5 Lessons From Establishing Telepsychiatry for California Prisons — Edward Kaftarian, MD

What are the biggest challenges to starting a telepsychiatry program? How do you choose and manage the right technology? How do you manage medications? How do you attract and manage staff?

Find out how California’s Chief Executive of Telepsychiatry, Edward Kaftarian, MD, stood up a successful prison telepsychiatry program for 120,000 inmates across 25 institutions in rural remote areas.

00:00 Thank you everyone for tuning in to Telehealth: Failures and Secrets to Success webinar. My name is Milton Chen. I’m the founder and CEO of VSee and This American Doc. And for today, I’m really excited to have Ed joining us, so Ed is credited for the person behind the California, Telepsychiatry, the mentor behind the Prison System. I think he build a largest network of anywhere. They’re extremely excited to see your insight. I guess Ed, I don’t think we can read the official bio there, there’s something about you not in your typical bio. You can share with the audience that’s maybe like. Just something different.

00:46 Oh sure, so a couple things about me, something, that I’m a big time skiier and I was teaching skiing in Colorado. So, that was kind of fun. And another thing that I think is unusual about me is that I don’t like Star Wars. I’m sorry.

01:09 Why you don’t like Star Wars?

01:10 You know, I used to love it. And as a kid growing up in The 80s, I love Star Wars, but I don’t like it so much anymore.

01:24 Thank you so much. I think what we do is I thought we’d turned the floor to you and you can present something and then we can open up to the audience member for them to ask questions okay so?

01:38 So should I go forward with the presentation?

01:40 Yeah.

01:42 Can everyone, so can you see the screen then? Prison Telepsychiatry? Okay, so, first thing I wanna ask you is, which country has a highest rate of incarceration? And that’s probably a question everybody can answer. Unfortunately, it’s us, the US, we have a highest Incarceration by far in the world. And, I mean it’s a tragedy, really, we’re land of the free home of the brave, and we’re locking people out. 2.3 million people behind bars. Just take a moment to let that sink in. 2.3 million of our brothers and sisters behind bars. A lot of them are Hispanics and blacks, disproportionately. It’s a tragedy, you know. It’s representative of failure on the part of America to take care of our population.

02:36 And how do we get here? Really, the, you can see here a graph that shows incarceration rate of people under state and federal jurisdictions per 100,000. Now, you see in the 1970s, 80s, and 90s, you see a massive spike in the number of people that are incarcerated and think about why that’s the case. You might have some ideas. One of those factors was the institutionalization that started in the late 50s. And what happened was the institutionalizations means that you close the state hospitals that were housing people with serious mental illnesses that in some cases before refractory to treatment at the time. And what happened was they closed the state hospitals and other facilities and all these people who didn’t have a place to go. So they went out to the street.

03:35 Ultimately, there was a big homeless population that started because of this, and a lot of people getting arrested for crimes of mental illness, you know, like trespassing and other crimes of mental illness. And what happened then was these people would fill up the jails and prisons, but you see here in the late 70s and 80s and early 90s, you have the war on drugs, and that was devastating to America. You had mandatory sentencing, which meant that people who were using marijuana, maybe they, if they like three strikes law, if they use marijuana, got arrested for it a few times, then they’d have a life in prison then. And this is not right. It doesn’t make any sense to take the decision out of hands of judges and make it mandatory that people serve time that cannot change.

04:33 And then of course, the war on drugs filled up our prisons with people that had substance use disorders, and they had a disorder, they had an illness of substance use, and instead of treating them, we locked them up. And so we took on a culture of incarceration to this day. Now, here we see the percentage of US inmates who are mentally ill. Now in the local jails, you see a very high percentage in the county jails of mentally ill people, about two thirds of them are mentally ill. In federal and state prison, it’s about half of the people that meet criteria for a significant mental illness. Now, this does not even account for people with substance use disorders. So this is non-substance use disorder. If you add in substance use disorders, you have about an 85 to 90% people who are afflicted with substance use disorders. And so, the vast majority of the people that are in prisons and jails need help from a mental of professional in some way.

05:40 Now, let’s talk a little bit about what happened in California. You know, it’s a success story. So the California Prison system telepsychiatry Program was developed from its roots to about 70 psychiatrists in a matter of only a few years. And I was proud to be part of that leading the way on this one, and we serve people in over 25 facilities and we’ve served all levels of care from outpatient to inpatient. We even have helped the state hospitals with healthcare, via telepsychiatry through the Department of Corrections in California. So that was a tremendous success story. And so why does it work? This is me seeing patient. Why does this work? Why does correctional telepsychiatry work? Several reasons. Doctors like to be in a comfortable environment. So as you can see, I’m in my office, is comfortable, it’s quiet. The temperature is just right and it’s clean, and that’s one of the best predictors of job satisfaction is being in a clean and comfortable environment and in a prison in jail, that’s usually not the case. So it’s usually a dirty, dark musky, dusty environment. And, you know, the inmates are the ones that typically are in charge of cleaning the environments. You can understand why it’s not like a hospital in terms of cleanliness. So having a job that allows you to work from home or work from a comfortable environment in an office space, at least more job satisfaction. And you have a more retention of doctors that way now.

