As the primary provider of inpatient behavioral health services in the Central Alabama region, Baptist Health is depended upon by its community at large to provide high-quality and continuous care without interruption.
THE PROBLEM
Staff have been working to resolve two separate but interrelated issues surrounding this imperative service line.
“The first issue we needed to address was the ability to efficiently and effectively assess patients who have been deemed at risk for suicidality for potential inpatient admission by our team of trained mental health services staff,” said Julie Firman, DNP, RN, system chief nurse executive at Baptist Health.
“All patients who come through our doors are screened by a registered nurse using the Columbia Suicide Severity Rating Scale (C-SSRS) to quantify initial risk level; however, patients who screen moderate- or high-risk require additional assessment by our qualified psychiatric intake team.
“On our Baptist Medical Center South campus, our tertiary care center and largest inpatient facility, we have Crossbridge Behavioral Health inpatient psychiatric facility, which is staffed 24/7 with intake team services,” she continued. “Our dilemma was how to create a streamlined workflow so that they could support our other acute care facilities – Baptist Medical Center East and Prattville Baptist Hospital – in the most efficient way possible during times when they did not have intake team coverage.”
Physically commuting was not efficient at all and telephone assessments, while more feasible, did not allow the intake team to fully assess the patient’s affect, mood and general demeanor to help determine the best and safest course of treatment, she added. It is very difficult to paint a full clinical picture via telephone only, she said.
“Second, we are very proud of our progress in opening and maintaining an inpatient geriatric psychiatry unit at Prattville Baptist Hospital, our community hospital that has served the area for over 70 years,” she noted. “This new service line is part of our long-term strategy at Baptist Health, and we knew going in that it would be difficult to recruit and retain psychiatric medical staff to support our efforts in this space.
“We have a fantastic medical group that provides coverage to this unit; however, there were certain scenarios and timeframes where we needed to look at creative alternatives for maintaining appropriate coverage around the clock,” she continued. “Our overarching goal for this unit was to develop a method to maintain continuity of care for this vulnerable patient population.”
PROPOSAL
Staff knew from the beginning that a telehealth system could provide value in helping to remediate these issues.
“Our organization already uses a virtual nursing platform and service, so we were fortunate to have some experience in this domain as well as existing audio/video infrastructure in place to use as a starting point prior to these behavioral health use cases surfacing,” Firman explained. “We have about 480 beds installed with our virtual nursing platform – including every inpatient medical-surgical bed, every emergency department bed and four intensive care units – across our three acute care facilities.
“Our goal with expanding the use case into behavioral health was to leverage, to the extent possible, this existing hardware and software setup,” she continued. “As this equipment is all hard-wired and installed into each patient care room, we also understood that we would need some modality of mobility to support the assessment of patients who were not physically in locations where we have the system available.”
Within the geriatric psychiatry unit, the logistics were a little more complicated. An extenuating circumstance within this unit was that staff were not able to use the existing in-room virtual nursing platform.
“We were unable to originally install the hard-wired equipment, as at the time we did not have a way to maintain the anti-ligature requirements for meeting standards of care in treating mental health patients while still maintaining functional quality of the audio and video to provide a usable caregiver experience,” Firman said.
“In this case, we turned to a separate telehealth platform that was already present within our organization as well to fill this void,” she continued. “Our primary outpatient and ambulatory telehealth software is already set up to be used via mobile device, and can be accessed via a laptop, tablet or smartphone with only a web browser.”
Staff posited that this system would provide the flexibility needed to support the behavioral health unit at Prattville Baptist and would be nimble enough that patients could be evaluated at the bedside or in common areas, which would not have been an option with the virtual nursing platform.
MEETING THE CHALLENGE
The virtual nursing system, which staff used to implement the remote assessment of patients at high risk for suicide, runs on the Solaborate platform from vendor Banyan Medical Systems. It is integrated with the electronic health record, Oracle Cerner, through an ADT feed to surface patient demographics, room numbers and census data directly within the application.
Access is tightly controlled and is only available through the secure network to maintain security and privacy. The approach to implementing the behavioral health intake team’s use of this platform was to largely mirror the workflows used by the virtual nurses; however, the most important differentiator in this case was to ensure that this nontraditional modality of patient communication did not exacerbate the patient’s condition or mental status.
