1. Telehealth Behavioral Health Consultation Services: Implementation Strategies and Challenges Jean Cobb, Ph.D. Behavioral Health Consultant, Cherokee Health Systems J. David Bull, Psy.D. Behavioral Health Consultant, Cherokee Health Systems Collaborative Family Healthcare Association 16 th Annual Conference October 16-18, 2014 Washington, DC U.S.A. Session # B1b Friday, October 17, 2014

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Learning Objectives At the conclusion of this session, the participant will be able to: Gain an increased awareness of how telehealth behavioral health consultation services can achieve the Triple Aim by helping to reduce costs, improve patient experience and population health, and reduce barriers to access care Gain understanding of an effective clinical model that implements telehealth behavioral health consultation services in integrated primary care settings Discuss challenges and recommendations for successful implementation of telehealth behavioral health consultation services Describe equipment and technology capabilities necessary for successful implementation of telehealth behavioral health consultation services

4. © 2014 Cherokee Health Systems All Rights Reserved Overview Increased workforce demand for behavioral health clinicians to practice in primary care Increased workforce demand for behavioral health clinicians to practice in primary care Patient access to behavioral health services Patient access to behavioral health services Rural clinics Rural clinics Advances in technology Advances in technology Achieving the Triple Aim: Reducing costs, improving patient experience and population health, and reducing barriers to access to care

5. © 2014 Cherokee Health Systems All Rights Reserved Telehealth Services at Cherokee Health Systems FY 2013-2014 TelehealthVisitsTelehealthPatients Providers Delivering Telehealth Services Locations with Telehealth Services 18,270 (5.7% of total visits ) 6,469 (10.6% of total patients) 4320

6. © 2014 Cherokee Health Systems All Rights Reserved

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11. © 2014 Cherokee Health Systems All Rights Reserved Implementation

12. © 2014 Cherokee Health Systems All Rights Reserved Implementation: Staffing Needs IT Support IT Support Behavioral Health Consultant Behavioral Health Consultant Primary Care Provider(s) Primary Care Provider(s) Nursing & Front Office Staff – one on-site staff person specifically designated as BHC’s “point person” Nursing & Front Office Staff – one on-site staff person specifically designated as BHC’s “point person”

13. © 2014 Cherokee Health Systems All Rights Reserved Implementation: Workflow (Initial Consult) PCP or nurse notifies BHC via phone/telehealth about new consult BHC adds patient to schedule and reviews Electronic Health Record BHC informs nurse/PCP by phone when ready and staff member escorts patient to BHC telehealth office/patient exam room End of Visit: BHC schedules follow-up (if any), coordinates with staff member for handouts or other appointments that day BHC provides feedback to PCP via telehealth, phone, or EHR. Patient escorted to check-out area or clinical area as appropriate

14. © 2014 Cherokee Health Systems All Rights Reserved Implementation: Workflow (Follow-up) Patient checks-in at front desk Staff Member informs BHC that pt has arrived. When BHC is ready, staff member escorts patient to BHC telehealth office End of Visit: BHC schedules follow-up (if any), coordinates with nurse/point person for handouts or other appointments that day BHC may provide feedback to PCP via phone or EHR as appropriate Patient escorted to check-out area or clinical area as appropriate

15. © 2014 Cherokee Health Systems All Rights Reserved Implementation: Schedule Same schedule as Primary Care Same schedule as Primary Care Mixture of planned follow- ups and availability for “on- demand” consults Mixture of planned follow- ups and availability for “on- demand” consults Coordinated visits Coordinated visits

16. © 2014 Cherokee Health Systems All Rights Reserved Implementation: Clinical Model CHS current model CHS current model BHC is covering two clinics simultaneously for warm hand-offs BHC is covering two clinics simultaneously for warm hand-offs Scheduled follow-ups limited to one clinic on specific days of the week Scheduled follow-ups limited to one clinic on specific days of the week BHC physically on-site at least monthly – critical for good working relationships and some strategic face-to-face encounters with patients BHC physically on-site at least monthly – critical for good working relationships and some strategic face-to-face encounters with patients

17. © 2014 Cherokee Health Systems All Rights Reserved Behaviorist with Patient Implementation: Billing & Coding Primary Focus of Clinical Attention Medical Behavioral Initial Assessment 96150 Re-Assessment 96151 Individual 96152 Group (2 or more) 96153 Family (with patient) 96154 Assessment or Intervention? Family (w/o patient) 96155 Therapeutic or Evaluative? Diagnostic Interview 90791 Individual (16-37 min) 90832 NOTE: Primary Diagnosis must match the CPT code selected. * Can also utilize 99406 (3-10 minutes) or 99407 (>10 minutes) for smoking cessation

18. © 2014 Cherokee Health Systems All Rights Reserved Implementation: Billing & Coding Add modifier GT “via interactive audio and video telecommunications systems” Add modifier GT “via interactive audio and video telecommunications systems” Originating Site = location of patient Originating Site = location of patient Distant Site = practitioner who furnishes and receives payment for covered telehealth services Distant Site = practitioner who furnishes and receives payment for covered telehealth services Per Centers for Medicare & Medicaid Services - can include MD, NP, PA, Nurse Midwife, Clinical Nurse Specialists, Clinical Psychologist, Clinical Social Worker, Registered Dietitian or Nutrition Professional Per Centers for Medicare & Medicaid Services - can include MD, NP, PA, Nurse Midwife, Clinical Nurse Specialists, Clinical Psychologist, Clinical Social Worker, Registered Dietitian or Nutrition Professional

