telehealth/mhealth: innovations in improving access to...

Telehealth/mHealth: Innovations in Improving Access to Care

Mark Carroll, MDMose Herne, MPH, MSMark Horton, OD, MDLyle Ignace, MD, MPH

Overview of Breakout Session

• Brief status of telehealth and mHealth in IHS

• Regulatory topics

– Credentialing and privileging

• Strategic opportunities

• Discussion

Facing the challenge of delivering health

care where it’s needed.

A Wide Range of Services

AIDS-HIV care

Behavioral Health

Cardiology

Dentistry

Dermatology

Diabetes care

ENT

Intensive care

Rheumatology

Neurology

Nephrology

Nutrition

Ophthalmology - JVN

Oncology/Palliative Care

Pharmacy

Radiology

Rehab services

Rheumatology

Remote Monitoring

Trauma

Wound care

Patient-Centered Care

Right care

Right place

Right time

http://www.mobypicture.com/user/Ludwig707/view/298092/sizes/full

http://www.amazon.com/gp/product/images/B003HC8NUW/ref=dp_image_z_0?ie=UTF8&n=2335752011&s=wireless

Right “Tool”

http://www.ihs.gov/listserver/index.cfm?module=signUpForm&list_id=196


“Right Emphasis”

• Relationships– New tools and technologies must enhance

relationships, especially if they are to be embraced and be effective in chronic care

The Mobile Revolution

Audie A. Atienza, PhD


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http://www.itu.int/ITU-D/ict/statistics/material/graphs/2010/Mobile_cellular_00-05-10.jpg


Remember 2008…

2009: 1.5 Trillion Text Messages Sent in US

4.1 billion SMS messages sent daily



http://www.unfoundation.org/global-issues/technology/mhealth-report.html

50+ Case Studies Described


mHEALTH IN INDIAN HEALTH:

CARE WHERE AND WHEN IT IS NEEDED

The IHS and its Tribal partners are committed to the appropriate use of innovative tools and

technologies to improve access to quality health care for American Indians and Alaskan Natives.

mHealth: “the integration of mobile technology, computing devices, and emerging delivery system

capabilities into a patient-centered model of care”.

Innovative uses of mHealth tools in Indian health care include: Mobile deployment of services

The IHS Joslin Vision Network Tele-Ophthalmology

program – to 14 facilities in AK and NC

Mobile mammography, for communities in the

Dakotas

Remote monitoring programs in diverse

geographies, for congestive heart failure and

diabetes care

USING mHEALTH IN AN EMERGING

MODEL OF PATIENT-CENTERED CARE:

THE 5 “RIGHTS”

1. RIGHT TOOL

2. RIGHT PLACE

3. RIGHT TIME

4. RIGHT SYSTEM OF CARE

5. RIGHT EMPHASIS: Relationships

CONSIDERATIONS FOR EXPANDED USE OF mHEALTH TOOLS

New tools must be integrated into initiatives to improve models of care. A key example is the IHS

Improving Patient Care initiative.

Use of handheld mobile technologies and wireless monitoring devices must occur in strict

compliance with emerging security and privacy standards.

Patient health information must be part of the IHS and

Tribal Electronic Health Records, for coordinated care at

the health care facility and community level.

mHealth services should complement developing work for

personal health records and other key activities that expand

access to health information for patients and communities.

Cultural acceptance of new tools and technologies is vital to program development and must be a

key component to mHealth project design.

mHealth and Patient-Centered Care:

Perspective from U.S. Indian Health Care

THE INDIAN HEALTH SYSTEM

A comprehensive health delivery system for ~1.9 million

American Indians and Alaska Natives.

Serving members of 564 federally-recognized Tribes in 35

U.S. states.

Comprised of Indian Health Service (IHS) direct health care

services, Tribally-operated health care services, and urban

Indian health care services and resource centers.

