Virtual Visits: Ensuring Greater Access and Convenience for Children with Mental Health Concerns

Amber McConville admits she was skeptical at first. She knew her son Hunter needed help – she and her husband had been struggling with him for years – but she wasn’t sure if virtual psychiatry was the right approach.

“I was hesitant,” McConville says. “I just felt, if they weren’t in the same room, Dr. McWilliams wasn’t going to be able to get an appropriate gauge on my son.”

More than three years later? “I would not go anywhere else and will not,” she says.

Children’s Hospital & Medical Center launched the first iteration of its innovative virtual mental health care program in late 2015. The response has been overwhelmingly positive.

“Families most often cite the access and the convenience,” says Jennifer McWilliams, M.D., a child and adolescent psychiatrist with Children’s Behavioral Health.

The confluence of two key factors drove the decision toward virtual visits: a growing number of children, including those in rural areas, struggling with mental health concerns coupled with fewer psychiatrists to care for them.

“Psychiatrists are retiring at a faster rate than we’re getting new providers in. That’s created a big crunch not just in Nebraska and lowa but across the country,” says Dr. McWilliams.

According to the Behavioral Health Education Center of Nebraska, 88 of Nebraska’s 93 counties qualify as “Mental Health Professions Shortage Areas.” (Eighty-nine of Iowa’s 99 counties have a mental health professional shortage.) of the only 156 psychiatrists practicing in Nebraska right now, all but 25 are based in metropolitan areas. Consequently, with the challenge of accessing quality care compounded, families in rural, western Nebraska often have to drive to Omaha or Lincoln – up to 4.5 hours one way – for relatively brief psychiatric appointments. That was an alternative facing the McConville family. They live in North Platte.

“The doctors here are wonderful, but when it came to mental health, they didn’t have the training that Hunter needed. So, my husband said, ‘We’re going to do some research,’ and he found Children’s,” McConville says. “We were going to make the trip down when they told us we could do a virtual visit instead. We both work full-time. Traveling is not something that would have been feasible.”

An avid football player who loves being outside, Hunter, 10, has struggled with high anxiety and attention deficit hyperactivity disorder (ADHD) for years. The McConvilles conduct their virtual visit appointments at their primary care provider’s office at Great Plains Health Center in North Platte. In this and each virtual visit site, a room is designated and equipped for the remote visits.

“Hunter and I will check in. The nurse gets his height and weight, then he goes into a room that has a speaker and a monitor. Dr. McWilliams starts off with him, and she’ll ask him questions. She knows how to loosen him up and get him to talk. Then, he comes out and gets me. She asks me how I feel like he’s doing and if I or his teachers have any concerns,” McConville says. “Hunter really likes it. With him being anxious being face-to-face with people, having that computer – she’s not right there staring him down – he actually likes that aspect of it.”

Dr. McWilliams ends each session by writing up an after-visit summary, which is sent to the child’s primary care provider, mailed to the family and posted to the child’s online health portal for easy access. Because all of her patients are physically located at a primary care office, hospital or physician clinic, Dr. McWilliams can prescribe and adjust medications in full compliance with the Ryan Haight Act, a measure enacted to prevent online pharmacies from distributing controlled substances without a valid prescription.

Hunter was one of the first children seen by Dr. McWilliams through a virtual visit.

“We had read that she was one of the best,” McConville says.

Dr. McWilliams arrived at Children’s in 2015, backed by her experience starting a virtual care program at the University of Iowa and practicing virtually with Nebraska Medicine. Children’s was doing little-to-no virtual psychiatry at the time.

“That’s what really drove me toward virtual psychiatry — with access being my passion; it really helps us to improve the mental health care for kids across the region.”

Jennifer McWilliams, M.D. Child and Adolescent Psychiatrist, Children’s Behavioral Health

“What’s been so special about doing it here at Children’s – there has been a solid executive commitment,” Dr. McWilliams says. “The IT part is huge, but also looking at how are we billing this? How are we working with payers to make sure that kids who should have access are able to get access? What are we doing as far as credentialing to make sure that the facility in North Platte feels comfortable with me providing care?”

