Tribal Perspectives on Patient Navigation for Rural Native Veterans Using Veteran Health Administration Services.

American Indian and Alaska Native (Native) Veterans enrolled in the U.S. Department of Veterans Affairs (VA) benefits program are far less likely to access health care compared to other racial/ethnic groups, in part driven by challenges posed by often distant, complex, and culturally unresponsive health care that does not easily interface with the Indian Health Service (IHS) and local Tribal Health Care. To address this disparity, in 2020 the Veteran's Health Administration's (VHA) Office of Rural Health (ORH) initiated the development of a patient navigation program designed specifically for rural Native Veterans. There are no navigation programs for rural Native Veterans to guide development of such a program. Hence, the project team sought perspectives from rural Native Veterans, their families, and community advocates, (n = 34), via video and phone interviews about the role and functions of a Veteran patient navigator and personal characteristics best be suited for such a position. Participants believed a navigator program would be useful in assisting rural Native Veterans to access VHA care. They emphasized the importance of empathy, support, knowledge of local culture, and of Veteran experience within tribal communities, adeptness with VHA systems, and personnel consistency. These insights are critical to create a program capable of increasing rural Native Veteran access to VHA services.

Examining Burnout and Perspective on Videoconferencing in the Mental Health Workforce.

Objective: To examine burnout and perspectives on videoconferencing over time for the mental health workforce. Methods: Members of an academic psychiatry department completed two anonymous surveys about virtual work and burnout 18 months apart (T1n = 274, response rate = 66.8%; T2n = 227, response rate = 36.7%). A subset completed the burnout subscale of the Stanford Professional Fulfillment Index (T1n = 145; T2n = 127). Results: Respondents were well satisfied with videoconferencing at both time points and satisfaction was higher at T2. Videoconferencing was not perceived to contribute to feelings of fatigue at either time point and burnout levels decreased from T1 to T2. Conclusions: Videoconferencing is well received by the mental health workforce and is not widely perceived to contribute to feelings of fatigue. Longer use of videoconferencing coincided with decreased levels of burnout. There are likely benefits to virtual work for the mental health workforce and virtual work may be protective from burnout.

Patient and Provider Satisfaction with Asynchronous Versus Synchronous Telepsychiatry in Primary Care: A Secondary Mixed-Methods Analysis of a Randomized Controlled Trial.

Background: Asynchronous telepsychiatry (ATP) consultations are a novel form of psychiatric consultation. Studies comparing patient and provider satisfaction for ATP with that for synchronous telepsychiatry (STP) do not exist. Methods: This mixed-methods study is a secondary analysis of patients' and primary care providers' (PCPs) satisfaction from a randomized clinical trial of ATP compared with STP. Patients and their PCPs completed satisfaction surveys, and provided unstructured feedback about their experiences with either ATP or STP. Differences in patient satisfaction were assessed using mixed-effects logistic regression models, and the qualitative data were analyzed using thematic analysis with an inductive coding framework. Results: Patient satisfaction overall was high with 84% and 97% of respondents at 6 months reported being somewhat or completely satisfied with ATP and STP, respectively. Patients in the STP group were more likely to report being completely satisfied, to recommend the program to a friend, and to report being comfortable with their care compared with ATP (all p < 0.05). However, there was no difference between the patients in ATP and STP in perceived change in clinical outcomes (p = 0.51). The PCP quantitative data were small, and thus only summarized descriptively. Conclusions: Patients expressed their overall satisfaction with both STP and ATP. Patients in ATP reported more concerns about the process, likely because feedback after ATP was slower than that after STP consultations. PCPs had no apparent preference for STP or ATP, and reported implementing the psychiatrists' recommendations for both groups when such recommendations were made, which supports our previous findings. Trial Registration: ClinicalTrials.gov NCT02084979; https://clinicaltrials.gov/ct2/show/NCT02084979.

Telemental Health for the Homeless Population: Lessons Learned when Leveraging Care.

PURPOSE OF REVIEW: The purpose of this paper is to review key lessons when using telehealth within the context of mental health and homelessness. We examine technological and bandwidth issues the homeless population might face when getting telehealth services, discuss clinical process adaption needed for working remotely, and highlight the lessons learned when leveraging mental health services to homeless patients across telehealth platforms. RECENT FINDINGS: Homelessness is associated with chronic, mental health disparities and access to mental health services is often less accessible among communities with unstable housing. Telehealth provides "OnDemand" treatment options while removing specific barriers found with in-person health care such as transportation, overwhelmed mental health facilities, i.e., appointment availability, and office hour limitations while reducing costs for both providers and patients. We provide two case examples to demonstrate successful delivery of telemental health services to homeless patients and review lessons learned when leveraging care.

