Telehealth and Primary CareLesley Manson, Psy.D.

Robynne M. Lute, Psy.D.Norman Bell, M.D.

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session #B1aFriday, October 17, 2014

Faculty Disclosure

We have not had any relevant financial relationships

during the past 12 months.

Learning Objectives

At 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.

References1. 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

2. American Telemedicine Association State Medicaid Best Practice telemental and behavioral health (2013). Retrieved from americantelemed.org

3. 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.

4. 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

5. Committee on National Security Systems (2010). National information assurance (IA) glossary. Retrieved from https://www.cnss.gov/assets/pdf/cnssi_4009.pdf

6. Copeland, J. & Martin, G. (2004). Web-based interventions for substance use disorders: A qualitative review. Journal of Substance Abuse Treatment, 26(2), 109-116.

7. Dahl, D. (2014). People, technology, and process meet the triple aim. Nursing Administration Quarterly, 38(1):13.

8. Frueh, B., Henderson, S., & Myri, H. (2005). Telehealth service delivery for persons with alcoholism. Journal of Telemedicine and Telecare, 11, 372-375.

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.

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

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

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.

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

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)

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

Telehealth Applications

1. Tele Consultation

• Direct and Indirect Care

2. Tele Monitoring

• Direct and Indirect Monitoring

3. Tele Education / Learning

• CMEs, CEUs

4. Tele Mentoring

• Direct Consultation and Professional Development

5. Tele Conferencing

• Case, Staff, and Professional Conferencing

Our Focus—Patient Care Applications

Photo Credit: Splashmarcomms.com

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

Empirical Support

• Overwhelmingly positive for TMH• No contraindications for use of VTC in MH care• Comparability

– Children– Adults– Geriatrics– Cognitively impaired

Photo Credit: Takomabibelot

Empirical Support

• Mental Health Disorders– Mood disorders– Anxiety disorders– Substance-use disorders– Psychotic disorders

• Treatment Settings– Outpatient– Inpatient– Institutionalized– Correctional settings

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

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

Telehealth ConsultationIndirect and Direct Care

Photo Credit: averaphoto42012 Photo Credit: ODCHC, 2009

Telehealth Monitoring

Telehealth Education / Learning

Telehealth Mentoring

Telehealth Conferencing

• 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 PracticeA.P.A., 2013

Core Guidelines

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

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.

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

American Telemedicine Association

Who we areThe 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.

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)

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.

Photo Credit: surroundsound5000

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

ODCHC, 2014

Under 101%

101-150% 151-200% Above 200%

0%

10%

20%

30%

40%

50%

60%

Percentage of Patients with Federal Poverty Level % Income

Percentage of Patients with Federal Poverty Level % Income

ODCHC, 2014

Percentage of Funding Sources

MedicaidMedicarePrivate Insurance (ACA)Self-Pay

ODCHC, 2014

Ages 0-5 yo Under 18 yo

Adults 18-64 yo

65 yo and Older

0

5000

10000

15000

20000

25000

30000

35000

Patient Demographics by Age

Patient Demographics by Age

ODCHC, 2014

Hispan

ic

Not Hisp

anic

Pacific I

slander a

nd Asian

Black

White

Native

Multirac

ial

Unknown

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

Patient Demographics by Race, Ethnicity

Patient Demographics by Race, Ethnicity

ODCHC, 2014

Community Health Care ServicesFamily Practice Immunizations Pediatrics Women's Health Geriatrics Complete Dental Care EMDR & Biofeedback Case Management Population Health Complex Case ManagementPromotoras Mobile HealthTelemedicine Programs Health EducationFamily Planning Prenatal & Birth Services Urgent Kids Care Teen HealthHomeless Outreach Wellness OutreachWellness Groups Wellness Community GardeningHIV/AIDS and HCV Care Alternative Medicine Nutritional Counseling STD Testing and CounselingBehavioral Medicine Mental Health Counseling Urgent and Same Day Care Benefits Enrollment Assistants Population 1 in 3 People Community Underinsured Uninsured ODCHC, 2014

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

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

• 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, syncopal attack, sleepiness• Utilized monitoring, assessments

– 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

• 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

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

• 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

– 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

• 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

USC Tele Behavioral Health

• Reserved for USC’s TeleBH Slides

Benefits of Telehealth

Photo Credit: U.S. Department of Agriculture

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

Helpful Resources• HRSA’s Office for the Advancement of

Telehealth• Centers for Medicaid and Medicare

Services (CMS) Telemedicine• CA Healthcare foundation• UC Davis Center for health and

technology• Teleconnect funds• Universal Services administrative

company• Telehealth optimization initiative

QUESTIONSLesley Manson, Psy.D.Doctor of Behavioral Health Program Arizona State University Email: lesley.manson@asu.eduPhone: (602) 496-6790

Robynne M. Lute, Psy.D.The School of Professional Psychologyat Forest InstituteEmail: rlute@forest.eduPhone: (417) 893-7979

Norman Bell, M.D., PediatricianOpen Door Community Health CentersEmail: nbell@opendoorhealth.comPhone: (707) 496-3984

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!