Peter Shore, Psy.D. & Tracey Smith, Ph.D.

Transcription

1 Peter Shore, Psy.D. & Tracey Smith, Ph.D. VA Psychology Leadership Conference Continuing Education Workshop April 14, 2012 San Antonio, Texas Contributing Authors (alphabetically) Ron Acierno, Ph.D., Anna Birks, Ph.D., Kathleen Chard, Ph.D.; LanaFrankenfield Frankenfield, LCSW; Linda Godleski, M.D.; Carolyn Greene, Ph.D.; Leslie Morland Psy.D.; Peter Shore, Psy.D., Tracey Smith, Ph.D., Steven Thorp, Ph.D.; Peter Tuerk Ph.D.; Matthew Yoder, Ph.D.

2 I came here today because: I want to start offering telemental health services at my facility as a provider/administrator. I/We am/are already providing TMH and want to learn more. I wanted to earn CEU s and this seemed more funthan theotherworkshop workshop.

3 Workshop Overview PART I: Clinical Notes from the Field Buy In TMH Overview Eid Evidence base for TMH Clinical Considerations Risk and Safety Management Satisfaction Home Based Telemental Health & Future Directions PART II: Implementation Staff Roles Needs Assessment / Gap Analysis Facility Implementation Logistics TMH Resources Discussion & Questions

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8 Three tier (You re not selling snake oil) Administration Providers Veterans

9 Administrative Buy In TMH may solve many problems for administrators Increase access Reduce fee basis costs Reduce travel costs Meet UMHSH standards Meet requirements in the MH Operating Plan Meet various performance measures Reduce no shows

10 Provider Buy In Selling TMH to your reticent provider. Identifying and supporting clinical champions. Converting the right Veterans to TMH to help providers. What s a reasonable amount of time to devote to TMH? Concerns over workload.

11 Veteran Buy In When recruiting Veterans and in early stages of treatment, clinicians should present the modality in positive terms, such as cutting edge rather than a second rate alternative to in person care Itmaybe advantageous for assessors and therapists to meet with clients in person initially, but it is not necessary to do so Respect Veteran choice & consider whether h policies create barriers to accessing care

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13 Telehealth Modalities The Office of Telehealth Services (OTS) has three basic telehealth modalities Clinical Video Their vision is one that extends across a spectrum of technologies that includes the telephone, secure messaging and mobile applications in ways thatcovers the continuum of care Telemental Health is situated within Clinical i l Video Home Telehealth Telehealth Teleradiology Store and Forward

14 Use of Telemental Health For all diagnoses, with rare exclusions By all mental health clinicians In multiple treatment modalities individual, group, couples, family therapy, medication management, emergency care, psych testing, etc. At multiple sites of care including: VA medicalcenters centers, VA CommunityBased Outpatient Clinics, VA emergency departments, non VA healthcare facilities, student health centers, homeless shelters, supervised dhousing sites, and place of residence

15 Typical VA Telemental l Health Program Majority of telemental health activity is hub and spoke model from facility to its CBOCs Provides access to general mental health services for Veterans in remote CBOCs Provides access to medical center specialists for Veterans in remote CBOCs Ease of Implementation Same Credentialing and Privileging Same Medical Record Same Workload and Reimbursement Mechanism Same Quality Management Oversight Same IT Department and IT Infrastructure

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17 Benefits of Telemental Health Lower cost without sacrificing quality of care 1 Veteran benefits with regard to lost employment time, as well as transportation costs and time 2 4 Technology is rapidly increasing system coverage area, thereby increasing reach to rural veterans 5 Satisfaction with service delivery is high among Veterans and providers 6 7 Efficacy data in telemental health: limited but supportive 8 1 Morland et al., 2003; 2 Bose et al., 2001 ; 3 Elford et al., 2000 ; 4 Trott & Blignault, 1998; 5 Dunn et al., 2000 ; 6 Frueh et al., 2000; 7 Monnier et al., 2003; 8 Ruskin et al., 2004

18 Evidence Base for CVT Feasibility & Acceptability Efficacy & Effectiveness Equivalence / Noninferiority Implement

19 How do we determine if CVT service delivery is as good as traditional face-to-face care?

20 Evidence-Based Therapy for PTSD in the VA via TMH PE studies # of Veterans in active treatment (N) Tuerk, Yoder, Ruggiero, Gros & Acierno, Gross, Yoder, Tuerk, Lozano, Acierno, Tuerk, Yoder, Grubaugh, Myrick, Acierno, Group CPT Studies Morland, Hynes, Mackintosh, et al. (2011) 13 (Group)

