Clinical Video Teleconferencing Into the Home: SC Rural Access to Veterans Health Resources

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1 Clinical Video Teleconferencing Into the Home: SC Rural Access to Veterans Health Resources Anna Birks, PsyD Director, Regional TeleMental Health Hub Charleston

2 TMH Definition the use of information and telecommunication technologies to deliver mental health services when a provider and Veteran are located in separate locations Video Teleconferencing (VTC) Technology Most often used Patient (or group of patients) in one location, clinician in a different location Use computer monitor, Tandberg, or software (e.g. Jabber) for conferencing Real-time transmission

3 VHA Urban, Rural & Highly Highly Rural, Rural and Census Defined Urban Areas VISN Rural Highly Rural Counties Census Urban Area Map generated by VHA Planning Systems Support Group, field unit for the VHA Office of Assistant Deputy Under Secretary for Health for Policy & Planning, April 6, 2007

4 Use of Clinical Video Telehealth For all diagnoses, with rare exclusions By all mental health providers Therapy services: Clinical assessment Individual and group psychotherapy Couples Therapy Psycho-educational interventions Neuropsychological testing Treatment planning Case management

5 TMH in VA Treat virtually every DSM (Diagnostic and Statistical Manual) diagnosis Modalities: individual, group, medication management, family therapy, couples therapy, psychological testing, etc Sites of care: VA medical centers, VA Community Based Outpatient Clinics, non VA healthcare facilities, student health centers, homeless shelters, supervised housing sites, and residence Is delivered by clinicians from multiple mental health professions and specialties including psychiatrists, psychologists, advanced practice clinical nurse specialists, physician assistants, social workers, RNs, addiction specialists, vocational rehabilitation specialists, and trainees.

6 Benefits of Telemental Health Technology is rapidly increasing system coverage area, thereby increasing the reach to rural veterans 5 Patient benefits with regard to lost employment time, as well as transportation costs and time 2-4 Satisfaction with service delivery is high among patients and providers 6-7 Lower cost without sacrificing quality of care 1 Decreased hospitalization utilization by an average of approximately 25% (Godleski, 2012) 1 Morland et al., 2003; 2 Bose et al., 2001 ; 3 Elford et al., 2000 ; 4 Trott & Blignault, 1998; 5 Dunn et al., 2000 ; 6 Frueh et al., 2000; 7 Monnier et al., 2003

7 450, ,000 TELEMENTALTH HEALTH GROWTH FY02-16 Overall TMH # s and VA Video Connect (VVC): clinical video-conferencing into the home 350, , , ,000 Vets Encounters VVC Vets VVC Encs 150, ,000 50,000 - FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 7

8 Regional hubs

9 VA video connect (VVC) Clinical video teleconferencing into the home

10 Veteran Uses Home-Based Telehealth for PTSD Treatment South Carolina ETV

11 Rationale for in-home telehealth Nearly six in ten Americans living with psychiatric disorders are not getting mental health treatment (Wang et al., 2005). Despite empirical evidence supporting the efficacy of psychotherapy for mental health, it is underutilized in the United States (Butler, et al 2014; Mott, 2014). Access and utilization of evidence based psychotherapy is even more limited in rural/geographically remote areas (Grubbs et al., 2017; Lindsay, et al., 2015; Morland et al., 2013)

12 Evidence for In-Home Telehealth In-Home Telehealth is feasible, safe and effective Active Duty US Military (Luxton et al., 2015) Veterans (Shore et al., 2014; Yuen et al., 2015) In-Home Telehealth shows comparable process outcomes to office based Satisfaction among patients undergoing Prolonged Exposure (Gros et al., 2016) In-Home Telehealth shows comparable process outcomes to office based Behavioral Activation and Therapeutic Exposure (Acierno et al., 2016) Psychotherapy for depression in older adults (Egede et al., 2015) Prolonged Exposure (Acierno et al., 2016)