07:26 Now, it’s good for the prisons in jails, the facilities like the fact that we’re out of the way, because we get in the way, sometimes, you know, the prisons and jails were not originally designed to have health care staff walking around, and the fact that we’re outside of the system that does help them with their safety and security and the general functioning of the prisons and jails. It also reduces transport risk and cost. Because if you have a jail prison that’s not located in the area that can hire psychiatrist, you might have trouble when a patient goes into crisis. Oftentimes we see people who the staff on it thought was, the patient was in a crisis and it turns out they just need their meds. They just need to see their psychiatrists, they just need their therapy. And if you can provide that, you might actually prevent the necessity of transport, which can put officers, nursing staff and inmates, and the public at large at risk.

08:33 Another advantages is that we can reach multiple sites all in the same day. You can go up from the north to the South and it’s just in a split second, so that leads to efficiencies and you can deploy resources that way you can bypass gates and elevators. If you have units that don’t need a psychiatrist full time all day long, it doesn’t matter. You can do a couple of hours in the morning and then switch to another location. You don’t even have to ride the elevator, which can be quite slow sometimes in prisons and jails. And those gates, if you worked in a jail or prison, you’ll know that sometimes you stand there just waiting for the officer to open up big gate and, that can, pretty much half the time can be consumed by that. So telepsychiatry actually has been proven to be more efficient that way.

09:24 Now, let’s talk about the hurdles. There are several hurdles, and this is probably not all of the hurdles, but five selected hurdles for creating a correctional telepsychiatry program. The first hurdle is buying support, buy in and support. I mean, you can’t do this alone. You can’t do this without the help of the on site administrators and central headquarters administrators, whether you’re working in a prison system like the department of corrections in California or in a local jail or jail system, County Jail system, you need buy in and support. So, in a bureaucracy, oftentimes, I’ve been told “no”. And what I’ve learned from doing this from working with state and local governments for so long is that “No” actually means “not yet”. So oftentimes bureaucrats, they see what’s right in front of them and not long term. Some of them do. Some of them see it long term. So you have to choose those people to be your champions and don’t get discouraged when a bureaucrat says no, because oftentimes, that just means we’re not ready for it yet, but you gotta keep the conversation going in that cycle that can go on for about a year and a half, two years sometimes. But in the end, usually they say yes, if it’s a good idea that can save money and make everyone’s job a lot easier, which is what telepsychiatry does in a correctional environment.

10:48 Now what you wanna do is demonstrate the proof of concept. So you say, just give us a little project, maybe one jail or one unit, demonstrate that’s, through data, that it can be more productive, higher quality sometimes then even onsite psychiatry. You’re gonna always need onsite psychiatry. So we’re never a threat of the onsite psychiatrists, but it is important to state that, in our experience, we have been able to prove that we are more productive and of higher quality than sometimes the on sites may provide. But of course, you need on site psychiatry and there can be high quality on site psychiatry as well, and you wanna celebrate the successes. So anytime you’re running a team and a matrix of people, you wanna always sell a rate to successes because that’s why people do it because they wanna see the product of their work. They wanna see that they’re making a difference. And with California and other areas, we have demonstrated success and we celebrate that success. Now, when you’re recruiting a managing stuff, it’s really important to support your doctors and empower them. Now, Doctors cannot be treated like widgets. They can’t be commoditized. You can’t think in our mind, well, this doctor doesn’t work out. I’m gonna replace them with someone else. There’s a difference between doctors and there’s some really high quality ones and not so high quality ones, just like any other industry, you’re gonna have good people at the job and not so good people at the job, and you wanna support and empower the people who know what they’re doing and are in it for the right reasons. And you wanna, in order to maintain your staff and to avoid, so for retention purposes, you wanna protect continuity care as much as possible. Although telepsychiatry enables us to go from one prison to another, and to change the assignment of each doctor, you really do wanna see if you can protect continuity of care, because that’s what it leads to therapeutic relationship. In some cases, for example, of an inmate reception center, that may not be a goal that we pursue because that’s just not how it works. Patients are seeing once and then they move on to the next thing. So in some cases, continuity is not the most important thing, but overall, it’s something that’s worth protecting when you can. And then the supervision matrix is also very important. As a leader of psychiatrists via telepsychiatry, I don’t lose sight of the fact that they are on site administrators too that are part of a supervision matrix, and it’s really important that you communicate with these people. So the telepsychiatry leadership and the onsite leadership, they have to get along, they have to be on the same page with stuff, and sometimes that means a little bit of compromise, but it’s always working together as a team.

