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Developing Telebehavioral Health Capacity for Patient Needs

Learn to establish telebehavioral health services, engage stakeholders, and coordinate activities with local, state, and federal partners. Lessons learned and strategies for sustainability.

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Developing Telebehavioral Health Capacity for Patient Needs

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  1. A TO Z DEVELOPING TELEBEHAVIORAL HEALTH CAPACITY TO SERVE THE NEEDS OF YOUR PATIENTS Health Centers Healthy Start Programs Ryan White HIV/AIDS Program Grantees and Service Providers Rural Health Clinics Session 6 Lessons Learned August 21, 2013

  2. Today’s Speakers Michael R. Lardiere, LCSW VP HIT & Strategic Development National Council for Community Behavioral Healthcare Cari Greb RN, BSN-BC Patient Care Coordinator-Home Telehealth James A. Haley Veteran’s Hospital Outpatient Clinic Cari.Greb2@va.gov Melanie Perez, PhD Licensed Clinical Psychologist Lakeland Military Sexual Trauma Coordinator Melanie.Perez3@va.gov Phil Hirsch, PhD Chief Clinical Officer HealthLinkNow phirsch@healthlinknow.com Jodi Mahoney, MBAChief Operating OfficerNorth Central Behavioral Health Systemsjmahoney@ncbhs.org

  3. Goals of the Training 1: Identify for their own organization one or more telebehavioral health service models that are clinically appropriate and a pathway to sustainability; 2: Identify and engage the range of stakeholders necessary to successfully establish telebehavioral health services; 3: Coordinate their telebehavioral health activities with pertinent local, state and federal partners.

  4. T/TA SERIES SCHEDULE • Session IV: Technology and Logistics July 17, 2013 @ 12:00 PM EST Register Here • Session IV: Office Hours Q+A July 24, 2013 @ 12:00 PM EST Register Here • Session V: Implementation August 7, 2013 @ 12:00 PM EST Register Here • Session V: Office Hours Q+A August 14, 2013 @ 12:00 PM EST Register Here • Session VI: Launch, Refinement, Lessons Learned and Wrap Up August 21, 2013 @ 12:00 PM EST Register Here • Session VI: Office Hours Q+A August 28, 2013 @ 12:00 PM EST Register Here • Session I: Overview & Laying the Groundwork May 22, 2013 @ 12:00 PM EST Register Here • Session I: Office Hours Q+A May 29, 2013 @ 12:00 PM EST Register Here • Session II: State Regulatory/Reimbursement Topograpy; Engagement and Outreach June 5, 2013 @ 12:00 PM EST Register Here • Session II: Office Hours Q+A June 12, 2013 @ 12:00 PM EST Register Here • Session III: Economics, Partnerships June 19, 2013 @ 12:00 PM EST Register Here • Session III: Office Hours Q+A June 26, 2013 @ 12:00 PM EST Register Here

  5. Jodi Mahoney, MBAChief Operating OfficerNorth Central Behavioral Health Systemsjmahoney@ncbhs.org

  6. Thumbnail of NCBHS’s Telehealth • Use 3 different forms of videoconferencing • Large Polycom Units – Office Based • Individual Polycom Software – Individual Computers • Customized Web Based Platform • All 7 of our Outpatient Offices have Polycom Equipment • Our Residential CILA Home has Polycom Equipment • 6 Local ED’s using web based platform and laptops to connect with our crisis workers for crisis assessments.

  7. Lessons Learned • Rural vs. Urban Utilization • Going Beyond Psychiatry • ED – VAC Project • Electronic vs. Paper • Start Small and Build • Clinicians Attitudes Towards Telemental Health • Perceptions of Client Suitability for Telemental Health • HIPPA • Develop Backup Process for Unplanned Downtime.

