STATE OF CALIFORNIA Budget Change Proposal - Cover Sheet DF-46 (REV 08/17)

Fiscal Year 2019-20

r • . Business Unit 5225

Department California Correctional Health Care Services

Priority No.

Budget Request Name Program Subprogram 5225-120-BCP-2019-GB 4650 - MEDICAL S E R V I C E S - 4650012 - MEDICAL ADMIN -

ADULT ADULT

Budget Request Description Statewide Telehealth Services Program

Budget Request Summary

California Correctional Health Care Services requests 17 positions and $6 million in fiscal year 2019/20 and $5.4 million in 2020/21 and ongoing to expand the Telehealth Services Program. Specifically, this request includes funding to (1) purchase telehealth equipment and software, (2) establish dedicated management oversight, and (3) provide information technology and business operations support for the expanded program.

Requires Legislation

• Yes M No

Code Section(s) to be Added/Amended/Repealed

Does this BCP contain information technology (IT) components? ^ Yes • No

If yes, departmental Chief Information Officer must sign.

Department CIO Cheryl Larson

Date

For IT requests, specify the project number, the most recent project approval document (FSR, SPR, S1BA, S2AA, S3SD, S4PRA), and the approval date.

Project No. Project Approval Document: Approval Date:

If proposal affects another department, does other department concur with proposal? • Yes • No Attach comments of affected department, signed and dated by the department director or designee.

Prepared By Date Reviewed By Date Erika Sky 8/14/18 Doug Chatfield 8/23/18

Department Director Date Agency Secretary Date Duane Reeder Yulanda Mynhier

Additional Review: • Capital Outlay • ITCU • FSCU • OSAE • CALSTARS • Dept. of Technology

PPBA Offgfnal Signed by: Date submitted to the Legislature / / Aaron Edwards

BCP Title: Statewide Telehealth Services Program

Budget Request Summary

Personal Services Positions - Permanent

Total Positions

Salaries and Wages Earnings - Permanent

Total Salaries and Wages

Total Staff Benefits Total Personal Services

Operating Expenses and Equipment 5301 - General Expense 5302 - Printing 5304 - Communications 5306 - Postage 5308 - insurance 5320 - Travel: in-State 5322 - Training 5324 - Facilities Operation 5326 - Utilities 5340 - Consulting and Professional Services

interdepartmental 5340 - Consulting and Professional Services

External 5346 - information Technology 5368 - Non-Capitai Asset Purchases -

Equipment 539X - Other

Total Operating Expenses and Equipment

Total Budget Request

Fund Summary Fund Source - State Operations

0001 - General Fund Total State Operations Expenditures

B C P Fiscal Detail Sheet BR Name: 5225-120-BCP-2019-GB

FY19 CY BY BY+1 BY+2 BY+3 BY+4

0.0 17.0 17.0 17.0 17.0 17.0 0.0 17.0 17.0 17.0 17.0 17.0

0 2,096 2,096 2,096 2,096 2,096 $0 $2,096 $2,096 $2,096 $2,096 $2,096

0 843 843 843 843 . 843 $0 $2,939 $2,939 $2,939 $2,939 $2,939

0 28 28 28 28 28 0 21 21 21 21 21 0 40 40 40 40 40 0 10 10 10 10 10 0 1 1 1 1 1 0 51 51 51 51 51 0 9 9 9 9 9 0 96 96 96 96 96 0 4 4 4 4 4

0 5 5 5 5 5

0 15 15 15 15 15

0 245 61 61 61 61

0 2,499 2,092 2,092 2,092 2,092

0 3 3 3 3 3 $0 $3,027 $2,436 $2,436 $2,436 $2,436

$0 $5,966 $5,375 $5,375 $5,375 $5,375

0 5,966 5,375 5,375 5,375 5,375 $0 $5,966 $5,375 $5,375 $5,375 $5,375

Total All Funds

Program Summary Program Funding 4650012 - Medical Administration-Aduit Total All Programs

$5,966 $5,375 $5,375 $5,375 $5,375

5,966 5,375 5,375 5,375 5,375 $5,966 $5,375 $5,375 $5,375 $5,375

BCP Title: Statewide Telehealth Services Program BR Name: 5225-120-BCP-2019-GB

Personal Services Details

Salary Information Positions

1401 1402 4800

5393

8239

8338

info Tech Assoc (Eff. 07-01-2019) info Tech Spec i (Eff. 07-01-2019) Staff Svcs Mgr i (Eff. 07-01-2019) Assoc Govti Program Analyst (Eff. 07-01-2019) Receiver's Med Exec (Safety) (Eff. 07-

01-2019) HIth Program Spec i (Eff. 07-01-2019)

