1. Rural TeleCon '07 10 th Annual Conference of the Rural Telecommunications Congress October 14 – 17, 2007 Rural TeleMental Health

2. F. Rose Rexroat, R.N.,C., MSN, Manager Community Services, Saint Joseph HealthCare, Inc. a Market Based Organization of Catholic Health Initiatives Carol L. Ireson, R.N., PhD, Associate Professor, College of Public Health, University of Kentucky

3. Rural TeleMental Health Understand how telehealth technology is utilized in a rural primary care setting Understand how telehealth technology can support provision of mental health services in rural areas Understand achievements, barriers, and future objectives

4. Why rural telemental health?

5. Economic Challenges. 25% to 39%, in area served, live in poverty compared to 18.7% in Kentucky and 16.3% nationally 80 - 100% of children at the targeted schools are on National Free and Reduced Lunch Program 7.8% to 12.6% of residents are unemployed 18 - 37% of residents qualified for Medicaid

6. Gaps in the Health System 81 of 120 Kentucky Counties are officially designated as a Health Professional Shortage Area (HPSA) Wolfe County has 1 PCP per 100,000, Morgan County has 4.8 PCPs per 100,000 Lawrence County has 11 PCPs per 100,000 (primarily located in the far eastern border in Louisa.)

7. Health Care Challenges 37.4% to 42.6% of residents reporting fair or poor health Over 6% of the population have diabetes higher than the Kentucky rate of 4.5% Obesity and overweight rates are among the highest in the state Over 5% of residents suffer from major depression

8. The Beginning Work as chair of the Kentucky Association of Free Health Clinics allowed the opportunity to educate two State Representatives and a Senator about a Mobile Health Service This discussion lead to implementation of the Eastern Kentucky Mobile Health Service (EKMHS)

9. Know your own strengths and weaknesses in developing the project! Identified and collaborated with experts… –Clinical experts –always focus on the clinical needs of patients –Technical experts – always have a technical consultant that can develop a plan to support your clinical needs –Research experts – help with assessment, analysis, outcome measurement

10. Collaborators Saint Joseph HealthCare, Inc. Catholic Conference of Kentucky Appalachian Regional HealthCare, Inc. Saint Claire Regional Medical Center Cabinet of Health Services, Dept. of Public Health

11. Collaborating Agency Roles SJHC Holds a personal service vendor contract with the DPH for: provision of services development and administrative oversight billing and medical record management Appalachian Regional HealthCare : Provides care regardless of ability for payment Referral for ancillary service

12. Collaborating Agency Roles St. Claire Regional Medical Center Second line of referral for care regardless of ability for payment Serves as hub manager for the five EKMHS sites and SJH Annual management fees of approximately $12,000 -15,000 paid by St. Claire for EKMHS / SJH Cabinet for Health Services / Department of Public Health Representatives John Will Stacy and Rocky Adkins, Senator Walter Blevins Service provider relationship for continued funding to support operation

13. Collaborating Agency Roles Catholic Conference of Kentucky Collaboration in carrying out the mission of the Catholic Church, Catholic Health Care. Lead role with legislative process to assure continued funding for the EKMHS Relationship building Continued presence and communication with state legislature

14. Support State Service Provider Contract - $325,000 for annual operations subsidy Budget 2007-2008 increase of $34,000 – FTE replacement factor for ARNP Bill for Services: Medicare, Medicaid, other third party payers SJHC has no expense subsidy for operations

15. The Goal of the EKMHS  To improve access to primary and specialist care for residents of five extremely rural communities located in Eastern Kentucky and  To build a provider referral network

16. Role of College of Public Health Kentucky Commissioner of Health designated the University of Kentucky, College of Public Health to conduct a community needs assessment to provide baseline data for use in: –Planning focused health promotion –Disease prevention programs –Future evaluations of the impact of the EKMHS on health status of clients served

17. Community Health Assessment 75 item questionnaire assessing disease burden, health risk behavior, access to care Administered at the county fair, homemaker groups, senior center

18. Needs Assessment Findings Disease burden –Heart disease, cancer, diabetes, injury, depression Health behaviors –Poor nutrition, lack of exercise Access to health care –No insurance, no money, not enough doctors

19. Service Delivery The Eastern Kentucky Mobile Health Service EKMHS) started seeing patients on May 6, 2003.

20. Communities Served Blaine in Lawrence County Hazel Green in Wolfe County Ezel, Cannel City, and Crockett in Morgan County

