Robert N. Cuyler, Ph.D., Senior Associate, OPEN MINDS The 2014 OPEN MINDS Planning & Innovation Institute June 3, :15am 12:30pm

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1 Robert N. Cuyler, Ph.D., Senior Associate, OPEN MINDS The 2014 OPEN MINDS Planning & Innovation Institute June 3, :15am 12:30pm

2 I. Overview Of The Current Telehealth Market II. Telehealth In An Integrated Environment III. Telehealth Case Studies Sherrie Williams, LCSW, Executive Director, Georgia Partnership For Telehealth Bob Franko, Vice President, Marketing & National Training Coordinator, Cherokee Health Systems, Inc. Jonathan Evans, President & Chief Executive Officer, Safe Harbor Behavioral Health IV. Questions & Discussion

3 Overview Of The Current Telehealth Market

4 Global market for telehealth increase from $11B in 2011 to $27B in 2016 Increase in doctor-patient direct care Huge increase in mobile solutions Employer/payer adoption Increased focus on interstate practice (ex. Federation of State Medical Boards) Retail/urgent care Deployment in Major Health Systems OPEN MINDS All rights reserved.

5 Interstate Practice limited by practitioner license Least complex technology needs of any medical specialty Just two talking heads, no need to lay hands Huge needs in limited-access settings Robust empirical base Practitioners are clustered in urban settings Readily adopted by consumers OPEN MINDS All rights reserved.

6 The best evidence for telemedicine, especially live interactive office/hospital-based telemedicine is in the psychiatry and neurology specialties Verbal interaction is the key assessment component ARHQ Research Review - Locatis & Ackerman, NIMH, 2013

7 Telemental health services are unquestionably effective in most regards, although more analysis is needed. Effective for diagnosis and assessment, across many populations (adult, child, geriatric, and ethnic) For disorders in many settings (emergency, home health) Are comparable to in-person care, and complement other services in primary care. Hilty et al 2013 Meta Analysis

8 Standards of care defined by states, vary widely Restrictions on interstate practice of medicine Federation of State Medical Boards attempting to improve portability Patchwork reimbursement policies Interoperability of Health Records Incentives for Providers

9 Shift from grant to sustainable and businessviable remains work in progress Reimbursement climate improving but fragmented Lack of exposure/training in clinical education Best fit when provides system leverage No business model has emerged as winner yet

10 Telehealth In An Integrated Environment

14% of population receive treatment for BH, but account for 30% of healthcare spending Fragmentation of care increases spending and worsens outcomes Costs for treating co-morbid conditions

11 14% of population receive treatment for BH, but account for 30% of healthcare spending Fragmentation of care increases spending and worsens outcomes Costs for treating co-morbid conditions twoto-three times higher than uncomplicated physical heath problems Effective integration could save $26-48 Billion annually Milliman Report: Economic Impact of Integrated Medical-Behavioral Healthcare, April, 2014

12 1. Specialist organization adds primary care capacity 2. Specialist organization co-locates services in primary care organization 3. Specialist organization merges with primary care organization 4. Primary care organization arranges behavioral health services using specialist web-based and telehealth services 5. Care coordination through shared consumer data

13 Behavioral health services have historically been siloed Limited models for collaboration Problems in maintaining rapid access of behavioral health specialists in physically colocated settings Problems in providing access to care in smaller and/or de-centralized primary care settings

14 Provider shortage and lack of access outside of urban areas Demographics of psychiatrists (aging, limited emergency access, boutique/quality of life choices)

15 Telemedicine can be a distribution system for all professionals Deliver multi-disciplinary team to all locations Can individualize care regardless of location (ex. PTSD, family therapy, eating disorder)

fee-for-service Dependent on risk-based payment systems Dependent on

16 Can be organized as internal network for larger systems or contracted network for smaller systems Dependent on shift away from fee-for-service Dependent on risk-based payment systems Dependent on system architects to recognize and prioritize innovating behavioral health delivery

17 Must be strategically driven by system leadership Potential to physically co-locate in central or hub setting and reach other spoke sites via telehealth Advantage of strong IT resources and integrated system EMR System can select, manage, and set priorities of behavioral health providers Compensation systems more readily designed for practitioner productivity, quality control, shared savings

18 Multi-hospital Health System Internal or Contracted Behavioral Heath Network Primary Care & Clinic Network Single EMR & Integrated Telehealth Network May be hub to Rural Hospital Spokes

19 Will open opportunities for inter-organizational work RFP to provider groups/networks to provide behavioral health integration Fee structure may range from fee-for-service, contracted rates, capitation, or shared savings Opportunity for behavioral heath networks to develop solution/services and offer services to multiple ACO organizations Technology platform more complicated as betweenorganization system without centrally-controlled IT, purchasing, technical support But allows smaller organizations to participate in behavioral health integration without co-location

