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Rural TeleMental Health

Rural TeleCon ' 07 10 th Annual Conference of the Rural Telecommunications Congress October 14 – 17, 2007. Rural TeleMental Health. Rural TeleMental Health.

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Rural TeleMental Health

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  1. Rural TeleCon '0710th Annual Conference of the Rural Telecommunications CongressOctober 14 – 17, 2007 Rural TeleMental Health

  2. Rural TeleMental Health F. Rose Rexroat, R.N.,C., MSN, Manager Community Services, Saint Joseph HealthCare, Inc. a Market Based Organization of Catholic Health Initiatives Carol L. Ireson, R.N., PhD, Associate Professor, College of Public Health, University of Kentucky

  3. Rural TeleMental Health • Understand how telehealth technology is utilized in a rural primary care setting • Understand how telehealth technology can support provision of mental health services in rural areas • Understand achievements, barriers, and future objectives

  4. Why rural telemental health?

  5. Economic Challenges. • 25% to 39%, in area served, live in poverty compared to 18.7% in Kentucky and 16.3% nationally • 80 - 100% of children at the targeted schools are on National Free and Reduced Lunch Program • 7.8% to 12.6% of residents are unemployed • 18 - 37% of residents qualified for Medicaid

  6. Gaps in the Health System 81 of 120 Kentucky Counties are officially designated as a Health Professional Shortage Area (HPSA) • Wolfe County has 1 PCP per 100,000, • Morgan County has 4.8 PCPs per 100,000 • Lawrence County has 11 PCPs per 100,000 (primarily located in the far eastern border in Louisa.)

  7. Health Care Challenges • 37.4% to 42.6% of residents reporting fair or poor health • Over 6% of the population have diabetes higher than the Kentucky rate of 4.5% • Obesity and overweight rates are among the highest in the state • Over 5% of residents suffer from major depression

  8. The Beginning • Work as chair of the Kentucky Association of Free Health Clinics allowed the opportunity to educate two State Representatives and a Senator about a Mobile Health Service • This discussion lead to implementation of the Eastern Kentucky Mobile Health Service (EKMHS)

  9. Know your own strengths and weaknesses in developing the project! Identified and collaborated with experts… • Clinical experts –always focus on the clinical needs of patients • Technical experts – always have a technical consultant that can develop a plan to support your clinical needs • Research experts – help with assessment, analysis, outcome measurement

  10. Collaborators • Saint Joseph HealthCare, Inc. • Catholic Conference of Kentucky • Appalachian Regional HealthCare, Inc. • Saint Claire Regional Medical Center • Cabinet of Health Services, Dept. of Public Health

  11. Collaborating Agency Roles SJHC Holds a personal service vendor contract with the DPH for: • provision of services • development and administrative oversight • billing and medical record management AppalachianRegionalHealthCare: • Provides care regardless of ability for payment • Referral for ancillary service

  12. Collaborating Agency Roles St. ClaireRegionalMedicalCenter • Second line of referral for care regardless of ability for payment • Serves as hub manager for the five EKMHS sites and SJH • Annual management fees of approximately $12,000 -15,000 paid by St. Claire for EKMHS / SJH CabinetforHealth Services / DepartmentofPublicHealth • Representatives John Will Stacy and Rocky Adkins, Senator Walter Blevins • Service provider relationship for continued funding to support operation

  13. Collaborating Agency Roles Catholic Conference of Kentucky Collaboration in carrying out the mission of the Catholic Church, Catholic Health Care. • Lead role with legislative process to assure continued funding for the EKMHS • Relationship building • Continued presence and communication with state legislature

  14. Support • State Service Provider Contract - $325,000 for annual operations subsidy • Budget 2007-2008 increase of $34,000 – FTE replacement factor for ARNP • Bill for Services: Medicare, Medicaid, other third party payers • SJHC has no expense subsidy for operations

  15. The Goal of the EKMHS • To improve access to primary and specialist care for residents of five extremely rural communities located in Eastern Kentucky and • To build a provider referral network

  16. Role of College of Public Health Kentucky Commissioner of Health designated the University of Kentucky, College of Public Health to conduct a community needs assessment to provide baseline data for use in: • Planning focused health promotion • Disease prevention programs • Future evaluations of the impact of the EKMHS on health status of clients served

