1. Telemental Health Across the Continuum of Care  Providing emergency Crisis mental health services since 2009, 2010 to rural coastal community.

2. Emergency Crisis Mental Health  Providing mental health evaluations in urban setting hospital since 2009 122 conducted between RB/UD in 2014  Expanded mental health evaluation service to rural coastal emergency room in 2010 60 conducted in Florence 2014

3. Early Considerations: Originating Site  How will patients in crisis respond to this method?  Can patients be adequately evaluated?  Is it safe?  Is efficient communication with emergency room staff possible?  Can a rural community be served remotely ?  What happens when things don’t work as planned? After a simple explanation of the process, patients in crisis (especially teenagers) became comfortable with the videoconference service. Patient dispositions were consistent with face to face evaluations No ill effects were experienced by patients, staff or property With effective coordination, communication with off site locations proved to be successful Connectivity – technical reliability improved over time We needed a functional Plan B to deal with real time technology problems. Before: We were concerned about…After: We discovered…

4. Early Considerations: Distant Site  What provider locations offered privacy, security and optimum access for the whole team?  How would we get those staff who were “less technology savvy” to successfully use the system?  Who would help problem solve and ensure the program’s success Designated a private area in the UD- ED with desktop devices. Initially, some crisis team providers had difficulty adapting their evaluation process using telemental health Some team members became process champions, supporting the learning of their colleagues Essential support was provided by a multidisciplinary group including: medical director, ED nurse manager, behavioral health manager, and hospital administration. Before: We were concerned about…After: We discovered…

5. Results of Telemental Health  Disposition of patient cases, including inpatient psychiatric admissions, sub-acute placements and home or community care settings were consistent with patients evaluated on-site.  Patients reported generally favorable experiences including willingness to participate in a telemental health visit again, if the need arose.  Mental health clinicians and ED staff have become comfortable with telemental health.  BHS staff at RB can now provide evaluations for patients at UD and in Florence, increasing flexibility and efficiency.  BHS now exploring offering services to other communities.

6. Lessons Learned  Developing new telemedicine services requires provider champions.  Adding telemental health to the ED is helpful to physicians, staff and patients. It reduces vulnerability by having a qualified mental health clinician consult when considering discharges.  Adding telemental health is generally welcomed. Replacing on- site services with telemental health can be perceived as a takeaway by ED physicians.  Differences in the availability of community mental health resources in rural versus urban settings was a significant challenge. Staff needed to gain a full understanding of available services and referral to community agencies.

7. Sustainability  Peace Harbor Hospital pays UD/RB Crisis Team a flat monthly rate for on-call coverage and a case rate per evaluation.  Licensed and non-licensed providers are able to bill commercial insurance, Medicaid (CCO) respectively.  The technology was largely already in place and being used for other telehealth services.  As the service has grown, adding additional equipment has proven to be cost effective. Staff have largely been able to meet the added demand. We are prepared for ramp up or our service to outlying communities.

8. Conclusions  Telemental health crisis evaluation is a viable means of providing critically needed mental health services.  Telemental health has improved access for rural patients to urban-based services.  Providers of telemental health services require practice in using technology and orientation to the resources of the communities they serve.  Over time, telemental health can improve productivity, but may also require changes in staffing patterns.  Telemental health is a value added program with minimal expense and far reaching benefits for mental health patients presenting to the emergency room in crisis.

9. Psychiatry Services  Who we are: PeaceHealth, Oregon West Network.  Inpatient, outpatient, CL, crisis, IOP, community based/integrated care teams  16 psychiatrists (4 inpatient, 1 CL, 11 outpatient), 3 NPs  Service area includes all of Lane County, diverse geography

10. Began providing psychiatry services to patients in Florence, PeaceHarbor Hospital rural coastal community 2010  No psychiatrists in that community  Outpatient, primary care consultation model: patients predominantly have or will have PHH PCP  Limited follow up visits generally, transfer care back to PCP  One of our psychiatrists providing service  Highly appreciated, very high patient satisfaction scores

11.  Added inpatient psychiatric consultations 2012, same psychiatrist  PHH inpatients in medical beds, psych consult  Recommendations to PHH attending  Added outpatient child/adolescent tele psych 2013  2 child/adolescent psychiatrists  Facility/room at PHH remodeled using charitable foundation grant

12.  Future is now!  Next project is child/adolescent psych consults to our other rural hospital, Cottage Grove  Similar primary care consultation model  Same foundation providing start up funds for facility  Also providing tele psych in town to a residential facility  Planning for expansion of tele psych services-further to coastal communities  Common essentials that make service run:  EMR  Able to bill for services, same as face to face  Providers experienced and/or willing to participate/learn

13. Health Technology Research Program National research project designed to learn if technology can help people with schizophrenia or schizoaffective disorder stay well and reduce hospital and emergency room visits.

14. Goals of Health Technology Program Help participants:  Decrease distress  Improve ability to manage mental illness  Prevent relapses and hospitalizations by:  Addressing common causes of relapse  Identifying early warning signs of relapse and developing action plan to respond to them  Move forward in life

15. The Components of the Treatment Model Include: 1) evidence-based pharmacological treatment facilitated by a web-based prescriber decision support system 2) brief, in-person, relapse prevention counseling with supplemental web- based learning modules, 3) Technology to Extend Care and Support to Schizophrenia (TECSS), a program that offers web- and phone-based resources to support persons with schizophrenia and their family members, peers or others 4) an interactive smart phone application to support medication adherence, facilitate coping with symptoms and improve daily functioning in individuals with schizophrenia, and 5) a web-based, self-administered cognitive-behavioral therapy (CBT) program for the management of hallucinations and paranoia. This research is funded by CMS (Centers for Medicare & Medicaid Services).

16. Role of Tech Tools Used in service of relapse prevention Used in service of client’s goals Tailored to the needs and choices of the individual

17. Provides Participants With an Option to Participate in: Individual case management Online support groups Education on schizophrenia Brief therapy using a cell phone Cell phone medication reminders Online therapy program for voices and paranoia Medication visits

18. Coping with Paranoia Website

19. Coping with Voices Website

20. Daily Support Website

21. Application for Rural Communities Provides opportunity to outreach and track patients in outlying areas Can provide real-time information to providers Interventions are available from home Supported by CMS as a potentially cost-saving intervention Applications available for various mental health conditions

22. Comments or Questions?