A RELATIONSHIP-CENTERED APPROACH

Critical Triggers for Quality Improvement

Improved

Outcomes

& Value

Improved

Self-care

and

Treatment

Effective

Relation-

ships

Connected

Care &

Remote

Monitoring

M Carroll, MD1; T Cullen, MD1; M Horton, MD,OD1; C Lamer, RPh1; S Ferguson, PhD2; M Veazie, DrPH1

I Indian Health Service; 2 Alaska Native Tribal Health Consortium

Smartphone Adoption and Usage

83% of U.S. adults have a cell phone

35% of U.S. adults have a smartphone

87% use it to access internet or email

25% use it as main access to internet

9% have apps to help track or manage health

17% have used phones to look up health info

Pew Internet Projecthttp://pewinternet.org/Reports/2011/Smartphones.aspx

Text Messaging

72% of adult cell phone users send or receive text messages

Pew Internet Project, Sept 14, 2010

41% of consumers prefer to receive a health-related task reminder through text messaging

Consumer Health Information Corporation http://www.consumer-health.com/press/2008/NewsReleaseSmartPhoneApps.php

HHS Text4Health Task Force (est. Nov 2010) Audie A. Atienza, PhD

text4baby


mHealth: Access and Quality of Care

Expanded models of care

Remote patient monitoring

Real-time support for dx and rx

Innovative access to information, training, and education

For care teams

For patients communities

Improved efforts at disease outbreak trackingand epidemiology

Last Mile Microwave Coverage

Social Media

• Standard Operating Procedures (SOPs) in

final approval stage

Facebook (updated version) – social

networking

YouTube -video sharing

Twitter - micro-blogging

Flickr - photo sharing

FDA Proposed Rules: July 2011

Best Practices

• What are new privacy and security standards?

• IHS planning to establish guidelines for using mHealth communications for a variety of scenarios

– Health promotion and education

– Reminders

– Other communications

Care Coordination for Hypertension Care:

Improving BP Control for Patients with Diabetes

Lyle Ignace, MD, MPH

July 27, 2011

Care Coordination for Improved BP Management

• GOAL:

– Improve BP Control for diabetic patients with poor BP control


• TOOLS:

– Home BP monitoring cuffs and data transfer device/service

– Improved care coordination processes


• DOES HOME BP MONITORING WORK?– Many studies show significant reduction in patients’ BP,

reducing risk for stroke, heart, disease, and other health problems

– Example:

• University of Toronto, Logan et al, implemented automated mobile phone-based telementoring

• Home BP monitoring data sent via mobile phone to care teams for DM patients with uncontrolled BP

• Systolic BP decreased by 9.1 mm Hg over one year, compared with 1.6 mm Hg decrease in control

In-home remote monitoring

Courtesy of Bonnie Britton, RN

Hospital Bed Days and ER Visits

Analyzed Charges are related to diseases being monitored

RCCHC/PPTN Patient Charge Data Ending June 2009

n=64

Hospital Bed Days

6 mos. prior to Telehealth = 199

During 6 mos. Telehealth = 99 50% decrease prior to during

6-30 mos. post Telehealth = 70 65% decrease prior to 30 mos. post

ER Visits

6 mos. prior to Telehealth = 27

During 6 mos. Telehealth = 5 81% decrease prior to during

6-30 mos. post Telehealth = 23 15% decrease prior to 30 mos. post


Total Charges

Analyzed Charges are related to diseases being monitored

RCCHC/PPCTN Patient Charge Data Ending June 2009

Statistically significant difference between pre-, during, and post-

telehealth charges

p value = 0.0088

6 mos. prior to Telehealth = $1.34 M

During 6 mos. Telehealth = $ 382 k 72% decrease

6-30 mos. post Telehealth = $483 k 64% decrease



• TIMELINE:

– Pilot activity with 12 Improving Patient Care initiative sites

– To begin late summer/fall


• EMPHASIS:

– The key part of this pilot is the care coordination team processes, not the facilitated access to home BP data

