TELEPSYCHIATRY: From Idea to Solution

1. TELEPSYCHIATRY: From Idea to Solution Developing and Implementing a TelepsychiatryProgram Trilok Shah, M.D. June 25, 2014

2. TOPICS • Benefits • Challenges • Economics • Technology & Logistics • Developing your program • Common Questions • Discussion

3. WHAT IS IT? Psychiatry services carried out using tele-video medium • Focus on the service not the technology • Has been around for long time

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

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

6. Increased Access to Providers • A Congressional report earlier this year said 55% of the nation’s counties have NO practicing psychiatrists, psychologists or SWs • Almost 90 million Americans live in federally-designated Mental Health Professional Shortage Areas • According to HHS, Illinois has a deficit of 169 Psychiatrists • In rural AND urban areas • Lengthy wait times

7. Improved Quality of Care • Clinical decisions by experienced psychiatrist • Would you want an internist to perform surgeries? • 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:10.4088/PCC.v03n0501 • PCPs prescribe 50% of psychotropic meds- often out of necessity • ED docs report being overly cautious in commitment decisions

8. Cost Benefits & Improved Workflow • A study of almost 100,000 users of the VA telepsychiatryprogram: Patients' hospitalization utilization decreased by an average of 25% with the implementation of telepsychiatry. • Linda Godleski, M.D.; Adam Darkins, M.D., M.P.H.; John Peters, M.S. (2012) Outcomes of 98,609 U.S. Department of Veterans Affairs Patients Enrolled in Telemental Health Services study from 2006–2010. • Psychiatric patients: • Remain in the ED 3times longer than non‐psych patients • Psychiatric boarding in the ED prevents 2 bed turnovers • Lack of bed turnover costs hospitals an average of $2264 per patient • Nicks and Manthey. “The Impact of Psychiatric Patient Boarding in Emergency Departments.” Emergency Medical International. 2012.

9. Value Beyond Fee for Service • Treat patients where they are • Improve staff and referral source satisfaction • Reduce burnout of primary care docs, and increase confidence of the treatment team • Reduce indirect costs • Recruiting and retaining providers • Decreased opportunity costs with increased throughput • Risk reduction

10. CHALLENGES • Reimbursement • Licensing • Credentialing • Liability • Security/privacy

11. 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

12. Reimbursement Private payers • Required to pay in some states • In IL it is up to the individual companies to decide whether or not to offer it asa covered service. • Telehealth Act (SB0647) passed both houses on May 30th • Sets some guidelines for private payers with regards to covering telehealth services- for example, it forbids insurance from requiring that initial visits be in-person. • Negotiate with your payers

13. CHALLENGES • Licensing • Currently need license in the state the patient lives in, except for federal institutions (V.A.) • Credentialing • Proxy credentialing not commonly used • Liability • More insurers provide liability coverage for telemedicine • Security/privacy • Encryption, BAA, protocols

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

15. Convene Your Team • Project Manager • Medical Staff Representative • Information Technology Representative • Financial Officer • Human Resources Representative • Legal Representative • Quality Improvement Representative • Consumer Advocate –patient education programs and information materials, consumer and community outreach

16. Assess the Need & Resources • Talk to • The primary care doctors at your facility and in the community • Potential referral sources • ED directors and docs • Patients • Support clinical staff • Current resources in the community • Questions to ask • How many patients are the current docs seeing with psych issues • Where are patients with psych issues currently going • What stress is the current setup putting on the providers • How long are the patients having to wait for psych services, and how much are they having to travel • What quality of care issues are there- stretching the PCP’s capacity to care of complex patients, safety and risk issues • What is the availability, capacity of the current resources • Subspecialty needs- child, geriatric, addictions

17. Develop Your Financial Plan • What will be the associated costs • Provider • Support staff • Equipment and setup – a much smaller barrier now • Cost savings • Improved workflow for the ED, other providers • Creates referral source for other on site providers- primary care docs, neurologists & other specialists, therapists • Creates revenue source for labs, imaging • Cost savings and convenience for patients • Reimbursement • Who are the major insurers for your patients • Negotiate with payers

18. Select Your Provider • Fits your needs • Availability • Experience • Subspecialty • Willingness to work with the whole team • Long term relationship with your facility and patients • Less likely to utilize your organization as a stepping stone

19. Our Providers Are… • Board certified/eligible psychiatrists • Adult/child/geriatric specialists • Experienced in implementing programs in ER, outpatient, and school settings • Local and interested in serving the patients here • 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