13:49 So IT issues. That’s a big one too, you know, and it’s never ending question of build versus lease. So if I wanna create a telepsychiatry program in a county jail, do I build it or do I lease it? And some of the really important questions to ask yourself and your organization is, how much do you wanna spend? What kind of quality do you wanna have? What’s your reliability needs and how flexible do you need to be? Now, one of the big advantages of leasing or hiring, you know for example, I’m on here with VSee, which is an excellent service. One of things to consider is, do you wanna build it all yourself, or do you wanna leave it in the hands of the experts that have been doing this, this is their bread and butter, and this is what they do every single day. Now, there can be a role for both. So there can be a literal for a local IT. You’re gonna probably have to have your local IT anyway, but working hand in hand with the company like VSee or a telehealth vendor, it’s really important that the IT staff locally and the company that provides a services work together. But in this day and age, you know, I used to say, you can choose to build or you can choose the lease. At this point. I think that it’s pretty clear from my standpoint, as an executive of a telepsychiatry company, I don’t wanna build a platform myself because that’s not my bread and butter, and I wanna be able to trust a company to say, this is what you do, and we do what we do. Audio and video is a very high indicator of whether you’re gonna be successful or fail. So, you want the quality to be there. And nothing ruins a program like bad audio and bad video. It bothers the patient, it bothers the doctors and at least to failure. So, but on the other hand, if you have good quality of audio and video, which is actually easy to achieve this day and age, then you’re gonna be successful and people love telemedicine.

15:52 Working with custody. So I say you’re listen first, you gotta put yourself and custody issues, custody, meaning the correctional officers that are there to keep the safety and security of the prisons in jails. They have a really hard job and it’s easy as healthcare providers to discount what they do just as it’s easy for custody to discount what healthcare does. Sometimes they call us carebears and hug-a-thugs, and that’s not helpful, but at the same time, I would say that I’ve worked with many custody staff that believed in the healthcare mission, but you wanna understand them first. They have a very tough job. They’re dealing with inmates that can be very unruly. Sometimes they can be combatic, hostile and really difficult, so you wanna be able to, you know, listen first, understand what they have to deal with. And we came later, we didn’t, you know, prisons and jails were not built for us from the beginning, and they’re not really designed for us to be there. So we’re a little bit of an odd duck, and we have to find a way to fit in. And so that should be at the top of our mind when we’re seeing patients and we’re dealing with custody officers, you wanna be able to win the hearts and minds of these people. And oftentimes, it’s helpful to keep your eyes open for the custody offices that real healthcare champions, that are the ones that really believe that mission of healthcare and can make things happen. Sometimes it’s lower level custody staff, sometimes it’s a lieutenant or captain, and in some cases it’s the warden so you wanna be able to engage with the people that actually believe in the cause.

17:32 Space Issues are another challenge, always a challenge. Like I said, these places were not usually designed for healthcare staff to be there. Fortunately, telepsychiatry is really helpful because we can put it in the smallest of spaces. We don’t need the doctor to come with on site with his desk and chair and take up a bunch of space. We just need a little bit of camera and we put it in whatever space can accommodate one patient. And that’s usually enough. So it can be challenging though even to find the smallest of spaces, especially if you’re looking for a confidential space. There can be differences between the inmate reception center and the regular clinics in terms of the level of confidentiality. So you wanna make sure that you spell that out to the patient and get their permission to see, hey, it is okay, there may be some limitations in confidentiality. One of the ways that you get and there are plenty of ways to get around it. One of the big ways is you can put a headphone on the patient. So no other inmate can hear what the doctor is saying.

18:31 Now, coming soon, there are gonna be all sorts of technology upgrades for working with inmates and working within a correctional atmosphere. And one of them, I think eventually one of them’s gonna, that we’re gonna, there’s gonna be a screen in every single unit, in every single cell, and we’re gonna be instantaneously be able to pop into a cell. Now. I would also like to see one day, we move away from prisons and jails. Like I said earlier in the green room, you know, having prisons and jails represents a failure of us to take care of our own people and to create support that a lot people to function in society. So I’d like to move away from prisons and jails and that’s my life’s passion. So anyway, thank you very much for allowing me to present this, and I’ll take some questions.

19:25 Thank you so much for… that was really, really insightful. Can you tell me about your mother. How you opened a session?