  8. Rural vs. Urban Utilization • Telebehavioral health originated from the need for “Access” in rural geographical areas. • Telebehavioral health is just as effective in urban areas (e.g. population density causes the same time/travel constraints as open space)

  9. Going Beyond Psychiatry • Telebehavioral health is suitable for the majority of services provided in CMHC’s. • Start small and build on it • Don’t assume staff are on board with technology • Develop backup processes for unplanned downtime

  10. ED – VAC Project • VAC Outcome of Connections • VAC Service Outcomes • VAC Satisfaction Survey

  11. VAC Connectivity Outcomes

  12. VAC Service Outcomes

  13. VAC Satisfaction Survey5 Hospitals/12 Key Participants/4 Respondents/7 Questions

  14. Electronic vs. Paper EHR is a necessity VS.

  15. Start Small & Build Overall Infrastructure Diagram 2005

  16. Start Small & Build Overall Infrastructure Design 2013

  17. Start Small & Build Overview Polycom Legacy 2005

  18. Start Small & Build Web Based Platform Polycom Overview 2013

  19. Clinicians Attitudes Toward Telemental Health • Don’t Assume Your Staff are On Board with Technology • Depends on mental health workers willingness to use technology • Research suggests worker concerns but attitudes and concerns have not been thoroughly evaluated Source: Canadian Psychology 2011, Vol. 52, No. 1, pg. 41-51

  20. Perceptions of Client Suitability for Telemental Health • Individual mental & physical health status • Client experience with technology • Client’s age • Level of trust Source: Canadian Psychology 2011, Vol. 52, No. 1, pg. 41-51

  21. HIPPA • Personal Health Information • Laptop Security • Encryption • Mobile Devices

  22. Develop Backup Processes for Unplanned Downtime • Phone • Access to Electronic Health Record

  23. Home Telementalhealth delivering innovative quality health care in the patient's home through technology James A. Haley Veterans' Hospital & Community Outpatient Clinic CariGreb RN, BSN-BC Patient Care Coordinator-Home Telehealth Melanie Perez, PhD Licensed Clinical Psychologist/ Lakeland Military Sexual Trauma Coordinator

  24. Any views or opinions presented here are solely those of the authors and do not represent those of the Department of Veteran Affairs

  25. Right care Right time Right place

  26. James A. Haley Veterans' Hospital & Community Outpatient Clinics • James A. Haley Veterans' Hospital (JAHVH) is part of the Veterans Integrated System Network (VISN) 8. • JAHVH and its four satellite community based outpatient clinics serves 116,000 veterans, and include the nation’s largest polytrauma rehabilitation center. • JAHVH, serves four counties in Central Florida. • Tampa (Main Hospital) • New Port Richey (Outpatient Clinic) • Zephyrhills (Community Based Outpatient Clinic) • Lakeland (Community Based Outpatient Clinic) • Brooksville (Community Based Outpatient Clinic)

  27. What is Home Telehealth? • Home Telehealthis the wider application of care and care management principles to the delivery of health services using health informatics, disease management protocols and Telehealth technologies to facilitate access to care and to improve the health of designated individuals and populations with the specific intent to providing the RightCare in the Right Place at the Right Time. • Goal of CCHT is to prevent unnecessary long-term institutional care.

  28. JAHVH Telehealth Program • Clinical Video TeleHealth (CVT) • clinics include: Diabetes, Renal, GI, Speech, Geriatrics, Smoking Cessation, Move, Cardiac, Pre-op, Mental Health, Lymphedema • TeleHealth • Mental Health, TeleMove, SCI, TeleHealth (medical) • Store and Forward • Dermatology, Retina

  29. Home Telehealth (HT) • VA initiative started in 2000. • Mental Health program in existence since early 2002. • A best practice model of care coordination combined with technology to facilitate a holistic, interdisciplinary approach to the care of veterans with mental health illnesses.

  30. Home Telehealth from the Veterans’ home Austin, TX. CCHT- JAHVH Patient’s home

  31. Home Telehealth Equipment

  32. Goals of Program • Teach Disease Self-management skills • Expand patient knowledge of diagnosis • Improvement in Depression, PTSD, Schizophrenia, and Bipolar management • Enhance communication and collaboration with providers • Improve access to clinics, and departments • Reduce healthcare costs , complications, provider no-show rates • Coordinate health care treatments • Decrease unscheduled visit to ED, Urgent Care and Acute Care • Improved patient satisfaction • Provides evidence based preventive health care