An Introduction to Generative Artificial Intelligence in Mental Health Care: Considerations and Guidance.

PURPOSE OF REVIEW: This paper provides an overview of generative artificial intelligence (AI) and the possible implications in the delivery of mental health care. RECENT FINDINGS: Generative AI is a powerful technology that is changing rapidly. As psychiatrists, it is important for us to understand generative AI technology and how it may impact our patients and our practice of medicine. This paper aims to build this understanding by focusing on GPT-4 and its potential impact on mental health care delivery. We first introduce key concepts and terminology describing how the technology works and various novel uses of it. We then dive into key considerations for GPT-4 and other large language models (LLMs) and wrap up with suggested future directions and initial guidance to the field.

Culturally Centered Implementation of Video Telehealth for Rural Native Veterans.

Introduction: Native American Veterans are the most rural and experience heightened risk for mental health (MH) challenges while facing significant health care inequities and access barriers. Rural Native Veterans (RNVs) have experienced historical loss and racial discrimination, contributing to mistrust of Veterans Health Administration (VHA) and other Federal systems. Telemedicine, including video telehealth (VTH), can improve access to MH care for RNVs by addressing barriers. Understanding the cultural context and existing community resources can improve engagement and implementation efforts with RNVs. Objective: This article describes a model of culturally centered MH care and a flexible implementation approach, Personalized Implementation of Virtual Treatments for Rural Native Veterans (PIVOT-RNV), used to disseminate the model. Methods: Participants included four VHA sites serving large RNV populations where PIVOT-RNV was applied to expand the availability of virtual solutions, including VTH, for RNVs. A mixed methods formative evaluation tracked VTH utilization and used provider and RNV feedback to inform iterative process improvements. Results: Where PIVOT-RNV was used, number of providers using VTH with RNVs, number of unique RNVs receiving MH care through VTH, and number of VTH encounters with RNVs grew annually. Provider and RNV feedback highlighted the importance of addressing the unique barriers and cultural context of RNVs. Conclusions: PIVOT-RNV demonstrates promise for improving implementation of virtual treatments and access to MH care for RNVs. The integration of implementation science within a cultural safety framework helps address specific barriers to adoption of virtual treatments for RNVs. Next steps include expanding PIVOT-RNV efforts at additional sites.

Resource Document on Best Practices in Synchronous Videoconferencing-Based Telemental Health.

Background: This document represents an updated collaboration between the American Psychiatric Association (APA) and the American Telemedicine Association (ATA) to create a consolidated update of the previous APA and ATA official documents and resources in telemental health, to provide a single guide on clinical best practices for providing mental health services through synchronous videoconference. Methods: A joint writing committee drawn from the APA Committee on Telepsychiatry and the ATA TMH Special Interest Group (TMH SIG). was convened to draft and finalize the guidelines. This document draws directly from the 2018 APA/ATA guide and the ATA s previous guidelines, selecting from key statements/guidelines, consolidating them across documents, and then updating them where indicated. Guideline approval was provided following internal review by the APA, the ATA, the Board of Directors of the ATA, and the Joint Reference Committee of the APA. Results: The guidelines contain requirements, recommendations, and actions that are identified by text containing the keywords "shall," "should," or "may." Conclusions: Compliance with these recommendations will not guarantee accurate diagnoses or successful outcomes. The purpose of this guide is to assist providers in providing effective and safe medical care founded on expert consensus, research evidence, available resources, and patient needs.

Suicide Among American Indian and Alaska Native Veterans Who Use Veterans Health Administration Care: 2004-2018.

