Abstract
At the southern end of Appalachia in northern Alabama the flat top remnants of the great mountain range are covered in oak forests. The valley between is broad and rich and still reminds us of the great Cherokee population that lived here, the alphabet of Sequoyah that he created here, the tragic deportation of the indigenous people, and the traditions of the pioneers that still rule in this region: self-reliance, independence, and hard work.
At a recent meeting of the Rotary Club, members gathered for an “all you can eat” at a local cafeteria to sustain the Alabama reputation of facilitated obesity and community spirit. The program for this day was presented by one Thomas Whitten, Director of the County Youth Service Center. He was introduced by a community activist and member whose efforts for children and other worthy objectives resonated well with her energy, talent, and abilities in business and community affairs. The director described a wonderful program of telepsychiatry for children and adolescents that had begun in this rural county of some 70,000 that has no full-time psychiatrist and no one in many miles with special experience in child psychiatry. For anyone in the telemedicine community, the presentation should have been altogether familiar. However, the story diverged from the routine in ways that made this telemedicine tale worth reporting.
The lack of services in this depressed area was appalling. The closure of the sock mills had been crippling to the economy. Yes, socks. This was the Sock Capital of the World after the spinning device that produced them was invented here and socks could have heels in them. However, that has gone away, and the work force either commutes long distances or is populating a pretty impressive number of initiatives in manufacturing such as garbage trucks. The only test track for garbage trucks in a very large area is right here in Alabama. The lack of services is not trivial. It is pervasive, hurtful, and tragic despite a devoted local hospital, great local doctors, and a proactive community. However, you do not get a child psychiatrist for 70,000 people. The adjacent counties are in a similar situation. The psychiatric needs in the legal sector alone are overwhelming with prolonged detention, undiagnosed and untreated problems, family crises, and poor school performance. The local activist approached the local judge, and meetings were held. Then came the time for energy and insight.
The county discovered telepsychiatry on its own and set out to make it happen. The local people knew that telemedicine was a technical matter beyond their skill level, and they were referred to the County Technical High School. The principal knew little of medicine and declared no resources or contacts. However, he said they had distance-learning equipment and were recent beneficiaries of the Broad Band Initiative. If the group could use the equipment for children, they were more than welcome to share. Lovely word, “share”! In the parlance of technocrats that is called multitasking, but sharing is so much a warmer word! Then the activist called the University of Alabama Department of Psychiatry and asked if there was anyone in the University who could do psychiatry through televisions. Oh, yes, there was. Dr. Lloyda Williamson, associate professor of psychiatry at the Tuscaloosa campus in the program of rural medicine, knew a great deal about that, having been engaged in a telepsychiatry program begun in 2007.
The University sent a feasibility team and found the distance-learning equipment was fine, and the school could provide a private place for appointments. The Center Director said he could arrange appointments and vowed to attend every session to assure the guidelines of the University's program were met. He contacted the local doctors, courts, and schools and found that routine appointments for troubled children would be a blessing!! The University's team said that because there was no established psychiatric practice with which to interact, the telepsychiatry program would need to articulate with the child's primary care doctor with its recommendations and that that doctor would handle prescriptions. Family counseling, chronic management, and selected interventions were to be routine. Someone in the lunchtime Rotary audience asked the obvious question as to who would pay for this. The activist had contacted Medicaid and got a thumbs up. Private insurance was not as sure, but some were very positive.
What is different about this story so far? This program did not emanate from a site of telemedicine expertise, followed by needs assessment, and the inevitable challenge of technology, facility, staffing, and buy-in. It started where a community saw the need and found telemedicine for itself. There was no national or regional initiative that reached out to a hapless underserved population. No, an enlightened community had a sense of what it needed. That community learned about telemedicine and found its solution. NO grant and NO budget.
The program runs every week and has been a huge success. There is no staff beyond the Center Director and his crew. The technology is maintained by the County Technical High School. The professional staff is provided by the University, and services are paid by Medicaid. This is nice. There is a program with essentially no budget but boundless enthusiasm that is gratefully accepted and endorsed by families and doctors and is a matter of huge pride for the Farmer's Telecommunications Cooperative that manages the broad band program. In their newsletter of December 2012, they described the program and lauded the community and providers who had made it possible. Hoorah for broad band!!
What does the program do? The audience at the Rotary asked all the right questions. They already covered the payments. Then they asked the hard one. What do you actually do? The answer was astounding. The Director knew precisely the diagnoses: attention-deficit hyperactivity disorder, disruptive behavior, bipolar disorder, and posttraumatic stress disorder. Yes, the latter has been a huge issue in not only dysfunctional families but also in the aftermath of April 27, 2011, when tornadoes excoriated the countryside in 42 of the 67 counties of Alabama. In DeKalb County, over 1,000 houses were damaged, with a total loss of 300. The people of this county rely heavily on mobile homes; 154 were damaged, and 78 of the fragile shelters were completely destroyed. The county lost over 500 barns and 63 chicken houses. However, in the state 238 people died, and many will never forget the tales of one family member being sucked away into the abyss from whatever shelter could be found in the few minutes of warning before the massive twister ground its way across the two mountains and the system ripped on to Georgia. Hundreds of children ended that terrible day in the cacophony of cyclonic winds at F5 with shattered homes, scattered and lost possessions, destroyed businesses, broken families, and devastated lives, huddled in the growing darkness of that spring evening with debris, rain, and cold, where there had been structure, security, love, and warmth. Well, telepsychiatry became the mainstay for professional intervention for the children so traumatized.
The program also became aware of a troubled youth in a school just a few months ago. With encouragement from family, school, doctors, and community the program arranged for a very private intervention in response to a gun at school. The court had its mandate, and telepsychiatry was a major part of the intervention and remediation.
Someone asked if any of the children required medications. Yes, that would be 85%. This is not a program for the child with a minor problem. This is mainstream, in-depth, and highly specialized psychiatric intervention, and apparently it is working in a place that had absolutely no service prior to its inception. What about privacy and medical confidentiality? Covered. Could you tell us more details about cases? No! Besides, the editor of the local paper was here! What if the child or family does not accept an intervention? No different from any other psychiatry case. Reference to family services and child protection services is needed, and you do what you can. What can the courts do? Not much until there is a crime or referral from child protective services. In other words, the program is just the same as psychiatry services that we never had before anyway!!
The audience was very keen to know when other medical services also lacking in the county might come by telemedicine. The consensus was that services could get going pretty quickly if the local people just sought them out! This is grassroots telemedicine and should serve as an encouragement to all of us in telemedicine that the time is here when demand will catch up with even our frenetic enthusiasm, and we should be ready to respond. Telemedicine works!