24. Output: Patient Volume Visits Average/day FYE 06/2003 733 FYE 06/2004 9704 FYE 06/2005 21329 FYE 06/2006 252811 FYE 06/2007 236010 23.3% New patient 76.7% Two or more visits

25. Income By Reimbursement Source FYE 06/04 FYE 06/05 FYE 06/06FYE 06/07 MEDICARE 13.0% 19.0%20.0%11% MEDICAID 5.0% 3.0%3.0%5% SELF PAY 57.0% 55.0%69.0%66% ALL OTHER 25.0% 24.0%8.0%18%  self pay includes self pay and other charity (DSH and St. Joseph Charity)  Bill for Services: Medicare, Medicaid, other third party payers  SJHC has no expense subsidy for operations

26. Patient Profile FYE 06/04 FYE 06/05 FYE 6/06 FYE 6/07 Female 64.9% 60.6% 58.2% 58.1% Male 35.1% 39.4% 41.8% 41.9% Pediatric 5.9%2.5% 1.9% 1.3% Caucasian 99.5% 100% 100% 99.5% Native Am. 0.5% 0% 0% 0.5%

27. Disease Burden MEDICATION AS AN INDICATOR HEALTH KYP.A.P. FYE 06/03 $6,495 $9,078 FYE 06/04 $108,202 $323,898 FYE 06/05 $109,649 $765,242 FYE 06/06 $176,076$1,174,954 FYE 06/07$196,461$1,014,639 H.K.: Health Kentucky, Inc. PAP: Patient Assistance Programs

28. Disease Burden MEDICATION AS AN INDICATOR TOTALAMOUNT / VISIT FYE June 2003$15,572 $213 FYE June 2004 $432,100$445 FYE June 2005$874,891 $410 FYE June 2006$1,351,029 $534 FYE JUNE 2007 $1,211,101 $513 TOTAL$3,884,693$423 AVG

29. The Role of Telemedicine for EKMHS Remote Access: To Specialists For follow up visits Referrals to or from any of the sites in the Kentucky TeleCare Network

30. Kentucky TeleHealth Network (KTHN) Sites

32. Telehealth Clinical Consultations 2003 2004 2005 2006 EKG310 43 67 Internal Medicine22 3 Pulmonary11 Conferencing4 Education Programs 2 Peds Gastroenterology 2 School Nurse access for primary care 3 November 2005 started laying foundation with KRCC for mental health clinic(s)

33. Role Of Grants / Funding Sources 1.OCTOBER 2002: USDA-RUS GRANT of $90,300.00 to add telemedicine technology to the MHS and to SJH 2.JUNE 2004: STEELE-REESE GRANT of $47,880.00 to provide cancer and diabetic screening for early detection 3.OCTOBER 2004: USDA-RUS GRANT of $235,636.00 to expand present telemedicine network

34. Need for Mental Health Services Analysis of diagnoses after one year of EKMHS operation found that number of women diagnosed with mental health disorders exceeded the sum of all other diagnoses Residents of the targeted communities do not use the local mental health service provider because of the stigma of going to a mental health clinic

35. Rural TeleMental Health Project Purpose To develop a comprehensive network of health care services by expanding the existing primary care and bringing mental health diagnostic and treatment expertise to residents of local rural communities

36. Role Of Grants / Funding Sources 2006 Appalachian Regional Commission of $303,882 and USDA-RUS Grant of $326,893 to expand the Kentucky Telehealth Network

37. SAINT JOSEPH HEALTHCARE SERVICE AREA WITH EKMHS SERVICE AREA (Morgan, Wolfe and Lawrence Counties) Primary Service Area Secondary Service Area Tertiary Service Area Floyd Pike LivingstonHopkins Christian Webster Logan Simpson Carlisle Allen Monroe Calloway McCracken Ballard Trigg Lyon Caldwell Crittenden FULTON Hickman Marshall Todd Union Henderson Davies McLean Muhlenberg Butler Ohio Warren Edmonson Marion Grayson Breckinridge Meade Hardin Hart Barren Green LaRue Metcalfe Taylor Casey Adair Cumberland Wayne Clinton Russell McCreary Pulaski Lincoln Boyle Mercer Washington Nelson Bullitt Jefferson Oldham Trimble Carroll Boone Kenton Campbell Gallatin Henry Shelby Spencer Anderson Owen Franklin Scott Grant Perry Garrard Woodford Pendleton Fayette Bourbon Harrison Rober tson Bracken Nicholas Clark Rockcastle Madison Jessa mine Knox Whitley Laurel Knott Leslie Harlan Letcher Bell Clay Lee JacksonOwsley Wolfe Breathitt Johnson Magoffin Estill Morgan Lawrence Martin Menifee Rowan Elliott Powell Bath Montgomery Lewis Fleming Mason BoydCarter Greenup Graves Hancock