IHS NCC Meeting27 July 2011

Mark B. Horton, OD, MDPhoenix Indian Medical Center

Director, IHS/JVN Teleophthalmology Program

IHS/JVN ProgramSummer 2011 Update

DM and DR In Indian

CountryParallel Epidemics

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

92 94 96 98 '00 '02 '04 '06 '08 '10

D M

P r

e v

e l a

n c

e

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

D R

E x

a m

R a

t e

Sustained 50%

DR exam rate

Doubling of DM prevalence during past decade

• Diabetic Retinopathy is the leading cause of new blindness

• Blindness due to DM/DR can be eliminated by timely Dx and Tx

• Conventional eye exams not a likely solution for timely DX

DR Surveillance in IHS: FY10IHS (2010)- 53% (43% - 63%) DR eye exam rate

44%

51%

63%

46%

59%

47%

43%

59%55%

57%

43%

53%

0%

10%

20%

30%

40%

50%

60%

70%

80%

DR

E

xa

m R

ate

ABD

ALA

ALB

BEM

BIL

CAL

NAS

NAV

OKL

PHX

POR

TUC

DR Surveillance std of care

failed in ~half of population

with DM

Urban and rural

All socioeconomic groups

AI/AN vs general US pop

DR Surveillance

ReportingGPRA Performance Measure

Performance

Measure

2009 Target 2010 Target 2011 Target Headquarters

Lead

TREATMENT MEASURES

Diabetes Group

6. Diabetic

Retinopathy:

Address the

proportion of

patients with

diagnosed

diabetes who

receive an

annual diabetic

retinal

examination.

[outcome]

During FY 2009,

maintain the

proportion of

patients with

diagnosed

diabetes at all

sites who receive

an annual retinal

examination at the

FY 2008 level rate

of 47% at all sites

. During FY 2010,

maintain the

proportion of

patients with

diagnosed

diabetes at all

sites who receive

an annual retinal

examination of

55% at all sites.

During FY 2010,

maintain the

proportion of

patients with

diagnosed

diabetes at all

sites who receive

an annual retinal

examination of

50.1% at all sites.

Mark Horton

Diabetic Retinopathy SurveillanceIHS-JVN Teleophthalmology Program

78 physical/81 logical + 14 Portable Sites in 21 States

1831001 1262 1624

10873

14500

3027

5532

3758

45465580

8,069

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

55000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Program Year

Cu

mu

lativ

ee

s

0

10002000

30004000

5000

60007000

8000

900010000

1100012000

13000

1400015000

16000

An

nu

al

IHS-JVN Exams

2000-2010

P

R

O

J

E

C

T

E

D

New IHS-JVN Developments

• Technical

– Software- RPMS/EHR interoperability

– Hardware- camera development

– Clinical- improved imaging protocols

• Operational- consortium deployments

• Business- Tribal collaborations

JVN-RPMS/EHR

Interoperability IHS-JVN CONOPS Summary

JVN Server

(PAO)

JVN Application

Server

DICOM PACS

Modality Worklist

Provider

Oracle DB

Image WebService

National Reading

Center (PIMC)

Healthcare

Facility

CDMP IE

(Mirth)HL7

JVN Image

Acquisition

Worstation

Pt

Demo

Image

&

Pt Info

JVN

Diagnostic

Display

1

2

3

45

9

Health Summary

RPMS

GIS

RPMS

GIS

CDMP IE

(Mirth)

RPMS

GIS

EHRCharge

Posting EHRCharge

Posting

6

7

8

9

Automated Workflow

• Pull of clinical data into JVN

Reader

• Push of JVN report and

business information into

RPMS/EHR

• EHR Consults Scheduling

and Notification

Camera Development

In Development• Designed for Tmed

• Light

• Small foot print

• Simi-automated

• Hardened

• $5-$10K

• DoD/University of Hi,

others

Current Technology

• Adapted from existing

commercial device

• Wrong features

• Fragile

• Expensive

• Orphaned

40 lb -

$20K -

Manual -

Discontinued -

No Parts -

New Clinical Protocols

• Extreme Remote Imaging protocol

• Mini-dilation Protocol

Improve image gradeability and over-referrals

• Remote sites with extreme logistics

• Small sites with low volume imaging

New IHS-JVN Developments

Consortium based deployments

PORTLAND

AREA

DM

PTS

FY10

EXAM

RATE

FY10

CHEHALIS 79 8.3%

NISQUALLY 120 6.5%

SHOALWATER BAY 12 25%

SKOKOMISH 40 5%

SQUAXIN ISLAND 33 60.6%

COWLITZ 74 38.5%

TOTAL 358 18.7%

Partnership for

improved outcomes

• Operations

• Business

• Clinical

Tribal Collaboration

• Budget flat since 2002

• Operational costs vs deployments and

development

• Interest from “related” non-bens

– Urban Clinics, Hawai'i, Pacific Islanders

– IHCIA

• Reading Center “franchise”

