Upload
hoangdung
View
218
Download
3
Embed Size (px)
Citation preview
Telehealth/mHealth: Innovations in Improving Access to Care
Mark Carroll, MDMose Herne, MPH, MSMark Horton, OD, MDLyle Ignace, MD, MPH
Overview of Breakout Session
• Brief status of telehealth and mHealth in IHS
• Regulatory topics
– Credentialing and privileging
• Strategic opportunities
• Discussion
Facing the challenge of delivering health
care where it’s needed.
A Wide Range of Services
AIDS-HIV care
Behavioral Health
Cardiology
Dentistry
Dermatology
Diabetes care
ENT
Intensive care
Rheumatology
Neurology
Nephrology
Nutrition
Ophthalmology - JVN
Oncology/Palliative Care
Pharmacy
Radiology
Rehab services
Rheumatology
Remote Monitoring
Trauma
Wound care
Patient-Centered Care
Right care
Right place
Right time
Right “Tool”
“Right Emphasis”
• Relationships– New tools and technologies must enhance
relationships, especially if they are to be embraced and be effective in chronic care
The Mobile Revolution
Audie A. Atienza, PhD
http://www.itu.int/ITU-D/ict/statistics/material/graphs/2010/Global_ICT_Dev_00-10.jpg
Audie A. Atienza, PhD
http://www.itu.int/ITU-D/ict/statistics/material/graphs/2010/Cellular_signal_03-09.jpg
Audie A. Atienza, PhD
http://www.itu.int/ITU-D/ict/statistics/material/graphs/2010/Mobile_cellular_00-05-10.jpg
Audie A. Atienza, PhD
Remember 2008…
2009: 1.5 Trillion Text Messages Sent in US
4.1 billion SMS messages sent daily
Audie A. Atienza, PhD
http://www.unfoundation.org/global-issues/technology/mhealth-report.html
50+ Case Studies Described
Audie A. Atienza, PhD
mHEALTH IN INDIAN HEALTH:
CARE WHERE AND WHEN IT IS NEEDED
The IHS and its Tribal partners are committed to the appropriate use of innovative tools and
technologies to improve access to quality health care for American Indians and Alaskan Natives.
mHealth: “the integration of mobile technology, computing devices, and emerging delivery system
capabilities into a patient-centered model of care”.
Innovative uses of mHealth tools in Indian health care include: Mobile deployment of services
The IHS Joslin Vision Network Tele-Ophthalmology
program – to 14 facilities in AK and NC
Mobile mammography, for communities in the
Dakotas
Remote monitoring programs in diverse
geographies, for congestive heart failure and
diabetes care
USING mHEALTH IN AN EMERGING
MODEL OF PATIENT-CENTERED CARE:
THE 5 “RIGHTS”
1. RIGHT TOOL
2. RIGHT PLACE
3. RIGHT TIME
4. RIGHT SYSTEM OF CARE
5. RIGHT EMPHASIS: Relationships
CONSIDERATIONS FOR EXPANDED USE OF mHEALTH TOOLS
New tools must be integrated into initiatives to improve models of care. A key example is the IHS
Improving Patient Care initiative.
Use of handheld mobile technologies and wireless monitoring devices must occur in strict
compliance with emerging security and privacy standards.
Patient health information must be part of the IHS and
Tribal Electronic Health Records, for coordinated care at
the health care facility and community level.
mHealth services should complement developing work for
personal health records and other key activities that expand
access to health information for patients and communities.
Cultural acceptance of new tools and technologies is vital to program development and must be a
key component to mHealth project design.
mHealth and Patient-Centered Care:
Perspective from U.S. Indian Health Care
THE INDIAN HEALTH SYSTEM
A comprehensive health delivery system for ~1.9 million
American Indians and Alaska Natives.
Serving members of 564 federally-recognized Tribes in 35
U.S. states.
Comprised of Indian Health Service (IHS) direct health care
services, Tribally-operated health care services, and urban
Indian health care services and resource centers.