21 Research within VA on TMH There have a been several clinical trials examining i the use of EBPs via TMH with Veterans that show equivalent outcomes Several more clinical trials being conducted now Prolonged Exposure Thorp et al Acierno et al Cognitive Processing Therapy Morland et al Morland et al Smith et al Thorp et al

22 Future Research Directions Clinical Effectiveness Data Cost Effectiveness Data Medical Cost Offset data Emerging Technologies In Home Care

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24 Clinical Satisfaction & Outcome Address routinely with the Veteran in each session Assess periodically in treatment planning Identify any areas for improvement or change

25 Veteran Satisfaction Value of change in access to services: travel time, driving, parking, waiting times Perception of working alliance with their clinician using TMH Did the Veteran believe their clinical condition was impacted at all as a result of TMH Changewith no show rates, treatment adherence, inter session assignment completion, medication management Was telehealth environment conducive to treatment

26 Provider Satisfaction Rapport with Veterans Overall progress of Veteran Is clinician satisfied with the overall progress of the Veteran receiving services using TMH Is the Referring Provider satisfied with the TMH services and Veteran progress?

27 Satisfaction Measures for Both Clinician and Veteran Overall comfort with the experience Was equipment easy to use in a clinical i l treatment t tsetting Was telehealth environment conducive to treatment Quality of transmission Ease of initiation of connection Consistent maintenance of a quality connection throughout entirety of session Absence of interference, pixilation, interruption

28 Enrollment Considerations Established mental health diagnosis and primary care assignment. Willing to participate in Telemental Health Services via informed consent. Does your facility require a different Informed Consent? Willing to participate TMH Acknowledges and accepts limits of confidentiality.

29 Enrollment Considerations Has adequate sensory abilities to participate. No active suicidal or homicidal ideation with or without high lethality. No active psychosis or uncontrolled substance use disorder. Etblihd Established primary care provider or mental tl health point of contact at local CBOC.

30 Special Considerations Elderly Rural Ehi Ethical Groups

31 EXCLUSION CRITERIA Rejects telehealth in the informed consent process. With immediate need for hospitalization. Acutely violent or unstable Veterans with poor impulse control Active suicidal or homicidal ideation Severely decompensated

32 EXCLUSION CRITERIA Dementia confusion or mild cognitive decline. Requiring involuntary commitment in states which do not legally acknowledge telehealth evaluations for this purposes states that require licensure in the state where Veteran is located if clinician in different state. Home Based: without access to DSL, cable, 3g or 4g internet connection/computer.

33 EXCLUSION CRITERIA Essential medical monitoring that is unavailable on site Psychotic disorders that may be exacerbated by telemental health (e.g. ideas of reference regarding tl television) ii Untreated Substance abuse/dependence (current and/or extensive history with elongated sobriety and relapse) Significant sensory deficits

34 Clinical Recommendations: Getting Started When recruiting Veterans and in early stages of treatment, clinicians should present the modality in positive terms, such as cutting edge rather than a second rate alternative to in person care Itmaybe advantageous for assessors and therapists to meet with clients in person initially, but it is not necessary to do so Respect tvt Veteran choice & consider whether policies create barriers to accessing care

35 Initial Session 1. Inform Veteran of TMH modality. 2. Orient Veteran to the TMH modality. 3. Establish trust, safety and rapport over TMH modality.

36 Clinical Recommendations Call your Veterans between sessions

37 Lessons Learned In session avoidance and hypervigilance can be more difficult to manage via telemental health Telehealth condition appears to pose additional clinical difficulties only for Veterans with very severe presentations Coordinated efforts and good professional relationships between facilities appeared to be animportantfactor When possible, visit and develop working relationships with support staff at CBOCs. The assistance they provide is invaluable and maybe different than their hiregular duties: Buy in is essential. il

38 Lessons Learned Be sure to coordinate with all players in advance (we know of one instance where the PSA set up the client in a room without TMH equipment) When the connection fails: Be sure to speak about this possibility in advance (at start of first session) and have a clear plan Security at all sites: Be sure to know the crisis protocol for each CBOC or site used and the physical address of those sites in the rare event that it will be needed

39 Vtel Tips & Tricks Fax machines can assist the session in a variety of ways: send and receive practice assignments, self report questionnaires, session handouts etc. The practice assignments can be collected at the start of the session and faxed to the therapist(s) to review while the veteran is completing their self report measures and practice assignment review

40 Vtel Tips & Tricks Creating pre sets on the VTel unit allows the therapist to swiftly change the views (e.g., 1 preset for therapist t at white board, 1 preset for close up of therapist, 1 preset for stuck point log). Telephone calls can be used to complete missed sessions for veterans participating in a group and to provide support inbetween sessions.

