Mental Health Services via Telehealth

Finger Lakes Community Health Community/Migrant Health Center Program (FQHC) Migrant Voucher Program in 42 Counties of NYS Clinical Sites: 9 Health Center Sites Administrative Office: Penn Yan, NY 175 Employees – 46% bilingual/bicultural 2

Where We Are 3 Blue Star – FQHC Site Red Circle – CM Services

What is Tele-Mental Health? Tele-mental health, like telemedicine, is the provision of mental health care from a distance. Tele-mental health uses two-way, high definition, live videoconferencing technology to provide mental health assessment and intervention. The goal of tele-mental health services is to eliminate disparities in patient care and give access to quality, evidenced-based, and emerging health care diagnostics and treatments. 4

Challenges in Service Delivery Cultural and language barriers in accessing care outside of health center sites Lack of availability of providers in rural areas Distance traveled to seek health care Coordination of access to specialty care Costs and liability issues related to enabling services provided to patients Stigma associated with mental health services 5

Why Telehealth? For our patients, we have found that it is necessary to have as many services available on site for our patients. For mental health services particularly in small communities, stigma is a major concern for patients. Transportation is a barrier to care in most rural communities. Tele-mental health can fit nicely into an integrated delivery system that breaks down silos as a more inclusive means of providing care that includes all of the patient’s healthcare team as well as the patient. Telehealth has allowed us to use technology as a tool to reach out to a wide variety of healthcare providers, regardless of distance, to increase access to care and collaborate with others in our region. 6

Challenges of Implementing Telehealth Difficulty in developing clinical and staff champions within the program. They must see the benefits of the program for patients. Need for seamless integration of broadband, systems & equipment, applications and program development into a cohesive sustainable model. General fear of new technology. Start up costs for equipment. 7

Telehealth & the Triple Aim Improved Access: Increased access to specialists, primary care doctors, behavioral health providers, remote home monitoring Better Care: Reduced readmissions into hospital Better access to clinical data (remote monitoring) More clinical educational opportunities, expertise / knowledge sharing Care coordination Lower or Stabilized Costs: Remote monitoring enables patients to be monitored at home Lower utilization rates of ambulatory care Better access = lower costs per patient 8

FLCH Telehealth Guidelines Telehealth / telemedicine is a tool. Program Management can uncover strengths and weaknesses in operations of your centers. Quality Improvement is FOREVER! Management of telehealth by facts = DATA Need to see cost benefits from different perspective. Keep a sense of humor! 9

What We Need To Connect? Telehealth Program Development – a 3 layer strategy Layer 1: Broadband/Internet Connectivity Layer 2: Telehealth infrastructure and end user equipment Layer 3: Telehealth Program Development and Clinical and Educational Applications 10

Layer 3 – Telehealth Applications Program Development is very important and can be tedious, but it is worth the effort! Develop a work plan that outlines who, what, how, where and when. Plan on 6-8 months of program development from the start to your first clinical visit. Plan on mock visits to help all parties run through the process. Document your process for staff to have. 11

Layer 3 – Program Development Workplan 12

How We Connect Internet Provider SidePatient Side 13

FLCH: An Integrative Model of Care Primary Care Behavioral Health Dental 14

Tele-Mental Health Clinical Process Referrals by Primary Care Provider to mental health services Intake process Scheduling with the Psychiatrist/LCSW Patient arrival and “rooming” procedures Clinical visit Documentation of clinical visit Follow-up Billing Quality control / outcome data tracking 15

Components for a Tele-Mental Health Program Work Plan Documents: Tele-Mental Health Clinical Process Tele-Mental Health Pilot Development Work Plan Tele-Mental Health Work Plan Detail Tele-Mental Health Emergency Evaluation Policy & Procedure Patient Documents Needed: Consent To Participate In A Tele-Mental Health Consult Tele-Mental Health Patient Emergency Info letter Tele-Mental Health Patient Experience Survey Tele-Mental Health Registry Sheet Tele-Mental Health QI Tool 16

Suggested Models of Tele-Mental Health Services Model 1: Licensed Clinical Social Worker (LCSW) provides mental health counseling sessions remotely via video Model 2: Patient Visit with LCSW on site and Psychiatrist Via Video Model 3: Patient Visit with Psychiatrist via video without LCSW on site. All via video 17

Model 1: Licensed Clinical Social Worker (LCSW) provides mental health counseling sessions remotely Model 1 Benefits: Allows the LCSW to expand his/her reach particularly for organizations that have multiple sites but few LCSW’s. To consider: a. Who will “room” the patient? b. Who will “telepresent” the patient and initiate the video call? c. Does the “telepresenter” understand the process in the event the patient becomes suicidal or has other concerns? d. Have a process to ensure that the LCSW, the patient and the primary care provider understand the outcomes/follow-up. e.Make a plan to wrap up the visit, huddle with the patient, and then bring him/her to the checkout area. f. How will follow-up be ensured? 18