BACKGROUND: American Indian and Alaska Natives (AI/ANs) veterans may be at elevated risk for suicide, but little is known about suicide among this population. METHODS: We conducted a retrospective cohort analysis of AI/AN veterans who received health care services provided or paid for by the Veterans Health Administration (VHA) between October 1, 2002, and September 30, 2014, and who were alive as of September 30, 2003. Age-specific and age-adjusted suicide rates through 2018, per 100,000 person-years (PY) at risk and 95% confidence intervals were computed. RESULTS: Age-adjusted suicide rates among AI/AN veterans in this cohort more than doubled (19.1-47.0/100,000 PY) over the 15-year observation period. In the most recent observation period (2014-2018), the age-adjusted suicide rate was 47.0 per 100,000 PY, with the youngest age group (18-39) exhibiting the highest suicide rate (66.0/100,000 PY). The most frequently used lethal means was firearms (58.8%), followed by suffocation (19.3%), poisoning (17.2%), and other (4.7%). CONCLUSIONS: Results suggest that: (1) suicide is an increasing problem among AI/AN VHA veterans; and (2) younger AI/AN VHA veterans are at particularly high risk and warrant focused prevention efforts. Findings are similar to those observed in general AI/AN population. There is a compelling need to review and strengthen VHA suicide prevention efforts directed towards AI/AN veterans.

Suicide-related behaviors among American Indian and Alaska Native Veterans: A population-based analysis.

American Indian and Alaska Native (AI/AN) Veterans are at elevated risk for suicide, but currently, no population-based research exists on precursors, including ideation, plans, or attempts. We employed two large national surveys to investigate the occurrence of suicide-related behaviors among AI/AN Veterans. Using cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS, 2010-2012) and National Survey on Drug Use and Health (NSDUH, 2010-2015), we compared weighted frequencies of suicide ideation in AI/AN Veterans and non-Hispanic White (NHW) Veterans. Suicide ideation among AI/AN Veterans was 9.1% (95%CI = 3.6%, 21.5%) and 8.9% (95%CI = 1.9%, 15.9%) in BRFSS and NSDUH, respectively, compared to 3.5% (95%CI = 3.0%, 4.1%) and 3.7% (95%CI = 3.0%, 4.4%) for NHW Veterans. Logit analysis suggested higher odds of ideation among AI/AN Veterans in both samples (NDSUH: OR = 2.68, 95%CI = 1.14-6.31; BRFSS: OR = 2.66, 95% CI 0.96-7.38), although sample sizes were small and confidence intervals were wide. Consistent findings from two national samples suggest AI/AN Veterans have more than twice the risk of suicide ideation relative to NHW Veterans. Ongoing efforts include weighing these results together with data on suicide deaths from medical and death records to develop effective suicide prevention approaches in collaboration with AI/AN Veterans and their communities.

Telemental Health and the Management of Psychosis.

PURPOSE OF REVIEW: The purpose of this paper is to review the application of telehealth in the assessment and treatment of psychotic illnesses. We present the contextual factors which make this approach to clinical care compelling, and review existing evidence about feasibility, acceptability, and effectiveness. RECENT FINDINGS: The use of telehealth with individuals that suffer from serious mental illness and psychosis has been demonstrated to be feasible and acceptable, with effectiveness that is comparable to in-person clinical care. Telehealth holds the additional promises of expanding access, connecting patients, families, and the general public to behavioral health resources, and reducing overall health care costs. We provide two case examples which demonstrate the successful use of technology for the delivery and coordination of effective patient care for individuals with psychotic illnesses.

Clinical Outcomes of Asynchronous Versus Synchronous Telepsychiatry in Primary Care: Randomized Controlled Trial.

BACKGROUND: Asynchronous telepsychiatry (ATP; delayed-time) consultations are a novel form of psychiatric consultation in primary care settings. Longitudinal studies comparing clinical outcomes for ATP with synchronous telepsychiatry (STP) are lacking. OBJECTIVE: This study aims to determine the effectiveness of ATP in improving clinical outcomes in English- and Spanish-speaking primary care patients compared with STP, the telepsychiatry usual care method. METHODS: Overall, 36 primary care physicians from 3 primary care clinics referred a heterogeneous sample of 401 treatment-seeking adult patients with nonurgent psychiatric disorders. A total of 184 (94 ATP and 90 STP) English- and Spanish-speaking participants (36/184, 19.6% Hispanic) were enrolled and randomized, and 160 (80 ATP and 80 STP) of them completed baseline evaluations. Patients were treated by their primary care physicians using a collaborative care model in consultation with the University of California Davis Health telepsychiatrists, who consulted with patients every 6 months for up to 2 years using ATP or STP. Primary outcomes (the clinician-rated Clinical Global Impressions [CGI] scale and the Global Assessment of Functioning [GAF]) and secondary outcomes (patients' self-reported physical and mental health and depression) outcomes were assessed every 6 months. RESULTS: For clinician-rated primary outcomes, ATP did not promote greater improvement than STP at 6-month follow-up (ATP vs STP, adjusted difference in follow-up at 6 months vs baseline differences for CGI: 0.2, 95% CI -0.2 to 0.6; P=.28; and GAF: -0.6, 95% CI -3.1 to 1.9; P=.66) or 12-month follow-up (ATP vs STP, adjusted difference in follow-up at 12 months vs baseline differences for CGI: 0.4, 95% CI -0.04 to 0.8; P=.07; and GAF: -0.5, 95% CI -3.3 to 2.2; P=.70), but patients in both arms had statistically and clinically significant improvements in both outcomes. There were no significant differences in improvement from baseline between ATP and STP on any patient self-reported ratings at any follow-up (all P values were between .17 and .96). Dropout rates were higher than predicted but similar between the 2 arms. Of those with baseline visits, 46.8% (75/160) did not have a follow-up at 1 year, and 72.7% (107/147) did not have a follow-up at 2 years. No serious adverse events were associated with the intervention. CONCLUSIONS: This is the first longitudinal study to demonstrate that ATP can improve clinical outcomes in English- and Spanish-speaking primary care patients. Although we did not find evidence that ATP is superior to STP in improving clinical outcomes, it is potentially a key part of stepped mental health interventions available in primary care. ATP presents a possible solution to the workforce shortage of psychiatrists and a strategy for improving existing systems of care. TRIAL REGISTRATION: ClinicalTrials.gov NCT02084979; https://clinicaltrials.gov/ct2/show/NCT02084979.