  17. Community Health Assessment • 75 item questionnaire assessing disease burden, health risk behavior, access to care • Administered at the county fair, homemaker groups, senior center

  18. Needs Assessment Findings • Disease burden • Heart disease, cancer, diabetes, injury, depression • Health behaviors • Poor nutrition, lack of exercise • Access to health care • No insurance, no money, not enough doctors

  19. Service Delivery • The Eastern Kentucky Mobile Health Service EKMHS) started seeing patients on May 6, 2003.

  20. Communities Served • Blaine in Lawrence County • Hazel Green in Wolfe County • Ezel, Cannel City, and Crockett in Morgan County

  21. Output: Patient Volume Visits Average/day FYE 06/2003 73 3 FYE 06/2004 970 4 FYE 06/2005 2132 9 FYE 06/2006 2528 11 FYE 06/2007 2360 10 23.3% New patient 76.7% Two or more visits

  22. Income By Reimbursement Source FYE 06/04 FYE 06/05 FYE 06/06 FYE 06/07 MEDICARE 13.0% 19.0% 20.0% 11% MEDICAID 5.0% 3.0% 3.0% 5% SELF PAY 57.0% 55.0% 69.0% 66% ALL OTHER 25.0% 24.0% 8.0% 18% • self pay includes self pay and other charity (DSH and St. Joseph Charity) • Bill for Services: Medicare, Medicaid, other third party payers • SJHC has no expense subsidy for operations

  23. Patient Profile FYE 06/04 FYE 06/05 FYE 6/06 FYE 6/07 Female 64.9% 60.6% 58.2% 58.1% Male 35.1% 39.4% 41.8% 41.9% Pediatric 5.9% 2.5% 1.9% 1.3% Caucasian 99.5% 100% 100% 99.5% Native Am. 0.5% 0% 0% 0.5%

  24. Disease Burden MEDICATION AS AN INDICATOR HEALTH KY P.A.P. FYE 06/03 $6,495 $9,078 FYE 06/04 $108,202 $323,898 FYE 06/05 $109,649 $765,242 FYE 06/06 $176,076 $1,174,954 FYE 06/07 $196,461 $1,014,639 H.K.: Health Kentucky, Inc. PAP: Patient Assistance Programs

  25. Disease Burden MEDICATION AS AN INDICATOR TOTAL AMOUNT / VISIT FYE June 2003 $15,572 $213 FYE June 2004 $432,100 $445 FYE June 2005 $874,891 $410 FYE June 2006 $1,351,029 $534 FYE JUNE 2007 $1,211,101 $513 TOTAL $3,884,693 $423 AVG

  26. The Role of Telemedicine for EKMHS Remote Access: • To Specialists • For follow up visits • Referrals to or from any of the sites in the Kentucky TeleCare Network

  27. Kentucky TeleHealth Network (KTHN) Sites

  28. Telehealth Clinical Consultations 2003 2004 2005 2006 • EKG 3 10 43 67 • Internal Medicine 2 2 3 • Pulmonary 1 1 • Conferencing 4 • Education Programs 2 • Peds Gastroenterology 2 • School Nurse access for primary care 3 • November 2005 started laying foundation with KRCC for mental health clinic(s)

  29. Role Of Grants / Funding Sources 1. OCTOBER 2002: USDA-RUS GRANT of $90,300.00 to add telemedicine technology to the MHS and to SJH 2. JUNE 2004: STEELE-REESE GRANT of $47,880.00 to provide cancer and diabetic screening for early detection 3. OCTOBER 2004: USDA-RUS GRANT of $235,636.00 to expand present telemedicine network

  30. Need for Mental Health Services • Analysis of diagnoses after one year of EKMHS operation found that number of women diagnosed with mental health disorders exceeded the sum of all other diagnoses • Residents of the targeted communities do not use the local mental health service provider because of the stigma of going to a mental health clinic

  31. Rural TeleMental Health Project Purpose • To develop a comprehensive network of health care services by expanding the existing primary care and bringing mental health diagnostic and treatment expertise to residents of local rural communities

  32. Role Of Grants / Funding Sources 2006 Appalachian Regional Commission of $303,882 and USDA-RUS Grant of $326,893 to expand the Kentucky Telehealth Network

  33. SAINT JOSEPH HEALTHCARE SERVICE AREA WITH EKMHS SERVICE AREA (Morgan, Wolfe and Lawrence Counties) Campbell Boone Kenton Primary Service Area Gallatin Pendleton Bracken Trimble Secondary Service Area Carroll Grant Mason Lewis Greenup Rober tson Owen Harrison Henry Oldham Fleming Carter Boyd Tertiary Service Area Nicholas Scott Franklin Shelby Bourbon Rowan Jefferson Bath Elliott Lawrence Woodford Fayette Montgomery Spencer Anderson Morgan Meade Bullitt Clark Menifee Jessamine Johnson Powell Martin Hancock Wolfe Nelson Mercer Magoffin Madison Henderson Washington Breckinridge Estill Davies Garrard Hardin Boyle Lee Union Breathitt Floyd Pike Marion McLean LaRue Webster Lincoln Ohio Grayson Jackson Owsley Knott Rockcastle Taylor Casey Perry Crittenden Livingston Hopkins Hart Butler Green Clay Letcher Edmonson Muhlenberg Laurel Leslie Adair Caldwell Pulaski Russell McCracken Ballard Metcalfe Lyon Barren Warren Harlan Knox Christian Carlisle Todd Logan Wayne Whitley Marshall Bell Cumberland Trigg Clinton McCreary Allen Graves Simpson Monroe Hickman Calloway FULTON

  34. 2006 Grant Goals Appalachian Regional Commission Grant $303,882 • Expand EKMHS telemedicine network adding mental health diagnostic and treatment clinic(s) • 4 school sites served by MHS • 3 Kentucky River Community Care sites of Jackson, Hazard and Campton • St. Claire Regional Medical Center Mental Health Services • 6 county impact area of Perry, Breathitt, Wolfe, Morgan, Lawrence and Rowan

  35. Saint Joseph Healthcare Service Area With EKMHS Service Area & ARC Grant Campbell Boone Kenton Primary Service Area Gallatin Pendleton Bracken Trimble Secondary Service Area Carroll Grant Mason Lewis Greenup Rober tson Owen Harrison Henry Oldham Fleming Carter Boyd Tertiary Service Area Nicholas Scott Franklin Rowan Shelby Bourbon Jefferson Bath Elliott Woodford Lawrence Fayette Montgomery Spencer Anderson Morgan Meade Bullitt Clark Menifee Jessamine Johnson Powell Martin Hancock Wolfe Nelson Mercer Magoffin Madison Henderson Washington Breckinridge Estill Davies Garrard Hardin Boyle Lee Union Breathitt Floyd Pike Marion McLean LaRue Webster Lincoln Ohio Grayson Jackson Owsley Knott Perry Rockcastle Taylor Casey Crittenden Livingston Hopkins Hart Butler Green Clay Letcher Edmonson Muhlenberg Laurel Leslie Adair Caldwell Pulaski Russell McCracken Ballard Metcalfe Lyon Barren Warren Harlan Knox Christian Carlisle Todd Logan Wayne Whitley Marshall Bell Cumberland Trigg Clinton McCreary Allen Graves Simpson Monroe Hickman Calloway FULTON

  36. 2006 Grant Goals USDA-RUS (DLT) Grant $326,893 • Expand Access by expanding the network to: • 4 Health Departments (Menifee, Morgan, Rowan & Lawrence) • 5 Schools (Owingsville Elementary, Bath County High School, Morgan County Middle and High School and Menifee Co.Complex K-12) • 3 SJHC Emergency Departments (SJ Berea, SJH, SJ East) • First Clinical Application for Sleep Wellness Center in Lexington and Berea • 8 County impact area (Fayette, Madison, Bath, Menifee, Wolfe, Rowan, Morgan and Lawrence)

