Khaled Rajab, MD, MBA

Academic medical center departments of psychiatry, like many other medical specialty departments, often struggle to find contemporary opportunities to grow and consolidate clinical services, maintain market share, and support other clinical departments. Psychiatry departments historically focus on outpatient clinics, hospital- and emergency-based services, and inpatient psychiatry units as common sources of clinical productivity and clinical revenue. Departments with the appropriately trained and privileged physicians can supplement clinical revenue with transcranial magnetic stimulation (rTMS), electroconvulsive therapy (ECT), and other neuromodulation interventions.

The development and recent explosion of opportunities in telepsychiatry come at an opportune time. Technologically advanced and secure telepsychiatry functionality, combined with robust EHR systems, permits high-level clinical service delivery from a secure remote platform. Telepsychiatry has proven to be acceptable as an alternative to in-person care by patients and physicians alike, and offers clear benefits in the pandemic environment, facilitates care without a transport burden, and, importantly, affords physicians a viable opportunity for home-based employment.

We discuss our recent experience with telepsychiatry in an academic department of psychiatry that led to significant expansion of clinical services provision and increased clinical administrative efficiency. We are now able to provide robust psychiatric support to emergency departments, hospital inpatient units, outpatient psychiatry services, and primary care clinics in a complex, geographically dispersed integrated health system in north and central Texas (from Dallas to Austin).

Baylor Scott & White Health Department of Psychiatry

Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. Baylor Scott & White Memorial Medical Center in Temple is a comprehensive 636-bed academic medical center and Level 1 trauma center and is a main clinical education site for the Texas A&M University Health Science Center College of Medicine. Baylor Scott & White Memorial Medical Center is a 2020 and 2021 Fortune/IBM Watson Health Top 100 Hospital and Top 15 Major Teaching Hospital in the US (no. 2 in 2021). The BSWH system includes 2 academic medical centers, 25 community and specialty hospitals, and 175 primary care clinics, all integrated into a single network with a common electronic health record (EHR) account.

The department of psychiatry is the only academic psychiatry department in the BSWH system. Personnel include 40 faculty physicians and other clinicians, 20 psychiatry residents, and 6 child and adolescent psychiatry fellows. The department of psychiatry is backed by the academic partnership among Texas A&M University Health Science Center, College of Medicine, BSWH, and the Central Texas Veterans Health Care System (CTVHCS). Departmental hospital operations at Baylor Scott & White Memorial Medical Center have included a 23-bed inpatient psychiatry unit with 1275 inpatient discharges per year, more than 2000 annual consultation-liaison encounters, and 24-hour coverage of the emergency psychiatry service.

Departmental outpatient operations include the Alcohol & Drug Dependence Treatment Program, Harker Heights Behavioral Health Clinic, McLane Children’s Hospital Behavioral Health Clinic, embedded psychiatric services in primary care clinics, collaborative care support to BSWH primary care clinics, a comprehensive neuromodulation (ECT, rTMS, ketamine) program, and a BSWH system-side hospital telepsychiatry consultation service, with more than 42,000 total outpatient encounters per year. The department participates in a strategic partnership between BSWH and a 102-bed freestanding psychiatric inpatient facility. The department is a member of the Neurosciences Institute. 

In 2019, we initiated a hospital telepsychiatry service to cover 26 BSWH hospitals that had had sparse in-person emergency psychiatric services coverage. This service was previously managed by a third-party telepsychiatry vendor, but this service proved to be excessively costly to the system. There was limited communication from consultants with the hospital staff. The services were provided by a large number of available telepsychiatry psychiatrists; thus, the emergency department (ED) and hospitalists did not have ongoing collegial relationships with the telepsychiatry group for informal advice such as “curbsiding.”

Mindful of these concerns, we started a 7-physician telepsychiatry service. Seven telepsychiatry faculty positions were developed at the psychiatry department, and one faculty member was chosen as service director with a 10% leadership stipend. All telepsychiatry physicians recruited had significant experience in telepsychiatry at other institutions; 1 has a geriatric subspecialty, and 2 have a child and adolescent psychiatry (CAP) subspecialty. A project manager with extensive medical administrative experience was appointed to take charge of this telepsychiatry initiative. All telepsychiatry physicians were credentialed at all facilities served, and all were hired as faculty members in the BSWH department of psychiatry. Most coverage shifts have 2 or 3 psychiatrists on duty.

