Agenda. Clinical and Operational Considerations for Appropriate Telepsychiatry Best Prac/ces for Designing and Implemen/ng Telebehavioral Health

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1 Clinical and Operational Considerations for Appropriate Telepsychiatry Best Prac/ces for Designing and Implemen/ng Telebehavioral Health RCPA- Fall 2014 Geoffrey Boyce, MBA Execu/ve Director InSight James R. Varrell, M.D. Medical Director, InSight Agenda Basics of Telepsychiatry Models of Telepsychiatry Clinical Efficacy Clinical Lessons Learned Clinical Q&A Overcoming Obstacles SeSng Up and Maintaining a Program Opera/onal Q&A Benefits of Telepsychiatry Telepsychiatry A medium for delivering psychiatric care through videoconferencing technology Increased Access to Providers 96% of coun/es in the US has unmet need for prescribers. 1 Access psychiatrists and other specialists who may not be local Konrad, T. Ph.D., Ellis, A., M.S.W., Thomas, K., M.P.H., Ph.D., Holzer, C., Ph.D., Morrissey, J. Ph.D. (2009, Oct). County- Level Es/mates of Need for Mental Health Professionals in the United States. Psychiatric Services, 60(10):

2 Appropriate Care May get care, but from providers without a behavioral health experese Studies indicate that PCPs recognize and diagnose less than half of mental disorders 1 May get overly restriceve care ED directors report being overly cau/ous in their commitment decisions May wait for care unel their issues escalate May wait unreasonable lengths of Eme to see a provider once they seek treatment Cost Effectiveness Value of is far beyond fee- for- service Allows for trea/ng consumers where they are Cuts costs for finding and retaining a provider Lowering hospital admissions Reducing all ED wait /mes Purchasing Technology is less of a barrier now Online plalorms are affordable Grants for hardware Pirl, W.F.; Beck, B.J.; Safren, S. A.; Kim, H. (2001). "A descrip/ve study of psychiatric consulta/ons in a community primary care center". Primary Care Companion Journal of Clinical Psychiatry, 3 (5): doi: /pcc.v03n0501 Effective Care Used to have to spend a lot of /me convincing people of telepsychiatry s efficacy Now there is a wide array of literature on the topic One important study VA s Telemental Health Efficacy Surpasses Face to Face Encounters According to a large- scale outcome study of almost 100,000 users of the VA telepsychiatry program, pa/ents' hospitaliza/on u/liza/on decreased by an average of 25% with the implementa/on of telepsychiatry. Additional Benefits Improved Accountability Improved Regulatory Compliance Joint Commission Standards for hospitals to improve throughput Risk Reduc/on and Improved Safety Improved Employee Reten/on Linda Godleski, M.D.; Adam Darkins, M.D., M.P.H.; John Peters, M.S. (2012) Outcomes of 98,609 U.S. Department of Veterans Affairs Pa/ents Enrolled in Telemental Health Services study from

3 Consult Vs. Treatment Models Models of Telepsychiatry Both categories are applica/ons of telemedicine Consult Models: remote providers gives second opinion Treatment Models: remote provider takes ownership of a consumer Scheduled Telepsychiatry Model A regular, remote provider supplements onsite care Usually scheduled sessions or blocks of /me Access specialists and prescribers Remote provider can do preqy much anything an onsite provider would do med mang., assessment, treatment team mee/ngs etc. A consistent provider who collaborates with the onsite team is key Popular SePngs CMHCs Residen/al programs Correc/onal facili/es Substance use disorder clinics Nursing homes Inpa/ent units On-Demand Telepsychiatry Model Rapid, on- demand access to a psychiatric professional Offer psychiatric assessment, admission and commitment decisions Requires a lot of infrastructure to have consistent, scalable responsiveness 24/7 InSight specializes in crisis telepsychiatry - average 1 hour response /me SePngs where this is popular: Hospital EDs Many are aware of the issue of ED boarding and the ramifica/ons that has for the pa/ent, hospital and community when people are wai/ng 24+ hours for assessment and treatment Crisis Centers Standalone or clinic or hospital affiliated Mobile Crisis Units We just launched a new program where mobile crisis teams bring a telepsychiatrist in to consumers homes with them Correc/ons Residen/al programs Any sesng where /mely access to care is cri/cal: cruise Ships, correc/ons etc. 3

