Karnataka telemedicine mentoring and monitoring program for complete integration of psychiatry in the general health care.

The National Mental Health Survey of India reported a higher prevalence and treatment gap of psychiatric disorders among the general population. Task shifting is one of the important solutions to meet this requirement. The prevalence of psychiatric disorders among primary care is about 30%-50%. Digitally driven primary care psychiatry program (PCPP) designed to innovate different module to upscale the skills of primary care doctors (PCDs) in live consultation of PCDs in their general patients. To exponential coverage of PCDs, Karnataka Telemedicine Mentoring and Monitoring (KTM) Program is been implemented across all districts of Karnataka. It is the training of trainer version of PCPP where psychiatrists serving in District Mental Health Program of all districts of Karnataka become trainers to implement of two digital modules (Telepsychiatric On-Consultation Training and Collaborative Video Consultations) of PCPP with the target to train all PCDs of Karnataka. This paper aims to provide a glimpse of this innovative KTM program and current progress with a preliminary analysis of translational quotient indicating skill transfer and retention. Copyright:

INTRODUCTION

Karnataka is a south Indian state with an area of 191,791 km2 and its population of 61,095,297 (Approximate 61.1 millions) with the density of 319 per km2 (). There are 2206 primary health centers across Karnataka state to cater to the health needs of the population (). The National Mental Health Survey of India (2015–2016) reported the prevalence of 10.6% psychiatric disorders in the general population and higher treatment gap.[1] Considering this huge load, integrating psychiatric care in general care is the only way forward to reduce the treatment gap, especially using digital training.[2]

Primary care is the availability of treatment near to patients' home. About 30%–50% of primary care patients do have psychiatric disorders, many of whom manifest bodily symptoms. They receive just the symptomatic treatment leading to chronicity and dissatisfaction among patients.[3]

It is noteworthy to mention here a couple of public mental health programs in Karnataka aimed at the integration of psychiatric care into primary care are. Bellary model, which became the template to roll out the District Mental Health Program (DMHP),[4] is probably the first example in the country where the integration of psychiatric care into general healthcare. Essentially, the primary care doctors (PCDs) are trained for a variable duration from 3 to 3 months; in identifying and managing psychiatric disorders. The traditional Class-room training model is used for the same. As of today, >600 (out of the 755) in the country is covered by the DMHP.

Another recent example of this integrative model is the “Manochaitanya” program in Karnataka, which actually takes specialist psychiatric care to the secondary care level and primary care psychiatry services are catered by the PCDs working at public PHCs.[35] However, this model has seen a substantial amount of success at the taluka (sub-district) level,[6] not seeing the same amount of success further downward, especially by PCDs. An important reason (among many others) is the questionable translational quotient (TQ) of Classroom training (CRT).[7]

CRT consist of traditional methods of teaching, including didactic lectures, video demonstrations, role-plays while providing voluminous teaching manuals. Evidently, these lack principles of adult learning and lack the “TQ” (the ability of a training method to convert knowledge base to deliverable clinical skills), an indispensable component of any adult learning exercise for utilizing the gained knowledge into clinical skills.

To improve the TQ of training programs of PCDs, the Tele Medicine Centre, of the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru has come up with this innovative module-based digitally-driven primary care psychiatry program (PCPP).[7] An essential part of PCPP is the Telemedicine based On-Consultation training (Tele-OCT) innovated by the first author (NM). It consists of live real-time clinical training of PCDs, (meaning training during their consultations with patients in clinics) that is supervised by a tele-psychiatrist (hub-specialist) using hub and spoke model of telemedicine. Clinical Schedules for Primary Care (CSP) Psychiatry, a brief, adopted and validated curriculum designed specifically for PCDs, acts as the curriculum for the Tele-OCT.[8] CSP enables the PCDs to identify and provide first-line treatment of common psychiatric disorders presenting to the primary care setups of low- and middle-income countries such as India, where typically the PCDs is spend <2 min per patient in their busy clinic.[9] A salient feature of Tele-OCT is that it has inbuilt direct skill transfer with a higher TQ.[8] Tele-OCT was also successfully piloted at Mandya district of Karnataka.[8] However, Tele-OCT is labor and time-intensive. Hence, to expand rapidly across Karnataka state, there is a need of more trainer psychiatrists to train PCDs in large numbers. This led to the birth of the Karnataka Telemedicine Mentoring and Monitoring (KTM) program.[10]

The KTM program is being executed by the faculty members of NIMHANS, Bengaluru, in collaboration with the officials of the Department of Health and Family Welfare, Government of Karnataka, the funder for the program, through the National Health Mission.[10] The overarching aim of the KTM program is to integrate psychiatric care into the general practice of PCDs. KTM program is essentially a psychiatrist-based Training of Trainers' (TOT) module. This is currently being implemented across all districts of Karnataka. The aim of this paper is to highlight the salient features of the KTM program. To the best of authors' understanding, this is the first of its kind, large scale public health program to integrate psychiatric care in primary care using telementoring and telemonitoring mode with innovative methods.

