Using Academic Consultation-Liaison Telepsychiatry to Meet the Mental Health Needs of Complex,Medically Ill Patients in Underserved Areas: A Case Report

Introduction

The nationwide shortage of mental health care resources is well documented, ^{1 –3} with rural areas facing especially pronounced shortages. Rural health care faces unique challenges, ^4,5 often related to limited resources or geographic distance from larger medical centers. Limited access to psychiatrists, particularly those with subspecialty training, is even more apparent in rural settings. ^{1 –3} Adequate responses to this deficit require increasingly innovative solutions. As rural hospital generalists and primary care physicians have taken on increasingly complex psychiatric assessment and management in both inpatient and outpatient settings, they would likely benefit from expertise of academic consultation-liaison trained psychiatrists for assistance. Telehealth resources grew exponentially during the COVID-19 pandemic ⁶ and could become a population health-oriented modality to meet mental health care needs in rural settings. Through our case, we aim to explore benefits and barriers of telepsychiatry utilization strategies to bridge mental health care disparities in rural settings.

Case Vignette

Ms. A, a 36-year-old female with history of depression and alcohol use disorder presented to a rural community hospital after 2 months of worsening cognitive impairment, ophthalmoplegia, and gait disturbance concerning for Wernicke encephalopathy. She left against medical advice (AMA) without psychiatric evaluation and was rehospitalized at a different rural hospital with worsening confusion and failure to care for herself. Subsequently, our telepsychiatry consultation (TPC) service was engaged to assess capacity for dispositional decisions.

The patient was eager to discharge but could not verbalize reasonable safety plans, including how she might navigate her home with new physical limitations, now requiring a walker. She incorrectly asserted that her home had running water and bathrooms, raising concern for confabulation. She was disoriented and could not state the date or her location. Montreal Cognitive Assessment ⁷ revealed deficits in visuospatial tasks (e.g., copying a cube), language, abstraction, and delayed recall. She reportedly scored 22/30, indicative of mild cognitive impairment (normal score ≥26). Despite her consistent preference for discharge, she was unable to comprehend associated risks. Our TPC service advised the primary team that she lacked capacity to leave AMA.

Over the next month of inpatient hospitalization with thiamine treatment and alcohol abstinence, she made marked improvements in cognitive and physical ability. As such, the primary team re-engaged our TPC service for reassessment of capacity. In the interceding time, the patient had learned to use walkers, could logically describe how she would utilize recommendations from occupational therapy to navigate her home, and could now accomplish basic cognitive (e.g., three-word recall) and attentional tasks (e.g., naming months of the year and days of the week backwards). Additionally, she demonstrated understanding of physical limitations and discussed risks/benefits of going home rather than seeking rehabilitative care. Importantly, she now accepted her team's treatment recommendations, including disposition. As such, the consulting psychiatrist determined she had capacity to accept recommended care.

Discussion

Although any physician can assess capacity, psychiatric consultation may be necessary in ambiguous/complex cases. In this case, our patient likely lacked capacity during initial presentation. If TPC had been engaged on initial contact, the patient's illness trajectory may have been altered, preventing further decline. Additionally, had TPC not been available subsequently, the primary team may have allowed the patient to leave AMA for a second time, potentially resulting in complications such as Korsakoff syndrome or death.

TPC represents a unique opportunity to meet mental health needs of rural areas with limited resources. The COVID-19 pandemic helped elucidate the value of telepsychiatry, first as a way to provide mental health care while limiting infectious disease exposure, ^{8 –10} then as a more population health-oriented strategy meeting broader needs. ¹¹ TPC can be useful in many emergency situations including crisis stabilization, safety evaluation, capacity evaluation, medication management, ¹² and patient volume surges during catastrophes such as natural disasters. ¹³

In community access hospitals without psychiatry departments, TPC facilitates timely and precise access to behavioral health crisis care. In cases where hospitals rely on outside contractors such as community mental health agencies, TPC can confirm findings of these contractors and provide physician care when otherwise only nonphysician behavioral health clinicians are available. Additionally, patients in rural settings presenting with increasingly complex psychiatric and other comorbid medical issues may require psychiatric consultants with subspecialty training and expertise beyond what generalists might provide. ¹⁴ Finally, in cases where patients require referral for inpatient psychiatric treatment, TPC can ensure appropriateness for these settings, obtain informed consent when indicated, and set patient expectations.

As a developing technology, optimization faces several barriers. For instance, telepsychiatry consultants may be from different health care systems and lack access to relevant electronic medical records data (e.g., laboratory/imaging study results, previously documented history). Cost remains a major disadvantage, as insurance may not cover TPC. ¹⁵ Additionally, if consultants live or work in a different state, they may lack familiarity with legal statutes of other states or locales. Although TPC may be particularly useful in rural areas, rural hospitals may not have access to reliable broadband internet connections and costly hardware solutions may be necessary to utilize these services. Finally, inherent to the nature of remote consultation, inability to perform in-person physical exam limits assessment.

Despite these barriers, there is some literature describing successful implementation of TPC services to rural inpatient and emergency department (ED) settings. ^{16 –20} When these services are unavailable, evaluations are typically performed by other physicians (e.g., internal/emergency medicine physicians) rather than psychiatrists. ²¹ Mental health providers generally have greater knowledge of community resources and are better able to perform targeted psychiatric evaluations. ²² These factors may create a milieu such that patients are more likely to accept recommendations from TPC. Utilization of these services correlates with several improved metrics including placement of fewer involuntary holds, more voluntary hospitalizations when deemed necessary, ^{23 –25} more community mental health referrals upon discharge, and lower readmission rates including those with self-harm diagnoses. ²⁶

However, it appears that consultants find teleconsults less satisfying than in-person consultation, but note value in improved access to care. ²⁷ Without the ability to conduct in-person physical exam, consulting teams may be apprehensive in placing consults for evaluation of delirium, agitation, and neurocognitive disorders. ¹⁹ This is consistent with previous evidence supporting telemedicine as an effective care delivery modality with high rates of patient satisfaction despite provider discomfort. ²¹

As telepsychiatry strategies and technologies continue developing, many improvement and optimization opportunities exist. If TPC can improve integration of historical clinical information into its platforms, this could streamline the consultation process and provide access to important clinical information during consultation. Additionally, with telepsychiatry skills being more broadly incorporated into psychiatry residency training, ²⁸ there may be opportunities for specific education around TPC skills within psychiatry residency and fellowship training. This training could expand across graduate medical education with other various medical specialties also finding success implementing teleconsultation. ^{29 –36}

Although available literature on telepsychiatric consultation is sparse, we found that our TPC service was unique from others for several reasons. Most notably, our TPC service provides consultation to critical access hospitals that are both unaffiliated with our health system, and in two separate states. Furthermore, while previous work has focused on telepsychiatric consultation to primarily ED settings, our TPC also can also provide consultation recommendations to inpatient general medical units. These qualities are new to TPC, and emerged during the COVID pandemic to address health disparities in psychiatry across rural Vermont and New Hampshire.

Conclusion

TPC is a developing and novel treatment modality by which mental health needs of broader populations can be met. Continuing to develop TPC programs may specifically enhance rural access to academic/subspecialty trained psychiatrists typically only available at academic medical centers in urban settings. Our case demonstrates not only successful implementation of telepsychiatry in a rural setting but also advantages this may provide by expanding access to consultation-liaison trained, academic psychiatrists, who may be better equipped to manage psychiatrically complex patients. While there has been some literature describing successful use of this technology, future work should focus on optimizing these processes and examining efficacy.