USING TELEMENTAL HEALTH TO EXTEND VA INTEGRATED CARE TO COMMUNITY SETTINGS: A WORK IN PROGRESS

1. USING TELEMENTAL HEALTH TO EXTEND VA INTEGRATED CARE TO COMMUNITY SETTINGS: (A WORK IN PROGRESS) Andrew Pomerantz, MD Chief, Mental Health and Behavioral Sciences White River Junction VA Medical Center White River Junction, Vermont VA National Office of Primary Care-Mental Health Integration Eastern Region Rural Health Resource Center Associate Professor of Psychiatry, Dartmouth Medical School

8. Some Definitions What is Telehealth? Varieties in VA: Home Telehealth Health buddies IVR Store Forward Retinology, radiology, dermatology General Telehealth

9. The Evidence Base If you want randomized controlled trials you may have to wait a little longer

10. VA database

11. Where are the limits?

12. PAST AS PROLOGUE “WRJ model” of integrated care APA Gold Achievement Award 2005 VA Advanced Clinical Access National Champion award 2007 Mandated in all VAMCs 2009 TELEMENTAL HEALTH Integrated Care to Bennington via Tele implemented 2004 QI study confirms Evidence Based care improved Berlin, NH Vet Center and second CBOC began 2009 VT Mental Health VA/National Guard partnership 2005-present 2008/9 plans for TMH

13. INTEGRATION OF WHAT? Mental Health/Substance abuse/Primary Care (extending the WRJ model) Telemental Health and Primary Care VA and rural veterans/families VA and Community Community Mental Health Center Federally Qualified Health Center

14. RATIONALE Rural Veterans have difficulty accessing MH care, despite its ready access in WRJ VA and 4 CBOCs Veterans and NG troops often resist specialized MH care at VA or CMHC Evidence suggests that veterans in community treatment may be sicker (more ED visits, higher incarceration rates)

15. and To accomplish several tasks: Provide integrated care for veterans and families using other medical homes but in need of “special” understanding (why VA exists) Leverage VA funding to catalyze development of integrated care and telehealth as part of the Vermont Healthcare

16. THUS The need to integrate the care, rather than build a stand alone VA system in a foreign land. And to take VA employees out of their comfort zone

17. SITES CMHCs: Clara Martin Center, Randolph, VT FQHCs: Richford Health Center (NOTCH), Richford, VT Little Rivers Health Center, Bradford, VT Indian Stream Health Center, Colebrook, NH Coos Family Services, Berlin, NH Midstate Health Center, Plymouth, NH

18. FUNDING VA Office of Rural Health & Office of Mental Health Services VA/National Guard Sharing agreement

19. Current issues Technology ISDN point to point Lowest setup expense Highest per-call expense T1 line Higher setup Low monthly subscription Privacy, security Waiting for NETC

20. Implementation Issues Cross Sector contract issues Credentialling, licensing Medical Records Fee for service Provider motivation and training Information sharing Infrastructure Ethical concerns

21. Program issues Patient Preparation Room – lighting, noise, comfort What to wear?? Patient satisfaction Choosing patients Choosing providers Contingency planning

22. Tasks completed to date Engaged with NOTCH 8/08 Mobilizing the internal WRJ facility 10/08 Conference with NOTCH/VA IT 12/08 Contract prepared 6/09 IT issues addressed Motivational interviews Preliminary budget developed Contracting contracting contracting 11/08-6/09 Planning meetings (X2) with Bradford sites ORH grant funded (5/09) Identification of other FQHC sites (ongoing)

23. Cost per visit? So far: About $100,000 Engineering a prototype costs more than the last product off the assembly line.

24. WHY DO YOU WANT TO DO TELE? (or do you?)