IHS NCC Meeting27 July 2011

Mark B. Horton, OD, MDPhoenix Indian Medical Center

Director, IHS/JVN Teleophthalmology Program

IHS/JVN ProgramSummer 2011 Update

REGULATORY UPDATE:

Credentialing and Privileging

June 9. 2011

Revisions to the Hospital and CAH Conditions of

Participation

(CMS-3227-F)

Credentialing and Privileging Requirements for Telemedicine Physicians and Practitioners

53

June 9, 2011

Published May 5, 2011, in the Federal Register:

Medicare and Medicaid Programs: Changes Affecting Hospital and Critical Access Hospital (CAH) Conditions of Participation (CoPs): Telemedicine Credentialing and Privileging (CMS-3227-F)

76 FR 25550:

http://www.gpo.gov/fdsys/pkg/FR-2011-05-05/pdf/2011-10875.pdf

Locating the Final Rule

54

http://edocket.access.gpo.gov/2010/pdf/201012647.pdf










June 9, 2011

Changes to the Hospital CoPs

The hospital requirements for credentialing and privileging of medical staff are contained under the Governing Body (§482.12) and Medical Staff (§482.22) CoPs

55

June 9, 2011

§482.12 Governing Body CoP

Requires the governing body of the hospital ensure that an agreement exists with a distant-site hospital to provide telemedicine services and that the agreement specifiesthat the governing body of the distant-site hospital ensures that all current Governing Body CoP requirements (§§482.12(a)(1-7)) are met with regard to its physicians and practitioners providing telemedicine services.

56

June 9, 2011

§482.12 Governing Body CoP (cont)

The governing body of the hospital has the option of granting privileges based on the recommendations of its medical staff, which has relied upon information furnished by the distant-site hospital regarding privileges for individual physicians and practitioners providing telemedicine services.

57

June 9, 2011

§482.22 Medical Staff CoP

The hospital can rely on this information for its privileging decisions only if certain provisions (at §482.22(a)(3)) regarding the distant-site hospital, and the individual physicians and practitioners, were met regarding:

Medicare-participation status of distant-site hospital

Privileges of individual physicians and practitioners, including list of current privileges for each provided by distant-site hospital

State License (does not apply to Indian health)

Internal review for purposes of periodic appraisal of individuals providing telemedicine services, including adverse events/complaints

58

June 9, 2011

Changes to the CAH CoPs

Critical Access Hospitals (CAHs) have CoP requirements under the Medicare regulations that are separate and distinct from the hospital CoPs. The term “credentialing” is used almost exclusively throughout the CAH CoPs.

59

June 9, 2011

Changes to the CAH CoPs (cont)

The new CAH requirements for credentialing and privileging are under the Agreements (§485.616) and Periodic Evaluation and Performance Review (§485.641) CoPs.

60

June 9, 2011

Changes to CAH CoPs

The requirements for CAHs are similar to those for hospitals, and/or designed to make the CAH credentialing and privileging requirements consistent with current hospital requirements … (abbreviated slide)

61

June 9, 2011

Changes to CAH CoPs (cont)

We also amended the Periodic Evaluation and Quality Assurance Review CoP (at §485.641(b)(4)) by adding a new paragraph that allows a distant-site hospital to evaluate the quality and appropriateness of the diagnosis and treatment furnished by the distant-site physicians and practitioners providing telemedicine services to the CAH’s patients under an agreement between the CAH and a distant-site hospital

62

How does the final rule differ from the proposed rule we published in May 2010?

First, we finalized the requirements proposed in the May 2010 NPRM with only minor clarifying revisions (e.g, specify in the provisions that the telemedicine agreement must be written).

