The Virtual Way To Mental Health Care

^{Image credit: Istock}Panic attacks had begun to overwhelm Matty Pitts, and he'd shown up at his doctor's office for help. The physician quickly connected the 22-year-old to a therapist - via computer.For the next 25 minutes, Pitts, sitting in a quiet exam room at Lincoln Family Practice in a rural county northwest of Charlotte, talked face to face with Julia Sherrill, who was on duty 40 miles away in Davidson. He told her about "the rough spot" he'd been having. A breakup with his longtime girlfriend. His father's death two years ago.When the session ended, a flurry of behind-the-scenes phone consultations took place among therapist, doctor and an on-call psychiatrist working in a third location. And just like that, Pitts got a new prescription and a plan for follow-up. Sherrill was "very understanding," the young man said later. He'd never met before with a mental health professional. "I feel like it helped."The family practice, part of the Carolinas Healthcare System, is on the front line of an ambitious plan to integrate mental and physical health care via technology. Integration has become the mantra of many systems nationwide, but Carolinas' work relies on virtual teams of specialists collaborating with its primary care practices.John Santopietro, chief clinical officer for behavioral health services, says system leaders feel they have little choice. North Carolina suffers one of the country's most acute shortages of mental health professionals. Nearly half of its 100 counties have a single psychiatrist at best. That means primary care doctors are the ones seeing, and trying to treat, the bulk of patients' often serious behavioral health problems.Early results are promising. The "telemental health"effort began in March 2014, and more than 50 of Carolinas' 200 physician practices are now participating in some aspect. They've seen scores on depression and anxiety screenings fall by nearly half, according to officials."The very fact that we are identifying patients in primary care who are having suicidal [thoughts] is a victory," said senior vice president Martha Whitecotton."These are the friends, neighbors, mothers, brothers, etc. that commit suicide, and people ask themselves why they did not see it coming."Behavioral health care has long been divorced from primary care, even though the evidence show that doing so leads to higher overall costs - up to three times higher, one study found - and poorer patient outcomes. Individuals with depression or anxiety are less likely to be compliant in taking medications or otherwise following doctors' direction. And research has suggested that people suffering from depression, for example, are at considerably higher risk of getting diabetes.Health systems are using various strategies to treat the whole patient. Utah-based Intermountain Health Care teams primary care providers with on-site psychiatric nurse practitioners, social workers and psychologists. In the Midwest, Advocate Health Care launched a hub-and-spoke approach last summer at four of its Illinois hospitals. Mental health teams at a central location provide around-the-clock virtual and telephone consults, screening high-risk patients on medical floors and those arriving at emergency departments.
 ^{Image credit: Istock}Until recently, there has been little or no financial incentive for such integration. But the Affordable Care Act is prompting greater change by rewarding providers who improve patients' overall health and reduce unnecessary hospitalizations. Another trigger is a federal parity law requiring insurers to provide mental health benefits at the same level as benefits for other medical care.Telemental health has particular appeal for younger patients, who are used to the convenience of online shopping and keeping up with family and friends through Skype and other social networking sites. Yet experts say virtual visits have broad value. Federal statistics show that about 80 million Americans live in areas with too few mental health professionals. In rural communities, long distances may only exacerbate shortages.Despite hurdles in some states, including training and licensing requirements, Carolinas' effort is drawing attention. Executives hope to have all of its physician practices looped in over the next decade. The goal, Santopietro said, is to extend behavioral health services to its 39 hospitals and 900 care locations in North Carolina, South Carolina and Georgia, "leveraging virtual care to do so."Costs are about $350 per patient, although those are likely to decrease over time. Whitecotton said other hospital systems are already asking for guidance in starting their own programs.
        
"I definitely think it's one to watch," said Melinda Abrams, a vice president at the Commonwealth Fund. "Mental health has been stigmatized and separated, but experience and data show that people will be healthier if they are in fact, treated together."
        
The Carolinas behavioral health team includes seven licensed social workers who conduct the virtual visits via computer, seven health coaches who follow up with patients on the telephone, and a nurse practitioner and psychiatrist who handle medication recommendations. The team is connected digitally across three sites.
        
Since the program launched, more than 3,000 patients have been referred for mental health services, according to program coordinator Melissa Candela. Virtual face time with the social workers takes place only in the beginning, but the phone follow-up calls continue on average for as long as four months. As of late October, about 800 patients were being actively managed with such calls.
        
The tele-services are provided at no extra charge on patients' primary care appointment. Most individuals have common issues such as depression and anxiety. People with severe mental illness are referred to outside psychiatrists.
        
Therapist Crystal Centeno works in an office in Charlotte, where some days she does up to seven virtual consults. Her first on a recent morning involved a 54-year-old man, who had gone to see his primary care doctor and admitted he was depressed. He tells Centeno he's heard voices for 15 to 20 years - information he never has shared out of fears he would be hospitalized.
        
"Do the voices ever tell you to harm yourself?" she asks, talking on a headset while watching him via computer. No, he says.
         
"Do the voices ever tell you to harm other people?" No.
        
"Is there anyone in your life you consider supportive, anyone you can call?" Again, no.
        
When they finish, Centeno confers with psychiatrist Manny Castro, who is on site that day. Castro recommends a medication for depression and a referral to a psychiatrist for treatment. Centeno calls the patient's primary care doctor and relays the options. She also enters details from both conversations into the man's medical chart.
        
She asks his doctor to give him the contact numbers for the behavioral health team, a 24-hour crisis hotline and a downtown Charlotte community clinic that offers mental health services on a walk-in basis.
        
"He can walk in anytime," she says. "It's near the Social Security office."
        
Primary care doctors within the system often hesitate initially to embrace the program, Castro said. Given time-crunched days, they worry that it will allow even less interaction with patients. But they soon realize that integration works in their favor; Pitts' doctor at Lincoln Family Practice said that while one patient is in a virtual session with a therapist, he can see other appointments and then loop back afterwards.
        
Plus, added Daniel Senft, the program is helping him learn to spot signs of mental illness earlier.
        
For many patients, including Gerald Manes, the telephone follow-up alone is often enough support to help them cope.
        
Manes, who owns a concrete company, realized last fall that the antidepressant he'd been taking was no longer effective. He was coping with a lot, too. He'd hurt his back falling off a ladder, couldn't work and was behind on his mortgage payments. Plus, he was struggling to help his son, a heroin addict.
        
"I was getting so emotional that if I saw somebody run over something in the road, I'd want to have a funeral," he said in an interview.
        
In September, Manes went to a primary care practice near his home in Midland, about 30 miles outside of Charlotte. He brought his old pill bottles. Physician Max Kelly saw that the antidepressant prescription was expired.
        
"It was evident that he was suffering from major depression," said Kelly, who suggested a new medication. But because Manes was uninsured and paying out of pocket for every office visit, the physician didn't want to ask him to return repeatedly.
        
"I told him, 'I don't know if this will work, but you can talk to behavioral health to see how things are going and if you're getting a response, '" Kelly remembers saying.
        
At first, Manes ignored the phone calls. It took nearly a month before he realized they weren't from telemarketers but from coaches on that behavorial health team.
        
His response to the new drug wasn't that great, the doctor recalled, so the team recommended another switch. More telephone calls led to a change in dosage. "Ever since then, he's been doing wonderfully," Kelly said.
        
Manes, 57, can't believe his luck. The follow-up calls have been nothing short of a blessing.
        
"They are so caring," he said. "I feel like I was talking to angels."© 2015, The Washington Post