Telehealth and Primary Care

1. Session #B1a Friday, October 17, 2014 Telehealth and Primary Care Lesley Manson, Psy.D. Robynne M. Lute, Psy.D. Norman Bell, M.D. Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC U.S.A.

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

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: Learning Objective #1 • Identify, define, and discuss multiple forms of telehealth service provision. Learning Objective #2 • List at least 3 empirically supported uses of telehealth for behavioral health care needs. Learning Objective #3 • Identify at least 3 benefits of using telehealth technology to assist Triple Aims objectives.

4. References American Psychological Association (2013). American Psychological Association Joint Task Force on the Development of Telepsychology Guidelines for Psychologists. Retrieved from https://www.apapracticecentral.org/ceguidelinestelepsychologyguidelines.pdf American Telemedicine Association State Medicaid Best Practice telemental and behavioral health (2013). Retrieved from americantelemed.org Anthony, K., Merz Nagel, D., & Goss, S. (Eds). (2010). The use of technology in mental health: Applications, ethics, and practice. Springfield, IL: Charles C. Thomas Publisher, LTD. Brady, C. (2013). The role of telehealth in an integrated health delivery system: How telehealth can provide the bridge between patients and health care providers. Managed Care Outlook, 26(15): 1 Committee on National Security Systems (2010). National information assurance (IA) glossary. Retrieved from https://www.cnss.gov/assets/pdf/cnssi_4009.pdf Copeland, J. & Martin, G. (2004). Web-based interventions for substance use disorders: A qualitative review. Journal of Substance Abuse Treatment, 26(2), 109-116. Dahl, D. (2014). People, technology, and process meet the triple aim. Nursing Administration Quarterly, 38(1):13. Frueh, B., Henderson, S., & Myri, H. (2005). Telehealth service delivery for persons with alcoholism. Journal of Telemedicine and Telecare, 11, 372-375.

5. 9. Godleski, L., Darkins, A., & Peters, J. (2012). Outcomes of 98,609 U.S. Department of Veterans Affairs patients enrolled in telemental health services, 2006–2010. Psychiatric Services, 63(4), 383-385. doi:10.1176/appi.ps.201100206 10. Institute of Medicine (1996). Assessing medical technologies. Washington, D.C: National Academy Press. 11. LeRouge, C. & Garfield, M. J. (2013). Crossing the telemedicine chasm: Have the US barriers to widespread adoption of telemedicine been significantly reduced? International Journal of Environmental Responsibility and Public Health, 10(2): 6472-6484. 12. Maheu, M., Whitten, P., & Allen, A. (2001). E-heath, telehealth, and telemedicine: A guide to startup and success. San Francisco, CA: Jossey Bass Publishing. 13. Myers, K. & Turvey, C. (2012). Telemental health: Clinical, technical, and administrative foundations of evidence-based practice. Waltham, MA: Elsevier Inc. 14. Nelson, E., & Bui, T. (2010). Rural telepsychology services for children and adolescents. Journal of Clinical Psychology: In Session. 66(5):490-501. 15. Nelson, E.-L., Davis, K.C., Sharp, S., & Borror, H. (2007). An integrated telehealth intervention for youth depression. Telemedicine and e-Health, 13(2), 193. 16. Nelson, E.-L., Ellerbeck, K., & Davis, K. C. (2008). Team-based approaches in pediatric telemental health. Telemedicine and e-Health, 14(1), 91. 17. Open Door Community Health Center (2014). Executive Team Communications and Telehealth Program Review. Eureka, CA. 18. Velasquez, S., Banitt Duncan, A., & Nelson, E. (2012). Technological innovations in mental health service delivery for rural areas. In Smalley, K. B., Warren, J. C., & Rainer, J. P. (Eds). Rural mental health: Issues, policies, and best practices. (pp. 149-172). New York, NY: Springer.

6. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

7. Telehealth and Primary Care • What is Telehealth? • Empirical support • Uses within primary care setting • Integrated care and collaboration • Providers • Community organizations • Stakeholders • Triple Aim objectives • Case Examples • Questions and Discussion

8. Definitions & Terms • Telemedicine: the use of electronic information and communications technologies to provide and support health care when distance separates the participants. (Institute of Medicine, 1996) • Tele-Behavioral Health (TBH): the provision of psychological and behavioral medicine services using telecommunication technologies.

9. Communications Technologies • Email • Chat and Instant Messaging (SMS) • Telephone • Cellular phones and Texting • Social Networks • Websites and Blogs • Videoteleconferencing (VTC) • Virtual Reality • Computer-Aided Therapy • Health Information Technology

10. Why Utilize Telehealth? • Provider Distribution • Capitated Health Care Services/Lower Costs* • Growing Population Health Concerns • Patients with Limited Access to Care • Provider Support Distance/Time/Travel • Patients and Families • Outreach Physician • Isolation of Providers • Patient Preference • National/International Travel and Needs • Cultural Considerations (e.g., use asynchronous communication to overcome language barriers)

11. Quick Stats • 74% of teleconsults led to a change in diagnosis or treatment • 60% of telehealth cases solved without a face-to-face visit • 75% of U.S. Consumers say they would use telehealth • 30% of smartphone users are likely to use wellness apps by 2015 • 500 mobile health projects worldwide

12. Telehealth Applications • Tele Consultation • Direct and Indirect Care • Tele Monitoring • Direct and Indirect Monitoring • Tele Education / Learning • CMEs, CEUs • Tele Mentoring • Direct Consultation and Professional Development • Tele Conferencing • Case, Staff, and Professional Conferencing

13. Our Focus—Patient Care Applications Photo Credit: Splashmarcomms.com

14. Tele-behavioral Health (TBH) in Primary Care • Mental health, substance abuse, lifestyle and health behaviors, psychosocial concerns • Research on VTC—mental health including psychiatry • Satisfaction research • Patients, their families, and clinicians endorse high levels of satisfaction with TMH • Comparability between TBH and same-room care • “Studies have demonstrated equivalence between same-room care and TMH care in psychiatric diagnosis, psychological assessment, treatment plan development, and treatment outcomes for both psychiatry and psychotherapy” (Turvey & Myers, p. 397) • Research includes large RCT • Effectiveness Research • Supported by large RCTs • Growing literature supporting asynchronous CBT over the internet • Future Directions • “need research into the growing availability of technologic adjuncts to therapy such as web-based programs to support intersession behavioral practice or relaxation” • Areas for improvement, despite literature supporting clinical and research effectiveness

15. Empirical Support • Overwhelmingly positive for TMH • No contraindications for use of VTC in MH care • Comparability • Children • Adults • Geriatrics • Cognitively impaired Photo Credit: Takomabibelot

16. Empirical Support • Mental Health Disorders • Mood disorders • Anxiety disorders • Substance-use disorders • Psychotic disorders • Treatment Settings • Outpatient • Inpatient • Institutionalized • Correctional settings

17. WHO and WHAT? • Primary Care Providers • Behavioral Health Providers • Specialty Medical Care • Specialty Mental Health Care • Medical Team Professionals • School Personnel • Social Support Network • Community Support/Services • Individual Direct Service • Medical Care • Behavioral / Lifestyle Medicine • Behavioral Health Services • Specialty Care • Population Health • Self Management • Outcomes / Monitoring • Mentoring • Learning

18. TRIPLE AIM • Improved patient care and satisfaction • Early identification and intervention w Specialty • Holistic approach/collaborative/pt centered • Improved compliance with medical treatment • Improved outreach and communication • Improved inclusion of support system and community • Ease and familiarity with service • Improvement of population health; reduced health disparities; consultation; education; mentoring; increased compliance • Improved cost containment; targeted use of resources; revenue generation; reduced hospitalizations; reduced non-compliance leading to additional costs; reduced ED visits

