Innovation in Technology: Efficient Access to Quality Services Jennifer Armstrong, Director of Crisis Care Services- Centerstone of TN Liam Barry, Director of IT Infrastructure-Centerstone of TN Jennifer Smith, Team Lead, Northern Region Mobile Crisis- Centerstone of TN

Centerstone Nation’s largest non-profit provider of community-based behavioral health services Annually serves over 60,000 children, adolescents, adults, seniors and their families in Tennessee Mission: To prevent and cure mental illness and addiction Part of a national collaboration promoting the Zero Suicide Initiative Recent mergers with other states including KY, IL, IN, FL Provide an array of services from outpatient services to residential Have used telepsychiatry for medication svcs, televideo for therapy with commercial payers,

Centerstone Crisis Services Crisis Center 9 local and national partners- crisis lines Crisis Call Team Crisis Follow-up Team (High Risk services available across all crisis lines, BCBS grant, NSSP grant, GLS grant) Crisis Chat/Text Team- NSPL Crisis Chat, Hopeline Chat 25 masters level clinicians AAS, CARF, CUSA, OES accredited Team office: Nashville, TN.

Centerstone Crisis Services Mobile Crisis Services- 3 regions across 21 counties Crisis Management Strategies team- local and national training; critical incident response Create a culture committed to dramatically reducing deaths by suicide Provide training for clinical staff to enhance knowledge and skills in the area of suicide prevention Consistently assess suicide risk levels among people in our care by using a suicide severity screening tool (C-SSRS). This tool must be completed by a clinical staff member at intake and at each contact with the client Ensure every person has a pathway to care that is both timely and adequate to meet their needs Provide continuing contact and support, especially after discharge from inpatient care

Remote Services- Crisis Call Center Why? 2009: Program cuts that reduced staff size from 15 to 6 3600 total calls per month; crisis call services only; 3 crisis lines managed Per TDMH contract, must have 24/7 access to live person: Centerstone Crisis Line and TN Statewide Crisis Line IT team research with current vendor (Cisco)- security, HIPAA concerns, etc..

Remote Services Equipment and Tools (approx. $2K per staff) Laptop Cisco Phone & Headset Home Internet Connection Cisco ASA Battery Back-up Private home office set up and monitored by IT staff

Remote Services

Remote Services Centerstone uses a Cisco ASA – Model 5505 to secure the connection. What is a Cisco ASA? The Cisco ASA is a device that creates a private connection from one location to another. The connection (or tunnel) is secure and private The tunnel is encrypted Quick and easy to set up The connection is monitored by our Network Operations center The cost of an ASA is approximately $400.00. What does ASA stand for? ASA is simply a marketing term by Cisco. It’s an acronym for: Adaptive Security Appliance

Remote Services Now what? Cc-Modeler Professional Software: Kooltoolz (www.kooltoolz.com) Workforce Management Improving Service Performace Projects needed staffing/where in meeting access standards Utilizes call volume and staffing patterns Staffing truly by volume

Remote Services Phase in: SLOWLY! Overnight, afterhours, then all day Daily IT correspondence; staff communication and monitoring Shift in service: Crisis intervention services only No I and R Afterhours functions for Centerstone of TN NSPL- relinquished regional services to backup for TN only -all outpatient locations move to vm afterhours/press 1 for crissi -automated referrals for Cstone outpatient services -

Remote Services Guidelines: Remote office must be set up in a private location in the home as assessed by IT staff. Access to an assigned Centerstone office location (all assigned sites must be within one hour of home office). Internet access provided by staff member. Staff will use equipment issued and installed by Centerstone Information Systems. Must attend all clinical supervision and team meetings. Monthly team meetings; bi-weekly (in-person) meetings; weekly phone supervision PROBLEMS: (i.e. home internet or electricity down, problems with server).

Remote Services Emergency Back-up Plan: Service disruptions: Determine if back-up coverage is warranted Utilize on-call staff Utilize back-up on-call staff as needed If outage exceeds 20 minutes, relocation to assigned Centerstone location for completion of shift. ISP outage; server down- outage;

Remote Services: Monitoring and QA: Monitor staff efficiencies as if on site Can only pull team asa and ar, but can use this to determine how time is spent, nature of services provided/calls taken Can for both incoming and outgoing calls- so for crisis call team and follow-up team

Remote Services Monitoring/QA:

Remote Services Monitoring/QA:

Remote Services Monitoring/QA:

Remote Services Monitoring/QA:

Remote Services Monitoring/QA:

Remote Services Communication:

Remote Services Pros Cons Right sized staffing Built in emergency back-up plan Staff retention Same monitoring capabilities Staff communication Coverage nationally during disasters Cons Agent Status/Availability Staff connectedness- ongoing struggle

Centerstone’s Mobile Crisis Funded by Tennessee Department of Mental Health & TennCare (state Medicaid) Overall contractual goal is to act as a diversionary resource to most appropriate, least restrictive setting Response is to any location requested in 20 county catchment area -Services under contract specifically reimburse for uninsured and TennCare insured but will not refuse Crisis assessment regardless of payer. -3 separate teams covering 20 counties -TN has O/P, iOP, respite, crisis stabilization units, partial hospitalization, MMCD, and voluntary treatment as alternatives to involuntary hosp -majority of assessments (~80%) occur in ED setting

Mobile Crisis: The Northern Region Seven county catchment area Average 250 assessments per month Response time average- 90 minutes Up to 98 miles roundtrip Average mileage per assessment- 54 miles -3 outpatient clinics

Implementation of Televideo The beginning 2012: Pilot project with HCA/TriStar and Cisco Remote connection from laptop to cart placed in ED using Movi/Jabber Response time averaged 30 minutes 1st six months averaged four assessments per month Next steps 2013: Two more HCA affiliations Cisco Movi/Jabber replaced with InTouch equipment -HCA/TriStar owns multiple ED’s in Middle TN as well as inpatient psych hospitals -issues with connectivity -issues with technology being user friendly -

Implementation of Televideo Currently Initial Assessment: Emergency Department: iPad to ED cart via InTouch Centerstone O/P Clinics: iPad to iPad/laptop via Cisco 427 assessments to date Average response time to date- 27 minutes Evaluation component for client feedback Involuntary Hospitalization: 1st Certificate of Need 2nd Certificate of Need to RMHI

Questions? Contact Information: Jennifer Armstrong, LPC-MHSP jennifer.armstrong@centerstone.org Liam Barry liam.barry@centerstone.org Jennifer Smith, LMSW jennifer.smith@centerstone.org