A RELATIONSHIP-CENTERED APPROACH
Critical Triggers for Quality Improvement
Improved
Outcomes
& Value
Improved
Self-care
and
Treatment
Effective
Relation-
ships
Connected
Care &
Remote
Monitoring
M Carroll, MD1; T Cullen, MD1; M Horton, MD,OD1; C Lamer, RPh1; S Ferguson, PhD2; M Veazie, DrPH1
I Indian Health Service; 2 Alaska Native Tribal Health Consortium
Smartphone Adoption and Usage
83% of U.S. adults have a cell phone
35% of U.S. adults have a smartphone
87% use it to access internet or email
25% use it as main access to internet
9% have apps to help track or manage health
17% have used phones to look up health info
Pew Internet Projecthttp://pewinternet.org/Reports/2011/Smartphones.aspx
Text Messaging
72% of adult cell phone users send or receive text messages
Pew Internet Project, Sept 14, 2010
41% of consumers prefer to receive a health-related task reminder through text messaging
Consumer Health Information Corporation http://www.consumer-health.com/press/2008/NewsReleaseSmartPhoneApps.php
HHS Text4Health Task Force (est. Nov 2010) Audie A. Atienza, PhD
text4baby
Audie A. Atienza, PhD
mHealth: Access and Quality of Care
Expanded models of care
Remote patient monitoring
Real-time support for dx and rx
Innovative access to information, training, and education
For care teams
For patients communities
Improved efforts at disease outbreak trackingand epidemiology
Last Mile Microwave Coverage
Social Media
• Standard Operating Procedures (SOPs) in
final approval stage
Facebook (updated version) – social
networking
YouTube -video sharing
Twitter - micro-blogging
Flickr - photo sharing
FDA Proposed Rules: July 2011
Best Practices
• What are new privacy and security standards?
• IHS planning to establish guidelines for using mHealth communications for a variety of scenarios
– Health promotion and education
– Reminders
– Other communications
Care Coordination for Hypertension Care:
Improving BP Control for Patients with Diabetes
Lyle Ignace, MD, MPH
July 27, 2011
Care Coordination for Improved BP Management
• GOAL:
– Improve BP Control for diabetic patients with poor BP control
Care Coordination for Improved BP Management
• TOOLS:
– Home BP monitoring cuffs and data transfer device/service
– Improved care coordination processes
Care Coordination for Improved BP Management
• DOES HOME BP MONITORING WORK?– Many studies show significant reduction in patients’ BP,
reducing risk for stroke, heart, disease, and other health problems
– Example:
• University of Toronto, Logan et al, implemented automated mobile phone-based telementoring
• Home BP monitoring data sent via mobile phone to care teams for DM patients with uncontrolled BP
• Systolic BP decreased by 9.1 mm Hg over one year, compared with 1.6 mm Hg decrease in control
In-home remote monitoring
Courtesy of Bonnie Britton, RN
Hospital Bed Days and ER Visits
Analyzed Charges are related to diseases being monitored
RCCHC/PPTN Patient Charge Data Ending June 2009
n=64
Hospital Bed Days
6 mos. prior to Telehealth = 199
During 6 mos. Telehealth = 99 50% decrease prior to during
6-30 mos. post Telehealth = 70 65% decrease prior to 30 mos. post
ER Visits
6 mos. prior to Telehealth = 27
During 6 mos. Telehealth = 5 81% decrease prior to during
6-30 mos. post Telehealth = 23 15% decrease prior to 30 mos. post
Courtesy of Bonnie Britton, RN
Total Charges
Analyzed Charges are related to diseases being monitored
RCCHC/PPCTN Patient Charge Data Ending June 2009
Statistically significant difference between pre-, during, and post-
telehealth charges
p value = 0.0088
6 mos. prior to Telehealth = $1.34 M
During 6 mos. Telehealth = $ 382 k 72% decrease
6-30 mos. post Telehealth = $483 k 64% decrease
Courtesy of Bonnie Britton, RN
Care Coordination for Improved BP Management
• TIMELINE:
– Pilot activity with 12 Improving Patient Care initiative sites
– To begin late summer/fall
Care Coordination for Improved BP Management
• EMPHASIS:
– The key part of this pilot is the care coordination team processes, not the facilitated access to home BP data
IHS NCC Meeting27 July 2011
Mark B. Horton, OD, MDPhoenix Indian Medical Center
Director, IHS/JVN Teleophthalmology Program
IHS/JVN ProgramSummer 2011 Update