Min Mid Max

Total Positions

CY BY BY+1 BY+2 BY+3 BY+4 0.0 5.0 5.0 5.0 5.0 5.0 0.0 4.0 4.0 4.0 4.0 4.0 0.0 1.0 1.0 1.0 1.0 1.0

0.0 1.0 1.0 1.0 1.0 1.0

0.0 3.0 3.0 3.0 3.0 3.0

0.0 3.0 3.0 3.0 3.0 3.0

0.0 17.0 17.0 17.0 17.0 17.0

Salaries and Wages CY BY BY+1 BY+2 BY+3 BY+4

1401 - infoTech Assoc (Eff. 07-01-2019) 0 322 322 322 322 322 1402 - info Tech Spec i (Eff. 07-01-2019) 0 322 322 322 322 322 4800 - Staff Svcs Mgr 1 (Eff. 07-01-2019) 0 80 80 80 80 80 c-riari Assoc Govti Program Analyst (Eff. 07-^"^y-^ - 01-2019)

Receiver's Med Exec (Safety) (Eff. 07-^^^^ • 01-2019) 8338 - HIth Program Spec i (Eff. 07-01-2019)

0

0

0

67

1,083

222

67

1,083

222

67

1,083

222

67

1,083

222

67

1,083

222 Total Salaries and Wages $0 $2,096 $2,096 $2,096 $2,096 $2,096

Staff Benefits 5150450 • - Medicare Taxation 0 30 30 30 30 30 5150500 • - OASDi 0 63 63 63 63 63 5150600 • - Retirement - General 0 440 440 440 440 440 5150800 • - Workers' Compensation 0 48 48 48 48 48

5150820 •

5150900 •

Other Post-Employment Benefits (OPEB) Employer Contributions

• Staff Benefits - Other

0

0

27

235

27

235

27

235

27

235

27

235 Total Staff Benefits $0 $843 $843 $843 $843 $843

Total Personal Services $0 $2,939 $2,939 $2,939 $2,939 $2,939

STATE OF CALIFORNIA Budget Change Proposal - Cover Sheet DF-46 (REV 08/17)

A. Budget R e q u e s t Summary

California Correctional Health Care Services (CCHCS) requests 17 posit ions and $6 million in fiscal year 2019/20 and $5.4 million in 2020/21 and ongoing to expand the Telehealth Services Program. Specifically, this request includes funding to (1) purchase telehealth equipment and software, (2) establish dedicated management oversight, and (3) provide information technology support for the expanded Telehealth Services Program.

Table A: Telehealth S e r v i c e s Program Funding Reques t

Descript ion FY19-20 FY20-21 and ongoing

Management Staffing (Salaries + Wages + Benefits)

$1,882,277 $1,869,953

Facility Staffing (Salaries + Wages + Benefits)

$265,101 $260,993

IT Staffing (Salaries + Wages + Benefits)

$1,170,133 $1,151,647

Subtotal Staffing $3,317,511 $3,282,593

New Equipment, Maintenance, and Licenses

$1,443,668 $1,071,764

Equipment Refresh $960,600 $960,600

Disaster Recovery $244,800 $60,600

Subtotal Equipment $2,649,068 $2,092,964

Rounding - Management Posit ions BY -$579 -$579

Rounding - Management Posit ions BY1 - -$614

Rounding - IT Expenses - $636

Subtotal Rounding -$579 -$557

G R A N D T O T A L $5,966,000 $5,375,000

B. Background/History

CCHCS is increasing the practice of providing medical and mental health services remotely through telehealth (which includes telepsychiatry and telemedicine, including tele-specialty). This has al lowed the Department to provide specialty health care to more patients than the convent ional, face-to-face approach. It also provides primary care services to cover for institutional provider vacancies while reducing costs associated with transport ing patients to appointments outside of the institutions. With the expansion and evolution of the use of the telehealth service delivery model comes the need to ensure the proper administrative structure and oversight of the program. Similarly, the expansion of Telehealth requires additional Information Technology (IT) and Business Operat ions support.

Telemedicine

Goal 5.5 of the Receiver's Turnaround Plan of Act ion relates to expanding and improving Telemedic ine capabil it ies. Specifically, the Receiver's report notes the need of "securing strong leadership for the Telemedic ine program to expand the use of Telemedicine and upgrade

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STATE OF CALIFORNIA Budget Change Proposal - Cover Sheet DF-46 (REV 08/17)

California Department of Corrections and Rehabil itation's (CDCR's) Telemedicine technology infrastructure."

Telemedicine began as a strategy to provide contracted tele-specialty services to a small subset of patients in remote areas but has grown to become a major strategy to deliver primary and specialty care using civil service clinicians. Cver the past 18 months, the Telemedicine provider workforce has expanded f rom 4 to 54 positions (including 29 newly authorized posit ions and 25 redirected vacancies), including some positions filled with clinicians who provide specialty services or target specific patient populations, such as those infected with the Hepatit is C Virus (HCV). This workforce is expected to double in the next two years as posit ions are redirected f rom the field to the Telemedicine program. It is anticipated that Telemedic ine providers will make up one quarter of the providers servicing hard-to-fill institutions. Currently, there are Telemedicine offices in Elk Grove, Rancho Cucamonga, Diamond Bar, Santa Ana, Fresno, Bakersfleld, and San Guentin State Prison (SG). Further expansion initiatives include Specialty Services, After-hours Triage and Treatment Area (TTA) coverage, and Cphthalmology Services.