  37. Technology Plan for EKMHS for the USDA RUS DLT Grant

  38. SAINT JOSEPH HEALTHCARE SERVICE AREA WITH EKMHS SERVICE AREA & USDA-RUS GRANT Campbell Boone Kenton Primary Service Area Gallatin Pendleton Bracken Trimble Secondary Service Area Carroll Grant Mason Lewis Greenup Rober tson Owen Harrison Henry Oldham Fleming Carter Boyd Tertiary Service Area Nicholas Scott Franklin Rowan Shelby Bourbon Bath Jefferson Elliott Woodford Lawrence Fayette Montgomery Spencer Anderson Menifee Morgan Meade Bullitt Clark Jessamine Johnson Powell Martin Hancock Wolfe Nelson Mercer Magoffin Madison Henderson Washington Breckinridge Estill Davies Garrard Hardin Boyle Lee Breathitt Union Floyd Pike Marion McLean LaRue Webster Lincoln Ohio Grayson Jackson Owsley Knott Rockcastle Taylor Casey Perry Crittenden Livingston Hopkins Hart Butler Green Clay Letcher Edmonson Muhlenberg Laurel Leslie Adair Caldwell Pulaski Russell McCracken Ballard Metcalfe Lyon Barren Warren Harlan Knox Christian Carlisle Todd Logan Wayne Whitley Marshall Bell Cumberland Trigg Clinton McCreary Allen Graves Simpson Monroe Hickman Calloway FULTON

  39. SAINT JOSEPH HEALTHCARE SERVICE AREA WITH EKMHS SERVICE AREA & USDA-RUS AND ARC GRANT Campbell Boone Kenton Primary Service Area Gallatin Pendleton Bracken Trimble Secondary Service Area Carroll Grant Mason Lewis Greenup Rober tson Owen Harrison Henry Oldham Fleming Carter Boyd Tertiary Service Area Nicholas Scott Franklin Rowan Shelby Bourbon Bath Jefferson Elliott Woodford Lawrence Fayette Montgomery Spencer Anderson Menifee Morgan Meade Bullitt Clark Jessamine Johnson Powell Martin Hancock Wolfe Nelson Mercer Magoffin Madison Henderson Washington Breckinridge Estill Davies Garrard Hardin Boyle Lee Union Floyd Pike Breathitt Marion McLean LaRue Webster Lincoln Ohio Grayson Jackson Owsley Knott Perry Rockcastle Taylor Casey Crittenden Livingston Hopkins Hart Butler Green Clay Letcher Edmonson Muhlenberg Laurel Leslie Adair Caldwell Pulaski Russell McCracken Ballard Metcalfe Lyon Barren Warren Harlan Knox Christian Carlisle Todd Logan Wayne Whitley Marshall Bell Cumberland Trigg Clinton McCreary Allen Graves Simpson Monroe Hickman Calloway FULTON

  40. How telemental health services will be delivered • Patients needing mental health services will be referred by the EKMHS Primary Care ARNP to a psychiatric nurse practitioner and psychiatrists located at St. Claire Regional Medical Center or Kentucky River Community Care • Students with behavior or mental health problems will be referred by school nurses employed by the Gateway Regional Health Department to the Mental Health Nurse Practitioner or Psychiatrists specializing in child and adolescent psychiatry via the Kentucky Telehealth Network

  41. Benefits for the Patient • Linked to physicians in a regional medical center and a metropolitan hospital(s) via a telemedicine connection – real time audio and video consultation • Connected to any agency / organization on the KTHN • Patients will not have to travel long distances to be seen • Eliminates the stigma of “going to the psychiatrist office”

  42. Benefits for the Community • Will impact the economic development of the region by reducing the absenteeism and decreased productivity of workers suffering from mental health problems • Early intervention for mental health problems will enhance their successful growth and development and prevent these problems from following them into adulthood • Through access to obtain mental health services for the EKyMHS, the end sites obtained access to primary care and other services

  43. Evaluation Plan • Number of adults and children receiving mental health services in their local communities • Distance and costs required to travel to receive mental health services vs. using technology • Satisfaction of patients with the telemedicine mental health services • Satisfaction of health care providers with the telemedicine technology for providing mental health service

  44. Cost effectiveness • We believe the program will be the most cost effective way to address the mental health needs of the rural population served • Reduces travel for the patient • Reduces travel for practitioners • Brings services to rural communities that can not support a FT or PT health care provider or specialist

  45. Sustainability Looked at how we could develop partnerships with our collaborators to build a network that can support the program • All end sites are responsible for T1 installation and ongoing costs • All end sites are responsible for all equipment repair / replacement after the first year warranty period • Education of end sites users on value of new delivery model to their clinical practice

  46. Future Goals Expansion of the TeleMental Health Network through an Appalachian Regional Commission Grant • To connect 3 rural CHI hospitals to the Network • To expand mental health services by adding 5 more KRCC clinics to the Network • To provide primary care services to the 5 new KRCC clinics • 8 county impact area

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