1. Telepsychiatry: Protocols and Lessons Learned Mick Pattinson, Ph.D., CEO Susan Morley, LCSW, Deputy Director Nancy Rowe, BA, Telemedicine Manager Northern Arizona Regional Behavioral Health Authority

2. NARBHAnet Background

3. 3 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 five northern counties of AZ, including Tribal areas; all are Mental Health Professional Shortage Areas 3

4. 4 NARBHA Overview (cont.) Northern Arizona: Approx. the size of New York plus New Jersey 62,000 square miles (54.4% of AZ area) Population 708,500+ (11.5% of AZ pop.) 4

5. 5 NARBHAnet History Drivers for starting telemedicine network: Large geographic area, sparse population Doctor and/or patient travel times and cost Recruitment/retention of psychiatrists State Hospital monthly staffings for patients NARBHA staff travel to provider sites/clinics Provider staff travel to outlying sites Provider staff travel to trainings/meetings 5

6. 6 NARBHAnet History (cont.) 6 1996 NARBHAnet established with $250,000 Tobacco Tax and $250,000 state funding. Six video sites. 1997 NARBHAnet has 12 sites; named to Top Ten in U.S. 1998 Connects to U of A network, southern RBHA network, and AZ Division of Behavioral Health Services. Named to Top Ten 2nd year. 1999 Named to Top Ten 3rd year. 2001 Central website, www.rbha.net, goes online.www.rbha.net 2006 Celebrates 10th anniversary.

7. 7 NARBHAnet History (cont.) 7 2007: 32 video endpoints in 21 locations. Newest sites are on AZ Strip (north of Grand Canyon), Apache and Navajo Reservations. Connections to U of A (171 locations) & RBHA (24 locations) telemed networks blanket the state.

8. 8 NARBHAnet Activity 8 Network use (in hours) by conference type July 1, 2006 - June 30, 2007 Total hours of video connection for the year: 12,210.5 (3,376 hookups)

9. NARBHAnet Clinical Services

10. 10 Live, 2-way, real-time, interactive video High bandwidth: 384K or 512K, 30 frames per second Clinical meetings have highest priority on NARBHAnet and can bump others Approx. 425 client visits via video per month Est. total patient services over NARBHAnet, November 1996 – August 2007: 36,637 NARBHAnet Clinical Stats 10

11. 11 August 2007: 10 psychiatric providers at 3 locations in N. AZ and 2 out-of-state locations: Dallas, TX (provider’s home) Cassadaga, NY (provider’s home) NARBHA HQ in Flagstaff (2 dedicated doctor rooms) Psychiatric inpatient facility in Show Low Provider clinic in Page NARBHAnet Clinical Activity 11

12. 12 Seeing patients at 8 clinics / inpatient facilities: Psychiatric inpatient facility in Show Low Provider clinics in Page, Holbrook, Winslow, Fredonia, Prescott, Springerville, St. Johns Occasionally Arizona State Hospital in Phoenix Aug. 2007: 616 telepsychiatry sessions Clinical Activity (cont.) 12

13. 13 Clinical Activity (cont.) Patient Services over NARBHAnet: April 1 – June 30, 2007 13

14. 14 Clinical Activity (cont.) Psychiatric services provided on NARBHAnet: Complete psychiatric evaluations (gen. 1 ½ hour) Medication management, follow-ups 3-way inpatient staffings (psychiatrist, clinician at patient’s home clinic, inpatient staff) Emergency and commitment evaluations Title 36 commitment hearings with judge Family involvement in patient treatment (when patients are placed out of the home) Specialty consultations (connections to state hospital neuropsychiatrist, U of A specialists, child psych.) ASL interpreter for psychiatric sessions 14

15. 15 Clinical Activity (cont.) Telepsychiatry at the patient end Therapist or case manager refers patient for psych. eval. Patient signs Informed Consent to Participate in Telemedicine Services form (part of medical record) At many clinics, all patients are seen via telemedicine unless they decline—can travel to alternative location First-time telemed patients oriented to the system by provider Therapist, case manager, or RN in room with patient Team approach Operates video equipment Helps if crisis Family member(s), others sometimes attend 15

16. 16 Little Colorado Behavioral Health Centers Apache County, AZ 11,000 sq. miles, 18,700 off-reservation residents Springerville and St. Johns clinics Replaced retiring local psychiatrist with telemedicine in 1996 when unable to recruit Psychiatric services now solely via telemedicine LCBHC Clinical Services 16

17. 17 Dr. Sara Gibson Sees patients from Flagstaff St. Johns is 165 miles away (3 hours) Springerville is 200 miles (3 hours, 20 min.) 11 years of telemedicine: approx. 10,750 patient sessions Joined by NP Ellen Morse in December 2002; together they now total 4.5 days per week of telemedicine LCBHC Clinical Services (cont.) 17