19:39 Yeah, I can tell you by My mother, but the reason why I put that out there is because I think the future is gonna be automated and with machine learning and artificial intelligence, we’re gonna, it’s gonna be a game changer. And the way that we practice medicine is gonna be very different. So that’s sort of like a taste of what’s to come.

20:03 Got it. It’s very eye-catchy. I guess that we’ll open this up to the audience. For the audience, feel free to type in your questions. We’ll take them on air. You mentioned is there’s always a need for outside psychiatry. I was a little bit surprised and puzzled by that because feels like we then eventually you can almost replace all of them. What are the things that outside psychiatrist could do that a telepsychiatry cannot do.

20:38 Not much. Honestly, telepsychiatry can do almost everything that an onsite psychiatrist can do. And in some cases, we have advantages over on site psychiatry. Like I was saying with the recruitment and retention and the ability to move from place to place in a split second. Onsite psychiatrist can’t do that. Now onsite psychiatrists are important. Now, what can they, so what can they do that a telepsychiatrists can’t do? Well if there’s a catastrophic failure, like for instance, if my internet goes down right now, then I can’t talk to you really, I have to pick up the phone and try to be this. So onsite psychiatrists are not as beholden to the technology, but the solution to that is to have fail safe mechanisms to make sure that the technology is always on.

21:26 Got it. That makes sense. But, in terms of market, what’s percentage of the prison and jail today already have like a telepsychiatry versus like everything outside.

21:39 So it’s still a small percentage. I mean, it’s a great opportunity and to expand. And we are orbit health is expanding significantly and rapidly. So, there is a great need across the nation and that cannot be understated. I don’t think that anyone’s done studies to indicate what percentage it is, but I imagine, I know that it’s a small percentage that’s growing very, very quickly. And another important thing to remember is that this concept has improved. So we’ve been doing this. I’ve been in correctional telepsychiatry for more than a decade, and I’ve seen great successes, very few failures. And when we fail, we learn from that failure. So I’d say that the concept has been proved, and it’s absolutely insane that we don’t have more of it. We need to.

22:32 Got it, okay. So we had out questions from the audience Petra is asking. So, who pays for this?

22:39 Who pays for it? well, in most cases, county and state governments pay for it.

22:48 Got it. So in this process is to come at ease and the records are a contractor on firms like us and provide a servicing them.

22:57 Yeah, yeah. So we’ve contracted with government entities and private entities. There is a private industry in prison too. So, it’s not just the private pairs, but it’s also… I’m sorry, it’s not just public pairs, it’s private pairs as well.

23:16 Okay, okay. Got it. So, in terms of like, for example, if you say psychiatrist practicing this in terms of great your kids, as you said, compare it more like, how does that compare to things like that to Medicare versus private insurance catch case, so like, comparable, how does that…

23:36 How does the rate of reimbursement compare?

23:39 Yeah, for the the physicians, I guess the reason I’m asking is I know like psychiatrist, there’s so much in demand, a lot of them, they don’t even take private insurance and everything just cash gives. Just cashes compensation for that. How does a payment to a psychiatrist comparing to…

24:00 So, it really depends on the pair, honestly, some government entities, some private entities they try and lobe all the psychiatrists and the vendors and say, well, we’re only gonna pay, you know, bargain basement for telehealth. Others that are more evolved, that see that you want telehealth a health. It’s like your air force. You want boots on the ground in the form of an army, but you also need an air force and organizations that have telepsychiatry, they are way ahead of organizations that don’t have telepsychiatry. They have an air force. Other people are operating with just an army. And so, some people are willing to pay for that. You know, Air Force requires that you’re willing to pay for it. And if you’re not like to pay for it, then you don’t retain the doctors. You know, it’s a hard question to answer specifically because it really depends on the pair of that, if they’re willing to pay for this service or not. If they are willing to pay for it, then we can hire quality doctors, reliable doctors, and we can retain these doctors and build a program

25:09 Okay, got it. So we have a question from Brad asking, so I guess he’s asking there seems, there’s a sort of telecommunication limitations in prisons where you cannot use some mobile phones or only landline. What are some of the practical ways you have self hasn’t been?

25:27 So this is actually a great depiction of why tell telepsychiatry is sometimes better than onsite. I have my cellphone here, I can’t bring myself on into the jail or prison, and people wanna be able to connect with family and make sure that, you know, there is access to the outside world. When you go into a jail or prison, you gotta give up this. So that’s an advantage. Now, as far as the technology limitations and barriers, that’s really up to the entity like the organization. There are some jails that have really super tough policies on what can be communicated to that side wall, and what doesn’t get communicated. And the ability to connect to psychiatrist outside of the prison laws, that really depends on the local IT and central command IT as well as the leadership. Like for example, the sheriffs and the people who run the present facilities, but in terms of the actual technology, it’s very easy to do. You just need somebody to turn the key and make it happen.