In partnership with virtual tech solutions company American Well, Children’s Behavioral Health team currently works with four sites that are affiliated with Children’s Physicians clinics in the Omaha area and four rural sites. By the end of the year, two new sites will be added. Other Children’s services utilize virtual visits, as well, including ENT, Palliative Care and lactation.

“In North Platte, Dr. (Dell) Shepherd was a great proponent of mental health care, and it was the same with the doctors in Albion and Clarinda, which helped us start the services at those sites,” Dr. McWilliams says. “Next, we looked at where my patients in North Platte were coming from. A sizable minority was driving up from McCook. I reached out to the community hospital there and said, ‘Is this something you might be interested in?’ and got a great response from the providers there. We have promoted virtual visits a lot, and that’s generated a lot of providers and practices reaching out to us saying they need services. We’re stepping back and looking at the map and saying, ‘Where in the state and the region can we have the most impact?””

Dr. McWilliams, who is an active member of the American Telemedicine Association and sits on the Telemedicine Committee for the American Academy of Child and Adolescent Psychiatry, treats children who are school age and above. She says most of her virtual visit patients have common mental health concerns: ADHD, depression, anxiety, autism and behavior disorders. A small group has more serious and persistent mental health problems, such as psychosis and bipolar disorder. Even though the care is virtual, Dr. McWilliams says she’s building real relationships.

“There are a few nuances that you have to pay attention to,” she says. “One of the hallmark traits of autistic kids is they struggle to make eye contact. That’s a little more difficult to assess on a screen. I always joke that, while I am completely uninteresting to autistic kids in person, I’m fascinating when I’m on screen – they look right at me. So, you’re working to get some more collateral information from teachers and parents.”

The virtual visit psychiatry program has been growing steadily over the last three years. Children’s brought on advanced practice provider Sarah Klein, APRN-NP, who is based in West Des Moines. She sees patients in Nebraska and Iowa virtually. All told, the team expects to see 2,000 patients this year, up from more than 900 in 2017.

“The attitudes and acceptance have improved so much among patients,” Dr. McWilliams says.

And the impact has been significant. Since implementing the virtual mental health care program, Children’s has lowered appointment “no-show” rates and families have saved a combined 100,000 miles of travel. That means less time away from school and work.

“My husband works out of town, and I work full-time. I don’t know where I would be able to find the time to get to Omaha with him,” McConville says. “Plus, Hunter misses very minimal schooling. This is something he’s willing to go to because it doesn’t take long.”

Michael Vance, Ph.D., director of Children’s Behavioral Health, believes a critical component to the program’s success was leadership from a dedicated physician: “We, as a group, knew that the key ingredient to establishing virtual care was to identify that marquee provider – that provider who’s willing to eat, sleep and drink virtual visits – because even the best-laid plans take a great deal of perseverance to push through. If you have that provider who says on a whim, ‘Yeah, I’ll try it, you’re going to end up with a lot of expensive electronic equipment collecting dust in the basement. You really need a Jen McWilliams.”

In addition to piloting an e-consult program for psychiatry, the department is also partnering with Children’s Center for the Child & Community on a virtual educational series for behavioral health – an 11-session series targeted toward primary care physicians.

“If we’re going to help all of the children that need help, we need to enhance the skills of the providers that are in their hometowns,” Dr. Vance says. “That’s really in line with what children’s hospitals should be doing.”

McConville says her son Hunter was struggling in kindergarten. By second grade, “it really occurred to us that he had some things going on that he needed help with.” In fifth grade now, Hunter’s mind is more at ease; his mother says treatment is bringing positive results. Reluctant, at first, to embrace a virtual visit approach, she’s turned into an advocate: “My friend recently said she thought her daughter needed to be evaluated, and I recommended Dr. McWilliams.”

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