Telepsychiatric Consultation as a Training and Workforce Development Strategy for Rural Primary Care

The overall purpose of this study was to examine a novel model for providing mental health care in the rural primary care setting. The model involved a consulting psychiatrist that reviewed cases and provided education to case managers and physicians. The study authors believed this model would lead to improved care and serve as a continual training opportunity to build a skilled workforce. This is of particular importance in underserved rural communities.

The group felt that the model was reliant on physician buy-in as it required more work of the primary care physician and a better understanding of their limitations. We felt that this was a potential pitfall in the model’s widespread use or was at least a factor that should be considered prior to implementation. We thought that primary care was an appropriate setting for this model as most mental health care begins at the primary office and are particularly important in rural settings.

This study was a qualitative study that utilized semi-structured interviews at 2 rural sites in Washington that had successfully implemented this method. Interviews of primary care physicians, psychiatrists, care managers, and ancillary staff were completed and themes from the interviews were developed. There was some initial discussion in the group about the fact that only well-performing sites were selected. However, we decided that because this was a pilot study using qualitative methods to examine the model, selecting well-performing sites made sense.

The investigators found several themes that were common among each group interviewed. The broad themes were: learning more about mental health, working with others, and communication. Based on these themes the model was reconfigured to better represent the bidirectionality of the learning that was occurring. Learning was also conceptualized as formal learning (simulations, lectures, and instructional activities) and informal learning (mentoring, trial-and-error, self-directed learning, and networking). The roles of each group were also further refined which the authors felt was particularly important for future implementation of the model. Our discussion of the new model revolved around the fact that we felt it better represented what was occurring based on the interviews. There was mention that because the model was changed based on the two sites studied it could make it less applicable to other sites of implementation. This point led to further discussion that there may be several subtypes of this model. We also discussed how we would like to know how sites performed prior to implementing this model. Our thought was that if they performed well prior to the intervention it was likely they would perform well again, and this knowledge could help differentiate the effect of the model vs. the people in the model.

This study concluded that the model provided continuous learning at the sites it was implemented. The group felt the fact concrete examples of learning were provided was especially important to support this conclusion. While we felt the model increased learning there was some skepticism regarding its widespread adoption. It was noted that certain personality types may better succeed in the model and buy-in is required from all members of the care team. The study authors felt investigating less successful applications of this model would provide further insight into the model. We agreed with this assessment and felt that was an important future study direction and would help determine which locations this model would work best at.

We felt this model was especially well suited for rural healthcare. The primary care doctors would be able to learn from the specialists and provide better care to their patients. Patients would save both time and money. They would not have to spend time going to see numerous specialists if they received their care from their primary doctor and would also save the increased cost of specialist visits. We believe this model could be adapted to other areas beyond mental health and that the needs of the community would be able to govern the specialists that are utilized. A particular area of need that came up in our discussion was pain management in rural communities.

The researchers noted that future studies should investigate the implementation of this model in a wider variety of sites and how this model addresses common problems such as staff turnover. We discussed the first point earlier and agreed that further investigation of this model was warranted. We discussed how every model is going to require new staff to learn their role and how to interact with the other team members. We also talked about how this issue could be minimized by incorporating transitions and continual training into the model. The group discussed how it would be interesting to have future studies to investigate if there is a role that is most important for the model to succeed.