26:39 Got it, okay. We have a question from Kamberline, this may be less slightly follow up to there. So she’s asking, have you provided a telepsychiatrist to clients in segregation? The equipment, like technology do use that.

26:57 Yeah, so the answer is yes, and we’ve done some really impressive, innovative things. Segregation is one of those really draconian, you know, medieval kind of things that we do, and it needs to go away. Honestly, these people suffer considerably in segregation. There are people who have spent 20 years in segregation and it drives them nuts, and it’s absolutely crucial to provide care to them. And in fact, this is one of the most important use cases of telepsychiatry, to get a camera into segregation. And in fact, it works really well because segregation rules are so tight. It takes so long to get inside segregation. Often times you have several sally ports, which is the gate that opens up for the staff to walk through. And if you have a camera right there in segregation, you avoid all of that. So yes, we have done it with great success.

27:57 Got it. So, we have a question from Chris. He’s asking its challenging to obtain the medical records for their treatments, for example, how do you get access to medication records? All these things before you provide the treatment.

28:18 So, the answer this question is much more auspicious than it used to be. So, when we first started when I saw my first patient over telemedicine over to over the video conferencing platform, they had to ship the records to me. So, I had, my whole room was filled with records and you would have been able to see records all over the place and that was crazy. I mean, that was really difficult to do. Now, when you have electronic health records, it’s actually pretty easy to do it. Again, it’s the same thing with connectivity. If you have decision makers that are on board, that will lead in the concept and are progressive, and it’s not even progressive, it’s like if they’re up to speed on what’s happening with healthcare, they’re gonna open the doors and let that through. And so these medical records, there’s easy access if you have the right willpower for it.

29:14 Got it. So, basically, now these days, it’s pretty like logging in on the patient files and it’s just as easy as that now or?

29:25 Absolutely. It’s just the click of a button and you get access to the patient record.

29:27 Okay, excellent. We have a question from the audience, Brad asking, so he’s having video critical to tell us psychiatry in the prison, can you do just like audio only? Is that good enough?

29:42 So Brad has a lot of good questions. So audio is not enough. To have a telemedicine encounter, you need both audio and video. Now you can have, and this is actually more of a legal and regulatory question than a clinical question, And I do encourage any time you wanna do telepsychiatry, you need access to legal counsel, and that’s not something that I’m providing right now, but generally speaking in a non legalistic way, I would say that you always need video or audio. If the video cuts up, for some reason, you can probably do audio, but it’s not usually a good idea. But sometimes in some rare situations where it’s absolutely necessary, you might be able to get away with audio, but you don’t wanna make that the mode of care that you do on a daily basis.

30:34 Got it. okay. So a question for Brad asking. How about using the wearable devices to monitor, like psychological stress of the inmates. If there food there as a basis to provide treatment. Have you ever seen that? Is that like, would that be useful?

30:54 Yeah,I’m sorry, I don’t think I heard the question. Are you saying, like there are peripheral devices for the inmates?

31:02 The wearabouts, like Fitbit to maybe like a stress monitoring into like a, just various way to, it’s wearable things that the patients will wear.

31:13 So that’s not something that has caught on. That is something that is being done in the telehealth community, not as much with prison and jail mates, but one day it will be like that.

31:28 There, okay. If you’ve had that, like how, what would be like an ideal wearable, suppose you go and design the ideal wearable for the prison population, what will you measure?

31:40 Okay, so, there are many things that I would like to measure, but let me give you an example. So the other day I saw somebody with PTSD and there is actually a blood pressure medication that can help improve PTSD nightmares, but you wanna know the patient’s blood pressure. If it’s too low, then you don’t wanna give them a blood pressure medication because it can bottom them out and then they might pass out and it can be dangerous. So, in the moment, I wanted to know what is this patient’s blood pressure, and rather than having a nurse come and take the blood pressure, I would rather have that information handy. Another example is orbit health. We treat a lot of people with substance use disorders, and oftentimes they come in in withdrawal of either alcohol or bensodise, things like zanax. It’s rampant out there are people are on zanax diune and all sorts of bensodise. They come to the jail and then they start withdrawing or even outside of the jail, in a non-prison setting, non-correctional setting. You have people, they’re in an active withdraw and withdraw with that treatment can be deadly. So delirium tremins has a high mortality rate, and so what you wanna be able to do is monitor their blood pressure and their calls. And if you have that, then you can feel comfortable and prescribing certain medications, and also it’ll allow you the opportunity to be able to protect the health care of the patient.

33:10 Got it. Got it. In terms of like the blood pressure, do you want that to be continuous? Is that sufficient?

