Mental Health Services via Telehealth Mary Zelazny, CEO Sirene Garcia, Dir. Of Special Programs

Finger Lakes Community Health Community/Migrant Health Center Program (FQHC) Migrant Voucher Program in 42 Counties of NYS Clinical Sites: 9 Health Center Sites 189 Employees – 51% bilingual/bicultural In 2015 over 62% of patients requested services in a language other than English 2

A Rural FQHC in New York State Star – FQHC Site Circle – Care M Services 3

Challenges in Service Delivery Cultural and language barriers in accessing care outside of health center sites Lack of availability of providers in rural areas Distance traveled to seek health care Coordination of access to specialty care Costs and liability issues related to enabling services provided to patients Stigma associated with mental health services 4

Why Telehealth? For our patients, we have found that it is necessary to have as many services available on site for our patients. For mental health services particularly in small communities, stigma is a major concern for patients. Transportation is a barrier to care in most rural communities. Telehealth can fit nicely into an integrated delivery system that breaks down silos as a more inclusive means of providing care that includes all of the patient’s healthcare team as well as the patient. 5

Challenges of Implementing Telehealth Difficulty in developing clinical and staff champions within the program. They must see the benefits of the program for patients. Need for seamless integration of broadband, systems & equipment, applications and program development into a cohesive sustainable model. General fear of new technology. Start up costs for equipment. 6

Telehealth & the Triple Aim Improved Access: Increased access to specialists, primary care doctors, behavioral health providers, remote home monitoring Better Care: Reduced readmissions into hospital Better access to clinical data (remote monitoring) More clinical educational opportunities, expertise / knowledge sharing Care coordination Lower or Stabilized Costs: Remote monitoring enables patients to be monitored at home Lower utilization rates of ambulatory care Better access = lower costs per patient 7

Some New Terminology to Know! 8

Telemedicine vs Telehealth Telemedicine - generally refers to the provision of clinical services from a distance. The Institute of Medicine of the National Academy of Science defines telemedicine as “the use of electronic information and communication technologies to provide and support health care when distance separates the participants.” Telehealth - refers to a broader scope of services that includes telemedicine, but also includes other services that can be provided remotely using communication technologies. The Office for the Advancement of Telehealth describes telehealth as including telemedicine and a variety of other services. 9

Originating Site: Location of the Medicaid patient at the time the service being furnished via a telecommunications system occurs. Telepresenters may be needed to facilitate the delivery of this service. Distant Site: Site where the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications system. Hub & Spoke Model: Refers to a larger hospital or specialty care group (hub) that provides care via telehealth to primary care or other sites (spokes) that lack access to those services. 10 Originating and Distant Site, Hub, Spoke?

Store and Forward vs Real Time Digital Dental Xray Image of Retina (Diabetic Retinopathy)y) Teledentistry Consult with Dr. Shawn at Eastman

Asynchronous – “Store and Forward” Fundus Photography in Primary Care

Synchronous – “Real Time”

Some Telehealth Guidelines We Live By Telehealth / telemedicine is a tool that can enhance your care model Program management can uncover strengths and weaknesses in operations of your centers. Quality Improvement is FOREVER! Management of telehealth by facts = DATA Need to see cost benefits from different perspective due to reimbursement challenges Keep a sense of humor! 14

Building Your Telehealth Capabilities Telehealth Program Development – We developed a 3 layer strategy: Layer 1: Broadband/Internet Connectivity Layer 2: Telehealth infrastructure and end user equipment including video conferencing units and diagnostic equipment Layer 3: Telehealth Program Development and Clinical and Educational Applications 15

Layer 1 - Broadband Broadband accessibility is critical!! For webcams – a solid connection (business class) is adequate 512k is ideal 384k is good quality For high definition cameras 2mbps downlink, 5mbps uplink minimum 16

Layer 2 - Equipment Video communications can be made using a variety of cameras, from a standard webcam to a high definition video camera. Connections can occur in 2 ways: 1. Direct call: camera to camera 2.Bridge call: 2 or more people calling into a common bridge to connect. In addition, a variety of diagnostic equipment is available: Examples: stethoscope, otoscope, oral camera, exam camera 17

Layer 3 – Telehealth Applications Program Development is very important and can be tedious, but is worth the effort! Develop a work plan that outlines who, what, how, where and when. Plan on 6-8 months of program development from the start to your first clinical visit. Plan on mock visits to help all parties run through the process. Document your process for staff to have. 18