38. 2006 Grant Goals Appalachian Regional Commission Grant $303,882 Expand EKMHS telemedicine network adding mental health diagnostic and treatment clinic(s) –4 school sites served by MHS –3 Kentucky River Community Care sites of Jackson, Hazard and Campton –St. Claire Regional Medical Center Mental Health Services –6 county impact area of Perry, Breathitt, Wolfe, Morgan, Lawrence and Rowan

39. Saint Joseph Healthcare Service Area With EKMHS Service Area & ARC Grant Primary Service Area Secondary Service Area Tertiary Service Area Floyd Pike LivingstonHopkins Christian Webster Logan Simpson Carlisle Allen Monroe Calloway McCracken Ballard Trigg Lyon Caldwell Crittenden FULTON Hickman Marshall Todd Union Henderson Davies McLean Muhlenberg Butler Ohio Warren Edmonson Marion Grayson Breckinridge Meade Hardin Hart Barren Green LaRue Metcalfe Taylor Casey Adair Cumberland Wayne Clinton Russell McCreary Pulaski Lincoln Boyle Mercer Washington Nelson Bullitt Jefferson Oldham Trimble Carroll Boone Kenton Campbell Gallatin Henry Shelby Spencer Anderson Owen Franklin Scott Grant Perry Garrard Woodford Pendleton Fayette Bourbon Harrison Rober tson Bracken Nicholas Clark Rockcastle Madison Jessa mine Knox Whitley Laurel Knott Leslie Harlan Letcher Bell Clay Lee JacksonOwsley Wolfe Breathitt Johnson Magoffin Estill Morgan Lawrence Martin Menifee Rowan Elliott Powell Bath Montgomery Lewis Fleming Mason BoydCarter Greenup Graves Hancock

40. 2006 Grant Goals USDA-RUS (DLT) Grant $326,893 Expand Access by expanding the network to: –4 Health Departments (Menifee, Morgan, Rowan & Lawrence) –5 Schools (Owingsville Elementary, Bath County High School, Morgan County Middle and High School and Menifee Co.Complex K-12) –3 SJHC Emergency Departments (SJ Berea, SJH, SJ East) –First Clinical Application for Sleep Wellness Center in Lexington and Berea –8 County impact area (Fayette, Madison, Bath, Menifee, Wolfe, Rowan, Morgan and Lawrence)

41. Technology Plan for EKMHS for the USDA RUS DLT Grant

42. SAINT JOSEPH HEALTHCARE SERVICE AREA WITH EKMHS SERVICE AREA & USDA-RUS GRANT Primary Service Area Secondary Service Area Tertiary Service Area Floyd Pike LivingstonHopkins Christian Webster Logan Simpson Carlisle Allen Monroe Calloway McCracken Ballard Trigg Lyon Caldwell Crittenden FULTON Hickman Marshall Todd Union Henderson Davies McLean Muhlenberg Butler Ohio Warren Edmonson Marion Grayson Breckinridge Meade Hardin Hart Barren Green LaRue Metcalfe Taylor Casey Adair Cumberland Wayne Clinton Russell McCreary Pulaski Lincoln Boyle Mercer Washington Nelson Bullitt Jefferson Oldham Trimble Carroll Boone Kenton Campbell Gallatin Henry Shelby Spencer Anderson Owen Franklin Scott Grant Perry Garrard Woodford Pendleton Fayette Bourbon Harrison Rober tson Bracken Nicholas Clark Rockcastle Madison Jessa mine Knox Whitley Laurel Knott Leslie Harlan Letcher Bell Clay Lee JacksonOwsley Wolfe Breathitt Johnson Magoffin Estill Morgan Lawrence Martin Menifee Rowan Elliott Powell Bath Montgomery Lewis Fleming Mason BoydCarter Greenup Graves Hancock

