Serving Low-Incidence Populations

1. Serving Low-Incidence Populations TelePsychiatry and Video Remote Interpreting Serving the Deaf Community Roger C. Williams, LMSW, QMHI-S, CT, NAD V

2. South Carolina has about 12,000 culturally Deaf residents About 250 Deaf individuals across the state who need services from SC Department of Mental Health Resources limited: One ASL-fluent psychiatrist Eight ASL-fluent clinicians The Challenge:

3. CLAS MANDATES - Language Access Standards 5-8.

4. Standard 5 • Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. LANGUAGE MATTERS!

5. Language assistance strategies • Health care organizations should use a wide spectrum of strategies for overcoming linguistic barriers to health care: • Use of bilingual providers/staff. • Bilingual/bicultural community health workers. • Interpreters (onsite and telephone).

6. Hidden costs of not bridging language barriers • Misuse of expensive bilingual staff. • Misdiagnosis, expensive extra-testing, re-visits. • Non-compliance. • Potential liability linked to medical errors • Longer hospital stays. • More complications. • Lower satisfaction rate. • Misuse of expensive Emergency Services. • Unpaid bills due to lack of proper communication and mishandling of the insurance/financial status of the clients.

7. Standard 6 • Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.

8. Standard 7 • Organizations must assure the competence of language assistance provided to those with limited English proficiency by interpreters and bilingual staff.

9. Bilingual Staff And Interpreter Services • Failure to interpret accurately, because of lack of understanding of particular words and idioms, often leads to both patients and providers trying to guess what questions are being asked and at the answers given. • Ineffective communication can: • compromise diagnosis and treatment • inadvertently breech confidentiality • Increase liability

10. Bilingual Staff And Interpreter Services • Effective communication is central for access and outcomes. • Never Rely on Crash Courses or “Survival Language Courses” pose a threat, because clinicians overestimate their fluency. • Never allow family, friends, and other untrained, ad-hoc persons to act as an interpreter • Never allow minors to act as interpreters.

11. Legal Considerations • Americans with Disabilities Act • Title VI of the Civil Rights Act • Section 504 of the Rehabilitation Act of 1973 • Tugg v. Towey 864 F. Supp. 1201 (S.D. Fla., 1994) • Belton v. Georgia 10-CV-0583-RWS (N.D. Ga., 2014)

12. Deaf & Hard of Hearing Services • Human Resources • ASL Fluent Psychiatrist • Two Regional Teams of Therapists and Paraprofessionals • Statewide Interpreter Coordinator and Interpreters

13. Deaf & Hard of Hearing Services • Technical Resources • Started tele-medicine use in 1996 • Polycom RealPresence Desktop on laptops • Separate monitors available • Internal network between 17 centers with 63 offices • Telemedicine connection with 25 ± ED’s • Single EMR across all clinic sites, with remote access

14. Deaf & Hard of Hearing Services • Cultural Resources • High degree of acceptance of new technology • Visually oriented community • Accustomed to use of video communication

15. Service delivery – mix of in-person and virtual • Driven by: • Client preference • Clinical appropriateness • Efficient use of resources • Results in: • Improved client satisfaction • Increased availability of services • Reduced costs

16. Normally done in-person • Scheduled intakes and assessments • Communication/psychological assessments • Appointments within 20 miles of regional offices • Forensic Assessments • Competency exams • Insanity determination • Psychological testing • Violation of testing protocol • Abuse investigations • Victim interviews

17. Normally done virtually • Routine medication checks • Urgent/unscheduled psychiatric assessments • Emergency appointments away from regional offices • Emergency interpreting appointments

18. It depends…. • Routine counseling appointments • Scheduled interpreting appointments

19. How do you decide which to use? • There is not a definitive answer to this question. It will require weighing several variables • These variables include: • Time sensitivity • Length of assignment • Nature of assignment • Routine vs. unusual • Form critical vs. content critical • Client factors • Linguistic features • Technological “comfort”

20. Time sensitivity of assignment • Urgent vs. scheduled • Emergency Room vs. Mental Health Clinic • Distant vs. local • Not only time but also expense Urgent Scheduled

21. Length of assignment • Know your break-even point • For clinical services, the cost of that person being on the road and unavailable to bill, compared to providing services which may not be billable • For interpreting, the number of minutes when the total cost of VRI equals the minimum hourly fee plus travel required of in-person interpreting. Short/Distant Extended/Local

22. Type of assignment • Routine • Client and clinician familiar with each other • Expectations from both sides clear and well-defined • Content emphasis vs. form emphasis • 20% Content • 80% Form • In Mental Health, form is often the critical element, especially in assessment Content Form

23. Client factors • Linguistic features • Degree of dysfluency • ASL fluency • Psychotic features • Ability/willingness to stay within camera requirements • Technological “comfort” • Familiarity with videophone and computers • Psychotic process Fluent Dysfluent

24. Remote or In-Person? In Person Remote Urgent Scheduled Short/Distant Extended/Local Content Form Fluent Dysfluent

25. Barriers • Insurance & Billing Restrictions • Technological limitations • Primarily bandwidth • Client concerns/resistance

26. Now lets put theory into practice • The following case vignettes are typical mental health situations • Using the variables from the earlier slides, assess their appropriateness for telemedicineuse • No right answers

27. Repeat Psychiatric Checkup • 15 minute appointment, 2 hours away • Stable medication • Assessment of side effects and medication response In Person Urgent Scheduled Remote Short/Distant Extended/Local Content Form Dysfluent Fluent

28. Intake Appointment • Scheduled at mental health center (MHC) an hour away, two hour appointment • Client is new to mental health center • Assessment includes paperwork and interviews In Person Urgent Scheduled Remote Short/Distant Extended/Local Content Form Dysfluent Fluent

29. Emergency Room Visit • Client brought in by police, disoriented and agitated • It is 10:00 pm Friday night, 2 hours before a live interpreter can arrive • Goal of assessment is retain or discharge, not treatment In Person Urgent Scheduled Remote Short/Distant Extended/Local Content Form Dysfluent Fluent

30. Roger C. Williams, LMSW, Q-MHI-S, NAD-5, CT rogerc.williams@scdmh.org 803-898-8301 – Voice 803-807-2701 – VideoPhone 863-230-4429 – Text/Cell Thank You!