33:18 You know, excellent question. With things like withdraw, you know, it can be a situation where your blood pressure is normal right now, but then in a couple hours, your body starts to withdraw even further and then you have a dangerous situation. So if you have a wearable, and this is actually really important for a correctional environment, because sometimes after your appointment, they go in and sit in a cell, and then that’s it. They don’t see people for a while. And if you have a wearable that automatically flags a certain blood pressure and automatically sends a nurse or a doctor to come care for the patient, then you might be, in those cases, you might be saving a life.

34:06 Got it, got it. Okay, that seems to be interesting area to pursue . We have another question from the audience, Brian, so he’s asking us, so what’s the price point for for as Telepsychiatry is for the personality, is it like more, it is like hourly, or is it like per patient?

34:25 You know, that depends on the business model, honestly. And you can do an hourly, you can do a capitated plan where you get paid a certain fee for covering the segment of the population. You could do every evaluation you do. You see a patient, you get reimbursed for that. So the models are varied in this context.

34:53 Got it, that probably makes sense. It’s just like, everything’s slightly different.

34:58 Yeah, everything’s different. I think ultimately, we’re gonna need to go into an accountable, accountable care organization. Sort of like philosophy for the entire nation where we’re not focused as much on fee for service. Because when you focus on fee for service, you’re incentivizing more care and we’re not necessarily interested in more and more care. We’re interested in quality care and efficient care and access to care. So accountable care is probably gonna be the direction that everyone’s going in over the next few years.

35:30 That makes sense. That is, you know, your presentation or shorter, like the huge percentage of the prison population has mental issues. Out of that, what percent of them actually get treatment?

35:43 Well, first of all, you have to recognize that a patient is mentally ill, and so you need good training processes. So, with our company, we’re in the inmate reception centers and also in the clinics, but in the reception centers where we identify if a patient need care and you would not believe how many people escape care for many, many, many years. For example, a PTSD, I’ve mentioned it a few times already, but oftentimes in a correctional atmosphere, it goes unrecognized and misdiagnosed as other things. And what we found is that our doctors, we relieve suffering and we save lives because we identify that he has a certain illness that needs to be treated.

36:31 Got it, got it. So, it is safe to say, almost essentially almost today, there are small minority, the populations getting treatment to the market.

36:43 It would say that It’s a continuum. I think that some people are getting no care and they need care. Some people are getting some care, but it’s not perfect care. Some people are gonna care when they don’t need care. That can happen too. And so what we do with our expertise in our ability is we can identify which people need more care, which people need in fact less care. We’re able to do that too. And we identify people who have not had any care that need care, that need care.

37:17 Okay, got it. So, we have a question from Randy, asking, how does the California handle the formulary issues in prescription, because lot had to provide them have their own set of go meds and like their, how did you handle that?

37:33 Yeah, I think it’s important that a formulary had enough medications that a doctor can treat every disorder and have a couple options, several options to treat each and every disorder that they face. And in California specifically now that our company is not just in California, we’re in other places, but the question was, California. So in California, in the various systems that we’re in, the formularies are usually very good and usually allow the doctor to prescribe several different medications. Now, if the patient needs a non formulary medication, then what we do is we review the situation and if we agree as administrators and we talk with the doctor and figure out what, is this is really necessary. And we’re never denying good care to our patients where if there’s not formulary option that makes sense, then we turn the key and make it happen. .

38:33 Okay. Got it. Okay. We have a question from the DD asking, so within the jails to the process for the medical calls, along with a lot of things, like general jail scheduling, ’cause something is very much like a limit, I guess, compliant and affected, early wakeup, early evening. How do you navigate a lot of these issues in jail?

38:59 How do you, wait, I’m sorry, can you repeat the question? How do we navigate which issues?

39:03 Yeah, in terms of the jails that have a lot of this process, in terms of, you know, like the when to wake up, you like all these.

39:15 Oh, right. So, like the programming, so when the patient’s waking up, when the shift change, all of those considerations of working in a jail. The schedule, the operating schedule, when this pill and all of that stuff. That’s a really good question. And orbit health isn’t, we are an expert at this. We’re expert navigating the correctional environment, and we’ve been doing this for a long time. In terms of being able to treat patients within the context of a jail system that has a lot of programming needs. What we do is we offer care in multiple points of the day. So, like orbit health will put a doctor in a regular clinic. They’ll put a doctor in the triage in the mornings, and we’ll put a doctor in the triage at night time. And we always wanna have an orbit doctor in all the times where a patient can access. And when it’s shift change. Sometimes what we do is we stop the clinic and allow shift change to occur, and then we start the clinic up later. And so we organize the process around the needs of the jail, but yeah, I mean, orbit health is a company that is very used to doing that. And, I as a psychiatrist, I’m very used to working with custody

40:35 Got it. Okay. Thanks for that. We have another question from Randy. So, in terms of, so any recommendations and tips on how to navigate the RSP process for these or correctional facility typical by laying few process. Are there any hints?