“We accomplished this by creating a standard script to properly orient the patient to the virtual platform prior to engaging our psychiatric intake team remotely,” said Joseph M. Cook, DNP, RN-BC, chief nursing informatics officer at Baptist Health. “Ensuring the patient understands what is happening before it happens was very important to us; we did not want to create a scenario where our telehealth staff were interacting with the patient prior to them being aware of the concept of virtual interview and assessment.
“We were also cognizant to always have a staff member physically present at the bedside to assist with the assessment and reassure the patient if necessary,” he continued. “Our intake staff are then able to access two cameras installed in each patient care room: one panning camera to view and assess the patient and any visitors at bedside, and one 20x zooming camera if there is a need to conduct any focused assessments.”
The intake team member is also on camera so the patient can interact with them as if the interview was taking place in person.
“We took a similar approach in our geriatric psychiatry unit, albeit with a different platform,” Cook explained. “We are using both the Amwell Now and Amwell Embedded applications, depending upon provider preference, to conduct mobile provider rounding and assessments on our patients within this unit.
“Our Amwell Embedded platform is also integrated within our Cerner EHR and can be accessed directly from Cerner Powerchart within the context of a patient’s chart,” he continued. “This allows providers to perform chart review, document notes and assessments, as well as launch the telehealth visit – all without leaving the patient’s chart.”
The geriatric psychiatry nurses are also very involved in this process. They are responsible for ensuring the device, typically an iPad, is connected to the platform, helping to initiate the virtual visit with the provider, and remaining with the patient to ensure that privacy and confidentiality is maintained throughout the session.
Logistically, once the provider launches the Amwell application from within the chart, the patient – with the nurse’s assistance – simply accepts the link via the iPad and two-way audio/video commences. It is a very simplistic and straightforward process, Cook noted.
RESULTS
To quantify the success of this initiative, Baptist Health focused on two primary outcomes.
“Our initial goal, which we have had great success with thus far, was to ensure that every patient who screened moderate or high risk for suicide received a comprehensive behavioral health assessment by a qualified professional in a timely and efficient manner,” Firman reported. “Since fully implementing this telehealth model in September, we have maintained 24/7 behavioral health intake team coverage for every phase of care at all three of our acute care hospitals.
“From a patient safety perspective, this was a very important milestone for us to achieve to ensure that we are providing the highest level of care to one of our most vulnerable patient populations,” she continued. “In addition, this new process has allowed us to come to more efficient and decisive clinical consensus about the course of treatment for these patients, which has helped improve throughput and bed placement decisions.”
For the geriatric psychiatric patients, the primary goal was to provide an uninterrupted continuity of care by maintaining daily medical staff coverage for all admitted patients.
“We recently implemented this telehealth system in November, but even in this short span of time we have a system that has allowed us to evaluate and round on every patient, every day by the same medical psychiatry group, without the need for temporary services or locums providers,” she said.
“Our patients are more comfortable when they are able to develop relationships with their care team, and the Amwell telehealth system has allowed us to maintain this continuity and familiarity throughout the department and patient population,” she added.
ADVICE FOR OTHERS
In Firman’s experience, the most important aspect when implementing any new technology within the clinical care setting is to ensure the patient is properly oriented to the technology itself, as well as the experience that he or she will receive.
“We learned this during our implementation of virtual nursing a few years ago, and it has held true for us with these behavioral health initiatives as well,” she said. “Our experience is that when we can increase comprehension of the technology through education, we are also able to increase acceptance and adoption of these new models for both staff and patients alike.”
Baptist Health also is looking at options for launching an external marketing and education plan, so that the community has a better understanding and appreciation of standards of care and technological innovations at the health system.
“Also, in our experience, the stationary, hard-wired equipment provides a better user experience from a connectivity standpoint, but we have learned that it is not absolutely necessary in areas that will not support it,” she said. “Installing A/V equipment in individual patient care rooms is a heavy capital investment, and I would encourage health systems to not let this deter you if mobile devices are your only option.
“We have had a very positive experience thus far with using the telehealth platform on a tablet attached to a mobile cart, with a very low capital investment and the ability to expand rather rapidly if needed,” she concluded.
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