DM and DR In Indian
CountryParallel Epidemics
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
92 94 96 98 '00 '02 '04 '06 '08 '10
D M
P r
e v
e l a
n c
e
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
D R
E x
a m
R a
t e
Sustained 50%
DR exam rate
Doubling of DM prevalence during past decade
• Diabetic Retinopathy is the leading cause of new blindness
• Blindness due to DM/DR can be eliminated by timely Dx and Tx
• Conventional eye exams not a likely solution for timely DX
DR Surveillance in IHS: FY10IHS (2010)- 53% (43% - 63%) DR eye exam rate
44%
51%
63%
46%
59%
47%
43%
59%55%
57%
43%
53%
0%
10%
20%
30%
40%
50%
60%
70%
80%
DR
E
xa
m R
ate
ABD
ALA
ALB
BEM
BIL
CAL
NAS
NAV
OKL
PHX
POR
TUC
DR Surveillance std of care
failed in ~half of population
with DM
Urban and rural
All socioeconomic groups
AI/AN vs general US pop
DR Surveillance
ReportingGPRA Performance Measure
Performance
Measure
2009 Target 2010 Target 2011 Target Headquarters
Lead
TREATMENT MEASURES
Diabetes Group
6. Diabetic
Retinopathy:
Address the
proportion of
patients with
diagnosed
diabetes who
receive an
annual diabetic
retinal
examination.
[outcome]
During FY 2009,
maintain the
proportion of
patients with
diagnosed
diabetes at all
sites who receive
an annual retinal
examination at the
FY 2008 level rate
of 47% at all sites
. During FY 2010,
maintain the
proportion of
patients with
diagnosed
diabetes at all
sites who receive
an annual retinal
examination of
55% at all sites.
During FY 2010,
maintain the
proportion of
patients with
diagnosed
diabetes at all
sites who receive
an annual retinal
examination of
50.1% at all sites.
Mark Horton
Diabetic Retinopathy SurveillanceIHS-JVN Teleophthalmology Program
78 physical/81 logical + 14 Portable Sites in 21 States
1831001 1262 1624
10873
14500
3027
5532
3758
45465580
8,069
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
50000
55000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Program Year
Cu
mu
lativ
ee
s
0
10002000
30004000
5000
60007000
8000
900010000
1100012000
13000
1400015000
16000
An
nu
al
IHS-JVN Exams
2000-2010
P
R
O
J
E
C
T
E
D
New IHS-JVN Developments
• Technical
– Software- RPMS/EHR interoperability
– Hardware- camera development
– Clinical- improved imaging protocols
• Operational- consortium deployments
• Business- Tribal collaborations
JVN-RPMS/EHR
Interoperability IHS-JVN CONOPS Summary
JVN Server
(PAO)
JVN Application
Server
DICOM PACS
Modality Worklist
Provider
Oracle DB
Image WebService
National Reading
Center (PIMC)
Healthcare
Facility
CDMP IE
(Mirth)HL7
JVN Image
Acquisition
Worstation
Pt
Demo
Image
&
Pt Info
JVN
Diagnostic
Display
1
2
3
45
9
Health Summary
RPMS
GIS
RPMS
GIS
CDMP IE
(Mirth)
RPMS
GIS
EHRCharge
Posting EHRCharge
Posting
6
7
8
9
Automated Workflow
• Pull of clinical data into JVN
Reader
• Push of JVN report and
business information into
RPMS/EHR
• EHR Consults Scheduling
and Notification
Camera Development
In Development• Designed for Tmed
• Light
• Small foot print
• Simi-automated
• Hardened
• $5-$10K
• DoD/University of Hi,
others
Current Technology
• Adapted from existing
commercial device
• Wrong features
• Fragile
• Expensive
• Orphaned
40 lb -
$20K -
Manual -
Discontinued -
No Parts -
New Clinical Protocols
• Extreme Remote Imaging protocol
• Mini-dilation Protocol
Improve image gradeability and over-referrals
• Remote sites with extreme logistics
• Small sites with low volume imaging
New IHS-JVN Developments
Consortium based deployments
PORTLAND
AREA
DM
PTS
FY10
EXAM
RATE
FY10
CHEHALIS 79 8.3%
NISQUALLY 120 6.5%
SHOALWATER BAY 12 25%
SKOKOMISH 40 5%
SQUAXIN ISLAND 33 60.6%
COWLITZ 74 38.5%
TOTAL 358 18.7%
Partnership for
improved outcomes
• Operations
• Business
• Clinical
Tribal Collaboration
• Budget flat since 2002
• Operational costs vs deployments and
development
• Interest from “related” non-bens
– Urban Clinics, Hawai'i, Pacific Islanders
– IHCIA
• Reading Center “franchise”
IHS NCC Meeting27 July 2011
Mark B. Horton, OD, MDPhoenix Indian Medical Center
Director, IHS/JVN Teleophthalmology Program
IHS/JVN ProgramSummer 2011 Update
REGULATORY UPDATE:
Credentialing and Privileging
June 9. 2011
Revisions to the Hospital and CAH Conditions of
