Tele-Behavioral Health: Filling the need when others cannot…

1. Michael D. Lynch, PhD, ABPPDirector of Tele-HealthNorthern Regional Medical Command01 March 2012 Tele-Behavioral Health: Filling the need when others cannot…

2. Disclaimer “The views expressed in this presentation are those of the author and do not reflect the official policy of the Department of Army, Department of Defense, or U.S. Government.”

3. Learning Objectives • Program Goal 1. The preparation of Tele-Health capabilities for ethically delivering diagnostic and therapeutic services effectively to diverse populations of clients in need of such treatment • Program Goal 2. Understanding the process for developing policies and procedures associated with the delivery of Tele-Health applications • Program Goal 3. Identifying best practice models for behavioral health care delivery and understanding the evidence based practice associated with the delivery of virtual behavioral health.

4. Concept Formation A form of care where Behavioral Health personnel interact systematically to meet the Behavioral Health and Health needs of their patients through collaborative development of treatment plans, provision of clinical services, and coordination of care through the use of technology.

5. Agenda Tele-Medical Home • Introductions and Overview • Why Tele-Health • Technical Applications • Use of Technology • Business Planning • Maximizing Resources • Conclusions and Wrap Up • Anyone, Anywhere, • Anytime Tele Health Behavioral Health Behavioral Health Primary Care Spoke Tele Health Asynchronous Synchronous Patient Centered Medical Home Tele Health Behavioral Health Tele-Health Tele- Behavioral Health Provider Consultative

6. Why integrate into primary care • Population Health • Prevalence of BH problems in PC • Per Capita Cost • Cost of unmet BH needs • Experience of Care • Better outcomes/satisfaction • Deliver the right care at the right time • Share information

7. ROI vs. Value: Cost offset • 20% reduction in overall h/c expenditures 1 • 4.5% increase in expenditures for new BH costs 2 • $128 PPPM less for overall health cost among patients with diabetes and depression (UC vs IC)3 • $457 to > $775 PPPM higher cost for chronic illnesses + depression than for chronic illnesses alone (< 6% for BH) 4 1Chiles JA, Lambert MJ, Hatch AL.. The Impact of Psychological Interventions on Medical Cost Offset: A Meta-analytic Review. Clinical Psychology: Science and Practice Volume 6, Issue 2, pages 204–220, June 1999 2 Bachman RE. An actuarial analysis of comprehensive mental health and substance abuse benefits in the state of New York. PriceWaterhouseCoopers, May 2002. 3 Bogner, H. et al. Diabetes, Depression, and Death A randomized controlled trial of a depression treatment program for older adults based in primary care (PROSPECT). Diabetes Care December 2007vol. 30 no. 12 3005-3010 4 Melek, R. & Norris D. Milliman Chronic conditions and comorbid disorders. Milliman. July 2008.

8. The Hidden Mental Health Network- Schurman et al. 1985 • 1980-1981 National Ambulatory Care Surveys • Nearly half of all visits with psychiatric diagnosis are seen in primary care

9. Yes, but can you do it on TV? South Central Veterans Healthcare System VISN 16 Arkansas’ Mississippi Delta and Ozark Highlands 395 markedly depressed patients from seven VA primary care practices Equivalent: • Medication adherence – 6 and 12 mo • Medication response – 6 and 12 mo • Symptom remission – 6 and 12 mo • Satisfaction – 6 and 12 mo 1 364 markedly depressed patients from five Federally Qualified Health Centers Equivalent: • (p) Medication, # meds, dose • Medication adherence • Treatment response • Symptom remission 2 1 Fortney, J et al. A Randomized Trial of Telemedicine-based Collaborative Care for Depression. J Gen Intern Med. 2007 August; 22(8): 1086–1093. 2 Fortney J et al. A Pragmatic Randomized Comparative Effectiveness Trial of Practice Based Versus Telemedicine Based Collaborative Care for Depression in Rural Federally Qualified Health Centers. Submitted for publication. National Institute of Mental Health, (R01 MH076908, MH076908-04S1)

10. NRMC Network Newport Dix West Point FT Drum Current Direction of Services Hub Provider Pre-Positioned Provider APG NC ITG Carlisle Barracks FT Meade FT Detrick FT Riley NRMC Hub FT Knox Pax River Ft Belvoir FT Hood Quantico FT Lee FT Eustis FT Bragg Camp Lejeune WB

11. Medical home – three part aim • Three Part Aim • Improve experience • Improve health of populations • Reduce per capita costs