What is Tele-Mental Health? Tele-mental health, like telemedicine, is the provision of mental health care from a distance. Tele-mental health uses two-way, high definition, live videoconferencing technology to provide mental health assessment and intervention. The goal of tele-mental health services is to eliminate disparities in patient care and give access to quality, evidenced-based, and emerging health care diagnostics and treatments. 19

Basic Equipment for Tele-mental Health INTERNET 20

Let’s Look at a Typical Scenario 1. Patient presents to primary care provider with symptoms of clinical depression 2.Primary care provider refers patient to counseling services and a visit with the psychiatrist 3.Patient makes an appointment with a counselor, but is unable to get to visits consistently due to transportation issues 4.Patient does not go to see the psychiatrist at the local mental health offices due to a fear of others recognizing him and thinking badly of him. 5.As a result of not getting consistent counseling or services from a psychiatrist, patient’s condition worsens 6. Patient stops seeking any care due to depression 21

Let’s Use Telehealth Technologies In Our Scenario 1. Patient presents to primary care provider with symptoms of clinical depression 2.Primary care provider refers patient to counseling services and a visit with the psychiatrist 3.Patient makes an appointment with a counselor, and is scheduled to come back to Health Center. Psychiatrist will be present via video 4.Patient comes to Health Center and is “roomed” by a nurse. No one knows why the patient is there. 5.Patient has counseling session and then sees the Psychiatrist via video. 6.Patient, LCSW and Psychiatrist “huddle” at the end of the visit to ensure understanding of treatment plan, meds. 22

Components for a Tele-Mental Health Program The following work plan documents are necessary: Clinical Process Pilot Development Work Plan Work Plan Detail Emergency Evaluation Policy & Procedure Quality Improvement Tool Patient documents needed: Consent to Participate In a Telehealth Visit/Consult Patient Emergency Info letter Patient Experience Survey Patient Registry Sheet 23

The Development of a Clinical Process for telemental health Important steps in the process: Referrals by Primary Care Provider to mental health services Patient Intake process Scheduling system with the Psychiatrist/LCSW Patient arrival and “rooming” procedures Clinical visit procedures Documentation of the clinical visit Follow-up care Billing details – who bills for the visit? Quality control / outcome data tracking 24

Suggested Models of Tele-Mental Health Services Model 1: Licensed Clinical Social Worker (LCSW) provides mental health counseling sessions remotely via video Model 2: Patient Visit with LCSW on site and Psychiatrist Via Video Model 3: Patient Visit with Psychiatrist via video without LCSW on site. All via video 25

Model 1: Licensed Clinical Social Worker (LCSW) Provides Mental Health Counseling Sessions Remotely Model 1 Benefits: Allows the LCSW to expand his/her reach particularly for organizations that have multiple sites but few LCSW’s. To consider: a. Who will “room” the patient? b. Who will “telepresent” the patient and initiate the video call? c. Does the “telepresenter” understand the process in the event the patient becomes suicidal or has other concerns? d. Have a process to ensure that the LCSW, the patient and the primary care provider understand the outcomes/follow-up. e.Make a plan to wrap up the visit, huddle with the patient, and then bring him/her to the checkout area. f. How will follow-up be ensured? 26

Model 2: Patient Visit With LCSW On Site And Psychiatrist Via Video Model 2 Benefits: Creates a real collaborative relationship and a team approach to the patient’s care. To consider: a. Who will be responsible for the management of the patient’s MH care? b. Who will “room” the patient at the remote site? c. Have a process to ensure that the LCSW, the patient and the psychiatrist agree and understand the outcomes and needed follow-up. d. Make a plan to wrap up the visit, huddle with the patient, and then bring him/her to the checkout area. e. How will the patient record be updated both by the psychiatrist and by the primary care provider? 27

Model 3: Patient Visit With Psychiatrist Via Video Without LCSW On Site Model 3 Benefits: Provides access to mental health services while breaking down geographic barriers. To Consider: a. Who will “room” the patient? b. Who will “telepresent” the patient and initiate the video call? Keep in mind that this will be a three way call! c.Does the “telepresenter” understand the process in the event the patient becomes suicidal or has other issues? d.Need to ensure that the LCSW and the Psychiatrist are up to speed on pertinent clinical/psycho-social info before the visit takes place. e.After the session, all three parties need to “huddle” to ensure that everyone is on the same “page” in terms of medications, treatment, follow-up, etc. f.There needs to be a process in place for the sharing of health information so that the patient’s record is up to date with all providers of that patient’s care. g.Care Management is very important and should be considered a part of the patient’s care team! 28