Facility improvements necessary to support expanded telehealth services are being completed at all institutions as part of the Health Care Facility Improvement Program (HCFIP). These improvements are al lowing CCHCS to expand telehealth for primary and emergency care, including after-hours care in the TTAs. These improvements have increased the number of possible Telehealth sessions between providers and patients.

Expanded use of telemedicine has streamlined and improved access to primary care and specialty health care to inmates, decreased risks to public safety incurred by inmates traveling outside of correctional facilit ies, and reduced costs by eliminating unnecessary travel expenditures and maximizing physicians' t ime and resources. CCHCS estimates that the use of telemedicine led to $14.2 million in cost avoidance for ODOR in 2017/18 by reducing inmate transportat ion costs (See Attachment A) . While the telemedicine program started as strategy to reduce vacancies and provide contracted telespecialty services to a small subset of patients in remote areas, it has evolved into a major component of CCHCS's medical delivery model for primary and specialty care using both contract and civil service providers.

Telepsychiatry

Telepsychiatry uses electronic communicat ions and information technologies to provide clinical psychiatric care services to inmates. In an exam room equipped with interactive videoconferencing equipment, mental health staff at the institutions present patients and their cases to a provider at a remote location also equipped with videoconferencing capability. The provider can observe and speak with patients about their mental health condit ion.

Information Technology

Between the expansion of telemedicine and the addit ion of telepsychiatry, the telehealth services provider workforce has increased dramatically. To accommodate the workforce expansion, CCHCS's telehealth off ices—including those in Elk Grove, Rancho Cucamonga, Diamond Bar, Santa Ana, Fresno, SO, and Bakersf le ld—have expanded in recent years. The expansion of providers and offices results in an increased need for telehealth equipment, infrastructure, l icensing, and IT support services.

Meanwhi le, CCHCS is planning to utilize telehealth to deliver addit ional services, such as after-hours care in TTAs, to reduce the number of patient send-outs. Since Telehealth Services relies heavily on functioning hardware, software, and network services, after-hours IT support needs to be available for providers and clinicians.

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STATE OF CALIFORNIA Budget C h a n g e Proposal - Cover Sheet DF-46 (REV 08/17)

CCHCS Information Technology Services Division ( ITSD) must plan for an increase In immediate and effective IT support services to handle the additional workload and hours related to the Telehealth Services Program expansion. The current IT support model for Telehealth Services only provides coverage f rom 6 a.m. to 6 p.m., Monday through Friday.

B u s i n e s s Operat ions

As Telehealth Services have expanded at the regional offices, the need for business operat ions support has also increased. (See Justif ication section.) Addit ional staff is required to provide this addit ional support.

Table B: Workload History

Workload Measure 14/15 15/16 16/17 17/18

State Telemedic ine Providers 5 12 12 26

State Telepsychiatry Providers 30 38 44 58

Telehealth Sessions between Providers and Patients

36,458 53,056 53,032 69,235

C . s tate Level Considerat ions

The Receiver's 2008 Turnaround Plan of Act ion addresses the need to provide competent health care in a proactive manner. The Telehealth Services Program provides effective and efficient ways to achieve this goal and to improve access to care for the patient population.

D. Just i f icat ion

This request addresses the resource needs of various aspects of Telehealth Services: Telemedic ine, Information Technology, and Business Cperat ions.

Telemedic ine

CCHCS intends to redirect a quarter of primary care providers to telemedicine services. This redirection will drive the need for addit ional support and supervisory personnel. Specifically, CC HC S is requesting the establ ishment of the fol lowing six positions: one Deputy Medical Executive (DME), two Chief Medical Executives (CME), and three Health Program Specialist Is (HPS I) to be effective July 1, 2019.

Medical Executives

Given the expansion of the provider workforce f rom 4 headquarters positions to 62 positions in Telemedic ine over the last 18 months, it was recognized that the new providers needed supervision and support. All Chief Physician and Surgeon (CP&S) telemedicine staff currently report directly to the Deputy Director for Medical Services. This is not a sustainable model for adequate day-to-day oversight, but exists because there are no Medical Executive positions within the Telemedicine program.

Between January 2017 and May 2018, there were nearly 27,000 unique patients who received primary care f rom an assigned telemedicine provider. This is equivalent to the number of patients seen at nine to ten prisons, which is roughly equivalent to one region; regions consist of seven to ten institutions each. The current management structure within CCHCS is one DME in each region. Within each region, every institution is allocated one CME position (as

- — well as at least one CP&S position). In keeping with the ratios of current structure, CCHCS

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STATE OF CALIFORNIA Budget Change Proposal - Cover Sheet DF-46 (REV 08/17)

requests one DME for Statewide oversight and two CME positions (one located in the northern region office in Elk Grove, the other in a southern region office).

Besides the treatment of patients, the telemedicine program also oversees a number of statewide Initiatives and services that explain the need for the Medical Executive posit ions. These include, but are not limited to:

• Primary care services that currently cover more than 20 institutions at a t ime, which covers vacancies and maintains care.

