TELEPSYCHIATRY FOR ILLINOIS HEALTH SYSTEMS Trilok Shah, M.D.

GOALS Background Discuss benefits of a telepsychiatry program Discuss steps to developing a telepsych program Discuss answers to commonly asked questions

BACKGROUND Graduated Medical School University of Illinois COM Psychiatry Residency from Advocate Lutheran General Board Certified by American Board of Psychiatry and Neurology Started In Touch Physicians telepsychiatry group to reach patients in underserved areas Implemented new telepsychiatry programs across a variety of settings Work with patients admitted to acute inpatient psychiatry units and with outpatient psychiatry clinic patients

WHAT IS IT? Psychiatry services carried out using audio-visual medium Focus on the service not the technology Has been around for long time

WHERE IS IT BEING DONE? Hospitals - ERs, Consults, Inpatient Clinics - Private practice, CMHC, FQHCs, RHCs Schools Correctional facilities Nursing/residential homes Locum tenens coverage

EMERGENCY ROOMS Community Hospital of San Bernardino, Dignity Health System Program for their emergency rooms Connected the emergency rooms at several different sites with one centralized psychiatry service Improved ER throughput, sped up bed turnover time, helped ER physicians with disposition Midwest Medical Center in Galena and FHN in Freeport, IL Telepsychiatry demonstration project for their ERs Connected ERs in rural hospitals with 24/7 psychiatry service. They had NO psychiatry services before the program.

PSYCHIATRY UNITS Swedish American Hospital in Rockford, IL Program for inpatient psychiatry unit Supports onsite psychiatrists who are overburdened Provides much needed weekend psychiatry coverage Offers the providers, the patients, and the managers more choice Continuity of care for patients, as opposed to locums docs turnover, and at a reduced cost

OUTPATIENT CLINICS Gibson Area Hospital in Gibson City, IL Program for their behavioral health clinic Huge influx of new patients for the hospital from all over the map Rosecrance in Rockford, IL Program for outpatient clinics and residential care patients Reduces the logjam that many clinics have in getting patients seen by a psychiatrist Eases burden on PCPs who are stuck dealing with complex psych issues on their own

OTHERS SCHOOLS California State University at San Bernardino Program for their student health center CORRECTIONAL FACILITIES California Department of Corrections Program for their correctional system

WHY IS IT BEING DONE? Increased Access to Providers Improved Quality of Care Cost Benefits and Improved Workflow Value Beyond Fee for Service

Increased Access to Providers A Congressional report earlier this year said 55% of the nation’s counties have NO practicing psychiatrists, psychologists or SWs According to HHS, Illinois has a deficit of 169 Psychiatrists In rural AND urban areas

Improved Quality of Care PCPs recognize and diagnose less than half of mental disorders Pirl, W.F.; Beck, B.J.; Safren, S. A.; Kim, H. (2001). "A descriptive study of psychiatric consultations in a community primary care center". Primary Care Companion Journal of Clinical Psychiatry, 3 (5): 190–194. doi: /PCC.v03n0501 PCPs prescribe 50% of psychotropic meds- often out of necessity

DEVELOPING YOUR PROGRAM Convene Your Telemedicine Team Assess the need & the current resources Develop your financial plan Select provider Select technology Develop protocols & do practice runs Set launch date & market Launch program

Convene Your Team Project Manager IT Representative Financial Officer Quality Improvement Representative Provider (?)

Develop Your Financial Plan What will be the associated costs Provider Support staff Equipment and setup – a much smaller cost now Reimbursement

Medicare & IL Medicaid Geography Rural for Medicare- Telehealth Payment Eligibility Analyzer HPSA for Medicaid Facility- office, hospital, RHC, FQHC, SNF, CMHC Provider- must have completed a psychiatry residency program CPT codes- most evaluation and follow up codes Reimbursement to the health professional is the same as in-person amounts. Originating (patient) site is reimbursed an additional $25 per telemedicine encounter

Select Your Provider Fits your needs Availability Experience Subspecialty Willingness to work with the whole team Long term relationship with your facility and patients

Our Providers Are… Illinois licensed, Board certified psychiatrists Local and interested in serving the patients here Adult and child specialists Experienced in implementing programs in different settings Are thoroughly vetted, and have clean practice records Go through extensive training process Able to help with credentialing, billing, technology, staff training, developing protocols, and with data collection for continuing program evaluation English proficient, and not requiring any visa sponsorship Backed by $1mil/$3mil liability coverage

Models We Offer Direct patient care Popular for CMHCs, RHCs, FQHCs A remote provider supplements onsite care Pre-scheduled appointments Provider can do what onsite provider would do: Med management Initial evaluation Follow-up care Treatment team meetings

Models We Offer Crisis Telepsychiatry Popular model for ERs Rapid, on ‐ demand access to a psychiatric professional Offer psychiatric assessment, admission and commitment decisions 24/7/365 availability Response time: Less than 1 hour

Models We Offer Consultation Model Consultation for onsite providers who are caring for patients with psychiatric issues Provider may participate in treatment teams taking part onsite Provide educational seminars on commonly encountered psychiatric issues- depression, substance abuse, suicide prevention, controlled medication prescribing

Model We Will Offer Online Provider Platform Providers sign up on our secure site to provide psychiatry and therapy services Patients select a provider based on the provider’s profile and reviews Patients schedule appointment online Patient and provider have brief call prior to initial appointment to ensure good fit Appointment takes place on secure platform

Select the Technology Work with your provider to ensure compatibility Engage your IT team, but do not let them be the sole decision makers Security is not just about the technology- it is also about how it is used Think about long term needs Need mobile unit? Technology costs are no longer prohibitive

Develop Protocols & Practice Runs Scheduling Medical records Prescribing - Controlled medications Orders - Ordering and receiving results Consents Loss of signal or loss of power Emergency situations

Keys to Sustainability Expect to encounter some resistance Train Expect to make adjustments Inform everyone early Keep the onsite team engaged Challenge team to focus on the positives Address fears about being replaced Support, not replace Keep the provider engaged Include them in your lists Familiarize them with the community’s resources Inform them of major changes in the organization

COMMON QUESTIONS Will patients like it? Does it work?

Will Patients Like It? A number of patients prefer this: Access Convenience Cost savings Distance is perceived as protective by some patients Neutral place So many patients already use similar technology to socialize/keep in touch with others

Do Our Patients (and Sites) Like It? Timeliness of Service Average time for our providers to respond to ER consult is less than 30 minutes Patient seen and documentation completed on average within 60 minutes Wait time for our outpatient clinic patients once they are checked in is less than 10 minutes Patients Satisfaction Patient satisfaction with psychiatrist 89% Patient satisfaction with telepsychiatry experience 91% 80% of patients reporting their telepsychiatry experience being equivalent to an in-person encounter, and 10% reporting that it was very close to being equivalent

Does It Work?

MORE COMMON QUESTIONS How does a typical telepsychiatry encounter go? Can the In Touch providers prescribe medications? How do In Touch providers document? Can the In Touch providers integrate with the healthcare team at my organization? Can we supplement the In Touch telepsychiatry services with our own psychiatrists?

RESOURCES In Touch Physicians Resource Center Practice Guidelines for Tele-Mental Health Services edicine_core_guidelines.pdf edicine_core_guidelines.pdf Practice Guidelines for Telemedicine Services ce-guidelines_videoconferencing.pdf ce-guidelines_videoconferencing.pdf American Telemedicine Association Telepsychiatry in the 21st Century atry_in_the_21st_century.pdf atry_in_the_21st_century.pdf

DISCUSSION Trilok Shah, MD President, CMO