Transcript Tele-Health Expansion
Tele-Behavioral Health:
Filling the need when others cannot…
Michael D. Lynch, PhD, ABPP Director of Tele-Health Northern Regional Medical Command 01 March 2012
“The views expressed in this presentation are those of the author and do not reflect the official policy of the Department of Army, Department of Defense, or U.S. Government.”
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Program Goal 1. The preparation of Tele-Health capabilities for ethically delivering diagnostic and therapeutic services effectively to diverse populations of clients in need of such treatment Program Goal 2. Understanding the process for developing policies and procedures associated with the delivery of Tele-Health applications Program Goal 3. Identifying best practice models for behavioral health care delivery and understanding the evidence based practice associated with the delivery of virtual behavioral health.
A form of care where Behavioral Health personnel interact systematically to meet the Behavioral Health and Health needs of their patients through collaborative development of treatment plans, provision of clinical services, and coordination of care through the use of technology. 4
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Introductions and Overview
Why Tele-Health
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Technical Applications
Use of Technology
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Business Planning
Maximizing Resources
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Conclusions and Wrap Up
Anyone, Anywhere, Behavioral Health
Synchronous
Tele Health Behavioral Health Anytime Tele Health Tele-Medical Home Patient Medical
Consultative
Primary Care Spoke Centered Home Tele-Health Tele Health Behavioral Health
Asynchronous
Tele Behavioral Health Provider
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Population Health Prevalence of BH problems in PC Per Capita Cost Cost of unmet BH needs Experience of Care Better outcomes/satisfaction Deliver the right care at the right time Share information 6
• 20% reduction in overall h/c expenditures 1 • 4.5% increase in expenditures for new BH costs 2 • $128
PPPM
less for overall health cost among patients with diabetes and depression (UC vs IC) 3 • $457 to > $775
PPPM
higher cost for chronic illnesses + depression than for chronic illnesses alone (< 6% for BH) 4 1 Chiles JA, Lambert MJ, Hatch AL.. The Impact of Psychological Interventions on Medical Cost Offset: A Meta-analytic Review.
Clinical Psychology: Science and Practice Volume 6
,
Issue 2
,
pages 204–220
,
June 1999
2 Bachman RE. An actuarial analysis of comprehensive mental health and substance abuse benefits in the state of New York. PriceWaterhouseCoopers, May 2002.
3 Bogner, H. et al.
Diabetes, Depression, and Death
A randomized controlled trial of a depression treatment program for older adults based in primary care (PROSPECT). Diabetes Care
December 2007
vol. 30 no. 12
3005-3010
4 Melek, R. & Norris D. Milliman Chronic conditions and comorbid disorders. Milliman. July 2008.
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• 1980-1981 National Ambulatory Care Surveys • Nearly half of all visits with psychiatric diagnosis are seen in primary care 8
South Central Veterans Healthcare System VISN 16 395 markedly depressed patients from seven VA primary care practices Equivalent: Medication adherence – 6 and 12 mo Medication response – 6 and 12 mo Symptom remission – 6 and 12 mo Satisfaction – 6 and 12 mo 1 Arkansas’ Mississippi Delta and Ozark Highlands 364 markedly depressed patients from five Federally Qualified Health Centers Equivalent: (p) Medication, # meds, dose Medication adherence Treatment response Symptom remission 2 1 Fortney, J et al. A Randomized Trial of Telemedicine-based Collaborative Care for Depression. J Gen Intern Med. 2007 August; 22(8): 1086 –1093.
2 Fortney J et al. A Pragmatic Randomized Comparative Effectiveness Trial of Practice Based Versus Telemedicine Based Collaborative Care for Depression in Rural Federally Qualified Health Centers. Submitted for publication. National Institute of Mental Health, (R01 MH076908, MH076908-04S1)
Current Direction of Services Hub Provider Pre-Positioned Provider
FT Hood FT Riley FT Knox Newport FT Detrick Dix NC Carlisle Barracks ITG FT Drum West Point FT Lee APG FT Meade NRMC Hub Pax River Ft Belvoir Quantico Camp Lejeune WB FT Bragg FT Eustis
Three Part Aim
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Improve experience
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Improve health of populations
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Reduce per capita costs
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Staffing limitations BH is a product line with multiple subspecialties which may only require limited FTEs Synchronous vs. Asynchronous applications 12
“ … great potential to improve access … adoption in routine health care has been slow … lack of clarity about the value of telehealth … slow adoption. “The simulation predicted savings billion per year … of $4.3 “ Payers, providers and policy-makers should work together to remove the barriers to the adoption of telehealth in order to make it widely available to all.”