• Expanding Human immunodef ic iency Virus/HCV Treatment and Addict ion Medicine programs.

• Contracted tele-specialty network through Health Net. • Dialysis and Transplant services, which deliver care to a group of patients that have

very high rates of hospital izations. • Expanding on-cali coverage for select institutions that may reduce the number of

institution-based provider's on-cali because each Telemedicine provider can cover more than one institution.

• Provision of care by civil service clinicians for patients who are clinically complex and high risk who use disproport ionate amounts of primary care, specialty and hospital services and costly medicat ions.

Support Staff

Despite the rapid growth of the Telemedic ine program over the past 18 months in terms of clinical staff, offices, and types of services, there has not been a commensurate increase in administrative managers or support staff. As a result, there currently are minimal staff to support the expanded services provided by telemedicine. By approving this request, CCHCS will be able to bolster its team of administrative staff to assist with the coordination of clinics and ensure that providers can dedicate their t ime and efforts to direct patient care.

The support staff handles a mult i tude of clerical tasks for the providers, such as, on-boarding activities, schedul ing, analyzing specialty medical encounter needs, tracking and monitoring specialty provider outreach activit ies, identifying and resolving gaps in specialty resources, and resolving complex specialty schedul ing issues.. As the provider workforce within Telemedicine has increased, so has the need for administrative support staff for assistance in program-level management duties. Addit ional HPS Is will develop metrics and analytics to determine statewide, regional, and institution needs. They will also determine effective and efficient deployment of Telemedic ine services and resources for both specialty and primary care to ensure that staff remain on target with CCHCS' mission. For specific workload details for the HPS Is, see Attachment B. '

Information Technology

CCHCS requests nine IT posit ions to support the expansion of telehealth. Telehealth sessions rely on immediate and effective IT support to ensure successful care Is del ivered to patients. The IT support workload is directly tied to the number of providers and sites, and as these numbers grow, so does the number of equipment and video conferencing sessions. Last year there were almost 70,000 sessions between remote providers and patients, and this number is expected to increase to over 205,000 sessions within the next two years. All of these sessions require numerous applications, equipment, and networks to be up and running concurrently,

. and to address the growth, ITSD needs addit ional staff to support the increased workload. Specifically, ITSD needs:

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STATE OF CALIFORNIA Budget C h a n g e Proposa l - Cover Sheet DF-46 (REV 08/17)

• Three IT Associates to address the increased Tier 1 support workload.' ' • Four IT Special ist Is to address the increased Tier 1, Tier 2, and Tier 3 support

work load, and provide field support, as needed, to the Telehealth hubs (Elk Grove, Ranch Cucamonga, Diamond Bar, Santa Ana, Fresno, San Quent in, and Bakersfleld).

• Two IT Associates for the IT Procurements Unit to support the program growth and ongoing hardware purchases, refreshes, upgrades, and licensing for specialized telehealth equipment.

Telehealth Services Equipment and Licensinq Expansion

The expansion of Telehealth Services providers, clinic staff, sites, services and after-hours care also results in a need for addit ional IT equipment, infrastructure, maintenance support, and l icenses.

• Specialty Desktops and Video Conference Cameras - Telemedic ine providers require specialty desktops and cameras for two-way video conferencing. All telemedicine providers also require stethoscopes. New desktops, cameras, and stethoscopes will be ordered for the new telemedicine providers and IT staff to support the providers.

• Video Conference Cameras and Speakers - Telepsychiatry providers utilize standard desktops or laptops, but require special Jabra cameras and speakers.

• Scanners - Due to documents that require "wet" signatures, such as medical or pharmacy orders, scanners are needed for each new Telehealth Services provider.

• Ophthalmology Equipment - With the expansion of the ophthalmology program to addit ional providers, new ophthalmology equipment pieces are needed. Ophthalmology is a special ized service provided through the Telehealth Services Program.

• Dragon Microphones - In order to dictate into the CCHCS Electronic Health Record System, every new provider needs Dragon microphones.

• Specialty Carts and Video Conference Cameras - A total of 37 carts were identified that are end-of-l i fe, no longer supported by the manufacturer, and extremely difficult to use in the field due to speed and complexity. Refresh dollars al lowed for 19 carts to be refreshed, but a remaining 18 carts need to be ordered that are not accounted for in the program budget. The 18 carts and cameras are requested as part of equipment refresh of obsolete equipment.

Table 0 provides a breakdown of the quantit ies required, l icenses, and ongoing costs for equipment, l icenses, and equipment maintenance for the new Telehealth equipment.

^ There are three levels, or tiers, of IT support. Tier 1 is the initial support level, it includes resolving basic issues, such as username or password issues, installing basic software applications, and navigation assistance. Tier 2 includes more in-depth technical support, such as on-site installations, software repair, and remote troubleshooting. Tier 3 is the highest level of support, it includes expert level troubling shooting and assisting Tier 1 and Tier 2 staff. Tier 3 staff are typically developers or have other expertise in coding or the backend of a product.

