FORT RILEY, Kan. -- A shortage of psychiatrists at Fort Leonard Wood, Missouri, spurred an effort on behalf of Irwin Army Community Hospital to help create a virtual healthcare pilot program.

Capt. William Pitts, chief of inpatient behavior health, said he and the staffs at both locations worked on the details of the program for several months before it went live Nov. 10.

The shortage of psychiatrists and psychiatric nurse practitioners is a nationwide problem of which the Army is not immune. Fort Leonard Wood reached a critical shortage. They were facing either shutting down the department or reducing the number of patients they could serve.

"They had some phycologists and social workers," Pitts said. "(But) there must be an attending physician or (nurse practitioner) to cover any hospitalized patient -- in any setting. In the absence of specifically identified personnel for the inpatient mission, the (active-duty) psychiatrist and psychiatric nurse practitioners must cover the inpatient mission as well if they want to keep the unit open."

The hospital looked for a solution and asked for assistance. Their plea for help went unanswered; not because no one cared, there simply wasn't any help to be had.

How the program developed

When Brig. Gen. Jeffrey J. Johnson, commanding general for the Regional Health Command Central and a former commander of IACH, visited Fort Riley in August, he asked "somewhat rhetorically" Pitts said, if they could help Fort Leonard Wood.

Not being a fan of reinventing the wheel, Pitts began looking at what other military and civilian facilities were doing. He found some private companies practicing tele-medicine, but their systems could not be replicated in the Army.

"There weren't a lot of models for us to use," he said. "Because there are no other processes like this across [U.S. Army Medical Command], we had to figure out what it would look like."

John Ingersol, chief of clinical operations at GLWACH, said they have used virtual health in other parts of the hospital for about six years.

"We were very excited to explore the opportunity to improve our behavioral health, our psychiatric inpatient services, with the same approach," he said.

They started with a needs assessment, which focused on the patients.

"Safety was a priority, a nonnegotiable priority," Ingersoll said. "We have been really careful about the safety planning. We built in numerous redundancies for safety."
In addition to the safety for the patients, they looked at the safety issues from a professional level.

"Every time I see a patient, I am putting my medical license on the line," Pitts said.
"Here I am seeing a patient in an acute, usually suicidal setting and I am hundreds of miles away. When we first conceptualized this, that was in the forefront of my mind -- I want to help you, I want to help the providers, but I would also like to have a medical license at the end of this too."

Ingersoll agreed their biggest concern was "getting it right.

"I think because of that we took a very cautious approach," he said. "We will provide good quality medicine, but we do have built in safety nets."

One of the safety nets is making sure there is always a provider on call who can go in if needed.

The one piece they have not been able to map out is the internal tracking. There is no clear way to document how much the project is costing IACH from a fiscal standpoint and how much free labor General Leonard Wood Army Community Hospital is receiving.

"Sometimes that is a wash when you are taking care of the same team," Pitts said.
With the early success of the program, he said they are already talking about ways to further develop it to the benefit of both hospitals.

"I think this program can really change the way we do inpatient psychiatric care," Pitts said. "We are not going to have a sudden influx of psychiatrists. Being an Army psychiatrist is not the sexiest of jobs. It will be harder and harder for the Army to keep the ones they have."

Having this kind of partnership could go a long way to make life more tolerable for the practitioners and increase satisfaction, he said.

"What this partnership brings us is the ability to alleviate the pressure on our providers, the call pressure on the weekends," Ingersoll said. "The burden that we've faced, hindered our ability to keep providers because of the stress.

Long-distance care

Making life more bearable for three providers at GLWACH means giving them a few hours a week off said Pitts. The plan they developed was for IACH providers to help cover weekends and holidays.

On Friday afternoons, the GLWACH team creates and sends IACH a list and brief summary of their clients. They email the information over on a secured account and then have a teleconference to discuss the cases.

If they have violent or psychotic clients who they don't think are appropriate for telehealth, they will screen those out and the GLWACH psychiatrists make in-person visits. IACH will also not see any new patients who haven't been seen in person.
When Saturday and Sunday roll around, IACH psychiatrists go in and see their clients then get on video teleconferencing with GLWACH staff.

"We meet with the nurse and the nurse gives us an update with what has happened … with that patient," he said. "We have our list of things we need to address based on what the team recommended or requested. Then we sit down and talk to that patient for 10, 15, 20 minutes, however long the patient needs. We are just doing basic medical rounding -- how are you today, has anything changed, do you have any concerns?"

The monitor is large enough to allow the doctors at IACH to observe the client and look for non-verbal cues. They can see if a person's lips tremor, if their cheeks quiver and how they are holding their hands.

Other things they can't see, like if the person is tapping their knees. But there is a nurse in the room the entire time. The nurse can serve as an advocate for the client.
Then Monday morning, the doctors at both hospitals convene another conference call to go over the weekend's work.

"They are still working a lot," Pitts said. "But at least we are taking some (of the workload). Even if it's only three or four hours each day of their weekend, that's a big deal when you are working seven days a week."

Pitts and Ingersoll said they look forward to where the program can go in the future.

"We think that this is going to be a lasting, and I think, mutually beneficial relationship," Ingersoll said. "Not only to the two facilities but more importantly, to the patients that we serve on both ends. This is a win for all customers."