Participation
(CMS-3227-F)
Credentialing and Privileging Requirements for Telemedicine Physicians and Practitioners
53
June 9, 2011
Published May 5, 2011, in the Federal Register:
Medicare and Medicaid Programs: Changes Affecting Hospital and Critical Access Hospital (CAH) Conditions of Participation (CoPs): Telemedicine Credentialing and Privileging (CMS-3227-F)
76 FR 25550:
http://www.gpo.gov/fdsys/pkg/FR-2011-05-05/pdf/2011-10875.pdf
Locating the Final Rule
54
June 9, 2011
Changes to the Hospital CoPs
The hospital requirements for credentialing and privileging of medical staff are contained under the Governing Body (§482.12) and Medical Staff (§482.22) CoPs
55
June 9, 2011
§482.12 Governing Body CoP
Requires the governing body of the hospital ensure that an agreement exists with a distant-site hospital to provide telemedicine services and that the agreement specifiesthat the governing body of the distant-site hospital ensures that all current Governing Body CoP requirements (§§482.12(a)(1-7)) are met with regard to its physicians and practitioners providing telemedicine services.
56
June 9, 2011
§482.12 Governing Body CoP (cont)
The governing body of the hospital has the option of granting privileges based on the recommendations of its medical staff, which has relied upon information furnished by the distant-site hospital regarding privileges for individual physicians and practitioners providing telemedicine services.
57
June 9, 2011
§482.22 Medical Staff CoP
The hospital can rely on this information for its privileging decisions only if certain provisions (at §482.22(a)(3)) regarding the distant-site hospital, and the individual physicians and practitioners, were met regarding:
Medicare-participation status of distant-site hospital
Privileges of individual physicians and practitioners, including list of current privileges for each provided by distant-site hospital
State License (does not apply to Indian health)
Internal review for purposes of periodic appraisal of individuals providing telemedicine services, including adverse events/complaints
58
June 9, 2011
Changes to the CAH CoPs
Critical Access Hospitals (CAHs) have CoP requirements under the Medicare regulations that are separate and distinct from the hospital CoPs. The term “credentialing” is used almost exclusively throughout the CAH CoPs.
59
June 9, 2011
Changes to the CAH CoPs (cont)
The new CAH requirements for credentialing and privileging are under the Agreements (§485.616) and Periodic Evaluation and Performance Review (§485.641) CoPs.
60
June 9, 2011
Changes to CAH CoPs
The requirements for CAHs are similar to those for hospitals, and/or designed to make the CAH credentialing and privileging requirements consistent with current hospital requirements … (abbreviated slide)
61
June 9, 2011
Changes to CAH CoPs (cont)
We also amended the Periodic Evaluation and Quality Assurance Review CoP (at §485.641(b)(4)) by adding a new paragraph that allows a distant-site hospital to evaluate the quality and appropriateness of the diagnosis and treatment furnished by the distant-site physicians and practitioners providing telemedicine services to the CAH’s patients under an agreement between the CAH and a distant-site hospital
62
How does the final rule differ from the proposed rule we published in May 2010?
First, we finalized the requirements proposed in the May 2010 NPRM with only minor clarifying revisions (e.g, specify in the provisions that the telemedicine agreement must be written).
Based on public comment, we added new provisions to the final rule that will apply to the credentialing and privileging process and the agreements between hospitals and CAHs and non-hospital, distant-site telemedicine entities that provide telemedicine services
§482.12(a)(9) and §482.22(a)(4) for hospitals; §485.616(c)(3) and §485.616(c)(4) for CAHs
June 9, 2011 63
How does the final rule differ from the proposed rule we published in May 2010? (cont)
The new provisions will allow for the governing body of the hospital (or the CAH’s governing body or responsible individual) to rely upon the credentialing and privileging decisions made by the distant-site telemedicine entity.