13 In-home Telehealth benefits: Increased reach, access & engagement Lower cost without lower quality Reduced patient, provider, clinic burden Travel time; transportation costs Missed employment time Less burdensome for childcare Reduces no shows rates May reduce shame/stigma barriers Reduced travel time Increased privacy & comfort Reduce missed opportunity rates

14 Veteran case example Face to Face Appointment CVT into the home appointment Veteran leaves home 7am Drives to clinic Parking & shuttle 830-9am Check in 845-9am Session 9-10 Shuttle to parking Drive home Total time : 5 hours 9am Veteran logs on and provider calls Session over 10am Total time: 1 hour

15 HRSA Rural Veterans Health Access Program (RVHAP) 2016; South Carolina and two other states awarded Goal is to Increase the delivery of mental health services or other health care services for veterans living in rural areas through technology and VA/non-VA partnerships.

16 Rural Community Provider Recruitment Practice and Provider Appropriateness for Project Rural location by FORHP designation Ambulatory Primary Care with adult patients/via PCMH or similar environments (primarily RHCs or FQHCs) Interest in working more closely with Veteran patients and assessing further behavioral health care needs Provider openness to technology use VCP is a prerequisite for SC RAVHR participation Criteria for VCP - 30 days wait time until next available appointment or 40 miles from nearest VA

17 Technology Based Trainings 1) Overview of project, rationale for CVT in home, PTSD screener, Veteran ID within clinic, referral process, PTSD Consultation resource 2) PTSD signs/symptoms, diagnosis requirements, Review rationale for CVT in home, PTSD screener and referral process check in 3) Psychoeducation on PTSD Evidence Based Psychotherapies & research, discussion on challenges/ wins with referrals

18 Primary Care PTSD 4 question screener

19 PTSD Consultation Program Any provider treating Veterans with PTSD can ask a question or request a consultation about anything related to PTSD. Step 1: Call or to ask a question or request a consult. We just need your contact information and a brief summary of your question to match you with a consultant. We try to respond within 24 hours. Step 2: Discuss your questions. We can often respond via . Phone consultations are up to 30 minutes in length. We work hard to find a time that fits your schedule. Step 3: Review recommendations. You and the consultant will review the recommendations. You retain responsibility for all aspects of your patient's care. The consultant offers suggestions but does not provide treatment or assume responsibility. 19

20 Charleston VA Homebased Telemental Health Program Referral/Logistics Eligible Veterans will Consent to participate in clinical video teleconferencing into the home. Will be assessed for their current technical resources including internet connection and functional computer. Be enrolled with VA Currently experiencing PTSD/trauma related psychological distress

21 Homebased Telemental Health Program Delivery Veteran patients are offered one of two best practice treatments for PTSD via Homebased Telemental Health services delivered by VA clinical Psychologists. Typical treatment plan is around 8-15 weeks with one 90 minute telemental health session per week. No co-payment for Homebased Telemental Health program sessions/services.

22 Veteran progress Pt #1: White Male 50 s diagnosed with chronic PTSD; Saved 400 miles and completed 8 sessions of PE Pre PCL: 58 Post PCL: 33 Pre PHQ9: 18 Post PHQ9: 12 PCL : no or minimal symptoms reported 11-20: mild symptoms reported 21-40: moderate symptoms reported 41-60: severe symptoms reported 61-80: very severe symptoms reported PHQ Minimal depression 5-9 Mild depression Moderate depression Moderately severe depression Severe depression

23 Pt #2: White Male Age 55; Saved 282 miles and completed 5 sessions of PE Pre PCL: 44 ; Post PCL: 18 Pre PHQ-9: 14 Post PHQ-9: 4 Pt #3: African American Male Age 57, saved 184 miles Pre-treatment PCL: 68; PHQ-9: 18 As of session 2b, PCL 53 and PHQ-9 12

24 Challenges Time/availability/motivation of providers Competing projects/initiatives for rural community providers time Process for identifying Veterans Practice sites must meet FORHP rural designation Difference systems and information sharing challenges

25 Questions?