The clinics developed out of a need to provide psychiatric care to veterans receiving treatment at VA Community-Based Outreach Clinics (CBOCs) in rural Colorado. Although psychiatric care was available in these CBOCs, there were challenges regarding the availability of providers, wait-times, and provider panel size. Local VA psychiatrists spent hours driving to and from the CBOCs to treat patients. Also, there was a high provider turnover, with providers changing every 2—3 years. In response to these needs—coupled with the desire to expose psychiatric residents at the University of Colorado to work with rural veteran populations—discussion began in 2003 about the creation of a resident-based telepsychiatry service. The first clinic began in 2003 at the La Junta CBOC and has subsequently grown to four clinics, serving the La Junta, Alamosa, and Burlington CBOCs. The provider site consists of four private offices at the DVAMC, with a mix of desktop and room-based videoconferencing units and space for a resident and attending psychiatrist. Each contains a VA computer, linked to the VA network and electronic medical record. The clinics use remote IP videoconferencing links (>384K transmission) on the VA Intranet connecting the DVAMC with videoconferencing units in CBOCs, allowing live instantaneous interactions. The DVAMC transmits into CBOC rooms that are either conference rooms or private offices, using standing unit videoconferencing systems with full remote capacity, allowing the clinicians in Denver, CO, to control the cameras on the CBOC systems remotely. The VA electronic medical record system is used for documentation, ordering medications, and lab work. On-site social workers conduct a brief psychiatric intake before the first session and provide emergency support and case-management for the clinics The clinics run simultaneously one-half day per week for 3 hours, with an additional hour for group supervision. Appointment scheduling is done by the CBOC clerks, under the direction of the residents. Typically, 1 hour is allotted for new patient visits and 30 minutes for follow-ups.
Third- and fourth-year psychiatric residents participate in the clinics as an elective training experience, one-half day per week for an entire year. Residents are oriented to the clinic through a day of training in equipment use and clinic protocols, a clinical manual, and a site-visit with the attending psychiatrist to the CBOC for which they will provide care. During the visit, residents are introduced to the local CBOC staff and oriented to the CBOC infrastructure, and they gain an impression of the local community. There is one attending physician for the clinic sessions, which are simultaneous. The attending physician rotates between rooms, observing resident—patient interaction, and provides direct immediate feedback on clinical skills, with emphasis on telepsychiatry and work with rural veterans. The supervision focuses on 1) cultural interactions that have an impact on telepsychiatry and the doctor—patient relationship; 2) individual clinical skills; and 3) assigned readings around pertinent topics (Table 1). Each clinic day concludes with a 1-hour group supervision, where cases for the day are discussed, along with rural issues and career guidance related to the VA. Research training and board preparation are also undertaken.
TABLE 1.Learning Objectives and Core Curriculum