VHA INNOVATION #669: HOME-BASED TELEMENTAL HEALTH Peter Shore, Psy.D. Director of Telehealth, VISN 20 Department of Veterans Affairs Apps, Telehealth, Virtual Reality: Addressing Mental Health Needs of Service Wo/Men and Vets

VHA INNOVATION #669: HOME-BASED TELEMENTAL HEALTH Telemental Health (TMH) Telemental Health – Clinic- Based Implemented in VA To date, over 500,000 encounters. Clinic based settings Virtually every DSM Virtually every treatment modality Home-Based Telemental Health – Non-Clinic Based Computer-to-computer or video teleconference technology-to-personal support computer utilizing an external or internal webcam for viewing on patient side with Federal Information Processing Standards (FIPS) secure and encrypted software technology. Remote Mobile Access Clinics (R-MAC). Video teleconference technology-to- mobile device (i.e. Tablet, Smart Phone, Netbook that has two-way camera capability). R-MAC utilizes FIPS secure and encrypted software technology. Unsupervised clinical settings and/or non-clinic based settings.

VHA INNOVATION #669: HOME-BASED TELEMENTAL HEALTH Portland VA HBTMH Pilot ( ) Initiated December 2009 as pilot at Portland VAMC by Dr. Peter Shore. First pilot in VA to establish mental health services into homes via webcam, personal computer. To date, 250 Veterans via approximately 800 clinical encounters. Create a patient-centric / provider-empowered program aimed at serving the mental health needs of Veterans whose access to care is restricted by geography, limited resources or who are home bound due to psychiatric and/medical conditions. Treatment provided in the homes, care facilities and/or remote location where ever the Veteran is situated. CPT for PTSD, Behavioral Activation for Depression, ACT for Chronic Pain, Anger Management, Cognitive Remediation (CogSmart), Chronic Disease Management, Medication Management

VHA INNOVATION #669: HOME-BASED TELEMENTAL HEALTH Portland Pilot - Key Features Standard Operating Procedure Manual (SOP) Patient Support Person Peer Support Specialist Train the Trainer ASH-25 – A Structured Guide for the Assessment of Suitability for Home Based Telemental Health (Shore, 2011). Risk Management and Suitability Measure Phase I: First Veteran seen February 2010 by Dr. Shore. 9 Veterans, 60 encounters, 4,012 Total Miles saved. Approximately $11, in travel reimbursement saved. 99% show rate.

VHA INNOVATION #669: HOME-BASED TELEMENTAL HEALTH Portland Pilot - Benefits Increased access to MH services / decreased barriers to treatment 80% of all enrolled would not have rec’d MH Less Veteran stress associated with travel Less potential for passing on sickness with clinic visits Flexibility in scheduling Lower cost per encounter (Provider clinic space, miles saved, travel reimbursement saved) Inherent environmental benefits with reduced transportation requirements No-Show(s) TMHHBMTH FY (455 encounters, 27.9%) 2 (64 encounters, 3.1%) FY 11 (thru 8/10/11) 97 (680 encounters, 14.3%) 1 (290 encounters, 0.03%)

VHA INNOVATION #669: HOME-BASED TELEMENTAL HEALTH VHA Innovation Program Situated in Office of Health Information. Mission: facilitate health care innovations in support of VA as it transforms to an organization that is Veteran-centric, results-driven and forward-looking Innovative ideas are selected for their focus on quality, safety, efficiency and transparency, and solutions that enhance the care and services VHA provides to our Veteran Innovators pilot their ideas to test approaches and methods that can be staged in an initial clinical demonstration area using the VHA’s Innovation Sandbox Cloud (Sandbox) Program hosts annual competitions designed to apply the ingenuity of VA’s front-line staff to improve care, quality, access and transparency for our Veterans

VHA INNOVATION #669: HOME-BASED TELEMENTAL HEALTH 2012 VHA Employee Innovation Competition Idea: Home Based Telemental Health (HBTMH) Expand Portland based pilot across VISN 20 utilizing a centralized scheduling and referral system and establishing a viable model for R-MAC (Remote Mobile Access Clinics). Based on number of votes Total Rank: 19 out of 3,841 ideas Patient Centered Care ranked 6 out of 1,651. Access ranked 5 out of 349 Telehealth ranked 2 out of 83. Mental Health: 16 out of 1,054.

VHA INNOVATION #669: HOME-BASED TELEMENTAL HEALTH Project Background Dr. Peter Shore implemented Home Based Telemental Health pilot in December Innovation will utilize SOP and ASH-25 Project addresses There are two significant challenges facing the Veterans Health Administration (VHA): 1) Access for Veterans to mental health treatment; and 2) Timeliness for Veterans to receive mental health treatment Establish a centralized scheduling and referral system to access a registry of decentralized providers. R-MAC: Remote Mobile Access Clinic Establishes significant access to services otherwise not available. VJO, etc. The project is funded by VHA Office of Innovation for one year funding $970, Kick-off August Completion in FY14. VHA Product Effectiveness Team collaborating on collecting and analyzing data.