The telemedicine entity’s medical staff credentialing and privileging processes and standards must at least meet the CoPs related to credentialing and privileging.
June 9, 2011 64
What Are the Differences Between the Proposed Requirements and the New Provisions?
These new provisions will require the governing body of the hospital (or the CAH’s governing body or responsible individual): Through its written agreement with the distant-site telemedicine
entity
Ensure that the distant-site telemedicine entity as a contractor of services
Furnishes its services in a manner that enables the hospital (or CAH) to comply with all applicable CoPs and standards for the contracted services
Including the credentialing and privileging requirements regarding its physicians and practitioners providing telemedicine services
June 9, 2011 65
What effect will the final rule have on the CoPs?
Will allow hospitals and CAHs to make full use of the telemedicine services offered by non-hospital telemedicine entities without the duplicative and burdensome task required by the traditional credentialing and privileging process.
June 9, 2011 66
Benefits for Hospitals and CAHs
Will now allow hospitals and CAHs to take advantage of these streamlined credentialing and privileging options when using the telemedicine services of:
Other Medicare-participating hospitals,
Non-Medicare-participating telemedicine entities, or
A combination of both types of service providers
June 9, 2011 67
What is a telemedicine entity?
There is no statutory definition for a telemedicine entity contained in the Social Security Act.
Therefore, for the purposes of this rule, we needed to define a distant-site telemedicine entity as one that –(1) Provides telemedicine services;
(2) Is not a Medicare-participating hospital; and
(3) Provides contracted services in a manner that enables a hospital or CAH using its services to meet all applicable CoPs, particularly those requirements related to the credentialing and privileging of practitioners providing telemedicine services to the patients of a hospital or CAH.
June 9, 2011 68
The Importance of the Written Agreement
Similar to our regulations proposed for hospitals and CAHs using the telemedicine services of distant-site Medicare participating hospitals, the written agreement between the hospital or CAH and the distant-site telemedicine entity will be the foundation for ensuring accountability on both sides.
June 9, 2011 69
June 9, 2011
Summary
Proposed rule published May 26, 2010
CMS received over 100 comments from various stakeholders.
Final rule published May 5, 2011
Effective date: July 5, 2011
The result of outreach efforts by CMS to the telemedicine stakeholder community
Allows for a streamlined process for credentialing and privileging of telemedicine physicians and practitioners under written agreements between hospitals/CAHs and distant-site non-Medicare-participating telemedicine entities and distant-site Medicare-participating hospitals
70
Summary (cont)
Intent is to reduce burden and eliminate duplicative credentialing & privileging efforts by hospitals and CAHs that have telemedicine services agreements with distant-site telemedicine entities and Medicare-participating hospitals
CMS believes that the final rule will reduce the burden of the traditional credentialing and privileging process while still assuring accountability.
June 9, 2011 71
Note
• As per both CMS and Joint Commission, hospitals/CAHs may accept credentialing and privileges for telemedicine practitioners from distant hospitals/DSTE without appointment of telemedicine practitioners to the local hospital/CAH medical staff.
Next Steps for C & P
• Still awaiting new Joint Commission standards and interpretations
• New language has been drafted for the Indian Health Manual
• Facilities should review their med staff bylaws for compliance with new ruling
• Agreement templates are being drafted with OGC
STRATEGIC OPPORTUNITIES:
Behavioral Health
Business Planning
FORM FOLLOWS FUNCTION
What will be our new models of care?
What will it take to implement those models of care?
What will it take to support and sustain them?
