Managing innovation: a qualitative study on the implementation of telehealth services in rural emergency departments.

BACKGROUND: Telehealth studies have highlighted the positive benefits of having the service in rural areas. However, there is evidence of limited adoption and utilization. Our objective was to evaluate this gap by exploring U.S. healthcare systems' experience in implementing telehealth services in rural hospital emergency departments (TeleED) and by analyzing factors influencing its implementation and sustainability. METHODS: We conducted semi-structured interviews with 18 key informants from six U.S. healthcare systems (hub sites) that provided TeleED services to 65 rural emergency departments (spoke sites). All used synchronous high-definition video to provide the service. We applied an inductive qualitative analysis approach to identify relevant quotes and themes related to TeleED service uptake facilitators and barriers. RESULTS: We identified three stages of implementation: 1) the start-up stage; 2) the utilization stage; and 3) the sustainment stage. At each stage, we identified emerging factors that can facilitate or impede the process. We categorized these factors into eight domains: 1) strategies; 2) capability; 3) relationships; 4) financials; 5) protocols; 6) environment; 7) service characteristics; and 8) accountability. CONCLUSIONS: The implementation of healthcare innovation can be influenced by multiple factors. Our study contributes to the field by highlighting key factors and domains that play roles in specific stages of telehealth operation in rural hospitals. By appreciating and responding to these domains, healthcare systems may achieve more predictable and favorable implementation outcomes. Moreover, we recommend strategies to motivate the diffusion of promising innovations such as telehealth.

Tele-emergency behavioural health in rural and underserved areas.

INTRODUCTION: Challenges accessing behavioural health services in rural and underserved areas are compounded by severe shortages of behavioural health specialists, and difficulties placing patients. Tele-emergency (tele-ED) behavioural health is a promising solution for enhancing access to specialists and assisting in patient placement. This paper describes two tele-ED behavioural health models in the Midwest delivering mental- and substance use disorder services to rural and underserved adult populations. METHODS: We performed an in-depth examination of two tele-ED behavioural health programmes and their consultation processes. We provide a retrospective case-control analysis of patient characteristics, patient diagnoses, and disposition status for each model. Data were collected from 19 spoke hospitals across the two programmes between November 2015 and December 2017. RESULTS: Tele-ED was activated in 15% of the Avera Health sample and 58% of the Union Hospital sample. This is primarily a reflection of the sample selection process in each model and how each programme is operationalised. Suicide and/or poisoning by drugs were the most frequent diagnoses followed by mood disorders. Rate of transfer to another inpatient facility was much higher for tele-ED cases than controls in both models. DISCUSSION: This paper describes how two distinct tele-ED behavioural health models operating in unique contexts address challenges in access and placement for patients in rural and underserved areas presenting to EDs with behavioural health conditions. The notable difference in disposition rates between cases and controls is indicative of the impact each model is having on care practices and processes.

An Observational Study of Telemental Care Delivery and the Context for Involuntary Commitment for Mental Health Patients in a Group of Rural Emergency Departments.

Background: Rates for all-cause U.S. emergency department (ED) visits to rural critical access hospitals (CAHs) have increased by 50% since 2005. During the same time period, total number of U.S. hospital admissions for a mental health (MH) crisis has increased by 12.2%, with rural counties demonstrating the largest suicide rate increases overall. Introduction: Increasing number of rural patients are reporting need for MH care in the region's four rural EDs. Characteristics of ED telemental health services were evaluated, including MH diagnostic category, voluntary vs. involuntary commitment (IC), forensic vs. nonforensic presentation, ED throughput, disposition, and payor reimbursement. Materials and Methods: Observational 2.5-year program evaluation of telemental health care delivery for children (n = 114) and adults (n = 417) who were evaluated by a rural ED physician and received an MH diagnosis. Participants (N = 531) were treated by a licensed psychiatrist through telemental care delivery from September 2017 to April 2020. Results: Noncommitted ED MH patients (86%; n = 455) were distributed across three major diagnostic groups: (1) depression, anxiety, or other mental illness (35%); (2) substance abuse (33%); or (3) suicide risk (32%), with 47% admitted inpatients (IPs), 47% referred outpatient (OPs), and 6% admitted to CAH. Fourteen percent (n = 76/531) of ED MH patients were subsequently IC, with 67% of those assessed as needing IP care. Forty-nine percent (n = 37) of IC patients presented in police custody. Most common diagnosis for IC patients was suicidal ideation/attempt (χ2 [2, N = 452] = 12.884, p = 0.002). Admitted patients experienced significantly longer length of stay than those with OP referral (p = 0.001). Mean total payor reimbursements for ED MH care were significantly lower than actual ED costs (p < 0.001). Discussion: Innovative approaches to telemental care for IC and non-IC patients need to be piloted and comparatively evaluated in rural CAHs. Conclusion: As the gateway to critically needed MH care, rural CAHs and public services pivotal to care access (e.g., law enforcement) need additional resources and support.

