.
So where do we find that happy medium, where it’s an option, right, and it’s used in a way that can provide seamless experiences for both patients and physicians and care teams too? Where I’m kind of going with this is the AMA recently released our Future of Health report that looks at the digital health disconnect, and really that gap between the potential for digitally enabled care, but today’s reality of it kind of functioning in a parallel world, where it’s in-person and virtual versus it’s just kind of a seamless experience that delivers the right care at the right time with the right modality. It sounds like you’re really doing that well already.
Dr. Findling: That did not happen organically. And I think that’s really important for you to hear. If there wasn’t a pandemic or we weren’t forced to see people virtually or telehealth, I bet you people might not have embraced this as warmly because this is the way they did it. But for quite a long period of time, if you wanted to see new patients or if you wanted to remain able to serve the patients we’re privileged to treat, this is what you had to do.
So in many ways, acculturating to this was not an option, but once it happened, people learned what they liked and didn’t like, got better at things they weren’t as comfortable with, and then it became part of our armamentarium so that when greater flexibility occurred, people were comfortable offering people options. I don’t think it would’ve happened organically unless, of course, the first year or so of this gave people no choice.
Lloyd: Yes, the silver linings. We have to look at them sometimes.
Dr. Findling: This taught us and gave us options and allowed us to feel comfortable offering options to our patients and their families that we never had before. And I think that’s terrific.
Lloyd: So internally, you’re doing that really well in providing those really great experiences for patients, but as we start to think about the physician shortages that we hear about and just general workforce shortages, especially in health care, I’d be interested in your thoughts on where the opportunity for digital health companies to support some of that is.
And I ask that because a lot of our Future of Health work that we’re looking at right now is really looking at positive, impactful physician, health system practice and company partnerships that are really working as seamlessly as your internal department would, but then you’re bringing another player in to support and augment those services. What do you think the opportunity is for that? Is that something you would find helpful in psychiatry, and maybe even what does that look like potentially for you?
Dr. Findling: So ultimately, it’s a great question. Certainly, there are plenty of vendors out there, particularly in behavioral health. Some of our residents who graduated during the pandemic, joined some of those telehealth-only services. But one of the things that we want, because we still maintained our academic mission, we did our strategy here. The academic medical center was really focused on not bringing in vendors here, necessarily, but really expanding the team. So what might have been previously mostly doctoral-level driven by psychologists and psychiatrists, we brought in master’s-prepared therapists who are licensed. We started up just an access program specifically geared to offer access.
And the other thing is, we also started working with advanced practice providers, the same idea. We are not putting all our eggs in one basket. What we’re really doing is offering opportunities for people who can contribute meaningfully to join us. And that involved this kind of care. Collaborative care, this way, is in many ways facilitated because you could have more than one person on the visit at the same time, if necessary. And in many ways, this has facilitated a broader interdisciplinary model of care, and excellent behavioral health care is a team sport. That can only help patients.
Lloyd: Well, I think that’s a really good way to maybe ask for any additional final thoughts that you have. I’d love to hear if you have any thoughts on the biggest opportunities that still exist, even in psychiatry or beyond, for digital health, for telehealth, for digitally enabled care. And then we can close it out.
Dr. Findling: I think our current challenges really involve maintaining the high level of care and not reverting to where we were before. But as mandates are now coming down that expect people to be seen in person, at least at various intervals, I understand those concerns. Certainly, we treat people with scheduled compounds, and I understand that’s a concern, but being thoughtful about what that means. And we worry.
There are people who are three hours away from here that we would never have been able to see. And now we’re going to say, you need to come out here at least whatever the interval is. That impacts the patients on a practical level. And ultimately, I don’t quite think the world is ready for having some kind of collaborative care model, where people can live three hours away, have some of this done locally, and then maybe make a hike out here perhaps less frequently. We’re not really set up to do that. But that is an opportunity, isn’t it, getting people’s care closer to home and still maintaining some kind of connection from afar.
And then ultimately in our hands, the other challenge is simple and practical. As I mentioned, we built up our capacity, and I’m very proud of the fact that we built up our capacity to a substantial degree. But now we’ve hired all these people and our patients are coming back. Where do you put them? At what space? You’ve had an office for 20 years, but you’re only coming in one day a week. You’re not going to have your own office anymore.
So there’s a whole coordinated effort that seems a bit mundane, but it’s just the practical exigency of, oh, my gosh, we’re going to see more outpatients in person than before with more providers than before. We’re not always on site, and how do you coordinate that to meet regulatory expectations that seem to be changing. As these changes occur, they need to be done thoughtfully and carefully. I understand why some of the concerns exist, but at the end of the day, gosh, it would be a shame to lose this ability to help people in the way we’ve been able to.
The idea is to allow things to be thoughtful going forward and just for people to remember that for psychiatry, the pandemic is still with us, and it will be with us for years to come.
Lloyd: Well I think that is a great note to end on and a great reminder that we’re still not out of the effects of this at the end of the day. So thank you so much for joining us today. It was a pleasure to catch up with you and look forward to continuing to track the progress of your program at VCU Health.
Dr. Findling: Thank you.
Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA's STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