Telemental Health Response to the COVID-19 Pandemic: Virtualization of Outpatient Care Now as a Pathway to the Future.

The use of telemental health (TMH) has fostered the continued provision of mental health care during the COVID-19 pandemic, and ultimately prevented the significant drop in clinical visits as experienced by other health care disciplines. Many health care providers and systems rapidly virtualized care to include visits occurring in what previously were defined as nontraditional locations such as provider and patient homes. Emerging data and reports suggest that this rapid virtualization of mental health services occurred safely and effectively. Although it is uncertain how long the full virtualization will remain, we envision a future wherein mental health services are delivered using a hybrid in-person/TMH approach. This opinion provides an overview of current lessons learned from rapid virtualization due to COVID-19 mitigation strategies and recommends that mental health providers and systems use these lessons to define and promote hybrid care delivery.

Rapid Conversion to Telemental Health Services in Response to COVID-19: Experiences of Two Outpatient Mental Health Clinics.

Background: The COVID-19 pandemic triggered changes across health care systems, with many sectors seeing significant drops in patient visits. Rapid transition to telemental health (TMH) allowed for the continued delivery of mental health care. Although several guidelines and best practices are available for the methodical development of a TMH service, there are few documented procedures on rapidly converting to fully virtualized services. We discuss how two outpatient mental health clinics at the University of Colorado Anschutz Medical Campus rapidly virtualized clinical services during the COVID-19 pandemic. Methods: All current clinical appointments were converted to virtual, and all new clinical intakes were scheduled as virtual visits starting March 16, 2020. Virtualization included a modified needs assessment, updated clinic procedures, focused patient and staff training on TMH, and increased frequency of team meetings. We conducted a retrospective evaluation of clinic log and electronic health record data to examine the number of appointments and no-shows before and after COVID-19 virtualization. Results: Virtualization was operational within two business days. Scheduled appointments decreased 10.6% immediately postvirtualization, followed by an increase of 17.8% across the 6 months postvirtualization. No-show rates dropped from 11.9% pre- to 6.8% postvirtualization, leading to a 26.2% increase in completed visits. Discussion: Rapid virtualization of mental health services can occur effectively. Wider use and acceptance of TMH, especially to patient-homes, is likely in the foreseeable future as health care providers and systems reconceptualize service delivery. Future research must include analyzing the impact such changes make on clinical outcomes and patient visit volumes.

Asynchronous Telepsychiatry Interviewer Training Recommendations: A Model for Interdisciplinary, Integrated Behavioral Health Care.