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42 Group Tips Brief, structured check in assists with containment of group. Due to the diminished ability to see facial expressions and less time for check in, a structured and brief check in which includes veterans identifying and communicating their feelings helps to provide information to the therapist about the emotional state of the Veteran. Briefly review completed practice assignments prior to the start of group. Co therapist can quickly review practice assignments in group and note who is struggling.

43 CPT via VTC Unless otherwise suggested, the standard CPT protocol can be delivered. Delivered in both the individual and group format. Pre treatment orientation sessions are helpful for gauging theveterans understandingof CPT concepts, improving buy in, introducing the VTel modality and increasing client motivation.

44 CPT via VTC Pre treatment orientation sessions also allow for the therapist to gather detailed information about the traumatic event. This is especially ill helpful hlflfor group CPT where details are not shared. Training i in CVT will assist in therapist t confidence/ comfort. Collaboration with on site support staff is essential.

45 Case Illustration Veteran who successfully completed CPT reported that he had hdavoided d treatment for years but was willing to complete CPT via CVT because it was safer

46 Logistics: PE via Telehealth Available fax machines or an established electronic exchange protocol o to exchange written materials, homework, and questionnaires (fax preferable) If using fax machines that have to go through busy support staff, establish the use of a distinct, unique, and easily identifiable cover page so support staff will be cued that incoming fax is of immediate clinical relevance

47 Transfer of materials The new telepresence EX90s that are replacing the Tandberg's have built in document cameras

48 PE via Telehealth In most situations, no meaningful difference in the structure and process of treatment, the normal PE protocol can befollowed Overly stringent exclusion criteria are not needed if properproceduresare procedures followed Direct phone numbers for support staff, safety staff, and Veterans should be on hand during sessions Keep expectations for symptom improvement/remission high, just like in face to face PE

49 Logistics: Recording and Viewing i in PE via TMH Recording the sessions: Must teach client (in person or via TMH) how to record the session in the office he or she is in with a standard tape recorder or digital recorder Having a backup recorder in your office is helpful Veterans can be mailed their session tapes for homework review Logistics of watching videos in session: If no DVD players is available at the CBOC, clinicians can turn their telehealth camera towards the DVD monitor in their offices to facilitate watching the psycho educational PE video

50 Two stories about PE during imaginal (eyes closed) Motion sensor lights on client location went out during imaginal exposure due to stillness of client client didn t notice but therapist thought connection had failed Call actually dropped during imaginal therapist frantically tried to reconnect, and 5 minutes later re established connection, only to find client continuing with the narrative with eyes closed (unaware that call had dropped)

51 Potential Challenges in General Access to space and VTel units. Logistics such as escorting Veterans to a room, sending and receiving practice assignment and materials. Therapist/Veteran resistance to modality. Decreased ability to observe non verbal communication. Timedelay in communication requires therapist to pause between sentences/phrases.

52 Potential Challenges in General Containment challenges for group. Technical interference due to high use by multiple users (delay/visual pause). Managing and tracking visual pre sets for Veteran side.

53 Potential Challenges in General Fidgeting (hands or legs) not seen since camera is focused on head and torso Wheelchair h not seen (Veteran was wheeled around by wife, which meant she accompanied him on all in vivo exposures) Service dog not seen (might reduce anxiety it in session) Visual quality not quite clear at times: Is sniffling or difficulty breathing due to increased affect or due to illness (cold orflu) No physical contact means no shaking hands or handing tissues to client Clients with ihpoor hearing and closed eyes not able to read lips Thorp et al. (2011)

54 Previous VTC Experience Gone Awry? Did the Veteran have traumatic experiences on deployment while utilizing Video conferencing equipment? If so, what next? Use CVT, but monitor Veteran? Stop Telehealth?