43. SAINT JOSEPH HEALTHCARE SERVICE AREA WITH EKMHS SERVICE AREA & USDA-RUS AND ARC GRANT Primary Service Area Secondary Service Area Tertiary Service Area Floyd Pike LivingstonHopkins Christian Webster Logan Simpson Carlisle Allen Monroe Calloway McCracken Ballard Trigg Lyon Caldwell Crittenden FULTON Hickman Marshall Todd Union Henderson Davies McLean Muhlenberg Butler Ohio Warren Edmonson Marion Grayson Breckinridge Meade Hardin Hart Barren Green LaRue Metcalfe Taylor Casey Adair Cumberland Wayne Clinton Russell McCreary Pulaski Lincoln Boyle Mercer Washington Nelson Bullitt Jefferson Oldham Trimble Carroll Boone Kenton Campbell Gallatin Henry Shelby Spencer Anderson Owen Franklin Scott Grant Perry Garrard Woodford Pendleton Fayette Bourbon Harrison Rober tson Bracken Nicholas Clark Rockcastle Madison Jessa mine Knox Whitley Laurel Knott Leslie Harlan Letcher Bell Clay Lee JacksonOwsley Wolfe Breathitt Johnson Magoffin Estill Morgan Lawrence Martin Menifee Rowan Elliott Powell Bath Montgomery Lewis Fleming Mason BoydCarter Greenup Graves Hancock

44. How telemental health services will be delivered Patients needing mental health services will be referred by the EKMHS Primary Care ARNP to a psychiatric nurse practitioner and psychiatrists located at St. Claire Regional Medical Center or Kentucky River Community Care Students with behavior or mental health problems will be referred by school nurses employed by the Gateway Regional Health Department to the Mental Health Nurse Practitioner or Psychiatrists specializing in child and adolescent psychiatry via the Kentucky Telehealth Network

45. Benefits for the Patient Linked to physicians in a regional medical center and a metropolitan hospital(s) via a telemedicine connection – real time audio and video consultation Connected to any agency / organization on the KTHN Patients will not have to travel long distances to be seen Eliminates the stigma of “going to the psychiatrist office”

46. Benefits for the Community Will impact the economic development of the region by reducing the absenteeism and decreased productivity of workers suffering from mental health problems Early intervention for mental health problems will enhance their successful growth and development and prevent these problems from following them into adulthood Through access to obtain mental health services for the EKyMHS, the end sites obtained access to primary care and other services

47. Evaluation Plan Number of adults and children receiving mental health services in their local communities Distance and costs required to travel to receive mental health services vs. using technology Satisfaction of patients with the telemedicine mental health services Satisfaction of health care providers with the telemedicine technology for providing mental health service

48. Cost effectiveness We believe the program will be the most cost effective way to address the mental health needs of the rural population served –Reduces travel for the patient –Reduces travel for practitioners –Brings services to rural communities that can not support a FT or PT health care provider or specialist

49. Sustainability Looked at how we could develop partnerships with our collaborators to build a network that can support the program –All end sites are responsible for T1 installation and ongoing costs –All end sites are responsible for all equipment repair / replacement after the first year warranty period –Education of end sites users on value of new delivery model to their clinical practice

50. Future Goals Expansion of the TeleMental Health Network through an Appalachian Regional Commission Grant To connect 3 rural CHI hospitals to the Network To expand mental health services by adding 5 more KRCC clinics to the Network To provide primary care services to the 5 new KRCC clinics 8 county impact area

51. Lessons learned Working with two federal granting agencies requires a lot of communication Important to identify champions in each agency who can help with interagency communication, interpretation of regulations and correct processes Pay very close attention to the guidelines for definitions of in-kind and matching funds of each agency Patience and persistence are needed

52. Recommendations for joint federal grants Written guidelines Clear identifiers on application for joint grant with another federal agency Don’t try to maintain integrity of parts of one or both grants (scope of work) and then try to consolidate other parts (budget) When one grantee allows for funding to be used as match, all agents reviewing the grants need to know that provision

53. Recommendations for joint federal grants (continued) Point of contact for each organization for questions Joint federal grants should require different documents than those for a traditional grant Clarify reporting requirements and report cycle Clarify process for fiscal allocations and management

54. Questions Discussion