At a time when the number of people experiencing mental health challenges is increasing at an alarming rate, access to mental health care services is more critical than ever. Yet with the growing needs, it’s difficult for many clinics to meet patient demand; in the Duke Department of Psychiatry & Behavioral Sciences, for example, referrals have increased by nearly 50 percent since before the pandemic.
Faced with this conundrum, and as part of ongoing efforts to increase access to mental health care at Duke, the department joined a new Duke Health integrated care approach known as “e-comms” or “e-consults.” E-comms enables Duke primary care providers to contact select Duke medical specialists through Duke Health’s electronic medical record system to get advice about addressing their patient needs related to that specialty. Duke Psychiatry is among the 20+ specialty practices that have adopted e-comms.
“It’s kind of like phoning a friend,” says psychiatrist Nathan Copeland, MD, one of the main psychiatrists participating in e-comms. “Someone will send a question along the lines of, ‘My patient has depression and/or anxiety. Can you help?’ I do a chart review, see what medications the patient is taking, and see how we might be able to help.”
Win-Win for Both Providers and Patients
Copeland refers some of these patients to a psychiatrist, but he’s found that with psychiatry support through e-comms, the primary care provider can often meet the patient’s mental health care needs. This outcome is ideal, says Copeland, who believes that a patient’s care should be managed through primary care, or their “medical home,” when possible. Patients typically know, trust and feel most comfortable with their primary care providers—and not having to see a specialist saves them time and money.
And in turn, the e-comms process helps open up the schedule for psychiatrists to see more patients who require timely services for acute mental illness concerns. “Spending 15 or 20 minutes writing an e-comm compared to automatically referring that person for a one-hour intake appointment enables us to use time in novel way to improve patient care,” says Copeland.
In addition to helping primary care providers help their patients in the moment, Copeland approaches e-comms as a teaching opportunity. Rather than giving only discrete recommendations such as increasing a medication by 10 milligrams, he shares his thought process behind prescribing psychiatric medications, his approach to diagnosis and other broad concepts in addressing mental health issues.
“My objective is to educate and empower them, so that the next time they see that patient or a similar patient, they might have already learned what they should do next,” he says.
“I want to build a toolkit of approaches I can continue to use—and the e-consults give me that support and guidance.”
Robin Collin, DO, a physician at Duke Primary Care South Durham who has used psychiatry e-comms on multiple occasions, appreciates this approach. “The [psychiatrists] always answer my questions directly and even provide me insight I didn’t know I needed,” she notes. “They let me know what I’ve been doing that is right on track and where I can improve in my data gathering or treatment approach. I value this because I want to build a toolkit of approaches I can continue to use—and the e-consults give me that support and guidance.”
High Volume & Repeat Customers
Kate Medynskaya, an administrative fellow at the Duke Health Private Diagnostic Clinic who provides e-comms training and support to providers, says psychiatry is among the most heavily utilized specialties across the e-comms system. Since the department implemented e-comms in April 2020, Copeland and his colleagues, including Kristen Shirey, MD, and Cerrone Cohen, MD, have responded to more than 400 requests. Clinical social worker Kristen Stefureac, LCSW, triages the e-comms requests and assists when providers request referrals to resources for their patients.
Among those hundreds of requests, Copeland has noticed a number of “repeat customers”—providers reaching back out with questions either about the same patients or other patients. “I hope that's a sign that people find value in the service, and that they feel like they have a partner in the management of their patients’ mental health care,” he says.
Focus on Continued Expansion & Improvement
Duke Health launched e-comms in 2018 with the Department of Nephrology and added a few specialty practices in 2019, but the system took off shortly after the pandemic began in spring of 2020 with the onboarding of 10 new specialties. In addition, more than five new specialty-to-specialty e-comms programs—for example, urology and kidney/pancreas transplant—have been established.
In addition to continually expanding the specialty practices in the e-comms network, Duke Health leaders are also exploring ways to refine and improve the system. For example, they’re building in mechanisms for specialists to generate referrals more efficiently and developing strategies to meet the demand for this service while sustaining its growth.
Meanwhile, Medynskaya says the e-comms approach is getting “rave reviews” across the system, particularly from primary care providers who recognize that the process helps patients receive care “in the right place, at the right time and from the right provider.”
“E-comms is about communication and partnerships and finding new ways to increase mental health access and new ways to take care of people.”
And Copeland is excited about the ways it’s breaking down silos and promoting more integrated health care. “It’s about someone reaching out to us and trusting we’re going to help them and us responding back to them, which is very different from how things have worked in the past—‘you do your thing, I do my thing,’” he says. “E-comms is about communication and partnerships and finding new ways to increase mental health access and new ways to take care of people.”