  33. Provider Benefits • Decrease provider visits and phone calls to the provider • Increase quality of care and more efficient use of resources • Increase access to care • Improve provider no-show rates • Improve utilization of hospital resources

  34. Patient Benefits • “Just in time” healthcare advice from a nurse/provider • Increased access to health care • Coordination of care/services. • Deliver care to patients: • The Right Care at the • Right Place at the • Right Time

  35. Program Benefits • Care Coordinators are case managers who are able to leverage the use of health informatics, telehealth technologies and disease management strategies to coordinate care of patients with high risk, high cost or high utilization patterns • Team working on behalf of veteran to facilitate symptom management, improve quality of life, easing caregiver burden • Assists in navigating VA system by providing a single/additional point of contact

  36. Admission Criteria • More than 2 admissions to a Mental Health Facility • Multiple ED visits for psychiatric issues • Multiple appointment no-shows • Chronic suicidal ideation or High Risk flag • A diagnosis of Depression, Schizophrenia, Bipolar or PTSD • Currently prescribed a psychiatric medication • Patients having difficulty complying with medications • Patients that require close monitoring in order to improve compliance

  37. Exclusion Criteria • A home/residential environment that is unsafe for patient, staff, or equipment • Documented violence/aggression towards staff • Active substance abuse • Currently enrolled in MHICM • Homelessness • Unwillingness to participate in and adhere to program requirements • Patients without access to electricity or a cell phone

  38. Disease Management Protocols • Health Buddy • Username: view_content • Password: review • Authentidate

  39. What the Nurse sees

  40. HOME TELEMENTAL HEALTH IN ACTION

  41. Consult

  42. Consult

  43. Enrollment/Screening Process • All consults will print to centralizedprinter • Consults will be reviewed by Nurse within 24 business hours • Patient must have a home telephone "land line or cell phone” • Willing to enroll/participate in the Mental HT Program • Ability to use technology/Family willing to assist

  44. Enrollment process continued • Chart reviews by Mental Health RN • Schedules enrollment appointment • Orient and educate patient/caregiver to telehealth equipment (45 -60 min visit) via classes up to four patients or individual or telephone education • Monitor home Telehealth data/daily trends (notes titles in CPRS *Care Coordination*) • Not everyone receives equipment, Veterans have the choice to self-report using Interactive Voice Response (IVR) to answer questions

  45. Criteria for Discharge • Achieves goals • Non compliance with Telehealth plan of care • Becomes homeless • Becomes verbally abusive to Home Telehealth staff • Refuses to submit daily transmission • Admission to a facility greater than 27 days • Moves away from the catchment area • Requests discharge from program • Incarceration • Death

  46. Lessons Learned • Resistance comes from all sides • Engaged health system leadership: Buy in from Chief, Medical Directors, Clinic leaders and administration • Engaged Staff: Buy in from PCPs, psychiatrists and psychologist (training on the new program on how to refer, understanding the different roles of all the providers involved and how to utilize the Telemental Health services. • Clear lines of responsibility between teams to facilitate handoffs • Clarity around shared workloads (Standard Of Operation Procedures) • Measurable goals and outcomes must be agreed upon a priori • Mental health and medical health have different cultures we are in the process of developing a new culture where technology is part of the treatment team. • Can create dependence in mental health and medical providers

  47. Lessons Learned • Engaging Patients: • Goes far beyond ‘warm hand-off’ • Training Patients is taking longer than expected. • Put the patient first • Adequate resources • Staff “We had to get an additional RN person to assist with the Mental Health Consults,” • Funding • IT “currently working with vendors so that the information that is collected will be able to be put in chart in CPRS.” The Patient Centered Medical Home emphasizing patient self-management • Requires a shared vision among providers

  48. Resources • Perez, M, Kugeares, S, Lewis-Crosswell, J., Grossenbacher, A.S., Keune, K.M., Agliata, D., Gironda, R. (2012). Trauma Informed Care: New Norms Lead The Way at the VA. National Council Magazine, The Future is Now, 2012; (1):pgs:36-37. • http://www.thenationalcouncil.org/galleries/NCMagazine-gallery/12_NCCBH%20magazine%231_web.pdf • VA Telehealth Services: http://vaww.telehealth.va.gov/index.asp

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