This article is part of State of Health, a series examining health disparities, how they affect Michigan's children and seniors, and the innovative solutions being developed to address them. It is made possible with funding from the Michigan Health Endowment Fund.
Removal from even the worst of foster homes is a traumatic experience for any foster child, and that experience can get even worse if the child doesn't have timely access to psychiatric services.
It can take a while to find a child psychiatrist and get insurance approval for the child to see that psychiatrist. But telepsychiatry services, which offer remote psychiatrist visits via videoconference, can help to close that gap – and hasten the child's healing process.
"This is technology most kids already know how to use," says Melissa Peters, director of behavioral health for the Royal Oak-based nonprofit Judson Center, which offers telepsychiatry for children and adolescents. "Some kids think it's cool and may open up a little more."
Telemedicine and e-health programs that allow patients to talk to medical staff via phone or videoconferencing systems have the potential to create more equitable access to health care, but these programs are currently underutilized for a variety of reasons ranging from insurance issues to slow adoption by clinicians.
Still, many private and public healthcare providers are expanding their telehealth programming to meet the needs of their most vulnerable patients.
"Telehealth addresses the sector of people that cannot even address acute medical and psychiatric issues, much less think about a journey to wellness or being a whole person, if they physically had to go into an office and see a provider," says Sara Coates, director of integrated health for the Michigan Primary Care Association, a networking organization of health centers and stakeholders established in 1978.
Coates says telehealth programs can address social determinants of health ranging from language barriers to issues finding transportation and childcare. Patients who have been traumatized and suffer from anxiety may also find it difficult to navigate a traditional office visit and may find it easier to talk to a psychiatrist from the comfort of their own homes.
Coates says equitable healthcare programs should be about meeting patients where they are, helping them take care of themselves, and setting them on a journey to being a well person. She says telehealth is an important tool that can help accomplish those goals.
Areas where telemedicine shines
Bruce Retterath, a licensed psychologist who serves as clinical director at Grand Rapids-based Pine Rest Christian Mental Health Services, says telehealth is especially helpful for three purposes: behavioral health and psychiatry, post-acute follow-up care, and chronic condition management. Healthcare centers receiving grants to explore telehealth options are largely focused on those areas.
"For patients with chronic care conditions who come in and receive care on a regular basis, telehealth is uniquely poised to help them," Retterath says. "They don't have to take half a day off work and drive in for an appointment. They can do it over their lunch break or early in the morning or after work."
Pine Rest uses telepsychiatry to support patients recently discharged from an inpatient psychiatric stay. Retterath says Pine Rest served 930 children and 440 older adults in inpatient psychiatric units in 2017. A grant will allow the nonprofit to use telepsychiatry to follow up with those vulnerable populations after discharge.
"It's been shown in various studies that having a connection with a health clinician within the first week of leaving the hospital positively impacts recidivism," Retterath says.
Joyce Lee, a professor of pediatrics at the University of Michigan's Child Health Evaluation and Research Center, recently received a grant from the Michigan Health Endowment Fund to use e-health to improve care for pediatric diabetes.
The e-health project allows doctors and others on the medical team to connect electronically with children and their families and teach families how to manage their own glucose control data and make adjustments themselves, saving them multiple trips to a clinic.
"There is a ton of data being generated by glucose monitoring systems, and understanding patterns in data and how to adjust an insulin regimen or behavior around exercise and food in response to that data is important," Lee says. "Our program trains families how to use technology for data management and how to make their own changes in dosage so they're not so dependent on the clinic."
Judson Center's telepsychiatry program focused on children and adolescents has been running in Macomb County for more than a year. The center also recently received funding to start a telepsychiatry program in Wayne County focused on children in foster care.
Peters says there are very few psychiatrists with a speciality in children and adolescents, and they often get snapped up by private healthcare systems or large hospitals, making fewer available to smaller healthcare providers and nonprofits like Judson.
Because of that shortage, Judson contracts with a psychiatrist in another state for both their Macomb and Wayne telepsychiatry programs, Peters says. Most patients also have the option of seeing a doctor in person, and telepsychiatry offers an additional choice.
"It's just an option that can be a good fit in terms of the doctor they want to see and availability of appointment times," she says.
Overcoming obstacles to new technologies
While Michigan is fairly progressive in terms of legislative and insurance support for telemedicine, there is still room for improvement.
Some clinicians are skeptical of new technologies and prefer face-to-face interactions. But even healthcare teams that are on board with telemedicine may have difficulty fitting telemedicine appointments into their existing workflow.
One psychiatry practice may block off an afternoon one or two days a week just for telepsychiatry appointments. In another medical or psychology practice, a medical assistant may run five or six cases by a doctor in person, make notes, and then hold teleconference calls with individual patients.
Retterath says Pine Rest already uses Epic, a secure web portal for providers to interact with and view managed care information, and the nonprofit hopes to integrate telepsychiatry into that system by the end of the year.
"The clinician will log in, and see they have a telepsychiatry patient on their schedule, and they'll be able to push a button right on the schedule that opens up a video session with the patient, who is coming in through the portal," Retterath says.
However, insurance coverage is often a bigger problem for these visits. While Medicaid has covered some telemedicine appointments since 2006, and 2012 legislation removed the requirement that physicians had to see patients face-to-face for reimbursement, the uses of telemedicine and telepsychiatry are still limited by insurance coverage.
Coates says that while Medicaid will reimburse for telepsychiatry appointments at Federally Qualified Health Centers, psychiatrists often charge a much higher rate for an hour than the reimbursement covers. The Centers for Medicare and Medicaid Services will eventually make up the difference, but often many months after the cost was incurred by the health center.
Retterath says some private insurances will pay for telehealth appointments, but only if they're conducted in a clinical setting. That means if a patient goes to a clinic and has a telepsychiatry appointment with an out-of-state doctor, that visit will be covered. But if the patient wants to talk to the doctor from home or the workplace, the visit would not be covered by insurance.
Lee also considers lack of insurance a "huge barrier" to increased use of telemedicine, and says only a minority of private insurers will cover a telehealth visit from a patient's home to a clinic.
"I wish all insurers would cover it," she says. "I really want a model that allows patients to do it from home."
Photos by Adam Bird.