55 Potential Advantages Veterans who are highly avoidant may be more willing to attend VTel session due to the distance. Increasing access to EBP s to Veterans who would otherwise be unable to receive these types of services. For group, research has shown increased Veteran alliance with other group members

56 Potential Advantages The distance in TMH may be therapeutic in that it allows clients with PTSD to lower their guard initially as therapy is beginning: Several PE clients have expressed a preference for TMH vs. in person for this reason Therapists note that it is easier to focus discussions and manage time in TMH because the equipment is turned off at the designated end time Therapists have noted that they prefer TMH when clients are physically intimidating or have contagious illness One therapist who was allergic to dogs was able to see her client and his service dog successfully through TMH Thorp et al. (2011)

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58 Essential Information Licensing Involuntary detainment / commitment Liability Best Practices

59 Special Considerations High Risk Older Males Depression, Psychosis, Agitation Agitated Depression Stress from Veteran s POV High lethality lthlit of suicide iid plan Prior Suicide behavior Isolated and alone

60 Pre-Session Procedures Have all direct phone numbers for the Veteran site (phone in the room where CVT session is occurring/telehealth support staff/on call clinician/front desk/ security). Safety plans should be developed inadvance andfollowthe appropriate site s protocol. Walk through the back up plan with the Veteran in the event that the connection isdropped or failed (e.g. if after 3 attempts to reconnect VTel, the therapist will call the veteran and complete the session over telephone). Does your Veteran have your Emergency Contact Information?

61 Contingency Plans Know your clinical back up plan. Same day communication plan: Veteran crisis, appointment changes, therapist or Veteran running late, etc. Technology back up plan TCT, PSA, phone, combo

62 Contingency Plans Consult with your local facilities policy on responding to emergencies. In most cases, each facility has their own policies andprocedures procedures. If you work from medical center and access numerous clinics this is especially important.

63 Contingency Plans Emergency plans should address Medical Emergencies Voluntary and involuntary psychiatric hospitalization o Contacting Veteran end staff about need to hospitalize o Who decides where the Veteran is sent o What are the state and local llaws about this at the Veteran end

64 Contingency Plans How is the Veteran transported in these situations? Who will transport and who arranges transport? Who will wait with the Veteran? What happens if there is a fire alarm, weather alert, bomb threats, or other emergency alert?

65 ATA* on Emergency Evaluations Additional personnel in room in addition to family members. Services preferred to be provided on site and in person. Make a determination whether immediate intervention is deemed necessary for Veteran safety Obtain info on local regulations and emergency resources Identification of potential local collaborators * American Telehealth Association

66 ATA* on Emergency Evaluations Emergency protocols: roles and responsibilities in emergency situations, Outside clinic i hours emergency coverage Guidelines for determining at what point others should be brought in to assist Be familiar with local civil commitment regulations Local staff to initiate/assist with civil commitments Perception of control Safety issues

67 From VISN 20 HBTMH Pilot A Patient Support Person (PSP) has been identified and is accessible This can be a family member, caregiver or any adult within the home This may also include neighbor This is an individual who can be contacted to assist, where safe and indicated, in the event of an emergency PSP does not have to be in home during session, nor do they need to live with Veteran.

68 From VISN 20 HBTMH Pilot The PSP must be briefed regarding their role and expectations prior to initiation of treatment It is strongly recommended that the Veteran Support Person (PSP) receive brief behavioral emergency education to avoid potential risk Provider will need a Release of Information (ROI) signed by Veteran to allow Veteran Support Person contact in case of emergency

69 From VISN 20 HBTMH Pilot Once onsite responders or Emergency Personnel have arrived and have Veteran under care and have vacated the home, thehome Based Telemental HealthProvider will contact the Local VA/CBOC Provider and be notified of the emergency. HBTMH Provider to remain as point of contact until the Veteran's PCP confirms coverage. Only under extreme circumstances should PSP transport Veteran to the hospital. Seek guidance from emergency personnel (while on phone). If circumstances (distance, medical emergency), most likely transport. Always use good clinical judgment.

70 Imminent risk Ensure safety of Veteran, means and likelihood of self harm/others, level of urgency necessary to prompt immediate transport. Do not leave the Veteran alone.

71 Imminent risk If Veteran becomes unconscious and disappears from site of the provider: Provider to contact PSAor Veteran Support Person to provide visual assistance and evaluation of circumstances. Veteran is on the ground, he is unconscious. Veteran is having a seizure. Provider instructs PSA to contact onsite MD and PSP to contact from their home phone. (Active suicide intent and/or medical emergency when PSA or PSP is unavailable).

72 Referral Resources o How would you make referrals or consults for additional and/or specialty care? o Do you know community resources for the distant end? Examples are medical and mental health care for family members, food and clothing banks, housing, shelters, andchildcare childcare.

73 Key Points Rule #1 (all settings): All Local Emergency contact information (CBOC PSA, PSP, CBOC Security local ER, local ambulance, local, police and fire) will be readily accessible before and during the appointment. Have distant t side CBOC contact tinformation accessible. Consult with State Law regarding Consult with State Law regarding Police Holds.