20. 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

21. Develop Protocols & Practice Runs • Scheduling • Medical records • Sharing notes, storage of PHI • Prescribing - Controlled medications • Orders - Ordering and receiving results • Consents • Loss of signal or loss of power • Emergency situations

22. Keys to Sustainability • Expect to encounter some resistance • Train those involved • Expect to make adjustments • Collect quality and satisfaction data • Talk to patients, staff, referral sources to continue improving • Be proactive and inform everyone involved early about the program to avoid negative emotional reaction

23. Keys to Sustainability • Keep the onsite team engaged • Challenge team to focus on the positives • Address fears about being replaced • Support, not replace • Keep the provider engaged • Orient the provider to the different members of your team • Include them in your e-mail lists • Familiarize them with the community’s culture and resources • Inform them of major changes in the organization

24. COMMON QUESTIONS • Will patients like it? • Does it work? • Are there limitations to using this?

25. Will Patients Like It? • A number of patients prefer this • Access • Convenience • Cost savings • Distance is perceived as protective by some patients • Control is maintained, can walk out easily • Neutral place • So many patients already use similar technology to socialize/keep in touch with others

26. Will Patients Like It: Patient Satisfaction Study • A pilot study comparing satisfaction levels between psychiatric patients seen face to face (FTF) and those seen via videoconference (VC). • Patients were randomly assigned to one of two groups. • One psychiatrist provided all the FTF and VC assessment and follow-up visits. A total of 24 subjects were recruited; 18 completed study. • NO significantdifferences in patient satisfaction

27. Will Patients Like It: Another Patient Satisfaction Study • Evaluated client satisfaction and one-month mental health outcomes for telepsychiatry (VC) clients compared with face-to-face (FTF) consultation. • Clients were asked to complete a health survey before the consultation, a satisfaction survey after the consultation, and were contacted for a one-month follow-up survey by telephone. • VC clients demonstrated significantly more improvements on pre- and post mental health measures than the FTF group. • VC clients felt that they could present the same information as in person (93%), were satisfied with their session (96%), and were comfortable in their ability to talk (85%); this was similar to the FTF clients.

28. DOES IT WORK?FQHC Based Depression Study • From 2007 to 2009, patients at several federally qualified health centers were screened for depression. • 364 patients who screened positive were enrolled and followed for 18 months. • About half the patients received care from an on-site PCP and a nurse care manager. • The other half received care from an on-site PCP and an off-site psychiatrist via videoconferencing. • The primary clinical outcome measures were treatment response, remission, and change in depression severity. • The group receiving the care from the psychiatric team via telemedicine did significantly better.

29. Depression Treatment- RCT • The primary objective was to compare treatment outcomes of patients with depressive disorders treated by telepsychiatry (VC) to patients treated in person (FTF). • Secondary objectives were to compare rates of adherence, satisfaction with treatment, and costs of treatment. • 119 depressed veterans referred for outpatient treatment were randomly assigned to VC or FTF. Treatment lasted 6 months. • Hamilton Depression Rating Scale and Beck Depression Inventory scores improved over the treatment period and did NOT differ between groups. • No differences in dropout rates, patients’ satisfaction with treatment, adherence to appointments and medications.

30. Any Limitations? • No hand shake • Smell is absent: EtOH (need to rely on onsite staff) • Some psychotic patients? • Some evidence showing that even patients with paranoid delusions involving TV or cameras were able to participate in telepsychiatry sessions with no problems • Some patients with propensity for violence? • Would want to take precautions even if in-person. Also, would want to have staff in room with patient. • Patients with very significant cognitive impairments?

31. MORE COMMON QUESTIONS • Where are the In Touch providers licensed? • How are the providers credentialed at my organization? • How does a typical telepsychiatry encounter go? • Who takes medical ownership of the patient? • 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?

32. RESOURCES • In Touch Physicians Resource Center • http://www.intouchphysicians.com/resource-center.html • Practice Guidelines for Tele-Mental Health Services • http://www.intouchphysicians.com/uploads/3/4/2/8/3428956/ata_telemedicine_core_guidelines.pdf • Practice Guidelines for Telemedicine Services • http://www.intouchphysicians.com/uploads/3/4/2/8/3428956/ata_practice-guidelines_videoconferencing.pdf • American Telemedicine Association • http://www.americantelemed.org • Telepsychiatry in the 21st Century • http://www.intouchphysicians.com/uploads/3/4/2/8/3428956/telepsychiatry_in_the_21st_century.pdf

33. DISCUSSION Trilok Shah, MD President, CMO 773-916-7595 tshah@intouchphysicians.com www.intouchphysicians.com