18. 18 LCBHC Clinical Services (cont.) Dr. Gibson on telemedicine challenges: Medical records: duplicate copies kept at clinic and at doctor location—no EHRs yet Prescribing: must fax or mail to pharmacy or clinic now using InfoScriber web-based system; has improved quality and ease doctors no longer keep samples Physicians in non-clinical setting (NARBHA HQ) fire drills—providers now warned ahead of time so patient services not interrupted unnecessarily white-noise machines for privacy/confidentiality

19. 19 Comments from Dr. Gibson I have had nothing but a positive experience with it. My patients tell me things like “I feel like you’re right in the room with me.” One patient told me that the quality of care was better than they could get from anyone who lived there. I like where I live and telemedicine has enabled me to provide services to rural areas, yet still maintain the lifestyle that I want. I wouldn’t be working here if it weren’t for the telemedicine network. LCBHC Clinical Services (cont.)

20. NARBHAnet Clinical Policies & Protocols

21. 21 Provider Policy: Clinical Telemedicine Services Orientation of staff providing clinical services via video is required and must include: Use of equipment / camera angle / volume controls Orientation of new patients to telemedicine Patient can scan provider room with camera to be assured no one else is in the room Patient informed consent forms Patient refusal of telemedicine services Correct coding of telemedicine services for claims Documentation of staff orientation in personnel record 21 NARBHAnet Clinical Policies

22. 22 Provider Policy: Clinical Telemedicine Services Confidentiality/privacy: Provider room door is closed whenever a patient can be seen or heard on TV Signs on doors during clinical sessions All video equipment set to “auto answer mute” Clinical video equipment set to not answer calls when already in videoconferences Clinical video equipment password-protected Clinical video equipment turned off or camera lens covered when not in use All present in room must be approved by patient Clinical Policies (cont.)

23. 23 Provider Policy: Clinical Telemedicine Services Separate patient authorization required to record telemed session Clinical record keeping: All clinical records clearly document that the service was provided via telemedicine Patient records include signed Informed Consent to Participate in Telemedicine Services form Clinical record maintained at patient’s local clinic (duplicate kept at provider end) Privileging, credentialing, scope of practice Clinical Policies (cont.)

24. 24 Provider Policy: Clinical Telemedicine Services Prescriptions: Prescriptions for Federal Schedule II controlled drugs mailed to the pharmacy or clinic in envelope marked confidential Others faxed, called in, or electronically prescribed Appropriate services: Only those services approved by AZ Division of Behavioral Health are provided via telemedicine Services must be coded with the “GT” modifier to indicate that they were provided via telemedicine Clinical Policies (cont.)

25. 25 Clinical Protocols & Policies Clinical Telemedicine Services Protocol A clinician (case manager, therapist, RN) is in the room with the patient during telemedicine sessions This is a guideline, not a requirement Improves team treatment model NARBHAnet website, www.rbha.netwww.rbha.net Clinical telemedicine policies Procedures, protocols Information AHCCCS (AZ Medicaid) and Medicare telemedicine allowable codes

26. 26 www.rbha.net/clinical 26

27. Telemedicine Reimbursements

28. 28 Cost Reimbursements AHCCCS Arizona Health Care Cost Containment System (Arizona Medicaid) Medicaid reimbursement for services over telemedicine is available at state’s option At least 34 states now reimburse AHCCCS has reimbursed for NARBHA telemedicine services since day one (1996) NARBHA provides “Telemed allowable codes” spreadsheet for users on www.rbha.netwww.rbha.net

29. 29 Cost Reimbursements (cont.) 29 AHCCCS, cont. AHCCCS funds for behavioral health services are paid on a capitated basis through RBHAs and are not restricted to rural areas For capitated providers the 15% facility fee is 1.15 times the service value of face-to-face Appropriate authorizations required but no specific telemedicine authorizations necessary Use “GT” modifier on service code www.cms.hhs.gov/home/medicaid.asp

30. 30 Cost Reimbursements (cont.) Medicare Started paying in 1999 and has expanded coverage Covered services: Provided to eligible Medicare beneficiary Patient is in eligible facility—rural only (originating site located in non-metropolititan statistical area) Real-time, interactive video Non face-to-face services (e.g., EKG, radiology, pathology) Home telehealth services (with restrictions) 30

31. 31 Cost Reimbursements (cont.) Medicare, cont. No limitation on location of health professional delivering medical service (referring site) Eligible providers include: Physician Nurse practitioner Physician Assistant Clinical psychologist, clinical social worker 31

