Pilot Study of Asynchronous and Synchronous Telepsychiatry for Skilled Nursing Facilities

Specific Aims: This study aims to assess the acceptability of asynchronous telepsychiatry (ATP) and synchronous (STP) in rural Skilled Nursing Facility (SNF) population, in a 12-month randomized controlled trial. ATP relies on video recording of a psychiatric interview, where the video is later reviewed by a psychiatrist to make a psychiatric diagnosis and treatment recommendation to the primary treatment team. STP is real-time, face-to-face psychiatric assessment using video conferencing to come up with a psychiatric recommendation. People residing in SNFs generally rely on primary and consultant physicians to visit them and rarely have outpatient psychiatrist follow-up. SNFs offer more services than what is available to primary care office, and include 24-hours skilled nursing services, physical therapy, nutritional consultation, occupational therapy, social services, wound care, and psychiatric consultation when available. SNF residents are unable to live independently due to their multiple medical comorbidities and are therefore more medically ill than patients who are typically seen in primary care settings. The present study aims to demonstrate feasibility and to collect pilot data in SNFs. This study is funded by the University of California (UC Davis) Behavior Health Center of Excellence grant via the California Mental Health Services Act (Prop 63). In a larger, future study, we intend to demonstrate that ATP will be no different than STP in clinical outcomes but will be more accessible and cost effective. Aim 1: To assess whether ATP and STP models improve clinical outcomes: Hypotheses: Compared to STP, the ATP arm will: H1: show similar clinical outcome trajectory, reflected in improvement from baseline, as measured by Clinical Global Impression (CGI), Patient Health Questionaire-9 (PHQ-9), Brief Interview for Mental Status (BIMS), and overall behavioral symptoms; H2: have similar use of health care resources: psychiatric medications, additional interval psychiatric visits, number of emergency room visits and hospitalizations (medical, psychiatric, and overall); And H3: produce shorter waiting times for psychiatric consultation. Aim 2: To assess the acceptability of ATP and STP by examining satisfaction surveys from SNF residents (who are able to complete the surveys). Hypothesis: Compared to STP, ATP participants will show: H1: Similar levels of satisfaction as measured by: Telemedicine Satisfaction Survey as completed by participants. Aim 3: To conduct preliminary healthcare economics analysis and feasibility of producing estimates of cost-effectiveness of ATP vs. STP in SNFs. Hypotheses: ATP, compared to STP, will: H1: be more cost effective as measured by cost savings from reduced need for face-to-face psychiatrist time and similar use of other medical and psychiatric services.