Based on public comment, we added new provisions to the final rule that will apply to the credentialing and privileging process and the agreements between hospitals and CAHs and non-hospital, distant-site telemedicine entities that provide telemedicine services

§482.12(a)(9) and §482.22(a)(4) for hospitals; §485.616(c)(3) and §485.616(c)(4) for CAHs

June 9, 2011 63

How does the final rule differ from the proposed rule we published in May 2010? (cont)

The new provisions will allow for the governing body of the hospital (or the CAH’s governing body or responsible individual) to rely upon the credentialing and privileging decisions made by the distant-site telemedicine entity.

The telemedicine entity’s medical staff credentialing and privileging processes and standards must at least meet the CoPs related to credentialing and privileging.

June 9, 2011 64

What Are the Differences Between the Proposed Requirements and the New Provisions?

These new provisions will require the governing body of the hospital (or the CAH’s governing body or responsible individual): Through its written agreement with the distant-site telemedicine

entity

Ensure that the distant-site telemedicine entity as a contractor of services

Furnishes its services in a manner that enables the hospital (or CAH) to comply with all applicable CoPs and standards for the contracted services

Including the credentialing and privileging requirements regarding its physicians and practitioners providing telemedicine services

June 9, 2011 65

What effect will the final rule have on the CoPs?

Will allow hospitals and CAHs to make full use of the telemedicine services offered by non-hospital telemedicine entities without the duplicative and burdensome task required by the traditional credentialing and privileging process.

June 9, 2011 66

Benefits for Hospitals and CAHs

Will now allow hospitals and CAHs to take advantage of these streamlined credentialing and privileging options when using the telemedicine services of:

Other Medicare-participating hospitals,

Non-Medicare-participating telemedicine entities, or

A combination of both types of service providers

June 9, 2011 67

What is a telemedicine entity?

There is no statutory definition for a telemedicine entity contained in the Social Security Act.

Therefore, for the purposes of this rule, we needed to define a distant-site telemedicine entity as one that –(1) Provides telemedicine services;

(2) Is not a Medicare-participating hospital; and

(3) Provides contracted services in a manner that enables a hospital or CAH using its services to meet all applicable CoPs, particularly those requirements related to the credentialing and privileging of practitioners providing telemedicine services to the patients of a hospital or CAH.

June 9, 2011 68

The Importance of the Written Agreement

Similar to our regulations proposed for hospitals and CAHs using the telemedicine services of distant-site Medicare participating hospitals, the written agreement between the hospital or CAH and the distant-site telemedicine entity will be the foundation for ensuring accountability on both sides.

June 9, 2011 69

June 9, 2011

Summary

Proposed rule published May 26, 2010

CMS received over 100 comments from various stakeholders.

Final rule published May 5, 2011

Effective date: July 5, 2011

The result of outreach efforts by CMS to the telemedicine stakeholder community

Allows for a streamlined process for credentialing and privileging of telemedicine physicians and practitioners under written agreements between hospitals/CAHs and distant-site non-Medicare-participating telemedicine entities and distant-site Medicare-participating hospitals

70

Summary (cont)

Intent is to reduce burden and eliminate duplicative credentialing & privileging efforts by hospitals and CAHs that have telemedicine services agreements with distant-site telemedicine entities and Medicare-participating hospitals

CMS believes that the final rule will reduce the burden of the traditional credentialing and privileging process while still assuring accountability.

June 9, 2011 71

Note

• As per both CMS and Joint Commission, hospitals/CAHs may accept credentialing and privileges for telemedicine practitioners from distant hospitals/DSTE without appointment of telemedicine practitioners to the local hospital/CAH medical staff.

Next Steps for C & P

• Still awaiting new Joint Commission standards and interpretations

• New language has been drafted for the Indian Health Manual

• Facilities should review their med staff bylaws for compliance with new ruling

• Agreement templates are being drafted with OGC

STRATEGIC OPPORTUNITIES:

Behavioral Health

Business Planning

FORM FOLLOWS FUNCTION

What will be our new models of care?

