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The National Telehealth Webinar Series May 17, 2018
Presented by The National Consortium of Telehealth Resource Centers
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Webinar Tips & Notes Your phone &/or computer microphone has been muted Time is reserved at the end for Q&A Please fill out the post-webinar survey Webinar is being recorded Recordings will be posted to our YouTube Channel BSF3QK-yg
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Telebehavioral Health Models and Strategies for Rural Hospitals and Clinics
Jonathan Neufeld, PhD Director, gpTRAC
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Outline Intro to gpTRAC Conceptual Prerequisites Regulatory Context
Reimbursement/Sustainability Program/Service Design Q&A
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BACKGROUND
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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
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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
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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)
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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)
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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
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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.)
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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
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Direct Care & Telepsychiatry
Bill per coverage
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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
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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
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Contracted Services (Hospital)
$
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Contracted Services (Private Company)
$
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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 **
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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
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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
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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.
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Integrated Medical Record
Tele-health Equipment Primary Care Provider Behavioral Health Consultant Shared EMR
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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
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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
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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
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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)
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CoCM Rates
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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
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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
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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
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Service Networks SERVING NORTHEAST MINNESOTA WITH INTEGRATED PUBLIC HEALTH CARE AND HUMAN SERVICES THAT ARE EFFICIENT, ACCESSIBLE AND AFFORDABLE.
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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
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Emergency MH Evaluations
48-bed rural hospital
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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)
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Clinical Processes Should Drive Design
PROGRAM ESSENTIALS Sustainable revenue Motivated clinicians Community need Dedicated staff ALSO IMPORTANT Solid broadband Flexible technology Knowledgeable partners
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Resources (mentioned in Q&A)
Comparisons of telemental health software: Video Platforms:
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Contact Information Jonathan Neufeld, PhD (574)
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Your opinion of this webinar is valuable to us
Your opinion of this webinar is valuable to us. Please participate in this brief perception survey: 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
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