SOURCE:
The value proposition in the widespread use of telehealth
. Cusick CM, et
al.Journal of Telemedicine and Telecare
. June 2008 vol. 14 no. 4 167-168.
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The Comprehensive Care Plan will be based on an integrated treatment plan designed to be utilized within the primary care setting that increases access and provides quality care that is both sustainable and reproducible.
Patient Today
Unhealthy behaviors/High disease burden High utilization of resources Lower PCMH empanelment capability
Integrated Health Care Comprehensive, Coordinated Care Tele Health Delivery Behavioral Health, Wellness & Resiliency Patient Ideal
Healthy behaviors/Lower disease burden Less utilization of resources Higher PCMH empanelment capability
Comprehensive Care Plan
• • •
Behavioral Health
: Provider to Patient or Provider to Provider
Wellness
: Pre-Clinical Interventions
Resiliency
: Psycho-education and disease prevention 14
Provider to patient direct care
Medication Management Psychotherapy Assessment Store and Forward
Provider to provider consultations Project ECHO (Extension for Community Healthcare Outcomes)
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“I was living under a bridge” “Nintendo generation” “Frolicking through the fields” “Safety first” “Plan A does not work… a.k.a Dress to Thrill” “Sugar, Sugar” “NJ to CO to VA to NJ to MD to NJ” “Can’t pull the wool over the camera’s eye”
Evidence based No “a priori” contraindications Contraindications “The inclusion of cases for a telemental health consult is at the discretion of the referring and consulting clinicians. There are no absolute contraindications to patients being assessed using telemental health.“
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Technology Fully integrated room-based VTC units Desktop high resolution VTC Mobile VTC designed for medical offices Web based applications Hand held Web Cameras Connectivity VoIP ISDN Internet Mobile 3G – 4G Electronic Medical Record Permissions result in better integration outside provider portal Allows for prescribing at the patient site Different versions 18
Scheduling Different strategies or logistics in real time different functions TBH Provider availability Patient room vs. mobile unit Emergency Management Risk assessment Emergency notification Hospitalization Prescribing Electronic medical record portal Fax/next day delivery (hard copy) class 2/non formulary Medication recommendation for PCP Orders Electronic Medical Record Fax orders email orders Use of Clinical Care Coordinators 19
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Underresourced remote sites No space for VTC No support staff to monitor BH patient No financial resources for hardware and/or fiber Comfort level if you built it they will come relationship building Medical records Outside provider access to EMR Fax/scan of clinical notes into EMR Scheduling Coordinate provider and room schedules Payment and sustainability 21
Patient
Variable Business Practices Stovepipe Operations & Redundancy Limitations on Technology Credentialing
Provider
Provider start up delays (hiring actions) Space: Hub & MTF IM/IT (Phones, laptops, BBs, Aircards)
Mobile in-office solutions Full roll out vs. stepwise progression Availability of funds contingent on productivity Adding to the equipment base Hand held options Web-based encrypted software Add to the administrative support base ROI Evaluate outcomes 23
Implementing Tele-Behavioral Health has been shown to be efficacious both clinically and financially. Utilizing a Tele-Health delivery system allows access to needed behavioral health services when it is not feasible to provide on-site interventions. Tele-Behavioral Health is not a secondary option but clinically it has been shown to be as or more effective based on timeliness of care and increased compliance.
Deliver the right care at the right time.
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Michael D. Lynch, PhD, ABPP Chief, Department of Tele-Health Kimbrough Ambulatory Care Center Northern Regional Medical Command 703-588-0350 (O) [email protected]
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