4 Consultation Liaison Model When on demand psychiatric care is needed, but not with as strong of a /me crunch The individual is stable and receiving care, they just need a psychiatric perspec/ve Generally used for assessment and less about building the type of provider- pa/ent rela/onship that is done for the rou/ne model InSight averages a 4- hour response /me for these types of as needed requests Popular for: Med/surg floors at hospitals Non- emergent services Assessment before deployment, work release etc. Phone Consultation Model Doctor- to- Doctor consult or curbside consult Walks the line between telemedicine and standard prac/ce Op/on to escalate to video SePngs where this is popular: Inpa/ent units (admissions and orders) PCP or pediatric consulta/on Integrated Model Ini/a/ves for behavioral health integra/on Trea/ng people s mind and body comprehensively A number of different models of BHI Adop/ng BHI and telemedicine can be a nice marriage Maybe you can t jus/fy having a psychiatric perspec/ve on site, but could benefit from having a psychiatrist on your team Someone there to consult on prescrip/ons, be available for treatment team mee/ngs, clinical observa/on, etc. Popular for: Primary Care Facili/es FQHCs Asynchronous Model Some organiza/ons do this with store and forward or telepsychiatry Session is recorded (with permission) and reviewed by a prescriber later 4

5 Popular For: Busy people Travelers Rural communi/es Teens going off to college People with difficul/es gesng to sessions In-Home Model One of the newest applica/ons Has to be done appropriately obviously not for crisis care Lots of new logis/cal issues to address Op/on for facili/es and providers who want to do appointments with their regular caseload virtually Developing opportuni/es to shop for a provider who fits your needs online Only need computer with webcam and a strong internet connec/on Must be done in a secure, HIPAA- compliant plalorm Blended Model Models can be mixed and matched Blended models enable consumer to poten/ally access the same provider in a variety of sesngs Imagine: someone moving from a hospital, to a rehab facility to an outpa/ent clinic to an in- home care treatment model and being able to see the same provider that whole /me Technology is the way we can do this Enables more consistent and collabora/ve care across a system A provider can follow a pa/ent or at least beqer share info from one level to the next Popular For: ACOs Health Systems Universi/es Correc/ons Clinical Considerations to Telepsychiatry Case Study Dr. Jim Varrell Medical Director Child/Adolescent & Adult Psychiatry, Au/sm Specialty 5

6 Lesson 1. A Remote Provider Can be Effective Telepsychiatry is just connec/ng with another person through a different medium It works Providers have to learn how to project themselves through this medium A remote connec/on can be even more effec/ve in some cases General Clinical Standards for Telebehavioral Health Remote Provides must be trained to modify their clinical interview style slower and more exaggerated voice inflec/on Sound quality most important Small talk can put consumers at ease Increased direct collaboraeon among professionals Oven Social Worker or other onsite clinician present Rely on onsite staff to share things like hygiene, scent, wai/ng room interac/ons etc. Onsite staff may give diagnos/c tests and share materials Have to get in the habit of communica/ng regularly with onsite clinicians Child & Adolescents and Telepsychiatry Enjoy playing with new technologies and enjoy the novelty of telepsychiatry Much more likely to talk about things that are scary or in/mida/ng Different interac/on that they have had with adults Open up and talk faster about the things that are important to them Geriatric Populations and Telepsychiatry Sound is very important An older person may misspeak you if they cant hear you or you may incorrectly assume they have some sort of demen/a when it is really just a hearing thing Have someone else in the room to act as your hearing translator if needed Though there is a higher chance of having demen/a, this popula/on can s/ll get a lot out of telepsychiatry S/ll able to talk and engage and demonstrate their cogni/ve deficits Enough info to develop a treatment plan and course of ac/on 6

7 Developmental Disabilities & Telepsychiatry Depends on the level of disability Diagnos/c tools Not ideal for use via telepsychiatry History will s/ll be their history Observa/on of people profoundly impacted is s/ll very useful via telepsychiatry The younger or the least affec/ve, the harder telepsychiatry is to use because its difficult to decipher some clinical nuances VA and Military Populations and Telepsychiatry Very effec/ve because it reduces s/gma to care and allows for people traveling or in remote areas to have access to treatment Linda Godleski, M.D.; Adam Darkins, M.D., M.P.H.; John Peters, M.S. (2012) Outcomes of 98,609 U.S. Department of Veterans Affairs Pa=ents Enrolled in Telemental Health Services study from VA's Telemental Health Efficacy Surpasses Face- to- Face Encounters The first large- scale assessment of telemental health services, found that aver ini/a/on of such services, pa/ents' hospitaliza/on u/liza/on decreased by an average of approximately 25% Services include: medica/on management, individual therapy, couples therapy, group therapy, family therapy, behavior therapy, and psychological tes/ng Treated disorders include: affec/ve disorders, anxiety disorders, posqrauma/c stress disorder, psycho/c disorders, and substance abuse disorders Lesson 2. Select a Provider Who is a Good Fit Take the /me to find the right person Don t get bogged down on the technology Focus on services and people Provider should be trained in communica/ng via telehealth Create a sustainable rela/onship Employed provider models lend itself to that Contractors or locums have lots of turnover which is ineffec/ve Consumers deserve consistent care from a stable provider team Lesson 3. Integrate your Remote Provider onto the Care Team During OrientaEon- Give an understanding of the typical standards at your site What to do in an emergency? What are clinical expecta/ons? Length of /me for a typical evalua/on? What are the community resources? How to get a lab report? Which onsite person do you need to circle back with aver an evalua/on? Orient them as if they were onsite 7