74 Key Points Home Based Verify PSP is available before session begins via Veteran or PSP directly. PSP should be accessible during session. PSP does not have to be in same physical location as the Veteran during the session. Have local emergency personnel readily available before and during appointment.

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77 Secretary Eric K. Shinseki "For all of you, as well, success lies in your willingness to collaborate across the broad landscape of mental health care. How are we doing at creating our "pit crews" within each medical care facility? And you are not limited by the walls of the medical center. How are we doing at "pit crewing" our Medical Centers with our Vet VtCenters, and mobile clinics i with our rural mental health initiatives and home based telemental health care? VHA's Mental Health Conference, Baltimore, Maryland,, y August 23, 2011

78 What is HBTMH?

79 What is HBTMH? Home Based Telemental Health (HBTMH) is a computer to computer or video teleconference technology to personal to support computer or mobile device utilizing an external or internal webcam for viewing on Veteran side and provider side via Federal Information Processing Standards (FIPS) secure and encrypted software technology. Currently: Cisco Teleprescence (aka MOVI) then Jabber Unsupervised clinical settings.

80 MISSION from the ground Meet Veterans where they're at. Create a patient centric / provider empowered program aimed at serving themental health needsof Veterans whose access to care is restricted by geography, limited resources or who are home bound due to psychiatric and/medical di conditions. i Treatment provided in the homes, care facilities and/or remote location where ever the Veteran is situated. o Have included: CPT for PTSD, Behavioral Activation for Depression, ACT for Chronic Pain, Anger Management, Cognitive Remediation (CogSmart), Chronic Disease Management, Medication Management

81 VISN 20 Home Based Telemental Health (HBTMH) Pilot Program MISSION Meeting Vets Where They GOAL: create a truly Veteran centric / providerempowered program aimed at serving the mental health needs of Veterans whose access to care is restricted by geography, limited resources or who are homebounddue due to psychiatric and/medical conditions Treatments have included: CPT for PTSD, Behavioral Activation for Depression, ACT for Chronic Pain, Anger Management, Cognitive Remediation (CogSmart), Chronic Disease Management, Medical Management

82 Current State T21 initiative identifies IP Video into the Home as an OTS Pilot Program which utilizes Cisco Teleprescense with a structured scheduling interface. Only known other implemented HBTMH Pilot Program: VISN 20 Home Based Telemental Health Pilot Program (launched February 2010).

83 VISN 20 HBTMH Program Structure PhaseI: 1 provider, 10Veterans, 60 encounters Phase II: 6 providers, 500 encounters PhaseIII: Release (maintain3 providers, no max encounters) Veteran Support Person (PSP) Each Veteran registers a Veteran Support Person (PSP). PSP to assist in the case of a behavioral or medical emergency

84 VISN 20 HBTMH Program Structure Standard Operating Procedure Manual (SOP) Manual for program implementation, Veteran selection and clinicalpractice guidelines. (Shore, 2011) o Clinics, charting, etc. ASH 25 A Structured Guide for the Assessment of Suitability for Home Based Telemental Health (Shore, 2011). Risk Management and Suitability Measure Train the Trainer Phase II Provider trains incoming Phase I Provider

85 Phase I Overview 1 provider: Peter Shore, Psy.D. (Clinical Psychologist) 9 Veterans, 60 Encounters total (6 sessions via Telework) No PTSD tx as primary treatment EBTs for Chronic Pain, Depression, Cognitive Strategies t and Anger Management. Some general support, voc rehab counseling

86 Phase I (June September 2010) 9 Veterans, 60 encounters 4,012 Total Miles saved Approximately $11, in travel reimbursement saved 99% show rate: 0 Veteran cancellations / 1 Veteran reschedule / 2 no shows

87 Expected Benefits Increased access to MH services / decreased barriers to treatment Less Veteran stress associated with travel Less potential for passing on sickness with clinic visits Flexibility in scheduling Lower cost per encounter Provider clinic space, miles saved, travel reimbursement saved Inherent environmental benefits with reduced transportation requirements

88 Unexpected Benefits Stigma a non issue. Less guarded, more vulnerable vs. traditional TMH Identified d excellent platform for treatment t tresistant t history Honored o VA treatment e tresistant sta t Veterans Closer Veteran follow up Increased frequency of visits = shorter length of treatment Satisfaction Survey sample results suggest significantly higher levels than traditional TMH

89 Phase II Highlights (September 2010-present) March 2011: VISN Leadership approved VISN wide expansion Provider Pool expands via Train The Trainer : 38mental health providers and/or administrators have been trained. 7 of the 8 VISN medical centers have at least 1 provider. Oregon, Washington, Alaska, Idaho.