12. Why Telehealth? • Staffing limitations • BH is a product line with multiple subspecialties which may only require limited FTEs • Synchronous vs. Asynchronous applications

13. Center for IT Leadership – HealthPartners “ … great potential to improve access … adoption in routine health care has been slow … lack of clarity about the value of telehealth … slow adoption. “The simulation predicted savings of $4.3 billion per year … “Payers, providers and policy-makers should work together to remove the barriers to the adoption of telehealth in order to make it widely available to all.” SOURCE: The value proposition in the widespread use of telehealth. Cusick CM, et al.Journal of Telemedicine and Telecare. June 2008 vol. 14 no. 4 167-168.

14. Patient Today Patient Ideal Unhealthy behaviors/High disease burden High utilization of resources Lower PCMH empanelment capability Healthy behaviors/Lower disease burden Less utilization of resources Higher PCMH empanelment capability A Comprehensive Care Plan starts with Integration The Comprehensive Care Plan will be based on an integrated treatment plan designed to be utilized within the primary care setting that increases access and provides quality care that is both sustainable and reproducible. Integrated Health Care Comprehensive, Coordinated Care Tele-Health Delivery Behavioral Health, Wellness & Resiliency • Behavioral Health: Provider to Patient or Provider to Provider • Wellness: Pre-Clinical Interventions • Resiliency: Psycho-education and disease prevention Comprehensive Care Plan

15. Applications • Provider to patient direct care • Medication Management • Psychotherapy • Assessment • Store and Forward • Provider to provider consultations • Project ECHO (Extension for Community Healthcare Outcomes)

16. Story Time • “I was living under a bridge” • “Nintendo generation” • “Frolicking through the fields” • “Safety first” • “Plan A does not work… a.k.a Dress to Thrill” • “Sugar, Sugar” • “NJ to CO to VA to NJ to MD to NJ” • “Can’t pull the wool over the camera’s eye”

17. Populations Evidence based No “a priori” contraindications Contraindications “The inclusion of cases for a telemental health consult is at the discretion of the referring and consulting clinicians. There are no absolute contraindications to patients being assessed using telemental health.“

18. Where to begin? • Technology • Fully integrated room-based VTC units • Desktop high resolution VTC • Mobile VTC designed for medical offices • Web based applications • Hand held • Web Cameras • Connectivity • VoIP • ISDN • Internet • Mobile 3G – 4G • Electronic Medical Record • Permissions result in better integration outside provider portal • Allows for prescribing at the patient site • Different versions

19. Where to begin? continued • Scheduling • Different strategies or logistics in real time different functions • TBH Provider availability • Patient room vs. mobile unit • Emergency Management • Risk assessment • Emergency notification • Hospitalization • Prescribing • Electronic medical record portal • Fax/next day delivery (hard copy) class 2/non formulary • Medication recommendation for PCP • Orders • Electronic Medical Record • Fax orders • email orders • Use of Clinical Care Coordinators

20. Personal Health Records and Continuity of Care

21. Challenges and Solutions • Underresourced remote sites • No space for VTC • No support staff to monitor BH patient • No financial resources for hardware and/or fiber • Comfort level if you built it they will come relationship building • Medical records • Outside provider access to EMR • Fax/scan of clinical notes into EMR • Scheduling • Coordinate provider and room schedules • Payment and sustainability

22. Challenges Patient Variable Business Practices Stovepipe Operations & Redundancy Limitations on Technology Credentialing Space: Hub & MTF Provider IM/IT (Phones, laptops, BBs, Aircards) Provider start up delays (hiring actions)

23. The Way Ahead • Mobile in-office solutions • Full roll out vs. stepwise progression • Availability of funds contingent on productivity • Adding to the equipment base • Hand held options • Web-based encrypted software • Add to the administrative support base • ROI • Evaluate outcomes

24. Conclusion • Implementing Tele-Behavioral Health has been shown to be efficacious both clinically and financially. Utilizing a Tele-Health delivery system allows access to needed behavioral health services when it is not feasible to provide on-site interventions. Tele-Behavioral Health is not a secondary option but clinically it has been shown to be as or more effective based on timeliness of care and increased compliance. Deliver the right care at the right time.

25. Michael D. Lynch, PhD, ABPP Chief, Department of Tele-Health Kimbrough Ambulatory Care Center Northern Regional Medical Command 703-588-0350 (O) michael.lynch@us.army.mil Contact Information