Objective: Asynchronous telepsychiatry (ATP) is an integrative model of behavioral health service delivery that is applicable in a variety of settings and populations, particularly consultation in primary care. This article outlines the development of a training model for ATP clinician skills. Methods: Clinical and procedural training for ATP clinicians (n = 5) was provided by master's-level, clinical mental health providers developed by three experienced telepsychiatrists (P.Y. D.H., and J.S) and supervised by a tele-psychiatrist (PY, GX, DL) through seminar, case supervision, and case discussions. A training manual and one-on-one sessions were employed for initial training. Unstructured expert discussion and feedback sessions were conducted in the training phase of the study in year 1 and annually thereafter over the remaining 4 years of the study. The notes gathered during those sessions were synthesized into themes to gain a summary of the study telepsychiatrist training recommendations for ATP interviewers. Results: Expert feedback and discussion revealed three overarching themes of recommended skill sets for ATP interviewers: (1) comprehensive skills in brief psychiatric interviewing, (2) adequate knowledge base of behavioral health conditions and therapeutic techniques, and (3) clinical documentation, integrated care/consultation practices, and e-competency skill sets. The model of training and skill requirements from expert feedback sessions included these three skill sets. Technology training recommendations were also identified and included: (1) awareness of privacy/confidentiality for electronic data gathering, storage, management, and sharing; (2) technology troubleshooting; and (3) video filming/retrieval. Conclusions: We describe and provide a suggested training model for the use of ATP integrated behavioral health. The training needs for ATP clinicians were assessed on a limited convenience sample of experts and clinicians, and more rigorous studies of training for ATP and other technology-focused, behavioral health services are needed. Clinical Trials number: NCT03538860.

Remote Telepsychiatry Workforce: a Solution to Psychiatry's Workforce Issues.

PURPOSE OF REVIEW: The purpose of this paper is to demonstrate how a remote workforce may increase access to care while reducing physician burnout. We review workforce issues and organizational and individual obstacles for implementing a telepsychiatry workforce including administrative, logistical, and clinical considerations and offer resources for how to overcome barriers that may arise in implementing a remote workforce. RECENT FINDINGS: There is an increasingly unmet demand for mental health services and a shortage in psychiatrists. Burnout may be a key factor contributing to psychiatrists working less, pursuing less acute cases, and leading to worsened outcomes for patients and the psychiatrists themselves. Telepsychiatry provides comparable patient and provider satisfaction and equal outcomes when compared with face-to-face encounters. We provided 3 case examples to demonstrate psychiatrists demonstrating successful delivery of care in a range of clinic settings and workplace configurations while optimizing their quality of life and reducing their risk of burnout.

Telepsychiatry in an Alaska Native Residential Substance Abuse Treatment Program.

Introduction: Alaska Native communities experience high rates of alcohol and substance abuse and face challenges accessing quality, culturally appropriate treatment. Telepsychiatry could help bridge this gap, but no publications have examined its impacts for alcohol and substance abuse treatment directed at Alaska Native communities. This study explores one telepsychiatry clinic's impact on a residential substance abuse treatment serving the Alaska Native community in Anchorage, Alaska. Methods: Using a matched case - control design, 103 cases receiving telepsychiatry services between 2007 and 2012 were matched with 103 controls who did not. Outcome measures included length of stay, discharge plans, emergency room visits, and hospital admissions; clinical history, including previous suicide attempts, history of violence, and trauma history; social stressors such as current legal issues, unemployment, and homelessness; mental health, medical, and substance abuse diagnoses; and number of telepsychiatry appointments and nature of telepsychiatry services rendered. Results: Both groups exhibited high rates of mental and medical illness, socioeconomic challenges, and substance abuse. However, the telepsychiatry group demonstrated a significantly higher rate of post-traumatic stress disorder, history of violence, ongoing legal issues, and children in outside custody. It also remained engaged in treatment longer, had fewer discharges against medical advice, and was more likely to complete treatment. Discussion/Conclusions: Our study highlights this telepsychiatry clinic's real-world difference serving the complex substance abuse treatment needs of Alaska Native individuals. It also reinforces telepsychiatry's promise in serving other communities facing a high burden of addiction and mental illness yet facing barriers to high-quality, culturally competent services.

Best Practices in Tele-Teaming: Managing Virtual Teams in the Delivery of Care in Telepsychiatry.

PURPOSE OF THE REVIEW: To review and organize best practices around management of virtual teams for psychiatrists working in team-based telepsychiatry services. RECENT FINDINGS: An early but evolving literature in telepsychiatric team-based care is beginning to examine the importance of team function. Psychiatrists will increasingly have opportunities to engage in team-based telepsychiatry in evolving models that improve outcomes, enhance quality, and expand access to behavioral health treatments. While the literature is limited in psychiatry and medicine on virtual teams, there is a growing literature from applied psychology and business. This article synthesizes these findings along with lessons learned from the field to provide recommendations for psychiatrists involved in team-based telepsychiatry. Providing this type of care involves mastering the management of virtual teams. Psychiatrists are well positioned to play a distinctive and central leadership role for team-based telepsychiatry.

