TELEPSYCHIATRY: From Idea to

SolutionDeveloping and Implementing a Telepsychiatry

Program

Trilok Shah, M.D.

June 25, 2014

TOPICSBenefitsChallengesEconomicsTechnology & LogisticsDeveloping your programCommon QuestionsDiscussion

WHAT IS IT?Psychiatry services carried out using tele-video medium

Focus on the service not the technologyHas been around for long time

WHERE IS IT BEING DONE?Hospitals - ERs, Consults, InpatientClinics - Private practice, CMHC, FQHCs, RHCsCorrectional facilitiesNursing/residential homesLocum tenens coverageSchools

WHY IS IT BEING DONE?Increased Access to ProvidersImproved Quality of CareCost Benefits and Improved WorkflowValue Beyond Fee for Service

Increased Access to Providers

A Congressional report earlier this year said 55% of the nation’s counties have NO practicing psychiatrists, psychologists or SWs

Almost 90 million Americans live in federally-designated Mental Health Professional Shortage Areas

According to HHS, Illinois has a deficit of 169 PsychiatristsIn rural AND urban areas

Lengthy wait times

Improved Quality of CareClinical decisions by experienced psychiatrist

Would you want an internist to perform surgeries?PCPs recognize and diagnose less than half of

mental disorders Pirl, W.F.; Beck, B.J.; Safren, S. A.; Kim, H. (2001). "A descriptive study of psychiatric

consultations in a community primary care center". Primary Care Companion Journal of Clinical Psychiatry, 3 (5): 190–194. doi:10.4088/PCC.v03n0501

PCPs prescribe 50% of psychotropic meds- often out of necessity

ED docs report being overly cautious in commitment decisions

Cost Benefits & Improved WorkflowA study of almost 100,000 users of the VA

telepsychiatry program: Patients' hospitalization utilization decreased by an average of 25% with the implementation of telepsychiatry.

Linda Godleski, M.D.; Adam Darkins, M.D., M.P.H.; John Peters, M.S. (2012) Outcomes of 98,609 U.S. Department of Veterans Affairs Patients Enrolled in Telemental Health Services study from 2006–2010.

Psychiatric patients:Remain in the ED 3 times longer than non‐psych

patientsPsychiatric boarding in the ED prevents 2 bed turnoversLack of bed turnover costs hospitals an average of

$2264 per patient Nicks and Manthey. “The Impact of Psychiatric Patient Boarding in Emergency Departments.”

Emergency Medical International. 2012.

Value Beyond Fee for ServiceTreat patients where they areImprove staff and referral source satisfactionReduce burnout of primary care docs, and increase

confidence of the treatment teamReduce indirect costs

Recruiting and retaining providersDecreased opportunity costs with increased

throughputRisk reduction

CHALLENGESReimbursementLicensingCredentialingLiabilitySecurity/privacy

ReimbursementMedicare & IL Medicaid

GeographyRural for Medicare- Telehealth Payment Eligibility AnalyzerHPSA for Medicaid

Facility- office, hospital, RHC, FQHC, SNF, CMHCProvider- must have completed a psychiatry

residency program CPT codes- most evaluation and follow up codesReimbursement to the health professional is the

same as in-person amounts. Originating (patient) site is reimbursed an additional $25 per telemedicine encounter

ReimbursementPrivate payers

Required to pay in some statesIn IL it is up to the individual companies to decide

whether or not to offer it as a covered service. Telehealth Act (SB0647) passed both

houses on May 30thSets some guidelines for private payers with

regards to covering telehealth services- for example, it forbids insurance from requiring that initial visits be in-person.

Negotiate with your payers

CHALLENGESLicensing

Currently need license in the state the patient lives in, except for federal institutions (V.A.)

CredentialingProxy credentialing not commonly used

LiabilityMore insurers provide liability coverage for

telemedicineSecurity/privacy

Encryption, BAA, protocols

DEVELOPING YOUR PROGRAMConvene Your Telemedicine Team Assess the need in the community & the current

community resources Develop your financial plan Select provider Select technology Develop protocols & do practice runsSet launch date & marketLaunch program

Convene Your Team Project Manager Medical Staff RepresentativeInformation Technology Representative Financial Officer Human Resources Representative Legal RepresentativeQuality Improvement RepresentativeConsumer Advocate –patient education programs and

information materials, consumer and community outreach

Assess the Need & Resources

Talk to The primary care doctors at your facility and in the community Potential referral sources ED directors and docs Patients Support clinical staff Current resources in the community

Questions to ask How many patients are the current docs seeing with psych issues Where are patients with psych issues currently going What stress is the current setup putting on the providers How long are the patients having to wait for psych services, and how

much are they having to travel What quality of care issues are there- stretching the PCP’s capacity to

care of complex patients, safety and risk issues What is the availability, capacity of the current resources Subspecialty needs- child, geriatric, addictions

Develop Your Financial Plan

What will be the associated costsProviderSupport staffEquipment and setup – a much smaller barrier now

Cost savings Improved workflow for the ED, other providersCreates referral source for other on site providers- primary

care docs, neurologists & other specialists, therapistsCreates revenue source for labs, imagingCost savings and convenience for patients