Telehealth Increases Access to Care for Children Dealing with Suicidality, Depression, and Anxiety in Rural Emergency Departments.

Background: Targeted research efforts in implementation and evaluation of telemental health care for U.S. youth are needed to increase accessibility to care. Before telehealth, children and families may wait weeks for psychiatric evaluation. Introduction: Increasing numbers of pediatric patients are reporting the need for mental health care when they present to region's rural emergency departments (EDs). Outcomes of telemental health services were evaluated, with a focus on treatment throughput and referral. Materials and Methods: Observational 18-month program evaluation of outcomes for children age <18 years (N = 87) who received physical and mental health assessment by an ED physician. Children who subsequently received a mental health diagnosis were treated by a psychiatrist via telemental health visits (September 2017-May 2019) in 4 rural EDs. Results: The majority of children (ages 5-17) presented with depression- or anxiety-related disorders (49%) or suicidal ideation/attempt or self-harm (46%), with substance abuse accounting for 5% of cases. Mean ED wait times were 29 min [95% CI: 6-52 min] for children admitted to inpatient (IP) care compared with 33 min [95% CI: 22-43 min] for those discharged to outpatient (OP) care. Mean length of stay (LOS) of 8 h 56 min [95% CI: 166-906 min] was observed for children admitted to IP care compared with mean LOS of 6 h 58 min [95% CI: 382-454 min] for those discharged to OP care (p = 0.072). For suicidality cases, children who were subsequently admitted to IP care experienced a significantly longer mean LOS of 12 h 30 min [95% CI: 279-1221 min] compared with a mean LOS of 7 h 13 min [95% CI: 346-520 min; p = 0.015] for children discharged to OP care. Mean total payor reimbursements were significantly lower than actual ED costs (p < 0.001). Discussion: ED wait times and LOS were lengthy overall. Future evaluation of an evidence-based peds mental health triage screening tool is needed to support rural ED providers in peds mental health treatment. Conclusion: Additional resources and strategic policy supports are needed to bridge the mental health care treatment gap for rural children to address critical prevention, screening, and reimbursement needs.

Telehealth Decreases Rural Emergency Department Wait Times for Behavioral Health Patients in a Group of Critical Access Hospitals.

Background: Telehealth has been proposed as an important care delivery strategy to increase access to behavioral health care, especially in rural and medically-underserved settings where mental health care provider shortage areas predominate, to speed access to behavioral health care, and reduce health disparities.Introduction: This study was conducted to determine the effects of telehealth-based care delivery on clinical, temporal, and cost outcomes for behavioral health patients in rural emergency departments (EDs) of four Midwestern critical access hospitals (CAHs).Materials and Methods: Observational matched cohort study of adult (age ≥18 years) behavioral health patients treated in participating CAH EDs from 2015 to 2017 (N = 287). Telehealth cases were matched 2:1 retrospectively to nontelehealth control cases based on gender, age ±10 years, diagnosis group, and CAH, before implementation of telehealth in the rural hospitals (2005-2013; N = 153).Results: The greatest number of behavioral health cases evaluated was in the mood, anxiety, and other mental health disorders category. The majority of patients in the telehealth (74%) and nontelehealth (68%) cohorts were 18-44 years. Mean ED wait time for the telehealth cohort was significantly shorter at 12 min (95% CI 11-14 min) (p < 0.001) compared to a mean time of 27 min (95% CI 22-32 min) for the nontelehealth case controls (local provider only). The ED length of stay (LOS) for the telehealth cohort was significantly longer (M = 318 min vs. 147 min, p < 0.001) compared to the nontelehealth cohort. The end of telehealth visit to departure (EOTVtD) from the ED in minutes was evaluated to highlight factors potentially influencing delivery of behavioral health care in the ED. Across three behavioral diagnostic categories, time in minutes from end of telehealth visit to disposition/discharge was significantly longer for suicide and intentional self-injury cases (n = 100; 113 min, 95% CI 88-145; p = 0.004) compared to anxiety, mood, and other mental health disorders (n = 126; 66 min, 95% CI 52-83). There was a clinically meaningful difference in EOTVtD in minutes for substance abuse-related cases, which were shorter in length on average (n = 58; 71 min, 95% CI 54-94). Total ED costs for substance abuse-related cases for the telehealth (n = 58; $4556, 95% CI $3963-$5238) cohort were significantly higher than for the two other behavioral diagnostic groups (p < 0.001).Conclusions: Telehealth consultation in the ED for behavioral health cases was associated with decreased wait time and longer ED LOS. Similar to recent studies, the most common behavioral health cases involved mood and anxiety disorders. Costs related to treatment were highest for substance abuse-related cases, likely due to the additional interventions needed, especially related to resuscitation There are opportunities to improve ED efficiencies and post-telehealth visit protocols related to the timeframe extending from the EOTVtD from the ED, which continues to be a focus of future research. Additional research is also needed to determine if telehealth lends itself more effectively to specific categories of behavioral health cases.