20 Single or Small System Hospital without Behavioral Health Department Reach extends to owned/affiliated Primary Care, FQHC, or Rural Heath Clinic Reach may extend to long-term care Size & resources will not support internal behavioral health providers

21 No Risk/Low Risk Moderate Risk (example, uncomplicated depression) Significant Risk High Risk / High Resource (SPMI, significant medical comorbidity, co-morbid substance abuse) No intervention necessary Med management by primary care Access to resources and consultation Crisis Stabilization & Emergency Care Med management by psychiatrist, psychotherapy Management by primary, psychiatrist and care team

22 Opened 120,000 sq. ft. Virtual Care Center To support 75 telemedicine offerings Range: 24/7 Nurse Call Center Home Monitoring Tele-ICU Projects 3 million visits over 5 years System has 300,000 lives in revenue-sharing reimbursement models

23 Primary Care locations will offer behavioral health services via co-location & telehealth consultation Focus: Team-based management of behavioral health problems in primary care Goals: Improve outcomes for chronic and co-morbid conditions Reduce physician burnout via team approach Lower cost of care by reducing ED visits & hospitalization

24 Massive paradigm shift underway in health care Telemedicine has been about to happen Expect tipping point for telemedicine as riskbased payment begins to escalate Only practical way to supply right practitioner at right time at right location

25 Technology is ready for prime time Technology integration not yet ready (interoperability of EMRs is key) Lack of exposure and training for practitioners Telemedicine training and certification will be essential Systems and payers will favor knowledgeable providers and BH systems

26 Telehealth Case Studies

27 Sherrie Williams, LCSW, Executive Director, Georgia Partnership For Telehealth Bob Franko, Vice President, Marketing & National Training Coordinator, Cherokee Health Systems, Inc. Jonathan Evans, President & Chief Executive Officer, Safe Harbor Behavioral Health

28 + TeleMental Health Lessons Learned From the Frontline of Care

29 + Georgia Partnership For Telehealth GPT Headquarters is located in Waycross, Ga. Extended offices in Atlanta and Prattville, AL Field-Based TM Liaisons Support for Credentialing and Scheduling All Specialists & Allied Healthcare Providers are required to complete the modified application that is accepted by The Joint Commission. Dedicated toll free scheduling line.

30 + Facts & Stats 500+ rural and specialty sites within the GPT network. Over 180 specialists, representing 40 specialties. 8 encounters in January ,000 + encounters in ,000 + encounters in 2013

31 + Open Access Network Model Creates a web of access points Any Presentation Site can connect to any other site Specialty Center Presentation Site Presentation Site Presentation Site Presentation Site Specialty Center Specialty Center

32 +

33 + What We Know In GA, severe deficit of mental health care providers 376 HPSAs National mental health HPSA = 3900 Need at least 2600 more psychiatrists to fill gap Since GPT was developed, Mental Health has ranked as the top 3 requested services: C&A Psychiatry Adult Psychiatry Geriatric Psychiatry

34 + Lessons Learned Commitment from providers and presentation sites Providers must understand that telemedicine patients are treated just like traditional face-to-face patients Quality of connectivity has to be reliable and crisp Large screens are better than smaller monitors Sound has to be good Contract vs. billing

35 + Environments For Care Corrections Schools Community Health Centers Public Health Departments SNFs Hospitals Private practices

36 + PRESENTER Sherrie Williams, LCSW Georgia Partnership For Telehealth Executive Director

37 Utilization of Telepsychiatry in an Integrated Model of Care Jonathan Evans President & CEO InnovaTel Telepsychiatry. LLC

38 Telepsychiatry Implementation Safe Harbor Behavioral Health pioneered telepsychiatry regionally in 2007, with a SAMSHA Grant telepsychiatry expansion to a full time employed psychiatrist. 2012, providing 20 hours weekly to rural clinic in PA. 2013,expansion in multi-state clinics.

39 Compass Grant Compass team consists of nurse care managers, psychiatrist, PCP and internists. 2013, Compass Grant with St. Vincent s Medical Center to provide telepsych consultation service to 35 physicians in the primary care network. Weekly consultation meetings scheduled for case review and consultation. Screenings PHQ9 depression rating scales completed on patients during normal outpatient visits. A compass nurse care manager calls patients to determine stressors and barriers to care/recovery.

40 Compass Grant The team meets weekly via conference call to review all patients in the program. The telepsychiatrist will make treatment recommendations Starting an SSRI, consider switching meds due to blood pressure concerns, recommending therapy. Average LOS in the program is 6 months.

41 Compass Program Results (Unpublished) Many patients evaluated by psychiatrist in a timely manner vs. typical months waiting time. Multiple issues addressed at once via consultation with nurse care manager linking patient to community resources. Consultation model allows many cases for review in an hour.

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