19. Telehealth ConsultationIndirect and Direct Care Photo Credit: ODCHC, 2009 Photo Credit: averaphoto42012

20. Telehealth Monitoring

21. Telehealth Education / Learning

22. Telehealth Mentoring

23. Telehealth Conferencing

24. Core Guidelines • Competence of Provider • Standards of Care in Delivery • Informed Consent • Confidentiality of Data and Information • Security and Transmission of Data and Information • Disposal of Data and Information and Technologies • Testing and Assessment • Interjurisdictional Practice A.P.A., 2013

25. Core Guidelines • Competence of Provider • Competence in technology and impact of technology on pts and other professionals • Standards of Care in Delivery • Ensure ethical and professional standards of care and practice • Informed Consent • Obtain informed consent to address telehealth services and be cognizant of applicable laws and regulations • Confidentiality of Data and Information • Protect and maintain confidentiality of data and information A.P.A., 2013

26. Core Guidelines • Security and Transmission of Data and Information • Ensure security measures are in place to protect data/information from unintended access or disclosure • Disposal of Data and Information and Technologies • Dispose of data/information and the technologies used to protect from unauthorized access and account for safe and appropriate disposal • Testing and Assessment • Consider unique issues that may arise with testing and assessment approaches designed for in-person implementation • Interjurisdictional Practice • Comply with relevant laws and regulations to the practice related to jurisdictional and international borders.

27. Legalities: Originating & Specialty • Consultation • Evaluate • Diagnosis • Recommend • Review • Treatment • Tests • Confirms • Prescribes • Orders • Follows • Consents • Insurances • Scope • Additional activities • Hub and Specialty sites • Billing • Location Boundaries/Rules • Credentialing • Hub sites • Spoke sites • Specialists • Consultants • Store and Forward

28. American Telemedicine Association

30. Who we are The mission of the Open Door Community Health Centers is to provide quality medical, dental, behavioral health, and education services to everyone in our community; regardless of their financial, geographical, or social barriers.

31. Open Door Community Health Centers • Willow Creek Clinic: Primary Care, Dental, Teen Clinic (Willow Creek) • Humboldt Open Door: Primary Care, Teen Clinic, behavioral health (Arcata) • North County Clinic: Primary Care, Pediatrics, Behavioral health (Arcata) • Mobile Health Services: Promotoras, Care Coordination, Behavioral Health, Pediatrics, Telemedicine, Primary Care (Eureka & Fortuna) • McKinleyville Community Clinic: Primary Care, Teen Clinic (McKinleyville) • North Country Prenatal Services (Arcata) • Eureka Community Health and Wellness: Pediatrics, Primary Care, Telemedicine, Behavioral Health (Eureka) • Burre Dental (Eureka) • Ferndale Community Health (Ferndale) • Fortuna Community Health (Fortuna) • Del Norte Community Clinic: Primary Care, Teen Clinic, Dental (Crescent City) • Telehealth and Visiting Specialist Center: Telemed, Specialty Care, HIV (Eureka)

32. Primary Care Behavioral Health Program • Open Door Community Health Centers' Behavioral Health Program partners with each person to develop an individualized plan to improve physical and mental wellbeing leading to a healthier and happier community and quality of life.

33. Federally Qualified Health Center • We Serve 45,506 Community Members per year • Provide 202,000 Visits • Provide $6,000,000 in Free and Reduced Fee Services • 450 Staff • 85 Providers • Budget $40,000,000 Photo Credit: surroundsound5000 ODCHC, 2014

34. ODCHC, 2014

35. ODCHC, 2014

37. ODCHC, 2014

38. Community Health Care Services Family Practice Immunizations Pediatrics Women's Health Geriatrics Complete Dental Care EMDR & Biofeedback Case Management Population Health Complex Case Management Promotoras Mobile Health Telemedicine Programs Health Education Family Planning Prenatal & Birth Services Urgent Kids Care Teen Health Homeless Outreach Wellness Outreach Wellness Groups Wellness Community Gardening HIV/AIDS and HCV Care Alternative Medicine Nutritional Counseling STD Testing and Counseling Behavioral Medicine Mental Health Counseling Urgent and Same Day Care Benefits Enrollment AssistantsPopulation 1 in 3 People Community Underinsured Uninsured ODCHC, 2014