What will it take to implement those models of care?

What will it take to support and sustain them?

Telehealth Services NetworkThis proposal was developed as a collaboration of many people. At the request of Dr. Susan Karol, IHS Chief Medical Officer, and Dr. Theresa Cullen, IHS Chief Information Officer, a Telehealth Planning Workgroup was formed. This workgroup led the planning and development of this proposal. Participants and contributors to the proposal development included:

Tammy Brown, MPH, RD, BC-ADM, CDE

Mark Carroll, MD

Mandi Constantine, MEd

Stewart Ferguson, PhD

Chris Fore, PhD

Jonathan Doggette

Patrick Gormley

Mark Horton, OD, MD

Kathleen Keats, MBA, MSIT

John Kokesh, MD

Chris Lamer, RPh

Jill Moses, MD, MPH

Chris Patricoski, MD

Diane Phillips, RD, LD, CDE

Jay Shore, MD

Peter Stuart, MD

Mark Thomas, PE, MPH

Mark Veazie, DrPH

Chris Watson, RPh, MPHApril 2011

• Telehealth is a clinical mandate, not a technical initiative. We should:

– Provide a predictable level of service.

– Support local planning and decision making.

– Establish national coordination, planning and accountability.

– Improve efficiencies through regional and centralized services.

– Leverage existing expertise.

Key Concepts

79

Telehealth Service Expansion

• Four key components:

– Clinical Telehealth Services (for primary and specialty care)

– Modernized Infrastructure

– Regional Telehealth Resource Centers for technical/coordination/training capacity

– National Program Support

Improving the “Medical Home”Clinical Service

Discipline Telehealth Modality

Model of Care Additional Description

Telehealth Clinical Care Centers

Behavioral Health

o Videoconferencingo Store-and-forward

o Tiered model of serviceo Direct psychiatric careo “Surge service” – for

communities in crisiso 24/7 consultation and

clinical evaluationo Education and training

o After-hours call will be shared among 5 regions for night/weekend service to emergency departments

Nutrition and dietetics

o Videoconferencing o Individual and group nutrition counseling services via videoconferencing

o Availability of advanced practice nutrition counseling

o On-site assistance in region with program development

o Intra-network consultation for advance practice needs (e.g. renal, geriatric care)

Pharmacy o Videoconferencingo Store-and-forwardo Remote monitoring

o Regional telepharmacy service

o Centralized Mail Outpatient Pharmacy (CMOP) support

o After-hours pharmacy review

o Disease management assistance

o Anticoagulation clinicso Cardiovascular risk

reduction monitoringo Smoking cessation line

April 2011

Improving the “Medical Home” (cont.)

Clinical Service

Discipline Telehealth Modality

Model of Care Additional Description

Specialist Consultation

IHS JVN Tele-ophthalmology

o Store-and-forward o Expanded JVN deployment @ I/T/U sites

o Portable service model for sites too small for fixed deployment

o Hybrid model possible for regional service delivery

o Model will be based on DM prevalence and geographic specifics

Dermatology, Cardiology, ENT, and ID

o Store-and-forward o As needed specialist consultation, assisting with initial consultation and ongoing treatment needs

o Services available via partial FTE or contract

Population Health Consultation

Pop Health Support Network

o Videoconferencingo Store-and-forward

o Network of coaches & consultants

o Knowledge management system

o National coordination

April 2011

Alternatives AnalysisBehavioral Health

Specialty Service ModelsOn-site On-site + telehealth telehealth

Scalability Poor Good Good

Provider

Recruitment/Retention

Challenging, expensive and

erraticBetter Best

24/7 Coverage Dependent on clinic size Available Available

Access to range of

specialtiesLimited Available Available

Educational Access Local/internet National/regional/ local National/regional

Surge Response Poor Best Better

Collegial Support

OpportunitiesDependent on clinic size Best Best depending on affiliation

CostCare needed at other than

full FTE increments costly

Can adjust in less than full

FTE increments

Can adjust in less than full

FTE increments

AccessLimited by provider schedule

and housing

Potentially available on

demand

Potentially available on

demand

Cross-Coverage Dependent on clinic sizeNational/regional coverage

available

National/regional coverage

available

Patient/Provider SafetyExposed to road/air travel

hazards (sig in rural areas)Better Best

April 2011

Expanding Access to Quality Behavioral Health Services

Mose Herne, MPH, MS

July 27, 2011

Inpatient Mental Health Needs

• Significant challenges for IHS in meeting the inpatient mental health needs of its users