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STATE OF CALIFORNIA Budget Change Proposal - Cover Sheet DF-46 (REV 08/17)

Table C: New Telehealth S e r v i c e s Program Equipment and L i c e n s e Request

Item Quantity Unit C o s t

One-Tlme P u r c h a s e

C o s t (FY19-20)

Ongoing Per Unit

( includes L i c e n s e s )

Ongoing Annual C o s t (FY20-21 and

ongoing)

Telemedic ine Specialty Desktops and Video Conference Cameras

105 $2,400 $252,000 $600 $63,000

Stethoscopes 105 $1,100 $115,500 $750 $78,750

Telepsychiatry Video Conference Cameras and Speakers

50 $200 $10,000 $25 $1,250

Scanners 148 $300 $44,400 $25 $3,700

Dragon Microphones 148 $316 $46,768 $80 $11,840

Specialty Carts ( includes laptop, stethoscope, otoscope, derm camera, ECC device, and battery)

18 $44,000 $792,000 $5,250 $94,500

Video Conference Cameras for Carts

18 $7,500 $135,000 $1,071 $19,278

Ophthalmology Equipment 6 $8,000 $48,000 $500 $3,000

Specialty Carts (for HCFIP)

126 ~ ~ $5,250 $661,500

Video-Conference Cameras (for HCFIP cart)

126 ~ $1,071 $134,946

Total ~ — $1,443,668 — $1,071,764

Telehealth Services Equipment Refresh

Addit ional telehealth equipment results in an increased need for equipment refresh funding. ITSD has developed an equipment replacement schedule based on the expected service life of each type of equipment. Table D outl ines the proposed replacement rate and costs for various telehealth equipment that is purchased annually, to replace the oldest equipment in inventory or equipment that is inoperable and beyond repair. The annual cost in Table D comprises the total number of pieces of each type of equipment divided by the expected service life multiplied by the unit replacement cost.

CCHCS's current budget already Includes an amount for refresh of existing telehealth equipment. The requested ongoing costs associated for refresh of the new telehealth equipment are shown in Table D. This includes all telehealth equipment, including equipment located within each yard within the institutions, the TTAs, headquarters, and regional offices.

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STATE OF CALIFORNIA Budget Change Proposal - C o v e r Sheet DF-46 (REV 08/17)

Table D: Annual Ref resh - Telehealth Equipment P u r c h a s e Replacement Plan

Equipment Projected

Total Quantity

M T B F * Y e a r s

Units Rep laced Per Y e a r

Unit Replacement

C o s t

Annua! C o s t

(FY19-20 and ongoing)

Carts (cart only, no addit ional peripherals)

262 15 18 $20,000 $360,000

Telemedic ine Specialty Desktops

165 7 24 $3,000 $72,000

Telepsychiatry Video Conference Cameras & Speakers

105 6 18 $200 $3,600

Video Conference Cameras for Carts

262 7 38 $8,000 $304,000

Derm Cameras 262 7 38 $8,000 $304,000

Stethoscopes 427 6 72 $400 $28,800

Otoscopes 262 6 44 $1,700 $74,800

Laptops 262 3 88 $2,000 $176,000

Batteries 262 3 88 $450 $39,600

ECGs (only on half of the carts)

131 7 19 $3,200 $60,800

Dopplers 262 7 38 $500 $19,000

Ophthalmology Equipment 8 7 2 $9,000 $18,000

Subtotal Equipment Refresh Cost Annual ly $1,460,600

Minus Current Equipment Refresh Budget -$500,000

Total Equipment Refresh Cost Ongoing Need $960,600

*Mean t ime between fai lures (MTBF) Is the predicted elapsed t ime between Inherent failures of a system during operat ion. It Is typically part of a model that assumes the failed system Is Immediately repaired, as a part of a renewal process.

Telehealth Services Disaster Recovery

The Telehealth Services Program Is working to Improve the current disaster recovery plan. The basic tele-services system Includes one video communicat ions server (VCS) and one video communicat ions server expressway (VCS-E). The program currently utilizes two VCS and VCS-E devices configured as a high availability cluster to protect against hardware failure. However, the program needs to address the risk of a power outage, fire, or disaster related to the location of the current servers, which are both housed at the same data center.

CC HC S proposes to construct a remote site to ensure any disaster at the current data center would not affect service availability. If there Is a fai lure, the system will cut over to the operat ional system at the remote site and keep the program up and running, which would

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STATE OF CALIFORNIA Budget Change Proposal - Cover Sheet DF-46 (REV 08/17) •

result In little to no Impact on the provider's ability to provide care to patients In the event of a hardware failure or outage.

Table E provides the hardware and licensing costs for a secondary site with the capabil it ies equivalent to the current configuration for the Telehealth Services system. The use of a c loud-based service alternative for disaster recovery was reviewed, but a secondary site would be more cost effective. Costs associated for this system are shown In Table E.