Coverage hours are 8 AM to 10 PM weekdays and 8 AM to 8 PM weekends and holidays. Hospitals were brought on board gradually with 1 or 2 phased in every few weeks. All 26 facilities were phased in over a 12-month period. Education of local nursing and administrative staffs was a crucial part of this go-live process. Consultation requests are entered within the EHR. The on-duty administrators organize the incoming requests and schedule the appointments with the physicians on duty. After examining the patient, the physician charts immediately in the EHR. The consultant communicates with the attending physician in real time by EHR secure messaging and provides input for managing the patient.

This service has had a significant impact on ED length of stay (LOS) and sitter hours. Various metrics are monitored on a weekly basis, and feedback is provided to the team during weekly huddles. The volumes grew steadily, and the service has been well accepted by all the facilities served across BSWH.

Beginning in 2020, BSWH made the policy commitment to roll out the collaborative care/TEAM care model (originated at the University of Washington) to all 175 primary care clinics in the system. Clinic physicians in the department of psychiatry devote time weekly in 2-hour increments to interface and support the collaborative care manager and primary care providers (PCPs) in the primary care clinics in their standardized treatment of mild/moderate depressive and anxiety disorders according to protocolized treatment algorithms and regular structured outcomes measures.

Patients whose psychiatric illnesses are too severe/complicated for collaborative care management can be seen for a 1-time telepsychiatry-based consultation by the consulting psychiatrist for diagnostic clarity and treatment planning. Often, the single telepsychiatry consultation by the psychiatrist leads to an enhanced clinical care intervention plan that can then be effectuated by the PCP without ongoing local psychiatric care. More severe or complex patients may be disenrolled from the collaborative care model and referred for local ongoing outpatient psychiatric treatment. Currently, 4 department physicians participate in this model.

In response to the COVID-19 pandemic, in 2020 the department pivoted to 100% telepsychiatry for outpatient psychiatric services in a period of 10 days. With subsequent easing of social distancing requirements, we continued to offer the option of telepsychiatry services. Since that time, a persistent fraction of 30% to 35% of outpatients continue to have their care provided exclusively by telepsychiatry. Since offering telepsychiatry outpatient services, patient satisfaction has significantly increased and outpatient no-show rates, which had never been less than 10% despite numerous administrative initiatives, have now decreased to near zero.

Inpatient Service Staffing by Telepsychiatry

Our department has recently established a partnership for exclusive physician staffing of a freestanding 102-bed inpatient psychiatry unit, operated by a private company, as our inpatient unit. We were able to bring 2 full-time CAP psychiatrists to take care of the inpatient needs of the 28-bed adolescent unit, exclusively via telepsychiatry. This stabilizes the staffing of this unit, which is also a training site for residents and CAP fellows, liberating the rest of the CAP faculty to serve the clinic and children’s hospital. Overnight and weekend on-call/rounding on inpatient units can also be accomplished by telepsychiatry.

Since the beginning of these initiatives, the department has been able to effectively add 12 new physician positions, which are exclusively telepsychiatry service-based. This creates new employment opportunities for physicians skilled at working in this medium, establishes the department as one with substantial expertise in telepsychiatry, and facilitates hands-on experience in telepsychiatry to psychiatry residents who need to master this skill as part of their clinical repertoire. These additional physicians 

 require physical office space at the medical campus and need only minimal administrative support. This enables significant departmental growth (at this point, over 33% of our physicians work exclusively via telepsychiatry) and identifies our psychiatry group as a progressive, modern department.

An additional benefit to promoting telepsychiatry-based clinical services is the indirect, but significant impact on physician quality of life and preemptive burnout prevention. Robust telepsychiatry opportunities can facilitate many physicians to continue working from home while on maternity/paternity leave, recovering from an acute illness or injury, or while dealing with a chronic illness (such as immunocompromised states) that makes it unsafe to be in a common public setting such as a clinic or hospital. Home-based telepsychiatry physicians can avoid the time and expense of commuting and thus have more free time.

Academic psychiatry departments should embrace the opportunity for telepsychiatry as permitting increased size of the faculty cohort, support of other medical departments needing psychiatry consultation, and providing enhanced work-life balance for faculty members. Embracing modern technology should be seen as an option-generating opportunity to develop, grow, and optimize department functions.

 is medical director of behavioral health at Baylor Health Care System. 

 is a psychiatrist in Temple, Texas, who is affiliated with Baylor Scott & White Health. 

is an administrator within the Baylor Scott & White Health Department of Psychiatry. 

is chair, Department of Psychiatry, Baylor Scott & White Health, Central Texas Division, and clinical professor of medical education, College of Medicine, Texas A&M University Health Science Center, Temple, Texas.

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