90 Phase II PTSD Tx in the home 2 CPT cases completed. Pre PCL=52, Session 6 PCL=38, Post PCL=45 Pre Tx PCL=71, Session 6 PCL=55, Post Tx PCL=38 Closer collaborations between prescriber and psychotherapist via shared Veterans Peer Support Person Technical (PSP T) an HBTMH Beneficiary

91 Ongoing Data: as of March Unique Veterans 87.5% Male; Age M = % Married 27.5%; Divorced; 17.5% Single; 2.5% Widowed 30% OIF/OEF/OND; 40% Vietnam Total Encounters 354 (workload credit); Range per pt: 1 29 visits

92 More data Mean # of Sessions 8.7 Mean level of Service Connected Disability 40% % SC: 25% PTSD: 32%; Depression: 24%; Chronic Pain: 10.5% Treatment Types Insight Oriented Ψtx: 42.9%; CPT: 11%; CBT: 11%. Attrition Breakdown (n=13), 32.5%; Treatment Attrition: n=3 ; Technological Issues: n=10 Depression: 54% improved average reduction in symptoms of 19.6% Anxiety: (panic, GAD or PTSD), 73% improved average reduction in symptoms of 28.5%

93 Closing The Gap From the ASH 25: Would Veteran have received mental health services if they were otherwise not offered in the home? 80% responded NO (n=33)

94 What they re saying It was the best most convenient apt I have ever had with the VA. Itis an awesome program to outreach Veterans thank you! My experience has been excellent. Would like an easier and more reliable connection I would lose time from work, my husband doesn t have to take time off of work to take me to VA. I would feel more comfortable and safe doing this at home because my anxiety is so severe I would not feel safe, secure or comfortable. I would be unable to participate (if weren t available at home).

95 Results from CVT Satisfaction Survey Item #5 Strongly Agree endorsed. TMH n=54 HBTMH n=23 I felt comfortable with the equipment used 65% 74% I was able to see the clinician clearly 65% 70% I was able to hear the clinician clearly 69% 83% There was enough technical assistance for my meeting with the clinician 61% 78% My relationship with the clinician was the same during this session as it is in person 54% 65% The location of the telehealth clinic is convenient for me My needs were met during the session 70% 70% I received good care during the session 70% 87% The telehealth clinic provided the care I expected 70% 78% Overall, I am satisfied with this telehealth session 72% 83% I would recommend this type of session to other Veterans 76% 83% I would rather use Tlh Telehealth lhto see my provider than travel to a VA Medical 69% 91% Center 59% 100%

96 No-Show(s) VISN20 & Portland VAMC TMH HBTMH FY (455 encounters, 27.9%) 2 (64 encounters, 3.1%) FY 11 (thru 8/10/11) 97 (680 encounters, 14.3%) 1 (290 encounters, 0.03%) TMH: VISN20 wide HBTMH: Portland VAMC only

97 Where can HBTMH go? (Better question: where can t it?) Psychotherapy / med management Organ transplant follow up VJOC: Incarcerated Veterans from her office Hep C: Interferon tx follow up BehavioralFlag: Veterans seen inhomepotentiallyreduces risk Churches Community colleges for our student Veterans Caregiver Support Health Behavior Coordinators

98 Where can HBTMH go? (Answer literally anywhere) Home Based Primary Care: MH Providers save on travel doing home visits Group modalities ERange HUD/VASH Couples/MaritalTherapy (in evening) Severe mental illness (bipolar; schizophrenia) Suicidality Primary Care / MH integration Speech and Audiology Integration with other web based applications (PTSD Coach)

99 What else are the Veterans saying? It was the best most convenient appointment I have ever had with the VA. It is anawesomeawesome programto outreachveterans thankyou! My experience has been excellent. Wouldlike like an easierandmoreand reliable connection I would lose time from work, my husband doesn t have to take time off of work to take me to VA. I would feel more comfortable and safe doing this at home because my anxiety is so severe I would not feel safe, secure or comfortable. I would be unable to participate i t (if weren t available at home). )

100 Total Votes: 501 Total Rank: 19 (3,841 ideas ranked) Topic Area: Patient Centered Care (1,651 ideas); HBTMH ranked 6. Topic Area: Access (349 ideas); HBTMH ranked 5. Thank you for your support! The future looks bright for our Veterans who have difficulty accessing care.