VHA INNOVATION #669: HOME-BASED TELEMENTAL HEALTH Staffing Advisory work group Lead Innovation Coordinator Director of Operations Lead Clinical Psychologist * Lead Technology Consultant Peer Support Specialist, Technology * Program Support Assistant * Research Coordinator Approx 50 Mental Health Providers – VISN 20, Honolulu, Charleston, South Carolina * Full time paid contractors

VHA INNOVATION #669: HOME-BASED TELEMENTAL HEALTH Objectives Improve Access / Timeliness Expand Portland VAMC based pilot Feasibility of off hours to Veterans located on the East Coast and Hawaii Feasibility of array of non-VA settings Significant capture of Veterans not receiving care Improve Efficiency / Timeliness Centralized scheduling a referral system. “Air Traffic Control”: a consult comes into a centralized location (PACT Call Center) and a Medical Support Assistant accesses a registry of decentralized Mental Health providers based on specialty. The MSA links the Veteran to the next available provider in the “queue.” The location of the Veteran and provider is irrelevant given the nature of the modality. Zero Wait Time Access Significant cost savings to VA and Veteran Transform VA Health Care Borderless health care. Veterans seen anytime / anywhere Alternative video teleconferencing software. Establish new access points into existing programs R-MAC: Remote Mobile Access Clinic using Alternative communication devices (i.e. tablets). 250 iPads with cellular connectivity / 50 Netbook with MIFI

VHA INNOVATION #669: HOME-BASED TELEMENTAL HEALTH Metric Groupings Increased Access Appointment availability, Preference of modality. Improved Patient Care Clinical outcomes, perception of safety. Increased Operational Efficiency Decreased costs, cost avoidances, increased workload credit for TMH, improved data quality, improved system performance, preference of tools. Increased satisfaction General satisfaction, technical, clinical, veteran, provider.

VHA INNOVATION #669: HOME-BASED TELEMENTAL HEALTH How it works (37k’ foot view) Provider commits to.2 per week up until August 5, Provide subspecialty. Any VA providers submits consult via centralized mechanism. (Call center model). Consult triaged immediately, identification of decentralized provider via registry. Provider receives referral, contacts Veteran. Provider / Veteran mutually agree upon course of treatment, etc. If needed, provider applies for mobile device (iPad/Netbook) for synchronous visit. Treatment commences/completes. During treatment, Peer Support Specialist available / on-call for trouble-shooting technical. All workload captured by Provider’s medical center.

VHA INNOVATION #669: HOME-BASED TELEMENTAL HEALTH Ecosystem Processes to evaluate efficacy of technology Peer Support Specialist - Technology Special emphasis on mobile devices in non-VA settings Cross country access: South Carolina & Hawaii Each service drafts white paper Wide dissemination of iPads and Netbooks for clinical services and prove to be effective. New services: this innovation will create at least 5 new access points to services previously not available: i.e. VJOC, Caregiver support, Hospice Minimum of 25% all current TMH patients converted to in home, creating less burden to system Significantly low drop out rate and low no-show rates comparable to Portland pilot. Solve issue of extended hours. i.e. no distant side clinic personnel needed, no distant side clinic extended operation hours needed Developing a centralized scheduling program. The centralized scheduling and referral system establishes a “zero wait time” for Veterans scheduling Mental Health Services. TMH workload credit for facility increases by 10% Coordinate efforts with current ongoing research: Drs. Peter Shore, et. al (VA), Steven Thorp & Leslie Morland (VA), Greg Gahm & Dave Luxton (T2, DoD), Jim Spira (NCPTSD, VA), Ron Acierno (VA), Peter Tuerk (VA), Ray Folen (DoD)

VHA INNOVATION #669: HOME-BASED TELEMENTAL HEALTH Past Innovation #669 will leverage long history of success and lessons learned from Portland pilot. Showed significant benefits (expected and unexpected) Demonstrated feasibility of providing mental health care into non-clinic based settings. Followed a Standard Operating Procedure Manual and used ASH-25. Peer Support Specialist provided hands on technical support to Veterans. Patient Support Person part of emergency management protocols. Present Innovation implementing centralized scheduling and referral system to access registry of decentralized mental health providers. Registry of decentralized providers will see Veterans anywhere throughout VISN 20, including part-time on call crisis care. Innovation implementing full time Peer Support Specialist to provide on-call technical support to Veterans. Innovation deploying 250 iPads and Netbooks for short-term care. Use of iPads as an integrated synchronous / asynchronous clinic access point. Live care with Mobile apps as adjunct to routine car. Availability of off-hours access (South Carolina / Hawaii) Establish telehealth services in several new areas. “Tele-Justice” launched November Future Dr. Peter Shore, Innovation Lead, became Director of Telehealth for VISN 20 February Propose integrating the successful features of this innovation throughout telehealth programming in VISN 20. CVT to Home recently identified as #1 strategic planning priorities for FY14 (Telehealth Services, VACO) VISN 20 currently has MOUs in place with each facility to provide inter-facility care VISN 20 represents the largest geographic region in the U.S.

Peter Shore, Psy.D. Office (503) ext Mobile (503) Future home for results and resources: