Presenter Disclosures

1. Presenter Disclosures Dan Alicata “No relationships to disclose” (1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

2. Telepsychiatry in Rural Hawaii Daniel Alicata, M.D., Daniel Ulrich, M.D., Barbara Satterfield, M.S., R.N., Daniel Saltman, M.D. University of Hawaii, John A. Burns School of Medicine, Department of Psychiatry; Child & Adolescent Mental Health Division (DOH) PULAMA I KE OLA 2008 Approaching 2010: Hawaii’s Health Disparities May 22, 2008

3. An Overview • Review models of telehealth. • Examine the role of telehealth in providing mental health services to children, adolescents and their families on Moloka’i. • Introduce telehealth expansion with partners on the island of Hawaii.

4. Challenges for rural Hawaii • Experience ongoing shortages of health care professionals and services. • Lack of socioeconomic resources. • Geographic isolation. • Barriers to travel.

5. Geographicisolation • Models of telepsychiatry programs on the mainland can be • effective in Hawaii

6. Role of Telehealth • Access: improve access to health care in rural and other underserved areas. • Specialty care: provide centralized specialty health care consultation to decentralized primary care physicians, health care work force, therapists and educators. • Quality: improve quality of care by providing follow-up after discharge from hospital’s specialty services. • Cost: provide specialty care at lower costs to providers and patients.

7. Types of Telemedicine: • Interactive video vs. “store and forward” • interactive video:examination and discussion occurring in real-time. • store-and-forward:images and bioinformation are forwarded to the consultant, or receiving site, and interpreted at a later time.

8. “Store and Forward”

9. Home Care

10. Primary and Specialty Care

11. Rural Telepsychiatry

12. Factors Driving Telemedicine • Increased efficiency • Increased Convenience / Decreased travel time • Patients • Providers • Decreased costs of care • Increased access to care for underserved populations • Increased patient compliance / follow-up • Because we can!!

13. Child and Adolescent Telepsychiatry: Moloka’i • Challenges for Moloka’i • Developing partnerships • DOE Teleschool Network

14. Why Hawaii? Fulfill a Need!! • Hawaii - 6 main islands. • 283 schools within 7 School Districts. • Maui County  Maui, Moloka’i, Lanai - 30 schools. • Average 778 students eligible for mental health services each quarter.

15. Improved Access to Services for Special Needs School Children (IDEA) • IDEA – Individuals with Disabilities Education Act. • Schools are serving children with increasingly broad spectrum of health care needs. • Remote school districts experience great difficulty obtaining psychiatric and psychological consultation within the time frames mandated by the IDEA. • Virtual office hours through telemedicine provides timely access.

16. Goals for Moloka’i Telepsychiatry: • Augment psychiatric services to school children on Moloka’i • Network – develop multiple sending (Oahu) and receiving sites (Moloka’i). • Develop partnerships with: • Department of Education (Teleschool Network). • Moloka’i General Hospital – E. Aluli, M.D., Barbara Satterfield, M.S., RN. • Maui Community College, School of Nursing - Chair, Nancy Johnson, RN. • UH, JABSOM,Telehealth Research Institute - L. Burgess, M.D., and D. Saltman, M.D. • Hawaii Education and Treatment Interventions (HETI) – J. Draeger, M.D. (contracting mental health service provider to DOE)

17. Goals for DOE Teleschool Network: Objectives for the DOE Video Teleconferencing System • Facilitate the provision of timely and quality staff development activities in spite of geographic challenges. • Deliver sustained and focused support services to schools.  • Provide students with quality remedial and enrichment programs. • Reduce the time lost in traveling to workshops or meeting sites.

18. DOE – Teleschool / Telepsychiatry • Teleschool Network with 297 VTC units in schools and district offices from Kauai to the island of Hawaii. • Network - secure, enclosed, using internet protocol (IP) with a data stream of 384 Kb/s, Polycom VSX 7000 system.

19. Moloka’i Telepsychiatry: Teleschool VTC Sites Moloka’i – 7 Lanai – 1 Maui - 27 Oahu - 150 Kauai – 16 Big Island - 48

20. MHIS • Kualapuu Elem. • DOE-LSC • Kaunakakai Elem. • MGH-LKI • Moanaloa Elem. • Kilohana Elem. • Pharmacy • Provider at DOE Honolulu district office

21. Moloka’i IDEA-IEP Oahu

22. Telepsychiatry clinic: • Provide 4-direct patient care/consult hours/week. • Reimbursement – Agency (HETI) contract with DOE to provide Child and Adolescent psychiatric services. • Psychiatric services provided for children, adolescents and their families. • Any psychiatric condition. • Seen for initial evaluation, ongoing care as well as consultation with treatment, education and support staff (DOE, DOH, Family Court, Probations, DHS-CWS). • Patients / parents agreed to receive care through telepsychiatry. • Frequency: monthly face-to-face visits; weekly telepsychiatry clinics.

23. Progress • VTC clinics = 117 • Total hours = 392 - hours • VTC Encounters: total = 1,012 • students: total = 283 (28.0 %) • Teens: 13-19-years-old (78.1 %) • Parents/guardians: total = 355 (35.1 %) • Treatment/education staff: total = 374 (37.0 %)

24. American Academy of Child and Adolescent Psychiatry:Telepsychiatry Committee • To learn about the promise of telepsychiatry in providing universal access to services, and challenges along the way. • Focus is on collaboration with the multiple community systems serving these needy youth, including Primary Care Medicine, community- and school-based therapists, day programs, addictions programs, Family Court, Juvenile Corrections, Child Welfare Services, and the education system. • In this type of consultation, telepsychiatry can provide the “glue” that binds these community systems and youth together.

25. Future development: • JABSOM/DOP is partnering with DOH-AMHD, -CAMHD and The Mayo Clinic to achieve the following telehealth goals: - 1) establish linkages with Bay Clinic and the Family Guidance Centers in Hilo, Kona and Waimea. - 2) provide psychiatric services and consultation to patients, families, primary care providers and treatment staff directed by the island of Hawaii AMHD and CAMHD leadership. • Develop the telehealth training curriculum for JABSOM/DOP faculty, residents and fellows, and the education curriculum for medical students.

26. Research Goals: • Improve assessment of mental health outcomes. • Examine predictors of effective care delivered through telehealth. • Evaluate the impact of cultural factors on the success of telehealth interventions. • Investigate the economic impact of access to services through telehealth. • Explore the barriers to care delivered through telehealth. • Assess the impact of telehealth in preserving the rural mental health workforce.

27. Administration • Develop Manual: protocol and procedures. • Licensing: state guidelines. • Credentialing:physician/group covered by credential process at both sending and receiving facilities. • Liability:telemedicine part of standard and range of clinical care (carrier will request letter stating that VTC is part of the standard of clinical care). • Models of Care:consultation and direct service models. • Billing:Third Party Carrier, HMSA, handles the bulk of telemedicine care in Hawaii (Medicare, Medicaid, Quest).

28. Thank you!

30. Telepsychiatry in Rural Hawaii Daniel Alicata, M.D., Daniel Ulrich, M.D., Anthony Guerrero, M.D., Iwalani Else, Ph.D., Daniel Saltman, M.D., Barbara Satterfield, M.S., R.N. University of Hawaii, John A. Burns School of Medicine, Department of Psychiatry; Child & Adolescent Mental Health Division (DOH) PULAMA I KE OLA 2008 Approaching 2010: Hawaii’s Health Disparities May 22, 2008

31. Rural Child and Adolescent Telepsychiatry: Molokai An Overview • Challenges for Moloka’i • 75-Hour Pilot Project: Developing Relationships; stake holders • Project expansion: DOE - Teleschool Network

32. Challenges for rural Hawaii • Experience ongoing shortages of health care professionals and services. • Lack of socioeconomic resources. • Geographic isolation. • Barriers to travel.

33. Geographicisolation • Models of telepsychiatry on the mainland can be effective in • Hawaii

34. Challenges of travel: Travel by road • Maui • Road to

35. Road to Hana

38. Travel by air and by sea

39. Role of Telehealth • Access: improve access to health care in rural and other underserved areas • Specialty care: provide centralized specialty health care consultation to decentralized primary care physicians, therapists and educators • Quality: improve quality of care by providing follow-up after discharge from hospital’s specialty services • Cost: provide specialty care at lower costs to providers and patients

40. Learning Objectives • Understand the role of telemedicine in delivering specialty health services to rural areas • Appreciate the advantages of telemedicine for mental health care in rural areas • Learn models of care and applications of telemedicine in delivering mental health services • Explore new applications of telemedicine in meeting mental health needs of children in rural communities • Examine the issues facing telemedicine in future developments of mental health services • Develop research studies to examine diagnostic reliability, satisfaction, treatment outcomes, culture, infrastructure and sustainability

41. What is Telemedicine? “...the use of electronic information and communications technologies to provide and support health care when distance separates the participants...” Source: Institute of Medicine: Telemedicine: A Guide to Assessing Telecommunications in Health Care

42. Types of Telemedicine: • Interactive video vs. “store and forward” • interactive video: examination and discussion occurring in real-time • store-and-forward: images and bioinformation are forwarded to the consultant, or receiving site, and interpreted at a later time

43. “Store and Forward”

44. Home Care

45. Primary and Specialty Care

46. Rural Telepsychiatry

47. Factors Driving Telemedicine • Increased efficiency • Increased Convenience / Decreased travel time • Patients • Providers • Decreased costs of care • Increased access to care for underserved populations • Increased patient compliance / follow-up • Because we can!!

48. Iowa • Unique population • Agricultural • Dispersed • Elderly • Isolation of patients and providers • Time / cost of travel • Lack of support services • Iowa Communications Network • Collaboration: UI Dept. Psychiatry / • Department of Corrections; (Juv. Corr.)

50. Rural Child and Adolescent Telepsychiatry: Molokai • Challenges for Moloka’i • Developing partnerships • DOE Teleschool Network