TELEMENTAL HEALTH IN VA: HISTORY AND NEW OPPORTUNITIES

2. Historical Perspective - 1968 Medical television system connected the University of Nebraska Medical Center Omaha VA Hospital Lincoln VA Hospital Grand Island VA Hospital Used for a psychiatric treatment and training activities Cost $48,000/yr to connect one site with limited quality

3. Historical Perspective - 1968 Broadening of telemental health to large scale operations Massachusetts General Hospital to: Logan Airport Medical Station Bedford VA Hospital Positive outcomes: 2.5 years 150 patients

4. Historical Perspective – 1970’s and 1980’s 15 federally funded telemedicine projects in the 1970s Cumbersome and expensive technologies Resurgence in the 1980s with widespread entry into computer age

5. VHA Telemental Health – 1990’s VHA becomes a world leader in telemental health delivery starting in 1997

6. Historical Perspective

7. New Technical Realities Moore’s Law: Computer processing power and speed per unit of cost doubles every 18-24 months. Has held true since Moore first stated this in the 1960’s. The impact on TMH is that the capability of the equipment and the network is vastly better and considerably less expensive than it was only a short time ago.

8. Old Beliefs Die Hard “The human element is missing.” “Telemental health is less safe.” “It’s less effective than ‘real’ (i.e. face-to-face) therapy.” “Patients won’t like it.”

9. Recent Research Several recent studies have shown that, when comparing mental health services delivered by telemental health (TMH) vs. face-to-face (F2F): TMH & F2F have equal patient satisfaction. No difference in attrition. No difference in symptom and functional outcome reports. No interaction of modality with Axis II diagnosis. No increase in safety issues.

10. Limitations to Recent Research Most of the studies have been on telepsychiatry. A couple of small N studies on telepsychology and tele-addiction (same outcomes). Much room for investigation in this area. Despite these limitations, currently no data to suggest worse outcomes or lower satisfaction for TMH.

11. Traditional “Scarcity” Model Historically, telemental health (TMH) initiatives in throughout the VA have followed a “Traditional” or “Narrow” deployment strategy. Equipment was expensive and hard to come by, often costing over $8000 for each end point. Less expensive equipment, when available, would not provide useable video resolution or motion for clinical work.

12. Traditional “Scarcity” Model Facilities had a single originating room used by one dedicated TMH clinician or shared by several clinicians who each had scheduled time blocks. Services to remote sites were rationed and typically were limited to tele-psychiatry. The traditional model was also labor intensive, requiring associated mental health staff to be in the room with the veteran or nearby.

13. In the traditional model of telemental health service deployment, expensive equipment is set up in special rooms at both ends of the connection. Equipment expense may limit field deployment, so that not every CBOC will have telemental health endpoints. Access limitations at the facility end mean that services must be rationed out to the CBOCs. Typically, blocks of clinician time are assigned to each CBOC. Hence, a mental health clinician may not be available to most CBOCs for most of the week. [Point out examples] Service rationing may also apply to the types of services available. Many sites limit telemental health services to telepsychiatry. Some add limited blocks of therapy time. In the traditional model of telemental health service deployment, expensive equipment is set up in special rooms at both ends of the connection. Equipment expense may limit field deployment, so that not every CBOC will have telemental health endpoints. Access limitations at the facility end mean that services must be rationed out to the CBOCs. Typically, blocks of clinician time are assigned to each CBOC. Hence, a mental health clinician may not be available to most CBOCs for most of the week. [Point out examples] Service rationing may also apply to the types of services available. Many sites limit telemental health services to telepsychiatry. Some add limited blocks of therapy time.

14. Transition to a New Approach GOALS: 100% coverage of CBOCs. Access to a wide variety of clinical services at all remote sites. Mental Health clinician access throughout the CBOC clinic day.

15. Transition to a New Approach GOALS: Access to same-day assessment & treatment planning. Meet the mental health treatment needs of rural veterans who live far from the hospital or CBOCs. Use existing clinician capacity whenever possible.

16. “Broad” Telemental Health Deployment Strategy Many or most outpatient clinicians receive inexpensive, computer based or desktop videoconferencing units. Inexpensive “individual” sized video equipment at all remote sites. Attempt to equip multiple rooms at larger remote sites. Mental Health & CBOC conference rooms equipped with more sophisticated group videoconferencing.

17. “Broad” Telemental Health Deployment Strategy Utilize data compression capacity of new equipment to reduce bandwidth needs. New Paradigm: TMH is seen as widely available, rather than as a scarce resource to be rationed. Partner with remote non-VA sites to host video endpoints.

18. Non-VA Partnerships Reach rural veterans far from VA clinics. Partner site provides room, reception, and possibly network connection. VA assumes responsibility for MH care of veteran. VA can also provide some specialty consultation via video.

19. Start pointing out the different possibilities.Start pointing out the different possibilities.

21. Multi-site groups possible with videoconferencing units that have a built in mini-bridge. Also possible by using the VISN’s videoconferencing bridge.Multi-site groups possible with videoconferencing units that have a built in mini-bridge. Also possible by using the VISN’s videoconferencing bridge.

22. Telemental HealthEquipment Options

23. Point out key components of the clinician setup. Point out dual monitor / concurrent CPRS capability.Point out key components of the clinician setup. Point out dual monitor / concurrent CPRS capability.

24. Point out that the CBOC end is configured for minimal intervention. Equipment can double as computer monitor for exam rooms with space constraints. Point out that the CBOC end is configured for minimal intervention. Equipment can double as computer monitor for exam rooms with space constraints.

26. Point out that clinician can control the remote conference room camera.Point out that clinician can control the remote conference room camera.

27. New Initiatives $9 Million in FY 2006 to expand general and specialty telemental health care to CBOCs. Further expansion funds available in FY 2007 for CBOC equipment and for VISN-wide PTSD and Addiction TMH care.

28. Opportunities for Psychology Substance Abuse Continuity of Care Performance Measure. Evidence Based Psychotherapy for PTSD, Depression, Anxiety, Addiction, Health Psychology. Assessment and Treatment Planning. Limited psychological / cognitive assessment. Primary Care Integration with CBOCs.

29. For More information: Jamie L. Adler, Ph.D. Mental Health Service Line (116) William S. Middleton Mem. Veterans Hospital 2500 Overlook Terrace, Madison, WI 53705 608-280-7015 / Fax: 608-280-7203 jamie.adler@va.gov