Telepsychiatry: Picture to Picture, Face to Face

Eye on LSSI, Winter 2007-2008 ( Download PDF of entire publication)

It’s nine o’clock on a Thursday morning at the Nachusa Lutheran Home in rural Illinois. In about five minutes, 16-year-old Tommy*, a Nachusa Home resident for the past three months, expects to meet with his psychiatrist, Dr. Chris Fichtner, who just happens to be in Des Plaines, a suburb of Chicago that’s about 90 miles east. But all is copasetic.

Via a pilot project initiated in January 2007, Lutheran Social Services of Illinois (LSSI) has adapted the use of videoconferencing technology that lets Fichtner and Tommy or other clients from Nachusa’s treatment program “meet” face to face, although they are miles apart.

The actual video system equipment is called PolyCom.VSX-7000. A high-speed cable connection links the Nachusa Home and the conference room at LSSI’s office in Des Plaines. A secured call-up number and closed system allows communication only between those two sites, thus preventing any breach of confidential information. Both parties adjust a camera on their end, and a split-screen enables them to talk to and see the other person, as well as themselves, at the same time. The sensitive, state-of-the-art equipment can pick up subtle facial expressions and intonations of voice, provides high-quality sound and picture, and is easy to use.

Once Fichtner is “on,” a therapy session can begin. The session also usually includes the client’s primary caseworker at Nachusa, along with staff nurse, Barb Downey.

Fichtner originally came on board last year as a consultant to LSSI. He is boarded in general psychiatry and was the director of the Illinois Division of Mental Health (DMH) for two years (2003-2005) and before that, an administrator in mental health for 10 years. He currently has a private practice.

Fichtner sees an average of 10 to 12 kids a week, treating 100 LSSI clients overall. Twenty-four of the adolescents reside at Nachusa. Others are from the community or live in foster homes. Aside from the videoconferences, he makes a monthly visit to the facility for face-to-face sessions with clients.

As DMH director, Fichtner enjoyed developing ways to help individuals access mental health care and saw a shortage of mental health providers in rural areas. He was also aware of telemedicine or telepsychiatry programs.

According to Fichtner, telepsychiatry has been around for more than 40 years. It’s also been recognized for at least a decade as one strategy for increasing access to psychiatric services in underserved areas.

“Recruiting psychiatrists is not easy, especially in rural areas. The shortage of psychiatrists is especially severe when it comes to child and adolescent specialty psychiatric services,” he says.

The new program was initiated and achieved through a team approach. Mike Ouska, LSSI’s chief information officer, and Julie Kovacin, program director of LSSI’s Portage-Cragin Counseling Service in Chicago, made significant contributions to start up the program.

According to Kovacin, they worked through location, training and confidentiality issues. “The distance immediately presented problems,” she explains. “There were issues about where to keep the original chart and how to deal with it. This [presents] a problem, since the doctor and the pharmacy are not [located] where the client is, and there are rules [about] pharmacy prescriptions being originals. The nurse was a big piece of [solving] this [problem],” she adds.

For his part, Ouska looked at other social service agencies in Wisconsin that were using teleconferencing programs, watched demonstrations and talked to vendors.

“There were many options to buy,” he says. “The equipment is very high quality, and communications are easy. Participants don’t have to worry about equipment being in the way of the experience.” IS technicians are available to troubleshoot if necessary.

The new treatment vehicle receives a positive response

Tommy, who claimed to be terrified when first driven from the suburbs to the “cornfields” of north central Illinois, has gradually become more comfortable with the program.

“I was scared to participate at first,” he says, “but the program is very helpful and does work. It’s easy talking to the doctor. He gets you to feel right and get your moods back to normal. He talks to my aunt, too. I would tell others [clients who might be interested in the program] that it does work, if you’re open … but you’re not going to get anywhere if you’re not open.”

Adolescents like Tommy are the primary clients seen by Fichtner. Individuals served in the residential programs at Nachusa range in age from 12 to 17 years old and are involved in LSSI’s Alternatives to Detainment program (ATD) or the Choices unit. ATD is for youth who are involved with the juvenile justice system and are at risk of entering the Department of Corrections, and Choices is an inpatient substance abuse unit.

Stacy Noble, admissions coordinator, says having the Telepsychiatry Program has been a turning point for the program.

“LSSI has upgraded [its services] with technology, and other agencies may start using it,” she says. “It’s an effective way of providing services.”

Steve Hudzik, director of Nachusa Lutheran Home, says kids served by the program have responded very well to it. “They seem to enjoy this method of interaction and have even reported being more at ease during the sessions because they don’t feel as intimidated as [as they would if] speaking with a doctor in person,” he says. “Also, they are much more computer-oriented [than many adults] and very familiar with technology.”

Psychiatric services are and always have been a major and necessary part of the programs offered through Nachusa and LSSI.

For the last decade, prescription and treatment decisions were handled by Dr. Robert Slack, a psychiatrist who traveled regularly from Rockford to Nachusa. But last year, he announced his retirement. So, LSSI needed to find someone else to provide psychiatric services.

Overcoming the obstacle of distance

“We were in a bind,” he says. “We always had a psychiatric component to treat clients. Some doctors came on site. Some had contractual arrangements. But finding psychiatric services outside Chicago is difficult. The more rural [the area], the more [it] costs for them to come [out here].”

Then, Franklin recalled hearing about a program three years earlier similar to the Telepsychiatry Program. “I thought it might be cold [and impersonal],” he says. “But our psychiatrist was retiring, and I thought it was worth looking at.”

After visiting and reviewing telepsychiatry programs at other agencies, and seeing how it works at Nachusa, Franklin now thinks differently. “Adolescents are the primary clients seen by Fichtner, and they’re not as concerned [about the technology] as adults [would be],” he says, adding, “Adjustments were more difficult for staff, but now the caseworkers and nurse are very comfortable.”

Franklin says they are also using the program in other ways. “Using the equipment for a teleconference instead of [requiring] staff [to drive in for a meeting] is a true time-saver,” he says.

“The Telepsychiatry Program allows us to have more actual client service hours, since we do not have the cost of the travel time for two of three visits per month,” he adds. “We’ve always had to pay for the psychiatrist’s travel to and from Nachusa. Now, we are able to get more psychiatrist’s time for our dollar. It also more attractive to potential psychiatrists who might serve our clients, since they do not have to commit as much of their time to travel.”

According to Franklin, the pilot phase of the program is over, and the program is now in an operational phase. The Telepsychiatry Program has been so successful this year that the agency is looking at the possibility of expanding the service into other rural areas. Fichtner has suggested bringing in another psychiatrist with child and adolescent specialization, as well as an advanced practice nurse to pair up for a cost-effective program that may be offered in central and southern Illinois, if LSSI is able to secure funding for it.

“Our Telepsychiatry Program is an example of just how creative LSSI is able to be in providing quality services to our clients we serve, even with the obstacle of distance,” adds Franklin. “It’s another way our agency is innovative and client-focused.”