Telemental Health ProgramsTelemental Health ProgramsProgrammatic and Clinical Considerations

Douglas K. Novins, M.D.

Native American and Telehealth ProgramsDepartment of Psychiatry

University of Colorado School of Meidiciney

Disclosures of Potential Conflicts

Douglas Novins, MD

Source Consultant Advisory Board

Stock or Equity

>$10,000

Speakers’ Bureau

Research/Technical Assistance

Support

Honorarium for this talk or meeting

Expenses related to

this talk or meeting

SAMHSA/Georgetown Univ.

◘ ◘

NIMH ◘

NIDA ◘

ACF ◘

SAMHSA ◘

VA ◘

Sources

Most of the slides for these presentations were adapted p pfrom the Telemental Health Guide www.tmhguide.org

Sources• American Academy of Child and Adolescent Psychiatry (2008)

Practice Parameter for Telepsychiatry With Children and Ad l t J l f th A i A d f Child dAdolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 47:1468-1483.

• Hilty DM, Yellowlees PM, Sonik P, Derlet M, Hendren RL (2009) R l hild d d l t t l hi t d t lRural child and adolescent telepsychiatry: successes and struggles. Pediatric Annals, 38:228-32.

• Savin D, Garry M, Zuccaro P, Novins DK (2006) Telepsychiatry for T ti R l A i I di Y th J l f th A iTreating Rural American Indian Youth. Journal of the American Academy of Child and Adolescent Psychiatry, 45:484-488.

• Savin D, Glueck D, Chardavoyne J, Yager J, Novins DK (in press) C lt l C t d Child d Ad l t T l hi tCultural Competence and Child and Adolescent Telepsychiatry. Accepted by Child and Adolescent Psychiatric Clinics of North America, August 2010 Sh J M SM (2005) A D l t l M d l f R l• Shore J, Manson SM (2005) A Developmental Model for Rural Telepsychiatry. Psychiatric Services, 56:976–980.

NATP Telepsychiatry Servicep y y

Sixteen clinical programs serving children, adolescents, and adults in reservation and non reservationand adults in reservation and non-reservation communities in 6 states (Colorado, Wyoming, S. Dakota, Montana, Arizona, Alaska)

NATP Telepsychiatry Servicep y y

A broad array of clinical models based on each host program and community’s specific needsprogram and community s specific needs– Consultee-centered consultation– Patient-centered consultation– Direct, ongoing clinical services

Take Home Messagesg

Research to date suggests child and adolescent telemental gghealth services are largely comparable to face-to-face services in terms of acceptability. There is growing evidence that its effectiveness is comparable as wellevidence that its effectiveness is comparable as well.

The development and implementation of a telemental health clinic is often complex and takes time (often morehealth clinic is often complex and takes time (often more than a year).

Clinical telemental health practice has some differences from face-to-face practice, but skills developed for face-to-face work easily transfer to telemental health practice.

Effectiveness of Telemental Health

Key Research Findings to Datey g• High patient-provider satisfaction• Comparable therapeutic alliance• Two controlled trials suggesting assessment and

treatment via telemental health is comparable to face-to-face servicesface services.

Lessons from DisseminationScience…

Innovation more likely to be adopted if it:Offers unambiguous advantages in effectiveness or cost-effectiveness

++/++++

Is compatible with adopters’ values, norms, needs +/++++Is simple to implement +Can be experimented with on a trial basis +Has benefits that are easily observed ++++Has benefits that are easily observed ++++Can be adapted, refined, modified for adopter’s needs ++++Is low risk (for patients and families) ++++Is low risk (for programs) +Is relevant to adopter’s current work ++++Is accompanied by easily available or provided knowledge +++

Institute of Medicine (2006) Improving the Quality of Health Care for Mental andSubstance-Use Conditions: Quality Chasm Series. Washington: National Academies Press, p. 170.

p y y p grequired for its use

Developing a Telemental Health Servicep g

Step 1: Needs

Identification Step 2:

Step 6: SolidificationMonth 12

nt f cat nMonths 01-06

pInfrastructure

SurveyMonths 03-06

St 5

Step 3: Partnership

OrganizationsStep 5: Pilot

ImplementationMonths 09-11

Step 4:Structure

Configuration

OrganizationsMonths 03-06

gMonths 07-08

Clinical Considerations - Highlightsg g

• Telemental Health can be an effective way to deliver ymental health services to children and adolescents and their families, but it does require some adaptation from face to face delivery of clinical mental health servicesface-to-face delivery of clinical mental health services. Key considerations include the following:– Orient youth to this medium of interaction and answer their

ti ith di t t i f tiquestions with direct, concrete, informative responses.– Communication is more deliberate and animated to overcome

technological impediments to establishing rapport with youth.

Clinical Considerations - Highlightsg g

– Rapport-building can be facilitated by providing the youth experience with the technology

• how to use the remote control to manipulate the cameras so as to obtain a “close-up” of himself or his/her parents or to scan the t l hi t i t’telepsychiatrist’s room .

– The picture-in-picture feature can distract or upset some patients, If so, turn it off .

• e.g., children diagnosed with autism.– Hyperactive, oppositional, or developmentally impaired youth

may need parents’ assistance in using or interacting with the i tequipment.

Clinical Considerations - Highlightsg g

– Cultural issues can be more challenging than in typical practice for several reasons

• Differences in comfort with technology• Eye contact, non-verbal communication, and play• Geographic (and cultural) separation• Distinct institutional cultures

Clinical Considerations - Highlightsg g

Teen Child Young ChildSpace Large enough to allow for interactions

and playAssessment Teen should be

seen without parent for at least part of assessmentassessment

Behavioral Issues & Staffing

Staffing should be adequate to ensure safety. Staff should be easily accessible if they are not in the room.

Psychotherapy Telemental health is regularly used for individual familyPsychotherapy,Prescriptions

Telemental health is regularly used for individual, family, and group psychotherapy as well as medication management.

Administrative Issues - Highlightsg g

• Licensure – clinician must be licensed in the remote and local state (if practicing across state lines)

• Staffing – typical NATP clinic– Remote clinician– Local clinician (ideally in room)– Outreach worker (scheduling, follow-up)– IT specialist (on call)

Administrative Issues - Highlightsg g

• Record keeping – while paper record keeping is p g p p p gworkable, these clinics operate much more efficiently using electronic health records.Billi M di id d 3 d t i b f• Billing – Medicaid and 3rd-party payers reimburse for telemental health services in most states, but rules vary.

Telemental Health GuideTelemental Health Guide

http://www.tmhguide.org/