1. 1 Presented to FADAA/FCCMH 2011 Annual Conference By J. David Moore,M.D., DLFAPA ValueOptions Vice President and Medical Director August 24 th 2011 Telepsychiatry's Role in Improving Access to Mental Health Care

2. 2 Limited access to Psychiatrists Significant transportation problems for consumers especially in more rural counties Loss of revenue when Psychiatrists have to travel Significantly High “No Show” rates causing even more limited access to Psychiatrists Difficulty in getting timely initial assessments done for both urgent and routine cases Florida Needs and Issues

3. Support from CMS Reimbursement for Medicaid covered services, including those with telemedicine applications, must satisfy federal requirements of efficiency, economy and quality of care. With this in mind, States are encouraged to use the flexibility inherent in federal law to create innovative payment methodologies for services that incorporate telemedicine technology. For example, States may reimburse the physician or other licensed practitioner at the distant site and reimburse a facility fee to the originating site. States can also reimburse any additional costs such as technical support, transmission charges, and equipment. These add-on costs can be incorporated into the fee-for-service rates or separately reimbursed as an administrative cost by the state. 3

4. Support from CMS Telemedicine For purposes of Medicaid, telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient's health. Electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site. Telemedicine is viewed as a cost- effective alternative to the more traditional face-to-face way of providing medical care (e.g., face-to-face consultations or examinations between provider and patient) that states may choose to cover. This definition is modeled on Medicare's definition of telehealth services located at 42 CFR 410.78. 4

5. AHCA Support for the Technology AHCA released the draft language for use in the upcoming Community Mental Health Handbook in July, 2010 The Draft language has continued to be modified up until the release of the handbook. AHCA gave the go-ahead with our Pilot and informed us of the codes to use prior to the publication of the Handbook AHCA representatives received a live demonstration of our system and were convinced that we more than met any of their concerns about clarity, lack of delays, and sufficient audio and video to provide the services through this technology 5

6. AHCA Guidelines Telepsychiatry may be done by a psychiatrist enrolled in Medicaid and contracted or employed by a CMH Provider Telepsychiatry may be used for all but initial psychiatric evaluations, assessments, or examinations A current psychiatric evaluation needs to be documented in the clinical record before doing telepsychiatry The psychiatrist must be at a CMH Provider location (not at their home) 6

7. AHCA Guidelines (cont.) Telepsychiatry providers must have technical written policies and procedures that comply with HIPAA privacy regulations and address the safeguards required by CFR Title 45, Part 164.312 Asynchronous transmissions not accepted (live interactions only) The clinical record must include a brief explanation of why services were not “face-to-face” Documentation of the assessment including findings and plan must be documented in the record. 7

8. Pilot Development July 09, 2010 – ValueOptions®, the nation’s largest independent behavioral health care company, leverages Verizon Telehealth Collaboration Services to securely offer cost ‐ effective telepsychiatry to residents of Immokalee, Fla., a remote community in the headwaters of the Everglades. Immokalee, is a rural agricultural community 30 miles east of Naples. Nearly half the residents of this largely migrant population live below the poverty line and struggle accessing healthcare due to language barriers, transportation issues and childcare. Providing the same timely access to psychiatric services as the individuals living in the more urban Naples area has been a challenge. ValueOptions chose David Lawrence Center, with offices in Naples and Immokalee, to provide real ‐ time consultations between clinical specialists and those in need of services. The remote consultations were enabled by high ‐ definition video conferencing units. 8

9. Concerns for the Pilot to Address Will this technology be accepted by the consumers and the physicians/therapists? Will this technology help with the transportation issues? Will this approach reduce no show rates for medication Management appointments Will consumers see this as an effort by the provider to help them with their problems accessing Psychiatrists in rural/remote areas? Will the provider be able to address getting the prescriptions to the consumer or pharmacy? Will the technology effectively address the safety and privacy of the consumer 9

10. Do the Homework ValueOptions partnered with Verizon to develop the clearest and safest software and hardware possible for its pilot in Florida The Tampa ValueOptions Medical Director developed the different care scenarios that we wished to use in the pilot ValueOptions tested and re-tested the equipment prior to its deployment at the CMHC ValueOptions staff met with the CMHC clinical, administrative and IT teams to make sure all questions were answered When it became clear that a home to office scenario was not going to meet our criteria of clarity and consistent signal strength, ValueOptions determined that only the office to office scenario would be piloted 10

11. Improved Access? July 2010-June, 2011 David Lawrence Center Reports: –65% Increase in Total Number of Services Provided in Immokalee –79% Increase in the Total Number of Medication Management Services –229% Increase in Targeted Case Management in Immokalee 11

12. “No Show” Changes From 7/1/10-4/21/11, there were 333 FHP members seen using the Telepsychiatry technology. There were 43 who called to reschedule instead of not showing up for their appointment ( A rate of 15%) There were 7 no shows ( A rate of 2%) It appears that the use of the technology gave the consumers the feeling that since the provider was making an effort to help them access services, then they wanted to not just not show for the appointment and even wanted to reschedule. 12

13. Consumer Acceptance Rates I saw the doctor/therapist using tele-behavioral / tele- psychiatry equipment. 159Yes- 159 No- 0 100% I felt safe and comfortable using the tele-behavioral / tele-psychiatry health equipment. 158Yes- 157 No- 1 99% Using tele-behavioral health helped me with transportation problems. 157Yes- 155 No- 2 99% I would be willing to use tele- behavioral / tele-psychiatry for future visits with the doctor / therapist. 159Yes- 159 No- 0 99% 13

14. Provider Acceptance Rates I saw the patient using telebehavioral / telepsychiatry equipment. 98189% I felt comfortable using the tele- behavioral / tele- psychiatry health equipment to conduct the patient visit. 880100% The tele-behavioral equipment made it easier to see the patient. 880100% I would be willing to use tele-behavioral / tele-psychiatry for future visits with the patient. 880100% 14

15. Current Billable Uses of TelePsychiatry for Medicaid Medication Management Assessments Individual Therapy 15

16. –Developed first State-approved telepsychiatry pilot for Medicaid behavioral health –Developed care scenarios to improve access to care in rural market –Expanded telemedicine presence with additional FL providers. –Presented to AHCA with goal of expanding codes to include CM, initial assessments, practitioner consults, etc. –Deployment of 30 new connection points via new purchases and 1-3 year contracts. 16 Florida Telepsychiatry Expansion

17. Future Uses of Telepsychiatry Consultations with Emergency Department Physicians regarding Baker Acts and treatment recommendations Psychiatric Assessments in the Emergency Departments Consultations with FQHCs regarding mental health issues Having Virtual Team of Psychiatrists available for Psychiatric Assessments and Medication Management for other agencies Expansion of Assessments and Medication Management in the members home 17

18. This is Only the Beginning Questions? 18