1. © 2014 UA Board of Regents Telepsychiatry Sara Gibson, MD Medical Director, Telemedicine

2. © 2014 UA Board of Regents Terms and Definitions Telehealth the use of communication equipment to link healthcare practitioners and patients in different locations Telemedicine Telepsychiatry Telemental Health Telepsychiatry The standard of care is interactive (synchronous), real time videoconferencing that enables patients and health care providers at distant sites to interact “face-to-face”

3. © 2014 UA Board of Regents Why Telepsychiatry?

4. © 2014 UA Board of Regents Access to Care! The need for behavioral health medical services often exceeds local supply.

5. © 2014 UA Board of Regents

6. Why Telepsychiatry? Improve Access to Care Provider can see 4 new evaluations per day during driving time: Providers should be providing services, not driving! One provider can “go to” multiple smaller-need locations Improve cost efficiency reduced transportation expenses

7. © 2014 UA Board of Regents Why Telepsychiatry? (cont.) Improve patient access to specialists and mental health providers Improve quality of care Improve provider satisfaction and safety Driving is Dangerous Green! CO2 savings

8. © 2014 UA Board of Regents Telepsychiatry Models

9. © 2014 UA Board of Regents Systems and Models Expert Pharmacotherapy Most requested Most appreciated telepsychiatry service Child Psychiatry Therapy Individual Groups

10. © 2014 UA Board of Regents Systems and Models (cont.) Models Outpatient comprehensive psychiatric coverage Combined FTF (evals) & telemed (continued care) OR REVERSE Consultation Model Child Psych – to General Psychiatrist or BHMP – to PCPs Subspecialists Others may do prescribing

11. © 2014 UA Board of Regents Systems and Models (cont.) Models (cont.) Coordination between systems PCP Ambulance Emergency rooms University consult service

12. © 2014 UA Board of Regents Systems and Models (cont.) Models (cont.) Inpatient Nursing Homes Prison Legal (T36/commitment evaluations, testimony)

13. © 2014 UA Board of Regents Systems and Models (cont.) Tele-education Integrating teaching & psychiatry residents. ATA residency excellence Medical Students (1987 Minnesota RPAP) U TX requires med students to participate Trainings CME, Grand Rounds State, RBHA trainings Best Practices and committee participation

14. © 2014 UA Board of Regents Systems and Models (cont.) Other: Home monitoring (the fastest growing), Direct to Consumer Armed Services, Military Ships, ship to shore Combat field trauma Combat field PTSD Remote stations, surgery, psychiatry Antarctic, outerspace, underwater

15. © 2014 UA Board of Regents Systems and Models (cont.) Other (cont.): Europe Third World (Afghanistan, Africa) Disaster Planning and Response (ATA)

16. © 2014 UA Board of Regents Example Program NARBHAnet

17. © 2014 UA Board of Regents NARBHA Overview Private, non-profit corporation Contracts with AZ Dept. of Health Services to serve Medicaid-eligible & SMI populations Monitors behavioral health services provided by community-based agencies Serves the 5 northern counties of AZ, including Tribal areas; all are Mental Health Professional Shortage Areas

18. © 2014 UA Board of Regents NARBHA Overview (cont.) Northern Arizona Approx. the size of New York plus New Jersey 62,000 square miles (54.4% of AZ area) Population 724,600+ (11.5% of AZ pop.)

19. © 2014 UA Board of Regents NARBHAnet Today 2014 NARBHA WAN: >80 video endpoints 24 teleproviders (varies) 12 providers connecting from other states & 1 from Phoenix, AZ Connections blanket the state: to ATP network & other regional behavioral health authority networks (RBHAs), and ADHS/DBHS

20. © 2014 UA Board of Regents NARBHAnet Benefits >140,000 clinical services 1996 - 2014

21. © 2014 UA Board of Regents NARBHAnet Benefits Annually (2012 data) Per Year: $200, 000 savings 1200 more patient encounters 41.2 tons CO2 saved Improved Access to Care Recruitment and Retention of Psychiatrists

22. © 2014 UA Board of Regents LCBHC Clinical Services Sara Gibson, MD Sees patients from Flagstaff St. Johns is 165 miles away (3 hours) Springerville is 200 miles (3 hours, 20 min) 18 years of telemedicine: 17,000+ patient sessions 06/2014 100% of services via telemedicine since 1996

23. © 2014 UA Board of Regents Telepsychiatry Benefits Psychiatric services available to areas of physician shortage Improved access to care (patients seen sooner & more frequently) Psychiatric providers see more patients with the time they would otherwise spend driving Patients treated in their own communities Increased physician continuity (attrition, locum tenens) Psychodynamic advantage Emergency assessments available immediately

24. © 2014 UA Board of Regents Telepsychiatry Benefits (cont.) Specialty consults available Family involvement in treatment of inpatients More providers are available Those licensed in AZ but living out of state can provide patient services Improved recruitment and retention of psychiatric providers Can live where they choose No travel burnout Happier psychiatrists

