By Lena H. Sum
December 8, 2015
LINCOLNTON, N.C. — Nearly half of the counties in this rural state have a single psychiatrist at best. People in many communities face hours-long drives — or ferry rides — to see a therapist, counselor or even social worker.
But in concert with some of its hospital systems, North Carolina took a lead in tackling the shortage problem. These days, mental-health services may just as likely be delivered by computer or telephone.
The shift comes as health systems nationwide increasingly incorporate mental-health care into traditional health care — recognizing that a body might not heal if a patient is depressed or anxious. The Affordable Care Act has helped to propel change, as has a separate law requiring parity between benefits for mental health and physical health.
Integrated care is next to impossible, however, if there aren’t enough mental-health providers.
Building on a long-standing telemedicine center run by East Carolina University, the legislature in 2013 approved a statewide telepsychiatry program to increase access to patients in emergency rooms. The initiative, which launched last year, has been followed by two special mental-health task forces and a separate push by the state’s largest private system to expand “telebehavioral health” through primary-care clinics and providers.
And that’s why 22-year-old Matty Pitts recently found himself in his doctor’s office, talking for the first time ever with a therapist — via a computer screen.
Sitting in a quiet exam room at Lincoln Family Practice in the rolling hills northwest of Charlotte, the young man talked face to face with Julia Sherrill, who was on duty 40 miles away in Davidson. He told her about “the rough spot” he had been having. A breakup with his longtime girlfriend. His father’s death two years ago. Panic attacks that had begun to overwhelm him.
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. “I feel like it helped.”
The family practice is part of the Carolinas HealthCare System, which relies on virtual teams of specialists collaborating with primary-care doctors to identify and treat people so that they don’t wind up in a hospital emergency room. Early results have been promising. Carolinas’ effort began in March 2014, and more than 50 of its 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,” Carolinas Senior Vice President Martha Whitecotton said. “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 evidence shows 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.
Health systems are using various strategies to treat the whole patient. Utah-based Intermountain Healthcare links 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 in which mental-health teams at a central location provide around-the-clock virtual and telephone consultations and screening at four Illinois hospitals.
Telebehavioral 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 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.
Despite hurdles in some states, including training and licensing requirements, worries over privacy laws, and reimbursement issues, programs continue to grow. John Santopietro, Carolinas’ chief clinical officer for behavioral-health services, said the goal over the next decade is to extend behavioral-health services to its 39 hospitals and all physician practices across North Carolina, South Carolina and Georgia, “leveraging virtual care to do so.”
Costs are about $350 per patient, though those are likely to decrease over time.
“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.
More than 3,000 patients have been referred for services so far, according to program coordinator Melissa Candela. Virtual face time with the social workers takes place only in the beginning, but the 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 teleservices are provided at no extra charge to 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 consultations. Her first on a recent morning involved a 54-year-old man who had told his primary-care doctor that he was depressed. He tells Centeno he’s heard voices for 15 to 20 years — information he has never shared out of fear 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 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.
Primary-care doctors within the system often hesitate initially to embrace the program, Castro said. Given time-crunched days, they worry that it would allow even less interaction with patients. But they soon realize that integration works in their favor; Pitts’s 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 afterward.
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 that the antidepressant he’d been taking was no longer effective. He was dealing 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 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 said.
At first, Manes ignored the calls. It took nearly a month before he realized they weren’t from telemarketers but from coaches on the behavioral-health team. He wasn’t responding well to the new drug, so the team recommended another switch and then a dosage change. “Ever since then, he’s been doing wonderfully,” Kelly said.
Manes, 57, can’t believe his good fortune. 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.”