101 Don t worry it s only Technology (and it will change) MOVI/Jabber is a Third Party Software. Webcam is a Third Party Software. MOVI installation and usernames (step by step) in SOP. Connectivity issues. Common problems: DSL vs. Cable Modem vs. Satellite vs. Dial up vs. WIFI

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103 Current Innovation - Tablets Providers reach remote Veterans via secure and encrypted software with two way facing cameras. Providers (across multiple disciplines) access their VA network and Veterans

104 You teleworking from home Courtesy of: Ron Acierno, Ph.D.

105 Future Directions Continued VISN 20 pilot expansion Aspirational: National Workgroup Home Based Telemental Health. Interpret data from various demonstration projects. Develop OMHS OMHO/HBTMH Tool Kit and Operations Manual. Integrated Model.

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108 Whose who? * Know the landscape before venturing into the forest! Identify all CBOCs being served. Know the Ops Manager at each. Create an org chart for your catchment, identifying Telehealth Coordinators, TCTs, relevant PSAs. Road show to each site to develop relationships. (Most likely, you are visitors in their house). Have knowledge of the telehealth infrastructure at your own site as well as sites being served. Real estate,telehealth telehealth equipment (working/non working), working), etc.

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110 Provider & Staff Roles Successful TMH services articulate staff roles and monitor process and outcome Referring Provider Treating Provider Support staff

111 Referring Providers Typically the referring clinician will be a member of a CBOC s clinical staff who identifies a Veteran who needs and/or requests MH services. Existing staff at the CBOC may either not offer these services or may already be operating at capacity for those services Referring clinicians are responsible for screening Veterans to ensure their suitability for these services and for initiating iti the referral.

112 Referring Providers VAMCs that have successful u TMH services have implemented procedural systems that provide feedback to referring clinicians that the referral for services has: been received the results of the referral is communicated (e.g., the Veteran was appropriate for and accepted anebpfor PTSD via TMH or the Veteran was referred to an alternate treatment and why; discusses conditions for future successful referral) the outcome of the referral post treatment treatment

113 Treating Provider Thetreatingclinician needsto: to be appropriately trained to deliver these services dfi define the population of Veterans who are appropriate for these services for the referring clinics and providers collaborate with referring clinician and CBOC staff to establish high quality interactions on behalf of Veterans be familiar with the TMH equipment and how to create/enhance the clinical environment

114 Support Staff Program Support Assistants (PSA s) who will serve as telepresenters should be a part of any TMH planning team since their participation is crucial to the success of these services. Need to assess how these services affect their workload Get their input on the quality of these services over time Assess their equipment needs to support these services

115 Support Staff Telepresenters at CBOCs typically check the Veteran in and then show the Veteran to the telehealth equipment They must be familiar with the equipment and know how to fix simple problems Develop an alliance with Veterans Allay Veterans concerns about TMH such as being on television

116 Support Staff Telepresenters may also facilitate the exchange of printed clinical measures or educational materials bt between the provider and Vt Veteran via fax or scanner as well as maintain supplies of blank forms Telepresenters can help assure that TMH equipment does not get unplugged or moved at the remote sites Unplugging or moving equipment can lead to loss of directory information

117 Staff Interactions Treating Providers should plan regular site visits (at least tri annually) to remote sites to meet with telepresenters and referring providers There may be staff turnover so regular visits assist with staff training and successful operations May be helpful to let staff know that the goal of the treating providers it to help the remote facility with its workload

118 The first step

119 Developing a Strategic Plan An accurate assessment of the scope of services needed CanTMH assist with meeting the requirements of UMHSH? Can TMH increase access in geographically remote or challenging areas?

120 Developing a Strategic Plan Can TMH provide services where it is difficult to recruit staff with needed training and credentials? o Provide highly specialized services not available at most sites o Pay special attention to possible reductions in fee basis care & circuit rider clinician Increase treatment compliance and reduce no shows Provide services to Veterans who are not receiving VA care Augment service to high utilization h clients

121 Using VA Data to Assess Need VHA s Austin/DSS patient database can be provided by your local DSS coordinator Number of Veterans seen and demographics Types of visits identified by CPT or encounter codes: o outpatient encounters, annual number of clinic visits, clinic wait times, inpatient admissions and rates, length of stay, urgent care and emergency room visits

122 Using VA Data to Assess Need Diagnoses often identified by stop codes or ICD 9 codes (e.g. psychotic, affective, anxiety, personality, substance use disorder, d and cognitive/organic ii i disorders) Vt Veterans with service connected tdmental tlillness diagnoses, coupled with treatment history to identify those not currently receiving VHA services, who might do so if treatment was geographically closer

123 Using VA Data to Assess Need Fiscal data to evaluate utilization, fee basis, and ancillary costs Veteran utilization of services, no show rates, compliance Geographic location of the patient (e.g. zip code data) and distance from the VAMC and CBOCs

124 Using VA Data to Assess Need This data can be obtained by VISN/Facility/CBOC location as a whole for whichever area the Telemental lhealth lhservice is being bi considered, d then drilled down by zip code. The dt data can then be further imported dto a MapQuest type geographical software program that visually plots where such patients are clustered geographically.