– Recommendations from 2011 assessment include:

• Expand behavioral health services in partnership with Tribes, local, State, and regional providers

• Capitalize on emerging technologies, i.e., tele-behavioral health, to increase access to and quality of services for evaluation and treatment, enhance provider education through case consultation, and strive to prevent inpatient hospitalizations

Current Use of Tele-behavioral Health

• Improving access to behavioral health services:– The National Tele-behavioral Health Center of

Excellence (TBHCOE) was established to provide innovative and culturally–competent technical assistance to increase:

• access to behavioral health services

• training in suicide prevention for behavioral health staff practicing in Indian Country

– Use of tele-behavioral health technology is on the rise• Over 50 IHS and Tribal facilities in 8 IHS Areas are

augmenting on-site behavioral health services with tele-behavioral health services

TBHCE Support Activities

• TeleBehavioral Health Policies and Procedures

• Credentialing and Privileging guidelines

• Standardized Network Assessment

• TelePsychiatry formulary (in progress)

• Secure document sharing & messaging via AFHCAN (in progress)

• TeleBehavioral Health EHR template (pending)

• TeleBehavioral Health lab package (pending)

Goals of Tele-behavioral Health

• Improve quality and access to BH care

• Improve customer service

• Reform the IHS

• Transparency

• Tribal consultation – NTAC and BH Workgroup

TBHCE Direct Services to I/T/U

Psychiatry

• Adult

• Addictions

• Child/Adolescent

Psychology

• Adult

• Child/Adolescent

• Individual

• Group

• Family

TBHCE Activities• Coordinate 24/7

Coverage

• Credentialing

• National Standards– Practice

– EHR

– Formulary

– AFHCAN

– Network Assessment

• Billing TA

• TeleVideo Support• OIT Coordination• mHealth Initiatives• Program Evaluation• New Technology Eval.• Intensive case mgt• Training

– TeleBH– mHealth– BH/Primary Care (CME)– PHN/CHR training– Cultural competence

TBHCE Indirect Services to I/T/U

Education

No-Cost CME to I/T/U Primary Care providers via televideo.

Assessing and Treating Behavioral Health Issues in a Primary Care setting (piloting)

Clinical Support

Weekly Case Staffing to I/T/U Mental Health and Substance Abuse providers.

Emphasis on dual diagnosis, suicide prevention, and chronically mentally ill (in progress)

Targeted Outcomes

• Increase access to BH services• Increase quality of care through service coordination• 24/7 support for mental health emergencies• Use of innovative and multidisciplinary care models• Prevent hospitalization/reduce length of stay• Improve quality of life• Leveraging existing programs, i.e. VA, SAMHSA, HRSA• Collaboration across the system• Customer service, i.e. directly addresses BH needs as

outlined in numerous venues

BUSINESS UPDATE:

Reimbursement Policy

Is “telehealth” cost-effective?

Better Question:

Under what circumstances are new care models using telehealth tools cost-

effective?

SFerguson PhD, ANTHC

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

2001 2002 2003 2004 2005 2006 2007 2008 2009

Annual Travel Savings (by Case Role)

Primary Care Specialty Care

DATA FROM ALASKA

Red = A

White = B

Blue = C

Grey = D

Black = F

Capistrant’s Medicaid Grades

G Capistrant, ATA, 2011

• Incremental expansion in coverage by both Medicare and Medicaid programs

– CMS considering new approach to reviewing annual requests for additions to covered telehealth services

• Consideration within IHS for proposal to CMS re: national coverage determination for Indian health

Expanding Reimbursement

99

“Service to the point of need”

Improved access for many types of care cannot occur without telehealth

Thank You

telehealth/mhealth: innovations in improving access to...

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