What does remote full psychiatric care look like? B.C.’s Fraser Valley is finding out

For the last year or so, people in mental health crisis in B.C.’s Fraser Valley have had a choice.They can take a bed at one of the region’s eight hospitals with a psychiatric ward—including Surrey Memorial Hospital or Burnaby Hospital—or opt to take part in the recently launched Virtual Psychiatry Unit.It’s the first of its kind in B.C. and, likely, the country. As long as patients are over 18 and not at imminent risk of harming themselves or others, they can return home and receive the care they’d normally get from a hospital.That includes support from social workers, psychologists, general practitioners, peer support workers and social workers. “It’s the full range and scope of in-patient support, but done virtually,” says Anson Koo, program medical director for mental health and psychiatry program, Fraser Health Authority. Patients get a blood pressure cuff and all their vitals are monitored remotely, plus a healthcare professional will visit when needed.Importantly, they have access to a psychiatrist who will prescribe medications and monitor them for their efficacy and side effects.“This is how we are doing things more and more,” says Dr. Koo. “COVID opened our eyes to the possibilities of virtual care.”Studies already show that remote talk therapy is effective for supporting people with mental health conditions. Psychiatrists are increasingly offering comprehensive care remotely. There are fewer studies of its effectiveness, but a literature review study published in 2020 (with data up to 2019) showed patients with depression were as or more satisfied than those getting face-to-face psychiatric care.“It’s very much patient driven,” says Tyler Black, who works in the emergency department at B.C. Children’s Hospital and is a clinical assistant professor at the University of British Columbia. Half of his patients now prefer virtual sessions.Allison Crawford, medical director of virtual care and outreach for the Centre for Addiction and Mental Health (CAMH) in Toronto, says comprehensive telepsychiatry has soared by 2,000% since 2020. About 70% of the telemedicine system usage in Ontario is for psychiatry, she says. (In the U.S., a 2021 McKinsey & Company report found that 50% of psychiatric visits are now via telehealth, followed by substance use disorder treatments at 30%—both far ahead of other types of care.)Meanwhile, CAMH just opened the Virtual Urgent Care Clinic, where nurse practitioners offer same-day appointments to assess, prescribe, review and refill prescriptions (excluding opioids) virtually. Fraser Valley has been tracking the success of its new program, which has served 150 patients as of the end of August, 2023. Dr. Koo says 95% report a positive experience with 81% saying it was much better or somewhat better than in-person hospital care.“We had a number of goals in developing this program. Definitely it was to expand bed capacity. But also to improve patient satisfaction and outcomes,” says Dr. Koo, who notes that many patients who qualify say yes to the virtual unit, including new mothers and those who live far from hospital.CAMH began an outreach program that entailed flying in doctors to northern Ontario and Nunavut in the late 1990s. It was expanded to include full-scope psychiatry in the early 2000s. “It helped created more continuity of care,” says Dr. Crawford.That experience has shown it’s feasible to support patients at a distance, even as the scope of care for psychiatrists has expanded and patient needs have become more complex. “We now do almost everything through telepsychiatry, including emergency room assessment and admissions and even cutting-edge, at-home treatments via teleconference.” Dr. Crawford also orders blood tests and assesses safety risk of patients.Importantly, patients like the virtual option and Dr. Crawford says the all-important therapeutic alliance can thrive through telemedicine. “It’s the single biggest factor in psychiatry. That sense of being heard and having a connection and trust.”Dr. Black says this approach works for him, too. “One huge benefit is the decrease in no-show rates.” Plus, Dr. Crawford says when someone cancels, the doctor is already right at their laptop, and can fill the time more easily.When Dr. Black treats children and youth via video call, he can see their drawings and puppies and use those as conversation starters. “I’ve seen more kids’ pets in the last three years than I’ve ever seen,” he says.Images in the corner of the camera during calls can provide clues. “If someone has a bottle of pills next to to their Zoom camera, I call 911,” he says. In theory, remote psychiatrists could miss out by not seeing their patients up close. “For 99% of what we do, we rely on the subjective filter of what patients tell us.”Doctors will peer into their cameras and ask pointed questions to catch the signs of neuroleptic malignant syndrome in reaction to antipsychotic drugs, or a tremor that suggests substance withdrawal. But they need someone on the ground, nearby, to do a check-up if things seem worrisome.“Patient safety can’t just happen between a remote psychiatrist and a patient. There needs to be a care team to make these things work,” says Dr. Crawford, who relies on general practitioners and nurse practitioners in northern communities for CAMH’s program.For her, telepsychiatry will work best when it’s supported by data and is integrated into the system—which, currently, it’s not. “We need evidence for for how it can really help. We need to understand how all the different programs work and work within the system,” says Dr. Crawford. Dr. Black says privacy remains an issue. “I’ve had many times when patients have assured me they’re by themselves and then suddenly a roommate or a stranger walks by the camera,” he says.He’s hopeful that residency programs are keeping up and offering additional training. Dr. Crawford has helped develop a competency framework with the University of Toronto for psychiatry residents that includes skills for remote care. As well, the system needs to take into account equity issues and their impact on access to virtual care: not everyone has the right technology or a private space.The hope is that the system will continue to evolve to properly support psychiatrists whose patients want—or need—to be seen from a distance. “It’s really important for physicians and regulatory bodies to not be behind the tech curve,” says Dr. Black. “This is the way things are going.”

What does remote full psychiatric care look like? B.C.’s Fraser Valley is finding out

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