Model 2: Patient Visit with LCSW on site and Psychiatrist Via Video Model 2 Benefits: Creates a real collaborative relationship and a team approach to the patient’s care. To consider: a. Who will be responsible for the management of the patient’s MH care? b. Who will “room” the patient at the remote site? c. Who will “telepresent” the patient and initiate the video call? d. Does the “telepresenter” understand the emergency procedures in the event the patient becomes suicidal or shows other issues? e. Have a process to ensure that the LCSW, the patient and the psychiatrist agree and understand the outcomes and needed follow-up. f. Make a plan to wrap up the visit, huddle with the patient, and then bring him/her to the checkout area. g. How will the patient record be updated both by the psychiatrist and by the primary care provider? 19

Model 3: Patient Visit with Psychiatrist via video without LCSW on site Model 3 Benefits: Provides access to mental health services while breaking down geographic barriers. To Consider: a. Who will “room” the patient? b. Who will “telepresent” the patient and initiate the video call? Keep in mind that this will be a three way call! c.Does the “telepresenter” understand the process in the event the patient becomes suicidal or has other issues? d.Need to ensure that the LCSW and the Psychiatrist are up to speed on pertinent clinical/psycho-social info before the visit takes place. e.After the session, all three parties need to “huddle” to ensure that everyone is on the same “page” in terms of medications, treatment, follow-up, etc. f.There needs to be a process in place for the sharing of health information so that the patient’s record is up to date with all providers of that patient’s care. g.Care Management is very important and should be considered a part of the patient’s care team! 20

Finger Lakes Community Health LCSW’s at FLCH between sites Family Institute (FQHC in NYC) Tele-Psychiatry Tele-Mental Health 21

Tele-Mental Health Outcomes Tele-Mental Health Outcomes % had decrease in PHQ-9 scores Mean time to consult = 19 days Mean time to treatment = <24 hours 0% referred to Emergency Room 17% referred to higher level of care Increased interaction between primary care and psychiatrist High patient and provider satisfaction! 22

Finger Lakes Community Health Univ. of Rochester Medical Center Pediatric Neurology TelePeds Neurology 23

TelePeds Neurology Outcomes Focus Population: Children with poorly controlled symptoms of ADHD or other diagnoses. Decreased time to treatment (38 days vs 60 days). Exceeded national averages on NCQA performance measures 90% had changes or additions to their medication regimens 95% diagnosed with mental health co-morbidity 32% started mental health medications 100% referred to behavioral health 40% showed improvement in function at school and home High patient and provider satisfaction! 24

Finger Lakes Community Health St. Joseph’s Hospital Syracuse, NY TelePsychiatry for Children 25

TelePsychiatry for Children Workplan Steps January Agreement to collaborate by both parties February 2015 – Site visits: 1. To St. Joseph’s in Syracuse 2. To view the setup of a child playroom at Mental Health office March - April 2015: 1. Business Associate’s Agreement 2. Memorandum of Understanding 3. Credentialing of providers by FLCH May 2015: 1. Work plan development with details 2. Begin to set schedule of meetings to move work plan forward June 2015: 1. Test video equipment including peripherals 2. Test broadband connectivity levels between St. Joe’s and FLCH July 2015: 1. Meet and greet between St. Joe’s and FLCH providers 2. In-service for primary care providers (FLCH) 3. See “mock” patients to test process from check in to provider visit August 2015: 1. Live consults begin! 26

Care Coordination: Scheduling Pre-Visit Requirements Concurrent Chart Review Coordinate with PCMH Team/Specialty Team Quality Assurance Reports Case Conferencing: Providers, Care Managers, Patient Navigators Quality Improvement Activities: Data Collection Monitor and Report Outcomes Continuous Quality Improvement Regularly Evaluate Program Other Key Components for Successful Telehealth Programs 27

Resources Available on Tele-Mental Health The American Telemedicine Association (ATA) has great resources for clinical guidelines on a variety of clinical areas. They are a great source of information. 28

Consortium of Telehealth Resource Centers 29

Two thoughts to remember… Telehealth is not about fancy equipment and technology. It’s a tool used to improve access and enhance quality of care. Implementing telehealth is a process, not a destination. Steps to Success 30

FLCH Contact Information Mary Zelazny, CEO Sirene Garcia, Director of Special Programs Finger Lakes Community Health PO Box 423 Penn Yan, NY