Mental Health Services via Telehealth

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Finger Lakes Community Health

• Community/Migrant Health Center Program (FQHC)

• Migrant Voucher Program in 42 Counties of NYS

• Clinical Sites: 9 Health Center Sites

• Administrative Office: Penn Yan, NY

• 175 Employees – 46% bilingual/bicultural

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Where We Are

Blue Star – FQHC SiteRed Circle – CM Services

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What is Tele-Mental Health?

• Tele-mental health, like telemedicine, is the provision of mental health care from a distance. Tele-mental health uses two-way, high definition, live videoconferencing technology to provide mental health assessment and intervention.

• The goal of tele-mental health services is to eliminate disparities in patient care and give access to quality, evidenced-based, and emerging health care diagnostics and treatments.

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Challenges in Service Delivery

• Cultural and language barriers in accessing care outside of health center sites

• Lack of availability of providers in rural areas

• Distance traveled to seek health care

• Coordination of access to specialty care

• Costs and liability issues related to enabling services provided to patients

• Stigma associated with mental health services

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Why Telehealth?

• For our patients, we have found that it is necessary to have as many services available on site for our patients. For mental health services particularly in small communities, stigma is a major concern for patients.

• Transportation is a barrier to care in most rural communities.

• Tele-mental health can fit nicely into an integrated delivery system that breaks down silos as a more inclusive means of providing care that includes all of the patient’s healthcare team as well as the patient.

• Telehealth has allowed us to use technology as a tool to reach out to a wide variety of healthcare providers, regardless of distance, to increase access to care and collaborate with others in our region.

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Challenges of Implementing Telehealth

• Difficulty in developing clinical and staff champions within the program. They must see the benefits of the program for patients.

• Need for seamless integration of broadband, systems & equipment, applications and program development into a cohesive sustainable model.

• General fear of new technology.

• Start up costs for equipment.

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Telehealth & the Triple AimImproved Access:

• Increased access to specialists, primary care doctors, behavioral health providers, remote home monitoring

Better Care:• Reduced readmissions into hospital • Better access to clinical data (remote monitoring)• More clinical educational opportunities, expertise /

knowledge sharing • Care coordination

Lower or Stabilized Costs:• Remote monitoring enables patients to be monitored at

home• Lower utilization rates of ambulatory care• Better access = lower costs per patient

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FLCH Telehealth Guidelines

• Telehealth / telemedicine is a tool.

• Program Management can uncover strengths and weaknesses in operations of your centers.

• Quality Improvement is FOREVER!

• Management of telehealth by facts = DATA

• Need to see cost benefits from different perspective.

• Keep a sense of humor!

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What We Need To Connect?

Telehealth Program Development – a 3 layer strategy

• Layer 1: Broadband/Internet Connectivity

• Layer 2: Telehealth infrastructure and end user equipment

• Layer 3: Telehealth Program Development and Clinical and Educational Applications

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Layer 3 – Telehealth Applications

Program Development is very important and can be tedious, but it is worth the effort!

• Develop a work plan that outlines who, what, how, where and when.

• Plan on 6-8 months of program development from the start to your first clinical visit.

• Plan on mock visits to help all parties run through the process.

• Document your process for staff to have.

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Layer 3 – Program Development Workplan

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How We Connect

Internet

Provider Side Patient Side

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FLCH: An Integrative Model of Care

Primary Care

Behavioral Health

Dental

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Tele-Mental Health Clinical Process

• Referrals by Primary Care Provider to mental health services

• Intake process• Scheduling with the Psychiatrist/LCSW• Patient arrival and “rooming” procedures• Clinical visit• Documentation of clinical visit• Follow-up• Billing• Quality control / outcome data tracking

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Components for a Tele-Mental Health Program

Work Plan Documents:Tele-Mental Health Clinical Process Tele-Mental Health Pilot Development Work PlanTele-Mental Health Work Plan DetailTele-Mental Health Emergency Evaluation Policy & Procedure

Patient Documents Needed:Consent To Participate In A Tele-Mental Health ConsultTele-Mental Health Patient Emergency Info letterTele-Mental Health Patient Experience SurveyTele-Mental Health Registry SheetTele-Mental Health QI Tool

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Suggested Models of Tele-Mental Health Services

Model 1: Licensed Clinical Social Worker (LCSW) provides mental health counseling sessions remotely via video

Model 2: Patient Visit with LCSW on site and Psychiatrist Via Video

Model 3: Patient Visit with Psychiatrist via video without LCSW on site. All via video

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Model 1: Licensed Clinical Social Worker (LCSW) provides mental health counseling sessions remotely

Model 1 Benefits: Allows the LCSW to expand his/her reach particularly for organizations that have multiple sites but few LCSW’s. To consider:a. Who will “room” the patient?b. Who will “telepresent” the patient and initiate the video call? c. Does the “telepresenter” understand the process in the event the patient becomes

suicidal or has other concerns?d. Have a process to ensure that the LCSW, the patient and the primary care provider

understand the outcomes/follow-up.e. Make a plan to wrap up the visit, huddle with the patient, and then bring him/her to

the checkout area.f. How will follow-up be ensured?

