When the COVID-19 pandemic began forcing people across the state and nation into self-imposed quarantine earlier this spring, the care providers and staff at Yale New Haven Psychiatry Hospital (YNHPH) knew they had to find innovative ways to continue providing services to patients — regardless of whether they could meet in person.
In the span of two weeks, more than 50 people worked around the clock to launch telehealth services across the hospital’s five primary services: in-patient services, interventional psychiatric services (IPS), psychiatric emergency services (PES), in-patient and outpatient consultation services, and ambulatory services.
One of the leaders of the effort, Luming Li, MD, Assistant Professor of Psychiatry at Yale School of Medicine and Associate Medical Director of Quality Improvement at YNHPH, described the effort as “taking a crisis and making lemons into lemonade.”
“This is built from nothing. We started from scratch,” Li said.
Li said the process was very busy in the beginning, “where we were just trying to get a sense of our needs and how we could use technology to meet them.” From there, as they came to understand the initial round of challenges, they began to scale up the telehealth systems, address technological challenges and educational gaps, she said.
With the telehealth programs in place for nearly two months, Li said the teams at the hospital have, by and large, reached the maintenance phase of implementation.
“It was a really big partnership,” Li said. “People were really adaptable, and the patients are liking it.”
‘We didn’t skip a beat’
Amber Wimsatt Childs, PhD, Assistant Professor of Psychiatry and program psychologist at YNHPH’s adolescent day program, was providing 3 ½ hours of psychotherapy treatment to her patients four days a week, in a group-based format, before the pandemic swept the nation in March.
“We realized we quickly needed to find way to restore the level of service and care individuals needed, given the high levels of acuity throughout our program,” Childs said.
On March 16, the ambulatory team provided its last day of in-person care and on March 17, they created a plan to provide telephonic sessions until a more permanent workflow could be ironed out.
“We didn’t skip a beat in terms of providing some level of services,” Childs said. “We also knew that 25-minute telephonic sessions … were not going to be enough to maintain the level of care our teenagers needed. That was the backdrop of what created a desire to leverage technology to provide an IOP-level of care, virtually.”
While there was existing infrastructure in place to allow for individual video visits via MyChart, there wasn’t such a program to accommodate group-level intervention via telehealth. Childs said the challenge was to select a platform to support group-level services, while taking into consideration national guidance to remain in compliance with patient privacy and the protection of private health information. They ultimately settled on Zoom.
“There was this collective sigh of relief of being able to settle into the familiarity of seeing each other’s faces, and there was this shared recognition that … we are part of something together that’s bigger than any and all of this, and it provided this breathtaking moment of perspective and clarity,” Childs said.
‘Suddenly we were swimming’
The Behavioral Intervention Team had some minimal previous experience with the technologies available for telehealth visits at YNHPH when the COVID-19 crisis hit.
“We had been just putting our toes in the water when the tsunami hit and suddenly we were swimming,” said Raymone Shenouda, MD, Assistant Professor of Clinical Psychiatry and Medical Director of the Behavioral Intervention Team at YNHPH.
The team had to figure out what units had telehealth capabilities, including access to equipment, and then devise a workflow that would benefit both patients and providers.
“Our primary concern was that we did not want to be vectors [of COVID-19] ourselves,” Shenouda explained.
Through a process of trial and error and collecting feedback, they created a workflow using a combination of InTouch Health, a telehealth software, and the hospital’s Mobile Heartbeat app for inpatient visits; MyChart for outpatient consultations; and Zoom for internal communications. Shifts are rotating, with staff alternating working on-site at the clinic and from home.
Additionally, Shenouda worked directly with leadership from the hospital’s Interpreter and Translation Services to, when necessary, assign interpreters to telehealth visits with Spanish-speaking patients, to ensure those patients could still receive care.
“One very important thing we can all learn from COVID is, don’t plan out all different scenarios before you dive in. Start with a good enough system and then make it perfect as you go,” Shenouda said.
PES and the Transition to Telehealth
The psychiatric emergency services (PES) team only needed to make a relatively small expansion to an existing service, said Seth Powsner, MD, Professor of Psychiatry and of Emergency Medicine and Director of the CIU. PES has been using Apple’s FaceTime on iPads since 2016, to support psychiatric evaluations at the St. Raphael Campus from the Crisis Intervention Unit (CIU) at the York Street Emergency Department.
“The usual concern that Apple will not enter into a HIPAA-compliant [business associate agreement] for FaceTime has not been a significant issue for our emergency service,” Powsner explained. “FaceTime simply provides a communications conduit, one that is encrypted end-to-end, for us from one emergency department to another. No patient identifiers are evident to anyone outside our hospital system. The situation is different for a clinician communicating directly to a patient: patient, clinician, time, and duration of the ‘visit’ are known to Apple and possible the internet provider. However, this is less of an issue during this pandemic.”
The Office for Civil Rights (OCR) at the federal Department of Health and Human Services (HHS) is exercising enforcement discretion is to facilitate telehealth care, Powsner said.
One of the more significant changes from PES’s pre-pandemic workflow has use of telehealth within the hospital campus to comply with CDC based restrictions on clinicians older than age 65. Older people have more complications from COVID-19 illness. To avoid losing clinicians, older physicians, advanced practice nurses, and social workers avoid direct patient contact by using FaceTime from offices away from clinical areas, if not from home, Powsner said.
Powsner cited some technical challenges — poor sound, loss of connection, and finding suitable iPad cases and stands — in the PES transition to telehealth, but all of those issues have been addressed, he said.
‘What will absolutely sustain is possibility’
The experience has provided the YNHPH team with an increased culture of teamwork and collaboration, they said.
“We understood that we had to do things differently and we had to get things done, and folks were much more flexible than they may have ever been,” said Frank Fortunati, MD, JD, Vice Chief of Psychiatry at Yale New Haven Hospital. “The take-home for me was how this helped to foster a culture where everyone started to ask, ‘how do we accomplish this?’ not, ‘can we?’ or ‘should we?’”
Shenouda and Childs agreed, both noting an increased sense of camaraderie despite the challenges and initial chaos of the implementation.
“It typically takes two to three years to build up a program, really make a cultural shift, and implement something completely new and outside the box. That is a thing of the past,” Childs said. “Now we know that when working together, when we’re taking advantage of this collective and shared knowledge, we can make significant change and improvement in a very short period of time. It’s a positive omen for what’s going to be possible in the future.”
Childs, Li, and Shenouda said now that the infrastructure to support telehealth services in place, they hopes it will continue to be offered as an option to patients after the pandemic subsides.
“The technology opens up a really big opportunity for us in terms of future service delivery,” Li said. “Six to 12 months from now, we’re just going to have more options. This is an important, sustainable effort that we should do in order to provide access and provide more meaningful connections to patients even after this, because sometimes they don’t have other options.”
Childs said: “This completely broadens what we’re able to offer and unleashes the potential and capacity to treat populations that we were previously unable to target, and addresses barriers like transportation, availability, and geographic location. Those barriers do not have to be put back into place when COVID-19 starts to resolve and we start to get clearer sense of what the landscape looks like. We’re not sure that all aspects of telehealth will sustain beyond the crisis. Much of that depends on policy, regulations and what we learn about quality and outcomes. However, what will absolutely sustain is our ability to innovate and create possibility.”