125 From Data to Plan Identify which potential satellite Telemental Health sites (e.g. CBOC s and VET Centers) are likely to have sufficient patient numbersin particular diagnostic categories (patient need) to justify developing Telemental Health services. Assessing needs in this way gives the strategic planning committee overall numbers and locations of patients who might benefit from Telemental Health services. This is important in deciding the who, what and "where" of establishing Telemental Health services.

126 Consultation vs. Treatment Consultation model: distant clinician recommends diagnosis and/or treatments to proximate provider who is the care provider Treatment model: distant clinician is the care provider and may provide: Urgent or emergency care to new and/or previously seen Veterans Routine new assessment Routine follow up med management w/ or w/out therapy Routine psychotherapy w/o meds group or indiv Specialized programming (smoking cessation, CBT, etc.)

127 Hub & Spoke or Regional Model The widespread Telemental Health structure within VA consists of care delivered from a VA Medical Center to its CBOC s in a traditional hub and spoke model. CBOC s are part of the same organizational structure as the parent VAMC and therefore there is only a single department for credentialing/privileging, IT, medical record, QM, workload credit, reimbursement and billing. When delivering care beyond the facility s satellites, other procedural issues must be addressed as outlined in the VHA Handbook with Amendment 9/16/10.

128 Hub & Spoke Versus Regional Model VAMC - CBOC VAMC Other VA Site Established model Yes No Provides access to experts not available within a single VAMC No Yes Requires MOU between sites VHA Handbook amended No Yes Credentialing and privileging requirements between sites No Yes Needs access to two different medical records No Yes Requires coordination of IT needs from two different IT facility departments Requires scheduling of clinician, patient and equipment across facilities Quality Management information exchange required across facilities No No No Yes Yes Yes Requires agreement on workload credit and cost sharing No Yes Requires billing coordination between sites No Yes

129 What Kind of TMH Services? Depending on the data analysis services may include: Comprehensive general mental health services Limited general mental health services Specified specialty ilt services

130 Scheduling Scheduling must address: Clinician time Veteran time Clinician equipment Veteran equipment Bridge if necessary At present, look to local scheduling policies Clinician can begin by simplifying time units (e.g., TMH on Tuesdays) Futurelarge scale schedulingpackage opportunities

131 Logistics Where will Veterans be seen CBOC Community Clinic University Counseling Center Vet Center What hours of service will be provided Who will do the scheduling Provider room & equipment Veteran treatment room & equipment

132 Logistics Who will provide technical support to assure that the equipment is set up and operating correctly Who will provide emergency support and a mechanism Who will provide emergency support and a mechanism is in place for the distant clinician to contact staff at the site of the patient if an emergency arises or to convey follow up orders/instructions

133 Summary: Assessing TMH Services Domains Process Measures Outcome Measures Clinical # of unique patients with Patient satisfaction telehealth stop code vs. total domain for Mental Health Service Provider satisfaction # of telemental health encounters vs. total for Mental Health Service Clinical quality indicator achievement accomplished via telehealth visit (e.g., patient education) Business # of no shows Travel cost avoided # visits per FTE or per unit Travel time avoided domain of time Access to care Technical % of dropped calls % visits completed successfully domain

134 Discussion / Participants

135

136 Resources VHA Office of Telehealth Service Website Telemental Health Resources VHA Office of Telehealth Service SharePoint t.aspx Master Telehealth Document Library

137 OTS Website Telemental Health Resources OTS Home Page Telemental Health Resources Ops manual Credentialing and Privileging Informed Consent Coding Clinic Setup Guide SharePoint Portals VISN Contacts Training Publication Archives TMHJournal Club

138 TMH Training Program OTS Home Page Training Tab Click on RMTTC Training Programs TMH Training Program

139 TMH Training Program Telemental Health Toolkit: Video Conferencing Telemental Health Suicide Prevention and Emergency Care Request a Telemental Health Skills Request a Telemental Health Skills Assessment

140 A Veteran gives the last word

141 Tracey Smith, Ph.D. Peter Shore, Psy.D.