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Model 2: Patient Visit with LCSW on site and Psychiatrist Via Video

Model 2 Benefits: Creates a real collaborative relationship and a team approach to the patient’s care.To consider:a. Who will be responsible for the management of the patient’s MH care?b. Who will “room” the patient at the remote site?c. Who will “telepresent” the patient and initiate the video call? d. Does the “telepresenter” understand the emergency procedures in the event the

patient becomes suicidal or shows other issues?e. Have a process to ensure that the LCSW, the patient and the psychiatrist agree and

understand the outcomes and needed follow-up.f. Make a plan to wrap up the visit, huddle with the patient, and then

bring him/her to the checkout area.g. How will the patient record be updated both by the psychiatrist and by the primary

care provider?

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Model 3: Patient Visit with Psychiatrist via video without LCSW on site

Model 3 Benefits: Provides access to mental health services while breaking down geographic barriers.To Consider:a. Who will “room” the patient?b. Who will “telepresent” the patient and initiate the video call? Keep in mind that this

will be a three way call!c. Does the “telepresenter” understand the process in the event the patient becomes

suicidal or has other issues?d. Need to ensure that the LCSW and the Psychiatrist are up to speed on pertinent

clinical/psycho-social info before the visit takes place.e. After the session, all three parties need to “huddle” to ensure that everyone is

on the same “page” in terms of medications, treatment, follow-up, etc.f. There needs to be a process in place for the sharing of health information so

that the patient’s record is up to date with all providers of that patient’s care.g. Care Management is very important and should be considered a part of the

patient’s care team!

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LCSW’s at FLCH between

sites

Family Institute (FQHC in NYC)Tele-Psychiatry

Tele-Mental Health

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Tele-Mental Health Outcomes 2010-2014

• 63% had decrease in PHQ-9 scores• Mean time to consult = 19 days• Mean time to treatment = <24 hours• 0% referred to Emergency Room• 17% referred to higher level of care• Increased interaction between primary

care and psychiatrist

High patient and provider satisfaction!

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Univ. of Rochester

Medical Center

PediatricNeurology

TelePeds Neurology

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TelePeds Neurology Outcomes

Focus Population: Children with poorly controlled symptoms of ADHD or other diagnoses.

• Decreased time to treatment (38 days vs 60 days). Exceeded national averages on NCQA performance measures

• 90% had changes or additions to their medication regimens

• 95% diagnosed with mental health co-morbidity• 32% started mental health medications • 100% referred to behavioral health• 40% showed improvement in function at school and

homeHigh patient and provider satisfaction!

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St. Joseph’s Hospital

Syracuse, NY

TelePsychiatry for Children

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TelePsychiatry for ChildrenWorkplan Steps

January 2015 - Agreement to collaborate by both partiesFebruary 2015 – Site visits:

1. To St. Joseph’s in Syracuse2. To view the setup of a child playroom at Mental Health office

March - April 2015:1. Business Associate’s Agreement2. Memorandum of Understanding3. Credentialing of providers by FLCH

May 2015:1. Work plan development with details2. Begin to set schedule of meetings to move work plan forward

June 2015: 1. Test video equipment including peripherals2. Test broadband connectivity levels between St. Joe’s and FLCH

July 2015:1. Meet and greet between St. Joe’s and FLCH providers2. In-service for primary care providers (FLCH)3. See “mock” patients to test process from check in to provider visit

August 2015: 1. Live consults begin!

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Care Coordination:SchedulingPre-Visit RequirementsConcurrent Chart ReviewCoordinate with PCMH Team/Specialty TeamQuality Assurance Reports

Case Conferencing:Providers, Care Managers, Patient Navigators

Quality Improvement Activities:Data Collection Monitor and Report OutcomesContinuous Quality ImprovementRegularly Evaluate Program

Other Key Components for Successful Telehealth Programs

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Resources Available on Tele-Mental Health

• The American Telemedicine Association (ATA) has great resources for clinical guidelines on a variety of clinical areas. They are a great source of information.

www.americantelemed.org

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Consortium of Telehealth Resource Centers

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Two thoughts to remember…

Telehealth is not about fancy equipment and technology.

It’s a tool used to improve access and enhance quality of care.

Implementing telehealth is a process, not a destination.

Steps to Success

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FLCH Contact Information

Mary Zelazny, CEOSirene Garcia, Director of Special Programs

Finger Lakes Community Health PO Box 423

Penn Yan, NY 14527315-531-9102

Maryz@flchealth.orgSirene@flchealth.org

www.flchealth.org