Expanding Access to Care: Telemedicine in Georgia

1. The NCTRCWebinar SeriesPresented byThe National Consortium of Telehealth Resource Centers October 17th, 2019

2. www.telehealthresourcecenters.org

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4. Capacity Building through Telemedicine/ECHO Expanding Access to Care in Rural & Urban Settings Suleima Salgado, MBA / October 17, 2019

5. Overview This presentation aims to address recent developments in both telehealth and telemedicine in the state of Georgia. You will learn how the state built its infrastructure, discuss implementation strategies, hear lessons learned, and gain strategies on how to partner with various programs to increase access to care across rural and urban settings. In addition, there will be a brief discussion on reimbursement and the benefits associated with telemedicine for patients, physicians and payers. Objectives: Explain the need for greater healthcare access across rural & urban settings Highlight Georgia’s Public Health Telemedicine Infrastructure Explain various telemedicine programs in Georgia Discuss lessons learned/best practices in implementing and expanding telehealth programs

6. Georgia Department of Public Health • 159 County Health Departments • 159 County Boards of Health • Public Health Districts • 18 District Health Directors • Commissioner • 1 Board of Public Health

7. Georgia’s “Tele” Network • Extensive telehealth network that provides expertise statewide through video • Network recognized as one of the most robust and comprehensive public health telemedicine networks in the nation and a best-practices model of care • Network connects all 159 county health departments and specialty clinics • Allows connection to partners and providers ANYWHERE (patients at home, hospitals, universities, private practice offices, etc.)

8. Georgia’s “Tele” Network • Patients come to county health centers for telehealth visits • Nurses act as the hands, eyes and ears for physicians on the other end of the screen • DPH has approximately 40 physicians in its network, with access to 400 more • Provides services, such as dentistry, that the state previously lacked the resources to support

9. Georgia’s “Tele” Network • GA legislators appropriated $2.3M to DPH, specifically for telemedicine infrastructure. • The department utilizes a hub-and-spoke model for its network, and it installed dedicated circuits throughout the state to ensure that clinics had the bandwidth necessary to support telehealth solutions. • Programmatic funding also comes from federal, state, county, and grant funds to expand clinics, train staff, and technical support. • Partnership with other state agencies (Rural Health, Medicaid, DBHDD), universities, local hospitals, other telehealth networks, and private sector are integral and sustained through collaborative agreements and MOUs.

10. Meadows Health Community Morehouse School of Medicine State Agencies (Composite Medical Board, DCH, DBHDD) Tallahassee Memorial Healthcare University of Florida (Jacksonville) University of Georgia (Health Sciences) Women’s Telehealth “Tele” Partners • Augusta University • Children’s Healthcare of Atlanta • Community Service Boards • Concussion Institute at Gwinnett • Medical Center • Coweta County Fire Rescue • Emory University • Global Partnership for Telehealth • Gwinnett Medical Center Number of partners constantly changes based on community needs/demands

11. Collaboration Without Boundaries • Return On Investment • No registration cost for participants since virtual (telehealth) • Over 500 public health nurses and physicians tuned in to watch • Seven hours of CEU’s eligible for registered participants • 158 of the 159 counties participated • Cost savings: if we consider NOT having to pay for travel, food and lodging for each person who received training and average it at $500/person, this is a cost savings of $250,000.00 • Cost Savings Example • Statewide Conference (two-day training) • Two-day training, partner with a state university and training center, as well as local AHEC • Providers funded to present through grant • Virtual registration/ evaluation • Power Point slides provided virtually and in advance

12. Telemedicine • Originating Site • Originating Site - where a patient is located (CHD) • Telemedicine Cart - interactive and secure telecommunications system • Distant Site - where physician or practitioner is located • Telemedicine Cart • Distant Site

13. Why “Tele”? Provider Shortage

14. DPH “Tele” Specialty Services • Asthma/Allergy - pediatric • Audiology -pediatric • Behavioral Health counseling -pediatric school based • Community Paramedicine (Ambulatory) • Concussion –school based • Dental Services -school based • Dermatology -adult and pediatric • Diabetes Classes -adult and pediatric • ECHO (Infectious Diseases) • Emergency Preparedness / Disaster Response • Endocrinology -pediatric • Genetics/Developmental - pediatric • Infectious Disease - adult and pediatric • Interpreter Services • Lactation Support/WIC • Maternal Fetal Medicine (High Risk) - adult • Mental Health (HIV) – adult • Nephrology - pediatric • Neurosurgery -pediatric • Nutrition/WIC - adult and pediatric • Opioid Provider Education & Training • Orthopedic • PrEP- fall 2019 • Sickle Cell - adult & pediatric • Tele-therapy for early intervention (BCW)-pediatric • VDOT- Tuberculosis

15. Children’s Medical Services Provides care coordination to children from birth to age 21 who have disabling conditions or chronic diseases. Provides long-term specialized care, medical equipment, medications, hospitalization, nursing services, family education, social services, and case management. Patients obtain referral from physician or pediatric specialty evaluation Telemedicine Specialty Care Expansion SFY16 - (2) clinic sites, 516 patients SFY18 - (8) clinic sites, 781 patients CMS Nurses provide Care Coordination & can assist eligible families with medications, tests, or supplies, if needed.

16. High Risk OB (Centering Pregnancy) High risk OB care, reproductive endocrinology and genetic counseling via telemedicine to rural and urban areas in hospital, private practice and government clinics. GA only has approximately 20 maternal-fetal specialists. Access to telemedicine allows ultrasounds and Maternal Fetal Medicine consults to be done on- site, in real time. On-site telemedicine allows for better coordination of services Through a partnership with Women’s Telehealth, Dr. Patterson is included in facilitated discussions in Centering sessions on pre-term labor and gestational diabetes via the telemedicine cart. Telemedicine allows easy access to providers for many consult needs including cardiac, dermatology and mental health

17. WIC (Women, Infants, & Children) • Individual Education & Consultation • Group Nutrition services on demand • Breastfeeding Support & Boot Camps • Staff Training and Updates • Translations

18. TeleDentistry Tooth decay is one of the most preventable childhood chronic disease among children Collaboration with AU-School of Dentistry, private community dentist, local school system, area AHEC, GA-DPH State office of Telehealth and Office of Oral Health, and local county health departments Provides school-based dental screenings, cleanings, fluoride, x-rays, and education Referrals and case management for follow-up

19. TeleDentistry Process Flow Dentist, from his or her office, makes a diagnosis and connects with dental hygienist to discuss findings with student and develops a treatment and follow up plan, if needed. For more advanced treatment needs, case management begins and referrals can be made. All results mailed to caregiver Caregivers provide prior consent. Student is called out of class and seen during school hours. A thorough medical/dental history is captured Hygienists provide cleaning, fluoride, x-rays and dental education Hygienist collects initial information about students oral health, uploads and submits X-rays to dentist for review New questions, responses, and updates

20. TeleDentistry • HEALTH OUTCOMES • Children receive services they may not have gotten otherwise • Children learn how to care for teeth for lifetime • Children come to school ready to learn & experience less dental pain • School reduce absenteeism rates for dental related illnesses and appointments • Parents save w/ transportation costs, lost wages, & preventative care • Children are connected w/a dental home for future services • Dental providers receive information from screening and have payor source intact • Now have a new local dentist for clinical services • OVERALL SATISFACTION • 10 year operating program • Overwhelmingly positive results • Routine Customer Satisfaction Surveys conducted • Parents/Teachers express a high degree of satisfaction with the program, in large part because this program is designed in a way that makes accessing dental care easy and convenient for students. • Teachers and Administrators have made this a standard practice and recommend kids for referrals routinely

21. TeleDentistry Data

22. Pediatric & Adult TB • Patients needing ongoing clinical oversight from specialists. • Patients can come to local HD and see ID docs who already manage their care, virtually • Most patients are seen monthly, but some need to be seen more frequently due to the complexity of their care.  • VDOT (Video Direct Observation Therapy also available to TB patients utilizing network (Web-based)

23. TeleHIV • Providing help to patients living with HIV who may have health barriers to overcome in receiving treatment • Target: Urban and Rural settings • Barriers: transportation, stigma, work schedules, shortage of providers & distance to provider, long waits for appointments, language/cultural barriers, etc. Patient presents at GA-DPH clinic & reviewed by presenter. Public Health nurse connects consult via telemedicine platform (cart or mobile solution) Remote Infectious Disease specialists speaks with patient & reviews any images with patient and NP or PA via GA-DPH mobile telehealth device Licensed NP or PA utilizes video to discuss further with pt & develops a treatment & follow up plan for the patient New questions, responses, and updates

24. Tele Requirements (Georgia) • ORIGINATING SITES • A county outside of a Metropolitan Statistical Area (MSA) or • A rural Health Professional Shortage Area (HPSA) located in a rural census tract • The approved originating sites in GA are: • The offices of physicians and/or practitioners; • Hospitals ; • Rural Health Clinics; • Federally Qualified Health Centers • Local Education Authorities and School Based Clnics; • County Boards of Health; • Emergency Medical Services Ambulances; and • Pharmacies • Presenters must be an RN, LPN, or CNA to present patients and utilize billable services in our network • Q3014 billing code ($20.52 per encounter) for Presenting Sites (Medicaid) • https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Telemedicine%20Guidance%20%2020190930193618.pdf (Medicaid Manual)

25. Tele Requirements (Georgia) • DISTANT SITE PROVIDERS • Practitioners at the distant site who may furnish and receive payment for covered telehealth services (subject to State law) are: • Physicians; • Nurse practitioners (NPs); • Physician assistants (PAs); • Nurse-midwives; • Clinical nurse specialists (CNSs); • Certified registered nurse anesthetists; • Clinical psychologists (CPs) and licensed clinical social workers (LCSWs). • Registered dietitians or nutrition professionals; and • Speech Language Pathologists • Audiologists • Clinical psychologists (CPs) and clinical social workers (CSWs) cannot bill for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services under Medicare • These practitioners may not bill or receive payment for Current Procedural Terminology (CPT) codes 90792, 90833, 90836, and 90838

26. DPH Infectious Disease ECHO • Project ECHO is a lifelong learning and guided practice model that revolutionizes medical education & exponentially increases workforce capacity to provide best-practice specialty care and reduce health disparities. • The heart of the ECHO model™ is its hub-and-spoke knowledge-sharing networks, led by expert teams who use multi-point videoconferencing to conduct virtual education with community providers. • In this way, primary care doctors, nurses, & other clinicians learn to provide excellent specialty care to patients in their own communities.

27. Project ECHO https://echo.unm.edu/doc/ECHO_One-Pager_11.20.18.pdf

28. Invitation for ECHO Ami Gandhi - Hepatitis A/B issues in GA June 20, 2019 Harris/Felzien – Pregnancy & the newborn July 18, 2019 Dr. Reznik – HIV and oral health Aug. 15, 2019 Kimberly Brown – Update STD protocol Sept. 19, 2019 Dr. Felzien - Update on HIV guidelines Oct. 17, 2019 Dr. Chan – update on GA-AETC Nov. 21, 2019 Dr. Heckman – Mental Health & HIV Dec. 19, 2019

29. Challenges / Barriers • Reimbursement: Largest barrier. Medicare has restrictions on reimbursing locations, types of providers. Medicaid- varies by state but is supportive in Georgia. Private payers- vary widely. Also, telehealth is usually reimbursed at lower rate. • Interoperability: Ensuring platforms across agencies and systems can share information is key (Electronic Medical Records) • Provider Availability: limited number of specialty providers • IT Infrastructure: bandwidth (availability and affordability) • Funding: Telehealth initiatives frequently require funding both for technology and program design, implementation, and evaluation.

30. Questions • Suleima Salgado, MBA • Director of Telehealth, Telemedicine and Rural Health Initiatives • Project ECHO Program Manager • Office of the Chief of Staff • Georgia Department of Public Health • suleima.salgado@dph.ga.gov For more information, please contact:

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