Outcomes and Lessons Learned from the Tribal Veterans Representative Program: A Model for System Engagement.

American Indian and Alaska Native Veterans are more rural than Veterans of any other race or ethnicity and face significant barriers to accessing care. Since 2001, the Tribal Veterans Representative (TVR) Program, a partnership between the U.S. Department of Veterans Affairs (VA) and tribal nations, has trained liaisons from tribal communities to facilitate access to VA benefits and services. We delineate the TVR program model alongside supporting data. We reviewed TVR training materials and program evaluations to identify components of the program essential for increasing access to VA services and benefits. We then report a quantitative assessment of benefits attained in one tribal community. The TVR model is characterized by the exchange of two sets of knowledge and resources-'institutional' and 'community'-during a co-sponsored educational program aiming to train community liaisons about the institution. The institution leads the program's content; the community's traditions inform its process. Following the program, liaisons use support networks comprising trainers, trainees and local organizations to teach other community members to access health care and benefits. In the evaluation community, one liaison has facilitated access for hundreds of Veterans, with financial compensation exceeding $400,000 annually. The TVR program has begun to demonstrate its utility for other rural populations, though further formal evaluation is recommended. Compared with similar models to increase rural populations' access to health care and benefits, the long-term support networks from the TVR model may be most useful when the institution must build trust and engage with the target population.

Methodology for Evaluating Models of Telemental Health Delivery Against Population and Healthcare System Needs: Application to Telemental Healthcare for Rural Native Veterans.

Background: Rural American Indian and Alaska Native (AI/AN) Veterans face exceptional barriers to receiving quality mental healthcare. We aimed to identify models of in-person and telemental health service delivery with promise for adaptation and wide dissemination to rural AI/AN Veterans. Methods: Our method for matching specific populations with models of care includes (1) selecting frameworks that represent the healthcare organization's goals, (2) identifying relevant service delivery models for the target population(s), (3) assessing models against the selected frameworks, and (4) summarizing findings across models. We applied this approach to rural AI/AN Veteran populations. Results: Searches identified 13 current models of service delivery for rural AI/AN Veteran, rural AI/AN, and general rural Veteran populations. These models were assessed against four frameworks-the U.S. Department of Veterans Affairs' Office of Rural Health's Promising Practices, Veterans Health Administration's Guide to Mental Health Services, the Institute for Healthcare Improvement's Triple Aim Framework, and the American Indian Telemental Health Clinic framework. Discussion: The one model used for service delivery for rural AI/AN Veterans increases access and is patient-centered but lacks operational feasibility. Models for rural AI/ANs also increase access and are patient-centered but generally lack effectiveness evaluations. Models for rural Veterans demonstrate beneficial effects on mental health outcomes but do not emphasize cultural adaptations to diverse populations. Conclusions: Our approach to selecting models of service delivery considers the needs of operational partners as well as target populations and emphasizes large-scale implementation alongside effectiveness. Pending further testing, this approach holds promise for wider application.

Using Telepsychiatry to Enrich Existing Integrated Primary Care.

Background: Integrated care is characterized by evolving heterogeneity in models. Using telepsychiatry to enhance these models can increase access, quality, and efficiencies in care. Introduction: The purpose of this report is to describe the process and outcomes of adapting telepsychiatry into an existing integrated care service. Materials and Methods: Telepsychiatry was implemented into an existing integrated care model in a high-volume, urban, primary care clinic in Colorado serving patients with complex physical and behavioral needs. Consultative, direct care, educational/training encounters, provider-to-provider communication, process changes, and patient-level descriptive measures were tracked as part of ongoing quality improvement. Results: Telepsychiatry was adapted into the existing behavioral health services using an iterative team meeting process within a stepped care model. Over 35% of the requests for psychiatry services were medication related-and medication changes (type/dose) were the most frequent referral outcome of psychiatric consultation. Forty percent of patients in the service had multiple behavioral health diagnoses, in addition to physical health diagnoses. Discussion: Telehealth will become an increasingly necessary component in building hybrid/blended integrated care teams. Examples of flexible model implementation will support clinics in tailoring effective applications for their unique patient panels. Conclusions: An adapted integrated care model leveraging telepsychiatry is successfully serving the complex deep end of a primary care patient population in Colorado. Lessons learned in implementing this model include the importance of team attitudes.