Finger Lakes Community Health: An Integrative Model of Care Primary Care Behavioral Health Dental 29

Some Examples of Tele-mental Health Programs At Finger Lakes Community Health, we use telehealth technologies extensively to provide access to mental health and substance use specialists: 1.Access to Licensed Clinical Social Workers, Psychiatrists, Neurologists, Substance Use Counselors, MD’s (opioid dependence, Hep C, HIV) 2.Interpretation (Language) services for clinical and care management visits 3.Access to other specialty providers as needed 4.Case conferencing between our clinical team and outside specialists 30

Tele-Mental Health 31 Finger Lakes Community Health LCSW’s between sites at FLCH Institute for Family Health (FQHC) Psychiatry

Tele-Mental Health Outcomes % of patients had decrease in PHQ-9 scores Mean time to consults with LCSW * Same day appointments available via video consults Mean time to consults with psychiatrist: * Appointments with psychiatrist in under 30 days via video Mean time to treatment less than 24 hours 0% of patients referred to emergency room due for additional care Increased interaction and peer to peer learning between primary care, LCSW and psychiatrist. High patient and provider satisfaction!

TelePeds Neurology Finger Lakes Community Health U of Rochester Medical Center: Pediatric Neurology 33

TelePeds Neurology Outcomes Focus Population: Children with poorly controlled symptoms of ADHD or other diagnoses. Decreased time to treatment (38 days vs 60 days). Exceeded national averages on NCQA performance measures 90% had changes or additions to their medication regimens 95% diagnosed with mental health co-morbidity 32% started mental health medications 100% referred to behavioral health 46% showed improvement in function at school and home High patient and provider satisfaction! 34

TelePsychiatry for Children – Our Newest Program Finger Lakes Community Health St. Joseph’s Hospital Syracuse, NY 35

TelePsychiatry for Children Work Plan Steps January Agreement to collaborate by both parties February 2015 – Site visits: 1. To St. Joseph’s in Syracuse 2. To view the setup of a child playroom at Mental Health office March - April 2015: 1. Business Associate’s Agreement 2. Memorandum of Understanding 3. Credentialing of providers by FLCH May 2015: 1. Work plan development with details 2. Begin to set schedule of meetings to move work plan forward June 2015: 1. Test video equipment including peripherals 2. Test broadband connectivity levels between St. Joe’s and FLCH July 2015: 1. Meet and greet between St. Joe’s and FLCH providers 2. In-service for primary care providers (FLCH) 3. See “mock” patients to test process from check in to provider visit August 2015: 1. Live consults begin! 36

Other Key Components for Successful Telehealth Programs Care Coordination: Scheduling Pre-Visit Requirements Concurrent Chart Review Coordinate with PCMH Team/Specialty Team Quality Assurance Reports Case Conferencing: Providers, Care Managers, Patient Navigators Quality Improvement Activities: Data Collection Monitor and Report Outcomes Continuous Quality Improvement Regularly Evaluate Program 37

Other Telemedicine Programs at Finger Lakes Child & Adult Teledentistry Child & Adult Telepsychiatry Mental Health Counseling (LCSW) Digital Retinopathy Pediatric Neurology HIV/AIDS Care TeleHCV (Hepatitis C) Pulmonology TeleRD: (Registered Dietician, Cert. Diabetic Educator) TeleTAC (Treatment Adherence) Project Echo - Geriatric Language Interpretation Services Precepting of providers Programs in Pilot Phase Teledoc (open access) Opioid Dependence Dermatology Oncology Geriatrics Endocrinology Remote Home Monitoring Hub to Home – prevention of readmissions to hospital 38

Distance Learning/Admin Uses of Telehealth Board of Directors Training Staff Education Peer to Peer Learning Collaboratives Staff Meetings Case Conferencing Admin Meetings 39

Resources Available on Tele-Mental Health The American Telemedicine Association (ATA) has great resources for clinical guidelines on a variety of clinical areas. They are a great source of information. 40

Consortium of Telehealth Resource Centers 41

Steps to Success Two thoughts to remember… Telehealth is not about fancy equipment and technology. It’s a tool used to improve access and enhance quality of care. Implementing telehealth is a process, not a destination. 42

FLCH Contact Information Mary Zelazny, CEO Sirene Garcia, Director of Special Programs Finger Lakes Community Health PO Box 423 Penn Yan, NY