32. 32 Medicare, cont. Payment same as current fee schedule for service provided, plus rural site facility fee: $22 Use “GT” modifier on service code See “Telemed allowable codes” handout at www.rbha.net/clinical.html www.rbha.net/clinical.html For more info: www.cms.hhs.gov/home/medicare.aspwww.cms.hhs.gov/home/medicare.asp Private payers Many are willing to reimburse for telemedicine services Cost Reimbursements (cont.) 32

33. 33 Telemed Allowable Codes handout on www.rbha.net 33

34. NARBHAnet Results & Reactions

35. 35 Apache County vs. entire NARBHA system before (1996) and after (1997) implementation of telemed in Apache County: 35 Inpatient Days Comparison 1996 (before telemedicine) vs. 1997 (after telemedicine) Average Inpatient Days (Per 1000 Patients per Month)

36. 36 Client Satisfaction 1998 After 2 years of telemedicine on NARBHAnet: Rating of quality of picture and sound, ease of use, comfort with equipment: 85% Good to excellent 11% Average 4% Poor Believe treatment is as good or better via video: 82% Agree 7% Disagree 11% Unsure 36

37. 37 Client Comments, 2004 From Little Colorado Behavioral Health Centers: “I appreciate and like what this facility is doing for me. My children even benefit from me doing better by coming to this site.” “This is a great way to cover the miles for us that live remote.” “I think this service is long overdue for this area. Thank you!” “I feel like it’s very effective. I feel like you are right in the room with us.” 37

38. 38 Client Comments, 2004 (cont.) From Little Colorado Behavioral Health Centers: “It was different at first but is now more comfortable; seems to be very effective.” “I feel like we’re in this together.” “Coming here has made a great difference in me and my children because I am able to get medication and counseling.” 38

39. 39 Client Satisfaction 2007 39 Little Colorado Behavioral Health Centers: Survey conducted Dec. 2006 - March 2007 288 clients, 76 surveys returned (33.3% response rate) 86% said quality of care over telemedicine is same as or better than in person.

40. 40 Client Satisfaction 2007 (cont.) 80% of respondents either had no preference or prefer to see their psychiatric provider via telemedicine.

41. 41 Client Satisfaction 2007 (cont.) Compared to patient’s first telemedicine sessions:  Most (77%-79%) said sessions now run more smoothly and they are now more comfortable with the equipment.

42. 42 Client Satisfaction 2007 (cont.) Compared to patient’s first telemedicine sessions:  Most (65%-71%) said they are now more at ease and have fewer privacy worries.

43. 43 Client Satisfaction 2007 (cont.) Selected client comments: “Telemed is an outstanding program. I feel it has been a great help to me.” “I feel that during my sessions Ellen is in the room physically.” “It is a great service. I enjoy talking with Ellen and Scott.” “I really like the service I get with Little Colorado Behavioral Health Center. They have always treated me well and professional.” “Works for me.” 43

44. 44 Selected client comments, cont.: “Obviously very impersonal – but telemedicine has worked OK for us.” “Whether I see my Dr. in person or by the internet does not matter. I can speak freely with her regardless.” “Ellen and Becky are the greatest. I can tell them anything. I also know if I have a crisis, someone will be available to help me. I feel that I’ve made a lot of progress since I’ve started coming here.” “Having a clinician with me helps validate what was discussed.” Client Satisfaction 2007 (cont.) 44

45. 45 LCBHC Staff Comments 2004 Staff comments to Dr. Gibson: “I most appreciate that I get to be fully participating in the telemed sessions, taking notes and discussing events/observations with both the client and the doctor(s)—makes for a full circle, no unlinked treatment team stuff behind closed doors. When the clients have seen you or Ellen alone, I never get the gist of those contacts and often clients don't engage in counseling as fully.” 45

46. 46 Staff comments to Dr. Gibson: “In the seven years we have been working together on this I have only had one person not like it or want it. I moste recently have had a comment that it makes them feel more comfortable to be themselves because the psychiatrist is not right in front of them physically.” “I find it very useful and generally get good validation from you with my clients. Often hearing from you what I have been saying makes a difference. Also brainstorming what to do with a client is helpful.” Staff Comments 2004 (cont.) 46

47. 47 Staff Comments 2004 (cont.) Staff comments to Dr. Gibson: “Pros: Encourages team treatment for all psychiatric referrals Saves transportation and travel costs Convenient location for both staff and clients Allows clients to have access More resources than what this isolated area can offer Allows clients to see therapists and psychiatrists working together Cons: You don’t get to smell the clients, but the therapist has to.” 47

48. Q & A

49. 49 Susan Morley, MSW, LCSW NARBHA Director of Administrative Services/ Deputy Director 928-774-7128, susan.morley@narbha.org Nancy Rowe, BA NARBHA Telemedicine Program Manager 928-214-2163, nancy.rowe@narbha.org www.rbha.net www.narbha.org For More Information 49