Telepsychiatry is recognized for its potential to bridge gaps in access to specialist healthcare (Deslich et al. 2013; Hilty et al. 2013; McGinty et al. 2006; Simpson et al. 2001). However, there are limits in the ability of telepsychiatry to address the magnitude of need. When telepsychiatry is used as a mode of traditional consultation, in other words, one consultant to one patient, services can quickly be saturated and accrue unmanageable waitlists. Such models also miss opportunities to develop further capacity to manage mental illness within primary care in distal communities.

Integrated care models can also increase availability of high quality mental health care in the primary care setting and improve short- and long-term patient outcomes, including symptoms, functioning, and quality of life (Kates et al. 2011). Such programs vary in degree of integration along a spectrum including co-located, consultation-liaison, or collaborative care/chronic care models, with the latter being the most robustly evidenced to improve clinical outcomes and cost effectiveness of care (APA-APM 2016). It is thought that the most essential elements of the more comprehensive collaborative care interventions are: (1) evidence-based care, (2) team-based care, (3) measurement-based treatment to target, and (4) population-based care (APA-APM 2016; Raney and American Psychiatric Association 2015).

Additional capacity and access can be created by using telepsychiatry to create integrated care teams when resources to build a team, particularly specialists, are not locally available. Emerging evidence supports the utility of televideo-based communication to effectively achieve collaborative care (Fortney et al. 2013; Fortney et al. 2015). To harness this synergy, integrated care team members including psychiatrists will require competencies to practice in evidence based integrated care models via a team at a distance.

These competencies will need to span those necessary for integrated care and those necessary for the effective use of telemedicine. Recent scholarship has identified the competencies necessary for telepsychiatry across stages of learning and practice (Hilty et al. 2015; Crawford et al. 2016) and curricular approaches to attaining them (Sunderji et al. 2015). Similarly, competencies for psychiatrists to practice integrated care have been identified. Sunderji et al. (2016) mapped 40 knowledge, skill, and attitude domains through expert consensus. Generalism or the clinical expertise to manage a broad range of mental health and addiction presentations across the lifespan seen in primary care was an important skillset, as were the interpersonal, attitudinal, and communication abilities that enable psychiatrists to build trusting working relationships. These relationships are the foundation that allows the collaborative co-management of complex patients and attendant risk management and additionally foster knowledge exchange, resulting in capacity building across the team. More advanced competencies include program consultation, quality improvement, and the ability to advocate for and implement higher degrees of integration (e.g., the collaborative care model) and to situate one’s work in an interprofessional, organizational, and health system context (Sunderji and Jokic 2015).

Based upon these competencies identified in the literature (Hilty et al. 2015; Crawford et al. 2016; Sunderji et al. 2016), we propose competencies for the practice of integrated care via telemedicine. In our framework, we suggested telemedicine competencies at beginner, competent/ proficient, and expert levels. While settings that provide integrated care via telepsychiatry may be rich learning environments for the beginner, we assume here that the practice of integrated care via televideo requires that all telepsychiatry competencies at the beginner level have been attained, such as standard history taking, establishing trust and building rapport with patients via telemedicine, administering tools, documentation, and understanding issues of confidentiality and ethics in the context of telemedicine. At the competent/proficient and expert levels, the competencies summarized in Table 1 form a foundation for delivering effective integrated care by televideo:

Table 1 Individual practitioner competencies
Full size table

Assessing the development of these competencies should follow the same principles and methods recommended to assess other clinical competencies (Holmboe et al. 2010). Assessment should be workplace-based, continuous, and should include direct observation by supervisors as well as multisource feedback from other interprofessional team members. These approaches can be supplemented by additional methods, including case discussions, reflective exercises, and review of documentation. While recognizing that these methods of assessment can be used across competencies, we have suggested methods of assessment that best suit each competency. We are also developing simulation methods that can be employed via televideo and televideo-based observed structured clinical examination (OSCE) formats. Simulations can be used to assess competencies that may not arise reliably or frequently in the practice setting.

In addition to individual practitioner competencies, a number of implementation factors related to both internal and external organizational structures also need to be considered when developing collaborative partnerships that involve telepsychiatry. Although outside of the scope of this article, important barriers to implementation include (1) challenges with traditional catchment-based funding and physician remuneration models; (2) legal, ethical, and political factors; (3) variability of processes, protocols, and service agreements between sites; (4) access, quality, and reliability of technology; (5) lack of quality assurance practices; (6) inconsistency of care by practitioners; (7) specialist knowledge of or access to local resources; (8) individual patient, provider, and organizational beliefs, attitudes, and expectations relating to telepsychiatry and integrated care; and (9) organizational champions who support telepsychiatry (Alvarez 2002; Batterham et al. 2015; Deslich et al. 2013; Godleski et al. 2008; Hailey et al. 2009; Hsiung 2001; Luxton et al. 2010; Rohland 2001; Shore et al. 2007). Each of these need to be addressed to ensure optimal functioning of integrated care models and to allow providers to practice within the full scope of their competencies.

In the Department of Psychiatry at the University of Toronto, we offer clinical experiences in integrated care via telepsychiatry that senior residents may select to fulfill their core training requirements in integrated mental health care. As evidence for integrated care models via telepsychiatry continues to accrue, future directions for training should include (a) developing pedagogical approaches, clinical training experiences, and curricula for current and future psychiatrists; (b) integrating these with training experiences for other members of the practice team; (c) developing valid assessment tools; and (d) targeting and evaluating for higher order outcomes (i.e., at the patient, organization, or population level).

Given the potential of both telepsychiatry and models of integrated care to increase access to mental healthcare, developing and sustaining competencies in both of these areas is a priority. These competencies, and means of evaluating them, are just beginning to be elaborated. Here, we begin this work by synthesizing the unique competencies required to provide integrated care and participate in interdisciplinary teams, using telepsychiatry.