39. Essential to Develop TeleHealth Partnerships • Rural Area • Health Center • School Based • Community Based • Public Health • County Mental Health • University Centers • Identified Need • BH and/or MH • Pediatrics • Primary Care • Specialty Care

40. Case Example #1 • Male Child in 7th Grade • Hyperactive • Disruptive behaviors (home, school, social) • Problems with socialization • Familial substance abuse • Lives with mother and stepfather • History of stimulant medication in elementary school • Special education services • Poor judgment

41. Consultation with telehealth program for primary care specialty pediatrics and behavioral medicine • Assisted with school based consultation, treatment considerations, and monitoring • Obtained formal evaluation • Identified significant working memory concerns • Consultation to school re specific considerations for learning • Transitioned pharmacotherapy • Significant transitions over 4 years treatment • Headaches, anorexia, syncopalattack, sleepiness • Utilized monitoring, assessments

42. Improvements / Progress • Making friends • Sports • Academics “Presidential Achievement Award” • Graduated CA Exit Exam • A in math • Considering college • Self managing and monitoring • Satisfaction others are listening, supporting, and helping • Improved communication with caregivers/parents, school, medical professionals • Motivated to get a job

43. Improved patient and family care and satisfaction • Early identification and intervention w Specialty • Holistic approach/collaborative/pt centered • Improved compliance with medical treatment • Improved outreach and communication • Improved inclusion of support system and community • Ease and familiarity with service • Improved health; reduced health disparities; consultation; provider and community education; provider mentoring; increased friendships, social support, self-mgmt • Improved cost containment; targeted use of resources; revenue generation minimal; pt motivated toward college/employment Triple Aim Case 1

44. Case Example #2 • 12 yo male • Poor school performance • Concerns of Autism Spectrum • Trouble socializing • Unusual hobbies • Difficulty completing homework • Disruptive behaviors at school and home

45. Consultation with telehealth program for primary care specialty pediatrics and behavioral medicine/behavioral health services • Assisted with school based consultation, treatment considerations, and monitoring • Assisted with family and community support • No medication assistance needed • Obtained formal evaluation • Identified significant dysgraphia concerns • Consultation to school re specific considerations for learning

46. Improvements / Progress • Making friends • Considering Sports • Academic progress • Likes school • Reduced homework time • No fighting behaviors • Using voice recognition programs • Increased support from school • Motivation toward college • Self managing and monitoring • Satisfaction others are listening, supporting, and helping • Improved communication with caregivers/parents, school, medical professionals Photo Credit: Eva Blue

47. Improved patient and family care and satisfaction • Early identification and intervention w Specialty • Holistic approach/collaborative/pt centered • Improved compliance with medical treatment • Improved outreach and communication • Improved inclusion of support system and community • Ease and familiarity with service • Consultation; provider and community education; provider mentoring; increased friendships, social support, self-mgmt • Improved cost containment; targeted use of resources; revenue generation; decreased other specialty visits, pt motivated toward college Triple Aim Case 2

48. USC Tele Behavioral Health • Reserved for USC’s TeleBH Slides

49. Benefits of Telehealth Photo Credit: U.S. Department of Agriculture

50. Helpful Resources • Journal of Medical Internet Research • HHS Offices with Telehealth Projects • HRSA Office of Special Health Affairs • HRSA and Behavioral Health • HRSA Office for the Advancement of Telehealth • SAMHSA Center for Substance Abuse Treatment Technology Assisted Care Grants • Telemental Health Guide • Telehealth Operations Module • Telehealth Technology Assessment Center • American Telemedicine Association • Association of Telemedicine Service Providers • Telemedicine Information Exchange • Federation of State Medical Boards: Model Act for Licensing of Telehealth • HRSA Health Center Telehealth Policies: Liability coverage of telehealth under the Federal Tort Claims Act • CMS, Medicare Learning Network • Center for telehealth and e-Health Law on reimbursement • Interim Billing and Financial Worksheets, By State: SAMHSA HRSA Center for Integrated Health Solutions