40:57 So this one’s tough because it’s asking me about something, so I’ve been in corrections for a really long time, and orbit health has people that have a lot of experience with corrections. And over time we’ve built bridges to lots and lots of administrators and people who know who we are and what we’ve done. So the RFP process, that’s something that obviously you need people that have experienced that have connections with people that are gonna, I mean the RFP process is open to everybody, but when you know and trust a certain organization as specializing in correctional telepsychiatry, like what orbit health does, that gives us an advantage. But for people that don’t have that experience, what I’d say is just get into the space, get to know the people, submit your rfps. And like I said earlier, the more time you spend in the system, the more you get to know people, the more they trust you and the more the, the entire chance you’re gonna win an RFP based on your experience and what you can do for them.

42:11 Yeah, that’s great advice, so with Randy, I guess I don’t have right experience in the correctional but in general, I have a lot experience with the bigger government run. It’s something you just think you just have to use RFP process to get to know the program committee is understand the inside and then you would just keep on planing and keep on planing, keep on getting to know them, then you actually, then you win.

42:31 And one thing that I would suggest is not to over promise and under deliver. There are actually a lot of companies and some telepsychiatry companies that will promise the world and say, wow, I will do everything, we’ll do onsite, we’ll do telepsychiatry, we’ll fill all your needs and everything’s gonna be beautiful and perfect. And what we’ve seen as observers objective of the, I think objective observers of this is sometimes people win an RFP and they totally flop on their face. If you’re a company out there that wants to submit an rfp, I’d say, be honest. You know, be honest about what you can do and don’t over promise and under deliver, because you might get a short term victory early on, but we’re, you know, orbit health, we’re in it for the long run. We’re not in it for the short term victory and then falling on our face. So I’d suggest that for other people who wanna get into this space.

43:21 Okay. yeah. Thanks for the tip. We have an audience, Brian, asking, what kind of healthcare provider, do you use? Do you use only psychiatrists or do you also use psychologist?

43:36 So. Right now, we use psychiatric prescribers, mostly psychiatrists, but we do utilize nurse practitioners as well. So we have a team, team oriented approach with that. But currently we don’t have psychologists. Psychologists are obviously extremely crucial and valuable, and maybe one day we’ll do that, but there aren’t as many hiring shortages for psychologists and social workers and therapists. Right now, telepsychiatry, the main focus has been on psychiatry, but there’s no question that psychology is gonna have a piece of this, and it’s gonna help. It’s gonna be great when they do.

44:21 Appreciate that. In terms, another question from Randy, so he’s asking. He say he had difficulty coming with the sala ROI for telepsychiatry, and the correctional stays, so do you have any insider or references for him to do his research.

44:42 So he was having trouble seeing evidence of a return on investment. Is that right? Okay, well look, I can speak about the experience that I’ve had and my company orbit health has had. We’ve seen a return on our investment. We are profitable and, most important, they are economic returns on investment that I can tell you anecdotally. I don’t know that people have done extensive studies on specifically return on investment on telepsychiatry, but I can tell you from experience and everybody that I’ve talked to that’s an expert in this field and has experienced, telepsychiatry works in the correctional environment. It works, period, but it works in the correctional environment. It’s cost effective and probably more important than the economic drivers which have improvement. Like I said, proof of concept has been done, I would say more importantly is we’re seeing it in the patient’s eyes and in the outcomes of the patients were preventing hospitalizations. Patients are doing better on follow up visits. They tell us, Doc, you know, I hadn’t done telepsychiatry before, but this works and I, you have changed my life. So, from an economic standpoint and a human perspective, telepsychiatry has worked. I can tell yo from experience that there is a return on investment.

46:10 Awesome. I have a question from Chip asking, what about the provider licensing across state line? It’s at the same as normal. You had to have license in the state or what are they doing, is it more relaxed?

46:22 Yeah, so this is another legal slash regulatory question that I don’t necessarily wanna answer absolutely and definitively. I will answer the question though. Generally speaking, again, this is not legal advice, but generally speaking, you wanna have a license with the state where the patient resides. That’s one of the crazy things about practicing medicine in America these days. Look, I can get in a car and drive through 50 states and nobody will have any issue of that. But if I practice from California from wherever, and I’m seeing a patient that’s located into different state, in most cases, that state medical board will want me to have a license in that state. Now with the state federation of medical boards and the interstate compact and the efforts being made to have reciprocity. That’s definitely a step in the right direction, but we need to tell our governments that look, if I’m trained, I was trained all over the country and I happen to be in California now. And if I move to somewhere else like Alabama or Maine or Mississippi, I’m still the same being. I’m still the same doctor. Why do I have to have another license. Why, if I wanna treat somebody from California to Alaska, why do I need an Alaska license? It’s crazy and it needs to change.