SALIENT FEATURES OF KARNATAKA TELEMEDICINE MENTORING AND MONITORING PROGRAM

This essentially is a TOT version of the digitally-driven PCPP, incorporating its three modules of (CSP, Tele-OCT, and collaborative video consultations [CVC]). In CVCs, PCDs will consult tele-psychiatrists, for advice regarding the management of a patient. Final treatment, though, will be decided collaboratively.[7] In the KTM program, all 34 psychiatrists serving for the DMHP of Karnataka will be trained as “trainers” on the above-mentioned three modules of PCPP. These DMHP psychiatrists will impart all the three modules to each of their jurisdictional PCDs.

TOT for the trainers (DMHP psychiatrists) occurred in the following way: First, a 1-day preparatory workshop was conducted, where in they were oriented to the three modules of the PCPP. Next, each of the 34 trainers, in collaboration with the KTM telepsychiatrists, learnt the skills of conducting Tele-OCT and CVC and also the skills to teach these two to the PCDs. For getting the certification of a certified trainer, each one of them was mandated to undergo training in 3 Tele-OCT sessions in about 6–8 h covering 30–40 general patients). During the first of the three sessions, they were supposed to only see and observe the Tele-OCT conducted by the master trainer tele-psychiatrist involving the PCD. During the second, the trainer is allowed to try doing the tele-OCT, while the master trainer tele-psychiatrist will be observing and correcting the process. During the third session, the entire tele-OCT session will be conducted by the trainer psychiatrist with either least (or no) involvement by the NIMHANS faculty member. In short, TOT is conducted using STD format (STD acronym for see, try-and do-it-yourself). To deliver this, four-tier based modified hub and spoke model of telemedicine is designed for this program (hub at academic hospital level by master trainer KTM tele-psychiatrists, mini-hub at the district level by trainer DMHP psychiatrists, micro-hub at primary care level by PCDs and patients are spokes).[10]

After completing of TOT, DMHP psychiatrists are supposed to independently conduct Tele-OCT and CVC for remaining PCDs in their district, and KTM tele-psychiatrists shall monitor all DMHP psychiatrists to ensure quality control.

TARGET

All 34 DMHP psychiatrists of Karnataka will be certified KTM trainers who, in turn, are supposed to train all their jurisdictional 2206 PCDs across Karnataka state.

CURRENT STATUS OF SKILL TRANSFER

KTM program started in January 2019. Till January 2020, 820 h of Tele-OCT have been conducted, covering 422 PCDs across all districts of Karnataka in successful 588 Tele-OCT sessions. During this process, 34 DMHP psychiatrists have completed criteria for their trainers' certification, whereas the remaining three newly DMHP psychiatrists (in lieu of resignation of previous psychiatrists) are undergoing TOT sessions.

PRELIMINARY OUTCOME EVALUATION

Direct skill transfer (to the PCD) during the training sessions has been envisaged as a primary outcome. The secondary outcome is the CVC provided to patients. Preliminary data indicates that out of the 4106 general patients are consulted in the tele-OCT sessions till date, 1324 had one or the other psychiatric disorders amounting to 32.24% of their general practice. This aspect can act as one of the indicators to assess the effectiveness of PCPP. In this context, it may be noted that the desirable proportion of psychiatric consultation in the general practice of PCD ranges from 17% to 46%.[11] Finally, PCDs will undergo an evaluation to understand the extent of skill transfer, and retention is called as TQ of the training method.[7] This is assessed in the Tele-OCT evaluation session occurs at least 2 weeks after completing the three consecutive Tele-OCT training sessions. TQ (to assess skill transfer) from preliminary data analysis of 126 PCDs who have completed three consecutive Tele-OCT sessions is 62.65% (acceptable is 50% and above).

Limitations

It is very labor-intensive, time-consuming, and one-time expensive program, but authors feel that the benefits override in terms of patient's improvement, satisfaction, and saving of national budget.

FUTURE DIRECTIONS

TOT is completed for 34 DMHP psychiatrists till January 2020, but new 3 DMHP psychiatrists (two of them are working in Taluk Mental Health Program) are undergoing after the resignation of earlier ones. Once PCDs are trained, they are expected to treat psychiatry patients in their general practice. This program can also be scaled up and expanded to other states of India. There is a need for a periodic assessment of skill retention of PCDs. There is also a need to evaluate the effectiveness of program with patient and illness-related outcome using cluster randomized controlled trial is been delayed in view of COVID-19. There is a need to audit patient data from each of the PCDs. In view of the labor-intensive program and need of a huge number of trainer psychiatrists, further advancement using contemporary technological development such as artificial intelligence-based OCT (robotic OCT) may be planned.

CONCLUSIONS

KTM program is an ongoing program of psychiatrist-based TOT module of PCPP with an overall aim to integrate psychiatric care into the general primary healthcare by training PCDs using innovative methods by leveraging simple digital technology. Preliminary results appear promising and encouraging. However, there is a need to assess its effectiveness and impact in the real-world scenario.

Financial support and sponsorship

The study was funded by the National Health Mission, Government of India in the category of “innovation”.

Conflicts of interest

There are no conflicts of interest.