1. The National Telehealth Webinar Series May 17, 2018
Presented by The National Consortium of Telehealth Resource Centers

3. Webinar Tips & Notes
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4. Telebehavioral Health Models and Strategies for Rural Hospitals and Clinics
Jonathan Neufeld, PhD
Director, gpTRAC

5. Outline Intro to gpTRAC Conceptual Prerequisites Regulatory Context
Reimbursement/Sustainability
Program/Service Design
Q&A

6. BACKGROUND

7. Four Domains of Telehealth
Hospital & Specialty Care
Specialists see and manage patients remotely
Integrated Primary Care
Specialists (often MH) integrate services into primary care environment
Remote Monitoring for Transitions and Maintenance
Physiological and behavioral monitoring to maintain best function in least restrictive, least expensive, or most preferred environment
Direct to Consumer Services (Primary/Urgent Care)
Convenient access to needed/desired services; popular among younger, busier, and generally healthier patients; not recommended for chronic disease care
NOTICE: Domains are about service model, not technology (mostly; RPM)
Value drivers are different for each domain

8. Conceptual Framework
TELEMEDICINE IS A DELIVERY MECHANISM, NOT A SERVICE
Providers need no new certification or credentials
All regulations apply equally to telehealth
ANALOGY
Army field hospital operations

9. Regulatory Environment
FEDERAL REGULATIONS
All Healthcare & Privacy Regs (Stark, Anti-kickback, HIPAA)
Prescribing Controlled Substances (Ryan Haight Act)
In person visit required before prescribing controlled substances (or consultation model)
Telemedicine exemption (undefined)
Medicare (reimbursement)

10. Regulatory Environment
STATE REGULATIONS
State Healthcare Regs (may include separate MH regs)
Licensing Boards (many are silent regarding telehealth)
Medicaid (reimbursement)
Commercial payer regulations (reimbursement)

11. Changing Conventions
Goals and Technologies of Healthcare are Changing -
Telemedicine has almost always been defined as “live interactive video”
Asynchronous (“store and forward”) telemedicine is generally regulated and covered as a separate service (and only covered in a few states/plans)
Telephone, fax, and are (almost always) excluded

12. Changing Conventions New Approaches and Technologies
Population health - not every service is a “billable encounter”
Simple, low-cost telecommunications options are ubiquitous - cell phones, apps, text messages, IVR, etc.
Provider shortages are driving new workforce innovations - “Force multipliers” (provider consultations, collaborative care, ECHO, etc.)

13. A Successful Telehealth Service
FOUR COMPONENTS (in order)
Services (Assessing, Defining, Finding, Developing, Structuring)
Needs, Partners, Vision
Sustainability (Reimbursement and/or Value Proposition)
Operations (Policies & Procedures)
Technology

14. Direct Care & Telepsychiatry
Bill per coverage

15. Billing Direct Care Services
Service legally occurs at the patient’s location (implications for licensure, credentialing, etc.)
Provider has the right to bill for services (or turn over billing)
CPT is the same as in-person
Modifier “GT” added to indicate “via live 2-way video”
“GQ” is also available for “store and forward” services
Place of Service = “02” (telemedicine)
“Physical location” of the provider is irrelevant/immaterial
Think of “billing entity” instead

16. Most Telehealth is NOT THAT
MOST TELEHEALTH IS STRUCTURED DIFFERENTLY
Internal resources are re-deployed (MOST common)
Internal value generation is the goal (reducing costs/penalties)
External resources are engaged via contracts
REASONS:
Hard to interest hub/urban providers (busy enough already)
Hub-and-spoke model is hard to sustain financially

17. Contracted Services (Hospital)$

18. Contracted Services (Private Company)$

19. Common Challenges (in order)
Value generation & monetization
It will take time/effort/money; what will you get back?
Generating internal interest, utilization, acceptance
Need for champions among thought leaders (providers) and executives
Technical (or policy) decisions misunderstood, inflexible
Inadequate information
No unified vision OR inability to develop/support local vision(s)
** These are management issues, not telehealth issues **

20. Telehealth Models for Mental Health
Direct Services (Specialty Care; Integrated Primary Care)
Chronic Care/Collaborative Care Management
ECHO Groups
Networks for Sharing Resources
Emergency Evaluations & Placement

21. Program Model - Specialty Care
Providing an existing specialty service to a larger area.
“Outreach Clinics” without the travel time.
Primary Challenges:
Credentialing at patient site
Credentialing by proxy is possible, but often as difficult as direct credentialing
Coordinating resource use with local clinic (scheduling, rooms, staff, etc.)
Sustainability at rural (patient) site

22. Program Model - Integrated Primary Care
Contracting Psychiatry/MH for primary care clinics or EDs.
Direct Services or Collaborative Care (new model)
Service Components:
Initial evaluations (90791/90792)
Medication management (E&M Codes, )
Psychotherapy (90832/90834)
Crisis intervention (90837/90839)
Providers can integrate care via letters/reports, or be credentialed locally and use local EMR.

