Two Decades of Telehealth at Cherokee Health Systems:

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1 Two Decades of Telehealth at Cherokee Health Systems: Clinical, Operational & Financial Perspectives Gregg Perry, MD Jeff Howard, CPA Andy Rhea, MBA

2 Our Mission To improve the quality of life for our patients through the blending of primary care and behavioral health. Enhancing Life

3 Primary Service Area M i s s o u r i K e n t u c k y V i r g i n i a a n s a s Te n n e s s e e CLAIBORNE CAMPBELL GRAINGER UNION HAMBLEN ANDERSON JEFFERSON KNOX COCKE SEVIER LOUDON BLOUNT MCMINN MONROE N o r t h C a r o l i n a M i s s i s s i p p i A l a b a m a HAMILTON G e o r g i a

4 Cherokee Health Systems Last Fiscal Year: 75,863 Patients 399,690 Services 28,318 New Patients Number of Employees: 755 Provider Staff: Psychologists - 47 Cardiologist - 1 Psychiatrists - 8 Primary Care Physicians 41 Nephrologist - 1 NP (Psych) - 10 NP/PA (Primary Care) 51 Pharmacists - 12 LCSWs - 68 Community Workers 39 RNs - 70 Dentists - 2

5 Strategic Emphases Blended behavioral health and primary care Go where the grass is brownest Outreach and care coordination Telehealth Training healthcare providers Value-based contracting Healthcare analytics

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7 What Was Happening When We Implemented Telemedicine?

8 Clinical Applications Primary Care Specialty Mental Health BHC Consults Pharmacy Discharge/Aftercare Planning Mobile Crisis Online care of acute Primary Care and Mental Health Hospital Behavioral Services (Future Service) Admission (Second Certification) Interpretation Treatment Teams Supervision Hypertension Groups Nutritional counseling Community Health Coordinators Parent-Child Interactive Therapy

9 Telemedicine In Action

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17 Telemedicine In Action

18 Service Volume FY2017 Type of Visit Patients Visits Therapy / BHC Psychiatry 2,701 7,232 Primary Care 2,612 3,544 Total 5,466 11,087

19 Billing and Policy Considerations

20 ORIGINATING SITE Patient s Location (Q3014) DISTANT SITE Provider s Location (GT)

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24 Telehealth Policy Issues Medicare and state-by-state policies create inconsistencies Hands on initial visit, or periodic hands on visit requirements Controlled substances restrictions Need to balance access and restrictions State Boards of Medicine Medicare definition of originating sites does not include home, community, or other similar site Confusion over whether or not providers at FQHCs are eligible distant providers

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27 Initial Challenges Expensive video equipment Complicated network infrastructure setup required by IT professionals Inadequate and expensive internet bandwidth Dedicated office space for telemedicine setup Provider buy-in Training providers and nurses on workflow

28 Current Environment Inexpensive plug and play video equipment (Webcams, ipads, iphones) Easy to use cloud based video services (Zoom and Polycom) Cost effective broadband internet available in most rural and urban locations Dedicated office space no longer required Providers no longer fear telemedicine technology Telemedicine visits are part of everyday workflow

29 Lessons Learned & Strategies for Success Patients always point the way. Good technology is essential. Management support is key. Billing can be difficult. Advocating for policy change is important. Keep it simple.

30 Resources

31 Questions