Reimbursement Who are the major insurers for your patientsNegotiate with payers

Select Your ProviderFits your needs

AvailabilityExperienceSubspecialty

Willingness to work with the whole teamLong term relationship with your facility and

patientsLess likely to utilize your organization as a stepping

stone

Our Providers Are…Board certified/eligible psychiatristsAdult/child/geriatric specialistsExperienced in implementing programs in ER, outpatient,

and school settingsLocal and interested in serving the patients hereAre thoroughly vetted, and have clean practice recordsGo through extensive training processAble to help with credentialing, billing, technology, staff

training, developing protocols, and with data collection for continuing program evaluation

English proficient, and not requiring any visa sponsorshipBacked by $1mil/$3mil liability coverage

Select the TechnologyWork with your provider to ensure compatibilityEngage your IT team, but do not let them be the sole

decision makersSecurity is not just about the technology- it is also

about how it is used Think about long term needs

Need mobile unit?Technology costs are no longer prohibitive

Develop Protocols & Practice Runs

Scheduling Medical records

Sharing notes, storage of PHIPrescribing - Controlled medicationsOrders - Ordering and receiving resultsConsentsLoss of signal or loss of powerEmergency situations

Keys to SustainabilityExpect to encounter some resistanceTrain those involvedExpect to make adjustments

Collect quality and satisfaction dataTalk to patients, staff, referral sources to

continue improvingBe proactive and inform everyone

involved early about the program to avoid negative emotional reaction

Keys to SustainabilityKeep the onsite team engaged

Challenge team to focus on the positivesAddress fears about being replacedSupport, not replace

Keep the provider engagedOrient the provider to the different members of

your teamInclude them in your e-mail listsFamiliarize them with the community’s culture

and resourcesInform them of major changes in the

organization

COMMON QUESTIONSWill patients like it?Does it work?Are there limitations to using this?

Will Patients Like It?A number of patients prefer thisAccessConvenienceCost savingsDistance is perceived as protective by some

patients Control is maintained, can walk out easilyNeutral place So many patients already use similar

technology to socialize/keep in touch with others

Will Patients Like It: Patient Satisfaction Study

A pilot study comparing satisfaction levels between psychiatric patients seen face to face (FTF) and those seen via videoconference (VC).

Patients were randomly assigned to one of two groups.

One psychiatrist provided all the FTF and VC assessment and follow-up visits. A total of 24 subjects were recruited; 18 completed study.

NO significant differences in patient satisfaction

Will Patients Like It: Another Patient Satisfaction Study

Evaluated client satisfaction and one-month mental health outcomes for telepsychiatry (VC) clients compared with face-to-face (FTF) consultation.

Clients were asked to complete a health survey before the consultation, a satisfaction survey after the consultation, and were contacted for a one-month follow-up survey by telephone.

VC clients demonstrated significantly more improvements on pre- and post mental health measures than the FTF group.

VC clients felt that they could present the same information as in person (93%), were satisfied with their session (96%), and were comfortable in their ability to talk (85%); this was similar to the FTF clients.

DOES IT WORK?FQHC Based Depression Study

From 2007 to 2009, patients at several federally qualified health centers were screened for depression.

364 patients who screened positive were enrolled and followed for 18 months.

About half the patients received care from an on-site PCP and a nurse care manager.

The other half received care from an on-site PCP and an off-site psychiatrist via videoconferencing.

The primary clinical outcome measures were treatment response, remission, and change in depression severity.

The group receiving the care from the psychiatric team via telemedicine did significantly better.

Depression Treatment- RCTThe primary objective was to compare treatment

outcomes of patients with depressive disorders treated by telepsychiatry (VC) to patients treated in person (FTF).

Secondary objectives were to compare rates of adherence, satisfaction with treatment, and costs of treatment.

119 depressed veterans referred for outpatient treatment were randomly assigned to VC or FTF. Treatment lasted 6 months.

Hamilton Depression Rating Scale and Beck Depression Inventory scores improved over the treatment period and did NOT differ between groups.

No differences in dropout rates, patients’ satisfaction with treatment, adherence to appointments and medications.

Any Limitations?No hand shakeSmell is absent: EtOH (need to rely on onsite staff)Some psychotic patients?

Some evidence showing that even patients with paranoid delusions involving TV or cameras were able to participate in telepsychiatry sessions with no problems

Some patients with propensity for violence? Would want to take precautions even if in-person. Also,

would want to have staff in room with patient.Patients with very significant cognitive impairments?

MORE COMMON QUESTIONSWhere are the In Touch providers licensed?How are the providers credentialed at my organization?How does a typical telepsychiatry encounter go?Who takes medical ownership of the patient?Can the In Touch providers prescribe medications?How do In Touch providers document?Can the In Touch providers integrate with the

healthcare team at my organization?Can we supplement the In Touch telepsychiatry services

with our own psychiatrists?

RESOURCES In Touch Physicians Resource Center

http://www.intouchphysicians.com/resource-center.htmlPractice Guidelines for Tele-Mental Health Services

http://www.intouchphysicians.com/uploads/3/4/2/8/3428956/ata_telemedicine_core_guidelines.pdf

Practice Guidelines for Telemedicine Services http://www.intouchphysicians.com/uploads/3/4/2/8/342

8956/ata_practice-guidelines_videoconferencing.pdfAmerican Telemedicine Association

http://www.americantelemed.orgTelepsychiatry in the 21st Century

http://www.intouchphysicians.com/uploads/3/4/2/8/3428956/telepsychiatry_in_the_21st_century.pdf

DISCUSSIONTrilok Shah, MDPresident, CMO773-916-7595tshah@intouchphysicians.comwww.intouchphysicians.com