23. Integrated Medical Record
Tele-health Equipment
Primary Care Provider
Behavioral Health Consultant
Shared EMR

24. Chronic Care Mgmt (CCM; 99490)
Registry-enabled team-based care for multi-morbid chronic disease patients.
CPT: 99490, 99487, 99489, G0506
Services include:
Transitional Care Management
Coordination with Home- and Community-Based Clinical Service Providers
24/7 Access to Address Urgent Needs
Enhanced Communication (for example, )
Advance Consent
Use of a Certified Electronic Health Record (EHR)
Continuity of Care with Designated Care Team Member
Comprehensive Care Management and Care Planning

25. Collaborative Care Mgmt (CoCM; 99492/3/4)
Initiating visits and assessments, administration of rating scale(s) by a psychiatric care manager (PCM).
Care planning by the primary care team, jointly with the beneficiary, with care plan revision for patients whose condition is not improving adequately (treatment to target).
Proactive, systematic follow-up by PCM using validated rating scales and a registry
Assessment of treatment adherence, tolerability, and clinical response using validated rating scales; brief psychosocial interventions such as behavioral activation or motivational interviewing.
70 minutes of behavioral health care manager time the first month (60 minutes subsequent months; add-on code for 30 additional minutes)
Regular case review with psychiatric consultant

26. Collaborative Care (like CCM)
PSY
Chart review
Discussion with PCM
Recommendations to PCP
PCP
PCM
Behavioral Activation
Motivational Interviewing
Feedback to PCP
Reporting and Monitoring to PSY
Additional Therapy Services Pt

27. AKA “Behavioral Health Care Management”
Care manager (PCM) is not necessarily licensed
Nurse, LCSW, MH technician (any level of MH training OK)
“...with formal education or specialized training in behavioral health…”
Indirect supervision by the treating/billing physician or NP
If licensed, separate services by PCM are separately billable
PCM services can be in person or by video, and don’t always need to include the patient (data review, consultation with other team members)

28. CoCM Rates

29. CoCM Business Case Enrolled Patients = 50
Staff: PCM (20 hrs/wk) + Psychiatrist (2 hrs/wk)
Psych Weekly: 1 Case Review Session + 1 eval or 3 follow ups
PCM Weekly: 1 Case Review Session, 1 PCP Session,
10-15 therapy sessions, phone calls
Monthly Revenue = (50 * $145) + (50 * $90) = $11,750
Monthly Costs = PCM ($5,000) + Psychiatrist ($1,000) = $6,000

30. Billing Collaborative Care in FQHCs/RHCs
Slightly different reimbursement:
G General Care Management (average of 3 non-fac rates)
G Behavioral Health Care Management (average of 2 non-facility rates; currently $145.08)
Same requirements as regular CCM/CoCM

31. ECHO Groups Making “mini-specialists” out of Primary Care Providers.
Monthly online case conferences with a leader (specialist) and participants (PCPs)
Participants present cases and discuss treatment
Very complex cases can be referred to specialist
Findings:
PCPs develop specialty skills, keep more cases
Specialist sees only most complex cases

33. Service Networks
SERVING NORTHEAST MINNESOTA WITH INTEGRATED PUBLIC HEALTH CARE AND HUMAN SERVICES THAT ARE EFFICIENT, ACCESSIBLE AND AFFORDABLE.

34. Arrowhead Telepresence Coalition
Multiple organizations joining under a common telepresence platform - DHS/MN.IT telepresence network
70 separate organizations/entities
300 accounts on the
access to over 4000 users statewide
Primary purpose is improved behavioral health services

35. Emergency MH Evaluations
48-bed rural hospital

36. MH Emergency Care Pgm 12,000 ED visits annually No on-site MH
300 are purely psychiatric in nature
No on-site MH
Partnered with ITP
Team of 30 Psych Prescribers
47 Hospitals: ER, Med Consults, Inpt
2,500 Emergent Cases Handled
24/7/365 Patient Advocate Assistance (placement)

37. Clinical Processes Should Drive Design
PROGRAM ESSENTIALS
Sustainable revenue
Motivated clinicians
Community need
Dedicated staff
ALSO IMPORTANT
Solid broadband
Flexible technology
Knowledgeable partners

38. Resources (mentioned in Q&A)
Comparisons of telemental health software:
Video Platforms:

39. Contact Information
Jonathan Neufeld, PhD
(574)

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TRC activity is supported by grants from the Office for the Advancement of Telehealth, Federal Office of Rural Health Policy, Health Resources and Services Administration, DHHS