47:51 I appreciate that. We have a last question from the audience, Chip is asking, so are you effectively able to provide a drug rehab counseling via telepsychiatry.

48:02 Yeah, I mean, that’s one of our main missions. Orbit health is definitely more treating people as substance abuse disorders, and I think that it’s quite effective. Substance Use Treatment works for sure. Now, of course, people come in and out of substance, you say, relapse and they go through periods of time where they’re clean. So you wanna be able to see them in all phases of their addiction. And so it’s really important that you have flexible solution like telepsychiatry that can see them, whether they’re in the jail, whether they’re in the community and it does work. So the answer is yes.

48:44 Got it, Christian and now, I gotta apologize we can’t answer everyone’s questions. You can give your questions when we post the recording. I guess in, let me just ask like 3 rapid fire questions. The first things is, you shared a lot of really interesting things for the audience today. Well, if the audience can only learn one thing from you, what would be that one thing that would be the most helpful to our audience today.

49:11 Well, I would say that tell a psychiatry works for correctional environments and orbit health has had success, a lot of success in that and I would, if I can say two things. So one thing is we have the treatment, we can change the world. It’s right that we have the technology, we have the doctors and we have the expertise, but these people need help. And like you said, I mean, you were asking me about what percentage are in jails and prisons, not enough. And so the one thing that everyone needs to learn is we need more people serving prisons and jails.

49:53 Got it. The next questions is, uhm, what is something about one thing that you believe about digital health, telehealth, that no one else believes in yet?

50:04 What’s the one thing that I believe that other people don’t necessarily believe at this time? I would say that all information is knowable and this is like an AI machine learning kind of thing. One day we’re gonna have instruments that can measure all of the data that’s out there. Right now, we have, we’ve mapped out the entire human genome and we’re working on curing diseases on a molecular and genetic level. One day, all of these diseases are gonna be cured. Prisons are gonna go away because we’re gonna have the ability to change behavior on a genetic level. Now, the question is on an ethical basis, is that something that we’re gonna be able to deal with. So artificial intelligence and tele-mental health and telemedicine, they’re all part of the same tele health program and we’re gonna have the power to solve every problem. The question is, who’s gonna have access to the data? Who’s gonna have access to the treatment? And what’s that all gonna look like for society? That’s gonna be really interesting to see.

51:16 So listeners, for the final things, if you had let it three minutes to privately talk to President Trump about telehealth, what would you say to him?

51:26 I would say two things to the president. So Mr. President, if you’re listening. We need to knock down some of these barriers. We need one license where you can see everybody in America, every US citizen, every US person, we need to be able to see them all. And I think that the president can help with that. I think that he can push for that. The other thing at I would say To Mr. president is that we have a crisis here. Okay, we know about the opioid crisis, but we have a mass incarceration crisis here. We need you Mr President to step up, and you already commuted the sentence of a grandmother who was in prison for 21 years on a drug charge. We need more of that. We need to get these people out of prison and in treatment for their substitute problems, because these are all Americans. And like I said, every year a population equivalent to the casualties and the entire Vietnam War dies and dies with substance use disorders. But we have 2.3 million Americans that are host in jail and prison, and that needs to stop. So the criminal justice system is really broken and we need the government, the federal government, and all the local government to fight for change, ’cause it’s not right. It’s not right when I see somebody that has been in jail 100 times in a couple weeks ago, this happens and it happens all the time when I see people over and over again. But this person that I’m thinking of chronically seriously mentally ill with paranoid schizophrenia has no idea how to function in society, and he keeps getting picked up on trespassing in other kinds of mental illness. So that needs to change, Mr. President. We need your help with that.

53:29 That’s really well said. Thank you so much for sharing insights with us. We really appreciate it.

About the Speaker:

Edward Kaftarian, MD is an internationally recognized expert and innovator in the field of Telepsychiatry. As the Chief Executive of Telepsychiatry for the Statewide California Correctional Healthcare Services, he built the largest correctional telepsychiatry program in the world, with over 70 psychiatrists serving over 25 institutions.

He oversees all aspects of the telemental health program, including technology management, staff development, clinical care, logistics, recruitment, hiring, and overseeing the care of thousands of inmates. Dr. Kaftarian is board certified in General Psychiatry, Forensic Psychiatry, and Addiction Medicine.


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