25. © 2014 UA Board of Regents Telepsychiatry Benefits (cont.) Improved staff efficiency, productivity, morale due to less travel time More training & CMEs for clinicians, staff, psychiatric providers U of A Psychiatry Grand Rounds Decreased professional isolation Monthly Behavioral Health Medical Practitioners’ meeting Better communication / camaraderie among clinicians, staff, psychiatric providers Impromptu meetings can be connected at will

26. © 2014 UA Board of Regents Telemedicine Quality of Care Telemedicine is an Evidence-Based Practice ATA Meta-Analysis of Current Published Literature: Qualitative & quantitative research in mental health and telemedicine Currently being updated; in July 2009 there were 5300 telemedicine articles, 269 specific to mental health Journal - Telemedicine and e-Health

27. © 2014 UA Board of Regents Telemedicine Quality of Care Studies demonstrate that telepsychiatry is equivalent to FTF for: Assessment Diagnoses Therapeutic alliance Treatment adherence Clinical outcomes

28. © 2014 UA Board of Regents Acceptance 24+ patient satisfaction studies reviewed in literature; all overwhelmingly positive NARBHAnet acceptance 1998, 2006 Client satisfaction surveys Family (of client) satisfaction surveys Staff satisfaction surveys Satisfaction over time

29. © 2014 UA Board of Regents Best Practice Guidelines for Clinical Telepsychiatry

30. © 2014 UA Board of Regents Guidelines American Telemedicine Association (ATA) Guidelines on Telemental Health 2014: Core Operational Guidelines for Telehealth Services Involving Provider- Patient Interactions 2013: Practice Guidelines for Video-Based Online Mental Health Services 2009: 2 papers Practice Guidelines for Videoconferencing-Based Telemental Health Evidence-Based Practice for Telemental Health - NARBHA’s Sara Gibson MD and ATP’s Nancy Rowe were on original workgroup/contributors

31. © 2014 UA Board of Regents Guidelines American Association of Child & Adolescent Psychiatry (AACAP) Practice Parameter for Telepsychiatry with Children and Adolescents, December 2008 No absolute contraindication to or indication for the initial evaluation to be in person vs televideo Emergency Guidelines for Telepsychiatry Shore, JH, Hilty, DM, Yellowlees, P. General Hospital Psychiatry, 2007:29, 199-206

32. © 2014 UA Board of Regents Telepsychiatry Clinical Challenges Sensory deprivation Smell (alcohol, hygiene, pheromones) Touch (handshakes, therapeutic) Visual impairment Energy sense, “real presence,” auras Participant anxiety Provider resistance (new paradigm of technology) Coordination between two systems

33. © 2014 UA Board of Regents Rapport Good rapport leads to therapeutic working alliance. There is evidence that patients quickly adapt and establish rapport with their teleprovider. Ghosh 1997 Simpson 2001

34. © 2014 UA Board of Regents Rapport Minimize technological interface to improve rapport High quality technology User-friendly Zoom to life-size Use solid blue background (affect recognition) Eye contact - camera angle or alternate gaze Live, interactive Avoid picture-in-picture at patient end Another human present at clinical site

35. © 2014 UA Board of Regents Doctor-Patient Relationship Hilty et al., Primary Psychiatry, Sept 2002 Literature review reported no major impediments to the development of the doctor-patient relationship in terms of communication and satisfaction. Variety of settings, patients, practice styles, sites complicate objective assessment of telepsychiatry’s impact

36. © 2014 UA Board of Regents Therapeutic Alliance Due to high satisfaction by providers and increased access for patients, the opportunity exists for long-term doctor patient relationship, increasing therapeutic alliance and improving patient outcomes.

37. © 2014 UA Board of Regents Patient Dynamics by Diagnosis Basic Principle: Distance increases sense of safety, decreases olfactory flooding, prevents touch Social anxiety Agoraphobia PTSD Other anxiety (panic) Psychosis

38. © 2014 UA Board of Regents Resources Centers for Medicare & Medicaid Services: www.cms.hhs.govwww.cms.hhs.gov Center for Telehealth & e-Health Law (CTeL): http://www.ctel.org/http://www.ctel.org/ CTeL Resource Center: www.telehealthlawcenter.org/www.telehealthlawcenter.org/ Telehealth Resource Centers http://www.telehealthresourcecenter.org/ http://www.telehealthresourcecenter.org/

39. © 2014 UA Board of Regents Resources NARBHAnet website, www.rbha.netwww.rbha.net Clinical telemedicine policies Procedures, protocols Information AHCCCS (AZ Medicaid) telemedicine allowable codes summary

40. © 2014 UA Board of Regents Associations American Telemedicine Association (ATA) www.americantelemed.org Special Interest Groups (SIGs) include: Telemental Health Technology Business & Finance Home Telehealth & Remote Monitoring mHealth Emergency Preparedness & Response

41. © 2014 UA Board of Regents Telepsychiatry Sara Gibson, MD Medical Director, Telemedicine