Programmatic and Clinical Considerations

Transcription

1 Telemental Health Programs Programmatic and Clinical Considerations Douglas K. Novins, M.D. Native American and Telehealth Programs Department of Psychiatry University of Colorado School of Meidicine

2 Disclosures of Potential Conflicts Douglas Novins, MD Source Consultant Advisory Board Stock or Equity >$10,000 Speakers Bureau Research/ Technical Assistance Support Honorarium for this talk or meeting Expenses related to this talk or meeting SAMHSA/ Georgetown Univ. NIMH NIDA ACF SAMHSA VA

3 Sources Most of the slides for these presentations were adapted from the Telemental Health Guide

4 Sources American Academy of Child and Adolescent Psychiatry (2008) Practice Parameter for Telepsychiatry With Children and Adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 47: Hilty DM, Yellowlees PM, Sonik P, Derlet M, Hendren RL (2009) Rural child and adolescent telepsychiatry: t successes and struggles. Pediatric Annals, 38: Savin D, Garry M, Zuccaro P, Novins DK (2006) Telepsychiatry for Treating Rural American Indian Youth. Journal of the American Academy of Child and Adolescent Psychiatry, 45: Savin D, Glueck D, Chardavoyne J, Yager J, Novins DK (in press) Cultural lcompetence and dchild and dadolescent ttelepsychiatry. Accepted by Child and Adolescent Psychiatric Clinics of North America, August 2010 Shore J, Manson SM (2005) A Developmental l Model for Rural Telepsychiatry. Psychiatric Services, 56:

5 NATP Telepsychiatry y Service Sixteen clinical programs serving children, adolescents, and adults in reservation and non-reservation communities in 6 states (Colorado, Wyoming, S. Dakota, Montana, Arizona, Alaska)

6 NATP Telepsychiatry y Service A broad array of clinical models based on each host program and community s specific needs Consultee-centered consultation Patient-centered consultation Direct, ongoing clinical services

7 Take Home Messages Research to date suggests child and adolescent telemental health services are largely comparable to face-to-face services in terms of acceptability. There is growing evidence that its effectiveness is comparable as well. The development and implementation of a telemental health clinic is often complex and takes time (often more than a year). Clinical telemental health practice has some differences from face-to-face practice, but skills developed for faceto-face work easily transfer to telemental health practice.

8 Effectiveness of Telemental Health Key Research Findings to Date High patient-provider satisfaction Comparable therapeutic alliance Two controlled trials suggesting assessment and treatment via telemental health is comparable to face-to- face services.

9 Lessons from Dissemination Science Innovation more likely to be adopted if it: Offers unambiguous advantages in effectiveness or costeffectiveness ++/++++ Is compatible with adopters values, norms, needs +/++++ Is simple to implement + Can be experimented with on a trial basis + Has benefits that are easily observed ++++ Can be adapted, refined, modified for adopter s needs ++++ Is low risk (for patients and families) ++++ Is low risk (for programs) + Is relevant to adopter s current work ++++ Is accompanied by easily available or provided knowledge +++ required for its use Institute of Medicine (2006) Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. Washington: National Academies Press, p. 170.

10 Developing a Telemental Health Service Step 6: Solidification Month 12 Step 1: Needs Identification n Step 2: Months Infrastructure Survey Months Step 5: Pilot Implementation Months Step 4: Structure Configuration Months Step 3: Partnership Organizations Months 03-06

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12 Clinical Considerations - Highlights g Telemental Health can be an effective way to deliver mental health services to children and adolescents and their families, but it does require some adaptation from face-to-face delivery of clinical mental health services. Key considerations include the following: Orient youth to this medium of interaction and answer their questions with direct, concrete, informative responses. Communication is more deliberate and animated to overcome technological impediments to establishing rapport with youth.

13 Clinical Considerations - Highlights g Rapport-building can be facilitated by providing the youth experience with the technology how to use the remote control to manipulate the cameras so as to obtain a close-up of himself or his/her parents or to scan the telepsychiatrist s t i t room. The picture-in-picture feature can distract or upset some patients, If so, turn it off. e.g., children diagnosed with autism. Hyperactive, oppositional, or developmentally impaired youth may need parents assistance in using or interacting with the equipment.

14 Clinical Considerations - Highlights g Cultural issues can be more challenging than in typical practice for several reasons Differences in comfort with technology Eye contact, non-verbal communication, and play Geographic (and cultural) separation Distinct institutional cultures

15 Clinical Considerations - Highlights g Space Assessment Behavioral Issues &Staffing Psychotherapy, Prescriptions Teen Child Young Child Teen should be seen without parent for at least part of assessment Large enough to allow for interactions and play Staffing should be adequate to ensure safety. Staff should be easily accessible if they are not in the room. Telemental health is regularly used for individual, family, and group psychotherapy as well as medication management.

16 Administrative Issues - Highlights g Licensure clinician must be licensed in the remote and local state (if practicing across state lines) Staffing typical NATP clinic Remote clinician Local clinician (ideally in room) Outreach worker (scheduling, follow-up) IT specialist (on call)

17 Administrative Issues - Highlights g Record keeping while paper p record keeping is workable, these clinics operate much more efficiently using electronic health records. Billing Medicaid id and 3rd-party payers reimburse for telemental health services in most states, but rules vary.

18 Telemental Health Guide