Table E : Telehealth S e r v i c e s Program Disaster Recovery C o s t s

Descript ion One-Time C o s t

(FY19-20)

Ongoing Maintenance C o s t

(FY20-21 and ongoing)

Video Communicat ion Server Control $75,500 $22,000

Video Communicat ion Server Expressway

$65,000 $11,000

Telepresence Management Server $84,300 $24,000

Unified Communicat ion Server Chassis $20,000 $3,600

Total $244,800 $60,600

Summary

Table F Is a summary of the Telehealth Services Program IT request:

Table F: Summary of Telehealth Serv i ces Program Funding Reques t

Descript ion FY19-20 FY20-21 and ongoing

Staffing $1,170,133 $1,151,647

New Equipment, Maintenance, and Licenses $1,443,668 $1,071,764

Equipment Refresh $960,600 $960,600

Disaster Recovery $244,800 $60,600

Rounding ~ $636

Total $3,819,201 $3,245,247

B u s i n e s s Operat ions

As the Telehealth Services Program expands, the number of service requests, reported Incidents, and travel requests will l ikewise expand. So, too, will the space management needs, especial ly in the Southern California offices. CCHCS Is requesting an addit ional SSM I and an addit ional AGRA to manage and provide support for these offices. These staff would be located In the Rancho Cucamonga Regional Cff lce.

The SSM I will guide, direct, train, and review the work of the regional analysts. Including the three existing Business Cperat ions analysts, assigned to the Fresno, Rancho Cucamonga, and Bakersfleld offices, and the analyst being requested In this proposal, who will be assigned to the Santa Ana office. The SSM I will also be the lead for the ongoing construction and

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STATE OF CALIFORNIA Budget Change Proposal - C o v e r Sheet DF-46 (REV 08/17)

reconfiguration projects in various regions, Including Region IV, locations In Rancho Cucamonga, Diamond Bar, and Santa Ana; the Bakersfleld Region, and the Fresno Region.

The A G F A will be responsible for supporting the Rancho Cucamonga Regional Office, managing dally operat ions for approximately 20,000 square feet of office space, and support ing the administrative needs of approximately 120 CCHCS staff In two different locations. These dut ies will Increase as Telehealth Increases to 210 staff occupying approximately 48,000 square feet of previously-approved office space spread among 3 locations by 2019. Among the responsibil it ies of the A G F A are assisting In coordinating office moves. Modular Systems Furniture configurations and space utilization projects to accommodate addit ional staff and equipment In existing or new spaces; serving as a liaison for facil it ies-related Issues such as security, janitorial services, HVAC (heating, venti lation, and air condit ioning), building maintenance; and working with property managers and vendors to resolve Issues In a t imely manner. The A G F A will also be responsible for a variety of administrative duties, such as mall, managing office equipment, coordinating confidential document shredding, and managing office supply Inventories.

C o n c l u s i o n

The Telehealth Services Frogram Is expected to continue Its expansion. The number of providers and sessions conducted between providers and patients Is expected to triple. The program that started with one headquarters site In Elk Grove Is expanding to a total of seven hub sites throughout the State, each site having numerous sound-proof offices for remote providers. Addit ionally, the program has started exploring after-hours care to 10:00 p.m. and providing emergency care In TTAs. Due to the growth In the program, expansion of Telehealth sites, and Increase In service hours, there Is an Increased need for management and support resources, equipment, Infrastructure, l icensing, and IT support services.

E . O u t c o m e s and Accountabi l i ty

The expansion of telehealth services directly supports the Receiver's goal of Increasing access to care. The requested staff, equipment and refresh, and disaster recovery will enable ITSD to provide Immediate and effective IT support, Infrastructure, and equipment to ensure successful patient care Is del ivered In a t imely manner. Table G provides a summary of the anticipated outcomes associated with CCHCS's proposed expansion of telehealth services.

Table G: Projected Outcomes

Descript ion 18/19 19/20 20/21

State Telemedicine Providers 54 148 148

State Telepsychiatry Providers 80 105 105

Telehealth Sessions between Providers & Patients 135,000 205,000 205,000

Telehealth Institutions, Sites, & Provider Hub Locations

39 42 42

Telehealth Equipment (Specialty Carts & Desktops)

400 427 427

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STATE OF CALIFORNIA Budget Change Proposal - C o v e r Sheet DF-46 (REV 08/17)

F. A n a l y s i s of All Feas ib le Alternatives

Alternative #1

Approve 17 posit ions and $6.0 million fiscal year 2019/20 and $5.4 million in fiscal year 2020/21 and ongoing to expand the Telehealth Services Program. Specifically, this alternative would Include funding to (1) purchase telehealth equipment and software, (2) establish dedicated management oversight, and (3) provide information technology support for the expanded Telehealth Services Program.

Pros

• Provides appropriate executive, managerial , and support staff for the Southern California Regional Telemedicine offices.

• Provides appropriate IT support staff and procurement staff for the additional workload demand f rom Telehealth Services Program expansion.

• Provides on-site field support to address critical Telehealth Services requests in Southern California locations.

• Provides support, maintenance, and l icensing for the new Telehealth equipment and infrastructure related to the program expansion.