Telehealth Services NetworkThis proposal was developed as a collaboration of many people. At the request of Dr. Susan Karol, IHS Chief Medical Officer, and Dr. Theresa Cullen, IHS Chief Information Officer, a Telehealth Planning Workgroup was formed. This workgroup led the planning and development of this proposal. Participants and contributors to the proposal development included:
Tammy Brown, MPH, RD, BC-ADM, CDE
Mark Carroll, MD
Mandi Constantine, MEd
Stewart Ferguson, PhD
Chris Fore, PhD
Jonathan Doggette
Patrick Gormley
Mark Horton, OD, MD
Kathleen Keats, MBA, MSIT
John Kokesh, MD
Chris Lamer, RPh
Jill Moses, MD, MPH
Chris Patricoski, MD
Diane Phillips, RD, LD, CDE
Jay Shore, MD
Peter Stuart, MD
Mark Thomas, PE, MPH
Mark Veazie, DrPH
Chris Watson, RPh, MPHApril 2011
• Telehealth is a clinical mandate, not a technical initiative. We should:
– Provide a predictable level of service.
– Support local planning and decision making.
– Establish national coordination, planning and accountability.
– Improve efficiencies through regional and centralized services.
– Leverage existing expertise.
Key Concepts
79
Telehealth Service Expansion
• Four key components:
– Clinical Telehealth Services (for primary and specialty care)
– Modernized Infrastructure
– Regional Telehealth Resource Centers for technical/coordination/training capacity
– National Program Support
Improving the “Medical Home”Clinical Service
Discipline Telehealth Modality
Model of Care Additional Description
Telehealth Clinical Care Centers
Behavioral Health
o Videoconferencingo Store-and-forward
o Tiered model of serviceo Direct psychiatric careo “Surge service” – for
communities in crisiso 24/7 consultation and
clinical evaluationo Education and training
o After-hours call will be shared among 5 regions for night/weekend service to emergency departments
Nutrition and dietetics
o Videoconferencing o Individual and group nutrition counseling services via videoconferencing
o Availability of advanced practice nutrition counseling
o On-site assistance in region with program development
o Intra-network consultation for advance practice needs (e.g. renal, geriatric care)
Pharmacy o Videoconferencingo Store-and-forwardo Remote monitoring
o Regional telepharmacy service
o Centralized Mail Outpatient Pharmacy (CMOP) support
o After-hours pharmacy review
o Disease management assistance
o Anticoagulation clinicso Cardiovascular risk
reduction monitoringo Smoking cessation line
April 2011
Improving the “Medical Home” (cont.)
Clinical Service
Discipline Telehealth Modality
Model of Care Additional Description
Specialist Consultation
IHS JVN Tele-ophthalmology
o Store-and-forward o Expanded JVN deployment @ I/T/U sites
o Portable service model for sites too small for fixed deployment
o Hybrid model possible for regional service delivery
o Model will be based on DM prevalence and geographic specifics
Dermatology, Cardiology, ENT, and ID
o Store-and-forward o As needed specialist consultation, assisting with initial consultation and ongoing treatment needs
o Services available via partial FTE or contract
Population Health Consultation
Pop Health Support Network
o Videoconferencingo Store-and-forward
o Network of coaches & consultants
o Knowledge management system
o National coordination
April 2011
Alternatives AnalysisBehavioral Health
Specialty Service ModelsOn-site On-site + telehealth telehealth
Scalability Poor Good Good
Provider
Recruitment/Retention
Challenging, expensive and
erraticBetter Best
24/7 Coverage Dependent on clinic size Available Available
Access to range of
specialtiesLimited Available Available
Educational Access Local/internet National/regional/ local National/regional
Surge Response Poor Best Better
Collegial Support
OpportunitiesDependent on clinic size Best Best depending on affiliation
CostCare needed at other than
full FTE increments costly
Can adjust in less than full
FTE increments
Can adjust in less than full
FTE increments
AccessLimited by provider schedule
and housing
Potentially available on
demand
Potentially available on
demand
Cross-Coverage Dependent on clinic sizeNational/regional coverage
available
National/regional coverage
available
Patient/Provider SafetyExposed to road/air travel
hazards (sig in rural areas)Better Best
April 2011
Alternatives AnalysisBehavioral Health
Specialty Service ModelsOn-site On-site + telehealth telehealth
Scalability Poor Good Good
Provider
Recruitment/Retention
Challenging, expensive and
erraticBetter Best
24/7 Coverage Dependent on clinic size Available Available
Access to range of
specialtiesLimited Available Available