8 Teach About the Wider Community Context What community resources are available? What cultural aspects should be considered? Holidays, language, style, accents, interests, sports etc. Is the site on a farm? In an urban area? Etc. Maintain The Relationship Stay Connected Once you Launch Put on listserv Send organiza/onal newsleqers Invite to staff and treatment team mee/ngs Let them know if there has been a staff turnover Always Communicate! It takes a liqle extra effort, but it is cri/cally important Clinical Questions? Broad Obstacles and Challenges to Telepsychiatry Dr. Jim Varrell Medical Director Child/Adolescent & Adult Psychiatry, Au/sm Specialty 8

9 Reimbursement If a state is considered rural Medicare will reimburse Use: Medicare Telehealth Payment Eligibility Analyzer 21 states have legislated private payer coverage (more proposed) 12 states have legislated Medicaid coverage (more proposed) Some states say the provider has to be physically in the same state as the consumer for reimbursement Issues with narrowly defined services sites: hospitals, CMH, CHC, skilled nursing facili/es etc. What about schools, homes and private clinics? ATA and CTel are great resources for up- to- date informa/on Licensure S/ll need a license in the state you and the consumer are physically located - Many people overlook being licensed where they are physically located Need a Reciprocity/Compact/ Universal Licensure Op/on Federal government/va/military are posi/ve examples of how this can work Credentialing Lots of bureaucracy to be creden/aled at mul/ple sites Same process over and over again for providers Outdated bylaws and medical affairs processes PPD, proximity, etc. Low u/liza/on of proxy creden/aling JCAHO regula/on and CMS Regula/on fears E-Prescribing Telemedicine vs. internet pharmacies Real- /me video telemedicine occasionally gets unfairly confused with shady online ques/onnaire pharmacies Gray area for the definieon of physician- paeent relaeonship especially with telehealth Can a face- to- face evaluaeon be remote if accompanied by in- person appropriate care? 9

10 Overcoming Organization Obstacles Easy to See Challenges, Harder to See Solu/ons Before You Launch a Program Administrative, Clinical and Staff Buy-In Going to have resistance people who don t want to learn the new system People who feel like their jobs are being threatened It takes work for everyone to communicate, meet one another, orient to telepsychiatry and feel invested in the program Clue in relevant stakeholders early on IT, medical affairs, payer sources etc. Facilitators Providers Community Buy-In Policy makers, other organiza/ons, payer sources, grantors, referral sources, receiving facili/es Engage them early on Surprises oven result in nega/ve emo/onal reac/ons Challenge them to think about how they too can u/lize telemedicine Using telemedicine across a community is ideal 10

11 Select Your Partnering Organization Find a company that is a good fit for your needs is important Select Your Provider Define the profile of your ideal provider Do you need a psychiatrist? Can an APN in collabora/on with a psychiatrist work? Do you need a certain subspecialty? What personality or quali/es would work best with your team? Are their language or cultural factors? Are their scheduling constraints? Iden/fy non- starters Be ready to find a middle ground Select Your Technology Do you need a mobile televideo unit? What internal support capacity do you have? Is interoperability important? How will you create a secure environment for sessions? Would you want the in- home sessions ever? Lots of reputable technology op/ons Its a maqer of what works for your needs Don t let your technology decision be solely driven by your IT department Think about user experience Pay aqen/on to guidelines and best prac/ces Setting Up a Program 11

12 Demystify the Technology Put Telepsychiatry in its Place Make sure all par/es know why and how telepsychiatry is being used Support in- person care, not replace Technology shouldn t be the focus Conduct your orienta/on and training via televideo to get each side used to it Problems are generally just user error Design Workflows Proac/vely design a system that works for your organiza/on Goal should be integra/on When will you use telepsychiatry? How? Who will take the records? How will they be sent? Who will be the facilitator? What will they do? How will they communicate with the remote provider? How will scheduling work? Know Your Community Know the culture of the organiza/on and its surrounding area Know the resources available 12

13 Know Your Team Get to know your remote providers and the opera/ons team that supports telepsychiatry Know who to go to for ques/ons What services/ resources are available onsite? Questions? Geoffrey Boyce 13