• Provides staff resources to expand the external telemedicine specialty network, shifting more offsite appointments to telemedicine services, avoiding guarding and transportat ion costs.

• Reduces costs of Telehealth equipment maintenance and repair since the average age of the equipment and number of expected repairs would be reduced.

• Implements disaster recovery to address hardware failure or outages. • Provides necessary Business Operat ions support for the Southern California Regional

Offices. Cons

• Commits funding on an ongoing basis.

Alternative #2

Approve 9 posit ions and $1.7 million one-t ime and $3.2 mill ion ongoing starting In 2019/20 for ITSD to support the statewide Telehealth Services Program expansion of providers, clinic staff, off ices, services and after-hours care; purchase and refresh Telehealth equipment, and implement disaster recovery.

Provides appropriate IT support staff and procurement staff for the additional workload demand f rom Telehealth Services Program expansion. Provides on-site field support to address critical Telehealth Services requests in Southern California locations. Provides support, maintenance, and l icensing for the new Telehealth equipment and infrastructure related to the program expansion. Reduces costs of Telehealth equipment maintenance and repair since the average age of the equipment and number of expected repairs would be reduced. Implements disaster recovery to address hardware failure or outages.

Commits funding on an ongoing basis. Does not address executive, management , and support functions for the Southern California Regional Telemedicine offices.

Pros

Cons

PAGE 11-10

STATE OF CALIFORNIA Budget C h a n g e Proposal - Cover Sheet DF-46 (REV 08/17)

• Does not address need for addit ional Business Operations support for the Southern California Regional offices.

Alternative #3

Approve 20 positions and $3.5 million to meet the managerial and staffing needs beginning in 2019/20 to provide managerial support and oversight for the Telemedicine workforce.

Pros

• Al lows for the primary care telemedicine expansion beyond headquarters in Elk Grove to new office space in Rancho Cucamonga, Diamond Bar, Santa Ana, and SG.

• Mitigates high turn-over rates of telemedicine support staff caused by unmanageable workloads and staff burnout.

• Addresses the future need of addit ional overt ime for existing telemedicine managerial and support staff as workload continues to increase with utilization.

• Provides necessary executive leadership oversight and relief for Telemedicine. • Provides staff resources to expand and support dual appointment providers covering

the TTAs after hours to reduce on call provider burnout and unnecessary hospital send outs.

• Al lows providers to focus on direct patient care rather than administrative and clerical tasks, maximizing valuable provider t ime and resources.

• Addresses staffing deficiencies by providing the appropriate level of management based on California Department of Human Resources allocations guidel ines and al low reporting structures in line with Medical Services precedent and institution staffing models.

Cons • Does not address needs of other aspects of Telehealth, including Telepsychiatry. • Does not address all Telehealth IT needs. • Does not address need for addit ional Business Cperat ions support for the Southern

California Regional offices. • Impact to General Fund.

• CCHCS cannot be proactive in addressing the problem of broken or failing equipment.

Alternative #4 Approve 4 positions and $1.7 million one-t ime and $1.7 million ongoing starting in 2019/20 for ITSD to support the statewide Telehealth Services expansion of providers, clinic staff, offices, services and after-hours care; purchase limited Telehealth equipment, and implement disaster recovery.

Pros

• Provides four technical support staff to address some of the addit ional workload demand related to program expansion, and provides field support at provider hub sites.

• Improves technical support response t imes for Tier 1 and Tier 2 requests. • Provides support, maintenance, and l icensing for limited Telehealth equipment. • Implements disaster recovery to address hardware failure or outages.

Cons

• Commits funding on an ongoing basis. • The number of addit ional technical staff does not align with the program expansion.

Response t imes for Tier 1 and Tier 2 requests will fall short of the desired response t imeframes. Does not address needs of other aspects of Telehealth, including Telepsychiatry.

• Does not address Telehealth IT needs.

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STATE OF CALIFORNIA Budget Change Proposal - Cover Sheet DF-46 (REV 08/17)

• Does not address need for addit ional Business Operat ions support for the Southern California regional offices.

• The procurement of Telehealth equipment may be postponed or cancel led due to increasing staff work load.

G . Implementation Plan

Effective July 1, 2019, CCHCS wil l :

• Initiate the hiring process to establish and fill requested posit ions. • Maintain and support addit ional Telehealth Services equipment, infrastructure, and

l icenses. • Implement the updated Telehealth Services Equipment Purchase Replacement Plan

(see Table D) that includes new equipment related to program expansion. • Plan, develop and implement disaster recovery to address hardware failures or outages.

H. Supplemental lnformat ion

• At tachment A - Medical Transport Cost Avoidance • At tachment B - Telehealth Services Program Workload Analysis - Detailed descript ion

of workload related to the requested positions.

I. Recommendat ion

Alternative #1 - Approve 17 posit ions and $6.0 million fiscal year 2019/20 and $5.4 million in fiscal year 2020/21 for (1) purchasing telehealth equipment and software, (2) establishing dedicated management oversight, and (3) providing information technology support for the expanded Telehealth Services Program.

