Jay H. Shore

Cultural aspects of telepsychiatry

Telepsychiatry may involve working with clinicians, patients and systems of care that are both geographically and culturally distinct. In this context, culturally appropriate care is an important component of telepsychiatry. The outline for cultural formulation from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) provides general principles for addressing these issues. Two components of the outline are particularly relevant in telepsychiatry: (1) how the cultural background of patients (i.e. their cultural identity) influences their comfort with technology; and (2) the effect of cultural differences on the patient–provider relationship. Cultural differences between patient and provider are often highlighted in telepsychiatry by the patient and provider location (e.g. rural versus urban differences). Familiarity with the rural community and regular contact and feedback are important. Future research should examine the effect of telepsychiatry on patient–provider relationships, patient attitudes towards care and, most importantly, patient outcomes.

Practice guidelines for videoconferencing-based telemental health - October 2009.

ATAlogo_250px.tif Evidence-Based Practice for Telemental Health ATAlogo_200px.tif Evidence-Based Practice for Telemental Health ATAlogo_175px.tif Evidence-Based Practice for Telemental Health ATAlogo_150px.tif Evidence-Based Practice for Telemental Health ATAlogo_75px.tif Evidence-Based Practice for Telemental Health ATAlogo_70px.tif Telemental Health Standards and Guidelines Working Group Co-Chairs: Brian Grady, MD Kathleen Myers, MD, MPH Eve-Lynn Nelson, PhD Writing Committees: Evidence-Based Practice for Telemental Health Norbert Belz, MHSA RHIA, Leslie Bennett, LCSW, Lisa Carnahan, PhD, Veronica Decker, APRN, BC, MBA, Brian Grady, MD, Dwight Holden, MD, Kathleen Myers, MD, MPH, Eve-Lynn Nelson, PhD, Gregg Perry, MD, Lynne S. Rosenthal, PhD, Nancy Rowe, Ryan Spaulding, PhD, Carolyn Turvey, PhD, Debbie Voyles, Robert White, MA, LCPC Practice Guidelines for Videoconferencing-Based Telemental Health Peter Yellowlees, MD, Jay Shore, MD, Lisa Roberts, PhD Contributors: Working Group Members [WG], Consultant...

ATA practice guidelines for video-based online mental health services

Table of Contents PREAMBLE SCOPE INTRODUCTION Internet-Based Telemental Health Models of Care Today CLINICAL GUIDELINES A. Professional and Patient Identity and Location 1. Provider and Patient Identity Verification 2. Provider and Patient Location Documentation 3. Contact Information Verification for Professional and Patient 4. Verification of Expectations Regarding Contact Between Sessions B. Patient Appropriateness for Videoconferencing-Based Telemental Health 1. Appropriateness of Videoconferencing in Settings Where Professional Staff Are Not Immediately Available C. Informed Consent D. Physical Environment E. Communication and Collaboration with the Patients Treatment Team F. Emergency Management 1. Education and Training 2. Jurisdictional Mental Health Involuntary Hospitalization Laws 3. Patient Safety When Providing Services in a Setting with Immediately Available Professionals 4. Patient Safety When Providing Services in a Setting Without Immediately Available Professional Staff 5. Patient Support Person and Uncooperative Patients 6. Transportation 7. Local Emergency Personnel G. Medical Issues H. Referral Resources I .Community and Cultural Competency TECHNICAL GUIDELINES A. Videoconferencing Applications B. Device Characteristics C. Connectivity D. Privacy ADMINISTRATIVE GUIDELINES A. Qualification and Training of Professionals B. Documentation and Record Keeping C. Payment and Billing REFERENCES.

Using e-Health to Enable Culturally Appropriate Mental Healthcare in Rural Areas

The objective of this study was to review relevant research issues in the provision of culturally appropriate e-mental healthcare and make recommendations for expanding and prioritizing research efforts in this area. A workshop was convened by the Office of Rural Mental Health Research (ORMHR) at the National Institute of Mental Health (NIMH), the Center for Reducing Health Disparities at the University of California, Davis, the California Telemedicine and e-Health Center, and the California Endowment in December 2005, during which papers were presented concerning culture and e-mental health. Relevant literature was reviewed and research questions were developed. Major issues in the provision of culturally appropriate e-mental healthcare were defined, as were the barriers to the provision of such care in rural areas and interventions to overcome these barriers. Rural areas have increased barriers to culturally appropriate mental healthcare because of increased rates of poverty, increasingly large ethnic minority populations, and various degrees of geographical isolation and cultural factors specific to rural communities. Although culture and language are major barriers to receiving appropriate mental healthcare, including e-mental healthcare, they cannot be separated from other related influential variables, such as poverty and geography. Each of these critical issues must be taken into account when planning technologically enabled rural mental health services. This review describes one in a series of ORMHR/NIMH efforts aimed at stimulating research using culturally appropriate e-mental health strategies that address unique characteristics of various racial/ethnic groups, as well as rural and frontier populations.

Personal Characteristics Affecting Veterans' Use of Services for Posttraumatic Stress Disorder

OBJECTIVE Posttraumatic stress disorder (PTSD) is widespread among veterans, but many veterans with PTSD use few health services. This study examined how individual characteristics influenced use of outpatient visits by veterans with PTSD. METHODS The study assessed number of annual visits by 414,748 veterans with PTSD who sought care from October 2007 through September 2008 at U.S. Department of Veteran Affairs (VA) facilities. Negative binomial regression and adjusted risk ratios assessed the relationship of number of visits and demographic characteristics as well as place of residence, era of service, extent to which disability was connected to service history, and having comorbid illnesses. RESULTS Veterans from rural or highly rural areas had 19% (confidence interval [CI]=.80-.82) and 25% (CI=.72-.79), respectively, fewer visits than urban-dwelling veterans. Iraq and Afghanistan veterans had 21% fewer visits than veterans of prior eras (CI=.78-.81). Veterans with comorbid conditions had 64% more visits than veterans with only PTSD (CI=1.62-1.66). Veterans from rural or highly rural areas had 22% (CI=.87-.89) and 33% (CI=.64-.71), respectively, fewer visits to PTSD specialty clinics than veterans from urban areas. CONCLUSIONS Service use by veterans is lower in rural areas. The VA should build on existing efforts to provide more outreach and care opportunities, including telemental health and specialized PTSD services, in rural areas and for veterans of the current service era. Future research should investigate the impact of fewer visits on aspects of functioning, such as interpersonal factors, and the impact of system-level variables on service utilization.

A Lexicon of Assessment and Outcome Measures for Telemental Health

BACKGROUND The purpose of this document is to provide initial recommendations to telemental health (TMH) professionals for the selection of assessment and outcome measures that best reflect the impacts of mental health treatments delivered via live interactive videoconferencing. MATERIALS AND METHODS The guidance provided here was created through an expert consensus process and is in the form of a lexicon focused on identified key TMH outcomes. RESULTS Each lexical item is elucidated by a definition, recommendations for assessment/measurement, and additional commentary on important considerations. The lexicon is not intended as a current literature review of the field, but rather as a resource to foster increased dialogue, critical analysis, and the development of the science of TMH assessment and evaluation. The intent of this lexicon is to better unify the TMH field by providing a resource to researchers, program managers, funders, regulators and others for assessing outcomes. CONCLUSIONS This document provides overall context for the key aspects of the lexicon.

Review of American Indian veteran telemental health.

Rural American Indian veterans have unique healthcare needs and face numerous barriers to accessing healthcare services. Over the past decade, the Department of Veterans Affairs in conjunction with the University of Colorado Denver has turned to the promising field of telemental health to develop a series of videoconferencing-based clinics to reach this vulnerable population and improve mental healthcare services. The ongoing development, implementation, and expansion of these clinics have been assessed as part of a program improvement. The outcomes of these assessments have been documented in a series of published articles, controlled studies, program and case reports, and model descriptions. This article summarizes a decade of experience with the American Indian Telemental Health Clinics, the clinic model, and the literature arising from these clinics and presents lessons learned while establishing, maintaining, and evaluating these clinics. The ability to tailor the clinics to individual sites and cultures and to provide various services has been critical to the operation of the clinics. Culturally specific care through culturally knowledgeable providers, onsite tribal outreach workers, and collaboration with community services has proven essential in operating the clinics, as well as building rapport, trust, and engagement with the target patient population. It is hoped that the lessons learned and practices presented here can not only assist others working to improve the care for rural Native veterans but also serve as a model in the use of telemental health services for improving care and access to rural veteran and non-veteran populations.

Self-prescribed and other informal care provided by physicians: scope, correlations and implications

Background While it is generally acknowledged that self-prescribing among physicians poses some risk, research finds such behaviour to be common and in certain cases accepted by the medical community. Largely absent from the literature is knowledge about other activities doctors perform for their own medical care or for the informal treatment of family and friends. This study examined the variety, frequency and association of behaviours doctors report providing informally. Informal care included prescriptions, as well as any other type of personal medical treatment (eg, monitoring chronic or serious conditions). Method A survey was sent to 2500 randomly-selected physicians in Colorado, 600 individuals returned questionnaires with usable data. The authors hypothesised: (1) physicians would prescribe the same types of treatment at home as they prescribed professionally; and (2) physicians who informally prescribed addictive medications would be more likely to engage in other types of informal medical care. Results Physicians who wrote prescriptions for antibiotics, psychotropics and opioids at work were more likely to prescribe these medications at home. Those prescribing addictive drugs outside of the office treated more serious illnesses in emergency situations, more chronic conditions and more major medical/surgical conditions informally than did those not routinely prescribing addictive medications. Physicians reported a variety of informal care behaviour and high frequency of informal care to family and friends. Discussion The frequency and variety of informal care reported in this study strongly argues for profession-wide discussion about ethical and guideline considerations for such behaviour. These areas are discussed in the paper.

Innovation networks for improving access and quality across the healthcare ecosystem.

Partnerships between patient communities, healthcare providers, and academic researchers are key to stepping up the pace and public health impact of clinical and translational research supported by the National Institutes of Health. With emphasis shifting toward community engagement and faster translation of research advances into clinical practice, academic researchers have a vital stake in widening the use of health information technology systems and telehealth networks to support collaboration and innovation. However, limited interaction between academic institutions and healthcare providers hinders the ability to form and sustain the integrated networks that are needed to conduct meaningful community-engaged research that improves public health outcomes. Healthcare providers, especially those affiliated with smaller practices, will need sustainable infrastructure and real incentives to utilize such networks, as well as training and additional resources for ongoing technical assistance.

Family-focused therapy via videoconferencing.

A 30-year-old veteran with a diagnosis of schizoaffective disorder and his mother were referred for family-focused therapy (FFT), an empirically-supported, manual-based treatment. The veteran had had multiple hospitalizations and experienced chronic auditory hallucinations for self-harm. Minor modifications to FFT were made for implementation via videoconferencing (at a bandwidth of 384 kbit/s). This may have enhanced the treatment by making the process of communication and problem-solving more explicit. The course of FFT was successfully completed, and the veteran and family showed a high level of satisfaction with care as well as improved medication adherence, good quality of life, high levels of hope, good interpersonal functioning, and very mild negative and positive psychiatric symptoms. This veteran had previous exposure to telemental health, which may have influenced his willingness to receive tele-FFT and perhaps affected the outcome of the case. The ability to provide this type of service to people in rural areas is important.