19. © 2014 Cherokee Health Systems All Rights Reserved Implementation: Challenges Introduction & explanation of telehealth encounter Introduction & explanation of telehealth encounter Managing patient resistance Managing patient resistance Maintaining integrity of communication and care coordination Maintaining integrity of communication and care coordination Work flow Work flow Patient handouts Patient handouts When “point person” is busy When “point person” is busy Coordinating multiple follow-up appointments Coordinating multiple follow-up appointments Provider/ staff awareness of BHC schedule Provider/ staff awareness of BHC schedule Technology problems Technology problems

20. © 2014 Cherokee Health Systems All Rights Reserved Implementation: Challenges Crisis Situations Must have strong & efficient communication between BHC and on-site staff Must have strong & efficient communication between BHC and on-site staff Important to train staff in advance and have plan in place (guided by on-site and community resources) Important to train staff in advance and have plan in place (guided by on-site and community resources) May need staff to assist by: May need staff to assist by: Informing other patients that BHC is running late Informing other patients that BHC is running late Changing patient rooms if needed Changing patient rooms if needed Help patient access telephone and other crisis resources as needed Help patient access telephone and other crisis resources as needed Monitor patient for physical safety during crisis assessment & intervention Monitor patient for physical safety during crisis assessment & intervention

21. © 2014 Cherokee Health Systems All Rights Reserved Implementation: Lessons Learned The right team members The right team members BHC with strong communication skills with provider(s) and support staff is essential BHC with strong communication skills with provider(s) and support staff is essential Anticipate the need for increased support staff resources Anticipate the need for increased support staff resources Importance of initial training with providers & support staff (when & how to refer, services you can offer, etc.) Importance of initial training with providers & support staff (when & how to refer, services you can offer, etc.) Invite ongoing feedback from patients and team members Invite ongoing feedback from patients and team members

22. © 2014 Cherokee Health Systems All Rights Reserved Implementation: Lessons Learned Importance of training staff to let you know a patient has arrived or needs to be seen (allowing time for chart review, etc) Importance of training staff to let you know a patient has arrived or needs to be seen (allowing time for chart review, etc) Staff person should teach patient how to adjust equipment volume and give patient access to volume control Staff person should teach patient how to adjust equipment volume and give patient access to volume control Consider sound control measures (i.e. white noise machine) to protect confidentiality Consider sound control measures (i.e. white noise machine) to protect confidentiality Consider staying connected in between patient visits, so that providers and staff can “drop by your office” as needed Consider staying connected in between patient visits, so that providers and staff can “drop by your office” as needed

23. © 2014 Cherokee Health Systems All Rights Reserved Implementation: Lessons Learned It helps to have remote access to an on-site printer, but if not available have commonly used handouts on-site (or alternative plan to send by fax or email) It helps to have remote access to an on-site printer, but if not available have commonly used handouts on-site (or alternative plan to send by fax or email) Recommend scheduled BHC follow-up appointments be limited to one “originating site” on a given day Recommend scheduled BHC follow-up appointments be limited to one “originating site” on a given day Use clinical judgment for patients who are more appropriate for face-to-face encounters, strategically schedule them on days you are physically present Use clinical judgment for patients who are more appropriate for face-to-face encounters, strategically schedule them on days you are physically present Coach support staff on how to appropriately introduce telehealth (don’t “make a fuss” over it) Coach support staff on how to appropriately introduce telehealth (don’t “make a fuss” over it)

24. © 2014 Cherokee Health Systems All Rights Reserved Implementation: Recommended Technology Components Polycom high definition video codec* Polycom high definition video codec* High Definition LED/LCD TV - 720p or higher, using HDMI or Component connections High Definition LED/LCD TV - 720p or higher, using HDMI or Component connections Bandwidth capable of supporting 615kb** of video/audio traffic per telehealth session Bandwidth capable of supporting 615kb** of video/audio traffic per telehealth session End to End Quality of Service (QoS) across the LAN/WAN*** to prioritize audio and video traffic End to End Quality of Service (QoS) across the LAN/WAN*** to prioritize audio and video traffic * Cisco and LifeSize also make video codecs, but require more bandwidth to initiate a "high definition" call **This is what is recommended for a high definition connection using Polycom video codec ***The Wide Area Network Provider (such as AT&T, Windstream, Verizon) should also create QoS policies within the WAN

25. © 2014 Cherokee Health Systems All Rights Reserved Telehealth Guidelines American Telehealth Association American Telehealth Association Standards and Guidelines: http://www.americantelemed.org/resources/standards/ata-standards- guidelines Standards and Guidelines: http://www.americantelemed.org/resources/standards/ata-standards- guidelines American Psychological Association American Psychological Association Guidelines for the Practice of Telepsychology: http://www.apapracticecentral.org/ce/guidelines/telepsychology- guidelines.pdf Guidelines for the Practice of Telepsychology: http://www.apapracticecentral.org/ce/guidelines/telepsychology- guidelines.pdf 8 key issues: Competence, Standards of Care, Informed Consent, Confidentiality, Security and Transmission of Data, Disposal of Data and Information and Technologies, Testing and Assessment, Interjurisdictional Practice 8 key issues: Competence, Standards of Care, Informed Consent, Confidentiality, Security and Transmission of Data, Disposal of Data and Information and Technologies, Testing and Assessment, Interjurisdictional Practice

26. © 2014 Cherokee Health Systems All Rights Reserved Discussion

27. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!