Educational Access Local/internet National/regional/ local National/regional
Surge Response Poor Best Better
Collegial Support
OpportunitiesDependent on clinic size Best Best depending on affiliation
CostCare needed at other than
full FTE increments costly
Can adjust in less than full
FTE increments
Can adjust in less than full
FTE increments
AccessLimited by provider schedule
and housing
Potentially available on
demand
Potentially available on
demand
Cross-Coverage Dependent on clinic sizeNational/regional coverage
available
National/regional coverage
available
Patient/Provider SafetyExposed to road/air travel
hazards (sig in rural areas)Better Best
April 2011
Expanding Access to Quality Behavioral Health Services
Mose Herne, MPH, MS
July 27, 2011
Inpatient Mental Health Needs
• Significant challenges for IHS in meeting the inpatient mental health needs of its users
– Recommendations from 2011 assessment include:
• Expand behavioral health services in partnership with Tribes, local, State, and regional providers
• Capitalize on emerging technologies, i.e., tele-behavioral health, to increase access to and quality of services for evaluation and treatment, enhance provider education through case consultation, and strive to prevent inpatient hospitalizations
Current Use of Tele-behavioral Health
• Improving access to behavioral health services:– The National Tele-behavioral Health Center of
Excellence (TBHCOE) was established to provide innovative and culturally–competent technical assistance to increase:
• access to behavioral health services
• training in suicide prevention for behavioral health staff practicing in Indian Country
– Use of tele-behavioral health technology is on the rise• Over 50 IHS and Tribal facilities in 8 IHS Areas are
augmenting on-site behavioral health services with tele-behavioral health services
TBHCE Support Activities
• TeleBehavioral Health Policies and Procedures
• Credentialing and Privileging guidelines
• Standardized Network Assessment
• TelePsychiatry formulary (in progress)
• Secure document sharing & messaging via AFHCAN (in progress)
• TeleBehavioral Health EHR template (pending)
• TeleBehavioral Health lab package (pending)
Goals of Tele-behavioral Health
• Improve quality and access to BH care
• Improve customer service
• Reform the IHS
• Transparency
• Tribal consultation – NTAC and BH Workgroup
TBHCE Direct Services to I/T/U
Psychiatry
• Adult
• Addictions
• Child/Adolescent
Psychology
• Adult
• Child/Adolescent
• Individual
• Group
• Family
TBHCE Activities• Coordinate 24/7
Coverage
• Credentialing
• National Standards– Practice
– EHR
– Formulary
– AFHCAN
– Network Assessment
• Billing TA
• TeleVideo Support• OIT Coordination• mHealth Initiatives• Program Evaluation• New Technology Eval.• Intensive case mgt• Training
– TeleBH– mHealth– BH/Primary Care (CME)– PHN/CHR training– Cultural competence
TBHCE Indirect Services to I/T/U
Education
No-Cost CME to I/T/U Primary Care providers via televideo.
Assessing and Treating Behavioral Health Issues in a Primary Care setting (piloting)
Clinical Support
Weekly Case Staffing to I/T/U Mental Health and Substance Abuse providers.
Emphasis on dual diagnosis, suicide prevention, and chronically mentally ill (in progress)
Targeted Outcomes
• Increase access to BH services• Increase quality of care through service coordination• 24/7 support for mental health emergencies• Use of innovative and multidisciplinary care models• Prevent hospitalization/reduce length of stay• Improve quality of life• Leveraging existing programs, i.e. VA, SAMHSA, HRSA• Collaboration across the system• Customer service, i.e. directly addresses BH needs as
outlined in numerous venues
BUSINESS UPDATE:
Reimbursement Policy
Is “telehealth” cost-effective?
Better Question:
Under what circumstances are new care models using telehealth tools cost-
effective?
SFerguson PhD, ANTHC
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
2001 2002 2003 2004 2005 2006 2007 2008 2009
Annual Travel Savings (by Case Role)
Primary Care Specialty Care
DATA FROM ALASKA
Red = A
White = B
Blue = C
Grey = D
Black = F
Capistrant’s Medicaid Grades
G Capistrant, ATA, 2011
• Incremental expansion in coverage by both Medicare and Medicaid programs
– CMS considering new approach to reviewing annual requests for additions to covered telehealth services
• Consideration within IHS for proposal to CMS re: national coverage determination for Indian health
Expanding Reimbursement
99
“Service to the point of need”
Improved access for many types of care cannot occur without telehealth
Thank You