PAGE 11-12

Attachment A

Medical Transport Cost Avoidance

5225-120-BCP-2019-GB Statewide Telehealth Services Program

ATTACHMENT A

I I Telemedicine Services Medical Transport Cost Avoidance FY 2017/18

C A L i r O R N I A CORRECTIONAL HEALTH CARE SERVICES

Institution ASP GAG CAL GOG GGI

GGWF GEN

GHGF GIM GIW GMG GMF GOR GRG GTF

GVSP DVI FSP

HDSP

ISP KVSP LAG

MGSP NKSP PBSP PVSP RJD SAG

SATF SGG SOL SO

SVSP VSP

wspj

FY 2017/18 Telemedicine Average Transportation Cost Per Specialty Appointments Offsite Appointment^

389 320

1,202 300 544 753 908

1,480 1,606

826 362

1,163 763 515 966 913 336 517 425 667 794

1,635 2,063

450 226 315

3,840 526

1,458 293

1,257 817 472 563

| | 8 9

Medical Transport Cost Avoidance Estimate for FY

2017/18

Total 30,853

$460 • '^mu m... $176,940 $460 $147,200

$460 'M H B $552,920 $460 $136,000 $460 $250,240 $460 $346,360 $460 $417,660 1 $460 $660,800 $460 $736,760 ' $460 $379,960 $460 $166,520 1 $460 $534,980 $460 $350,980 1 $460 $236,900 $460 $444,360 $460 $419,980 $460 $154,560 $460 $237,820 $460 $195,500 $460 $398,820 $460 $365,240 $460 $752,100 $460 $946,980 $460 $207,000 $460 ^ $103,960 $460 $144,900 $460 $1,766,400 1 $460 $241,960 $460 $670,680 1 $460 $134,780 $460 $578,220 $460 $375,820 $460 $217,120 $460 $258,980

$460 'flH IHP $454,940 $14,192,380

' Based on 4 hours per transport x 2 staff (COs) x $57.51 per hour = approximately $460 per transport.

Attachment B

Telehealth Services Program Workload Analysis - Detailed description of workload related to the requested

positions.

5225-120-BCP-2019-GB Statewide Telehealth Services Program

Attachment B Medical Services Division

California Department of Corrections and Rehabliitai California Correctional Health Care Services Medical Services Telemedicine Services Unit

Workload Assumptions

|Work-hours per person per year * [ 2080|

Daytime Shift Days in Work Year 260 Weeks in Work Year 52 Months in Work Year 12

24/7 Services Hours In Work Day Days in Work Year Weeks in Work Year Months in Work Year

Assumptions The requested PY resources are to accommodate new workload requirements set forth by court orders as described in the Finance Letter narrative (dates) This is not an expansion of existing work previously established, | but rather new tasks related to the addition of activities for DSH beds to the workload.

Attachment B Medical Services Division

ATTACHMENT B California Correctional Health Care Services

Medical Services Division Telemedicine Staffing Proposal

PROJECTED ONGOING WORKLOAD

ACTIVITY TASK HOURS TO COMPLETE TASK

NUMBER OF TASKS PER YEAR

NUMBER OF HOURS PER YEAR

Specific Task

Medical Services and Telemedicine Services strategic goals tracking, reporting, and monitoring 6.00 260 1560

Lead teams on special projects and Initiatives Including TTA/ER project, dual appointment project, expansion of primary care and specialty providers, tele-ophthalmology, and other telehealth service initiatives

5.00 260 1300

Monitor, audit, and report on telemedicine Local Operating Procedures at the institutions for adherence to Telemedicine Services P&Ps

2.25 130 293

Apply project management tools to support improvement projects to enhance and expand tele-health services. Create timelines and charters, update stakeholders on goals and benchmarks, provide logistical expertise, and design ongoing maintenance for project sustainability

1.00 130 130

Preparation of reports, briefing documents, and presentation materials for CME/CEO conferences, FLO, LAO, CSA, Medical Leadership, Hospital Executives, Institutional Executives, etc.

2.00 52 104

Conduct targeted improvement projects as telemedicine subject matter expert on telemedicine specialty scheduling, primary care clinic logistics, and expansion initiatives

2.75 260 715

Provide completed staff work in support of institution improvement projects -detailed statistical analysis reports, telemedicine white papers, feasibility studies, and proposals

2.75 130 358

Conduct complex and detailed data analysis of primary care and specialty services performance and outcome measures 2.25 mi 585

Produce and track measures to determine efficacy of expansion initiatives and make recommendations for future expansion of new initiatives

2.00 52 104

Assist in the development of statewide policies and procedures for Telemedicine Services 1.00 130 130

Participate in primary and specialty care meetings and attend telemedicine all staff meetings 3.00 104 312

Attend internal and external training courses 8.00 20 160 Travel to institutions and external telemedicine sites to act as SME for ongoing coordination with stakeholders and to kick off new expansion initiatives

16.00 8 128

TOTAL HOURS PROJECTED ANNUALLY 5,878 TOTAL POSITIONS PROJECTED 3.31