December 2, 2020
Innovating with Telepsychiatry to Improve Mental Health Care in Health Centers
@NACHC
America’s Voice for Community Health CareThe National Association of Community Health Centers (NACHC) was founded in 1971 to promote efficient, high quality, comprehensive health care that is accessible, culturally and linguistically competent, community directed, and patient centered for all.
THE NACHCMISSION
@NACHC
John Fortney, PhD
ProfessorDirector, Division of Population HealthDepartment of Psychiatry and Behavioral SciencesUniversity of Washington
©University of Washington
STUDY TO PROMOTE INNOVATION IN RURAL INTEGRATED
TELEPSYCHIATRY
12/2/2020
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SPIRIT Quantitative findings
John Fortney, PhD
©University of Washington
Epidemiology of PTSD
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©University of Washington
Epidemiology of Bipolar Disorder
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©University of Washington
The Problem
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• There are highly effective treatments for PTSD and Bipolar Disorder
• CHC patients do not have access to these treatments• CHC Staffing
• 1 psychiatrist per 49,764 patients • 1 psychologist per 43,505 patients
• A large proportion of patients with PTSD and Bipolar Disorder are:• Unable to engage in specialty mental health treatment• Treated exclusively in primary care• Prescribed medications for depression
• PCPs are increasingly being challenged to care for patients with these complex psychiatric disorders• Obligated, but unprepared and under‐resourced
©University of Washington
Potential Solutions: TCC and TER
TCC ‐Telepsychiatry Collaborative Care
TER ‐Telepsychiatry Enhanced Referral Care
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©University of Washington
SPIRIT Overview
•Study Period: 2016 – 2020•Patients PHQ‐9≥10 Screened for Bipolar & PTSD
o3,131 screened positive (33% for Bipolar Disorder)o18% already prescribed medications by MH specialist
•1,004 Consented and Randomized to TCC or TER•Survey at baseline, 6‐ and 12‐months
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©University of Washington
Characteristics
9/12/2016
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Race/Ethnicity
White Hispanic
African American Other
Insurance
Uninsured Medicaid Medicare
Military Private
Employment
Full Time Part Time
Unemployed Other
Poverty
Poverty Not Poverty
©University of Washington
Screening False Positives
9/12/2016
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Screened + for PTSD
Diagnosed Not Diagnosed
Screened + for BD
Diagnosed Not Diagnosed
Comorbid Diagnoses
Depression
Generalized Anxiety
Alcohol UseDisorder
Drug UseDisorder
©University of Washington
Engagement
12
0
10
20
30
40
50
60
70
80
90
100
TCC Care Manager TCC Telepsychiatry TER Telepsychiatry TER Telepsychology
Proportion With Any Encounters
µ=10.2
µ=1.4 µ=4.3
µ=6.3
Telepsychiatry Collaborative Care Telepsychiatry Enhanced Referral
©University of Washington
Telepsychiatrist/Telepsychologist Encounters
13
0
1
2
3
4
5
6
7
Telepsychiatry Collaborative Care Telepsychiatry Ehnanced Referral
Specialist Visits Per Patient Per Year
Psychiatrist Psychologist
©University of Washington
Mental Health Functioning – Primary Outcome
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‐‐‐‐‐___
©University of Washington
PTSD Symptoms (PCL‐5)– Secondary Outcome
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‐‐‐‐‐___
©University of Washington
Euthymic Mood (Neither Depression nor Manic)– Secondary Outcome
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‐‐‐‐‐___
©University of Washington
Depression– Secondary Outcome
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‐‐‐‐‐___
©University of Washington
Generalized Anxiety– Secondary Outcome
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‐‐‐‐‐___
©University of Washington
Side Effects– Secondary Outcome
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‐‐‐‐‐___
©University of Washington
Conclusions20
•No difference in outcomes between TCC and TER
• Both TCC and TER substantially improved outcomes↑Mental Health Functioning↓PTSD Symptoms↓Bipolar Symptoms↓Depression Symptoms↓Anxiety Symptoms↓Side Effects
•TCC can generate similarly good outcomes with 1/6th
the amount of telepsychiatry/telepsychology time.
©University of Washington
No Show Rates
22
@NACHC
Susan Ward‐Jones, MD
Chief Executive OfficerEast Arkansas Family Health Center, Inc.
Susan Ward-Jones, MD, CEOEast Arkansas Family Health
Center
December 2, 2020
"Innovating with Telepsychiatry to Improve
Mental Health Care in Health Centers"
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EAFHCUsers: 18,590Encounters: 75,252
Service Area: Crittenden, PoinsettMississippi and Phillips County
Sites: 7 Healthcare Delivery Sites 3 SBHCs 1 Admin - HIV/AIDS Case Management Site
Joint Commission Accredited since 1997
NCQA PCMH Level III
HRSA Quality Health Care Leader 2016, 2017, 2018 & 2019
Annual Budget - $20 million
Patient Demographics:
Gender:Female: 62%Male: 38%
Age: 0-17 years: 18%18-64 years: 66%65 and older: 16%
Insurance:Uninsured: 26%Insured: 74%
o Medicaid: 35%o Medicare: 20%o Private Insurance: 19%
Race:Black/AA: 64%White: 33%Other: 3%
EAFHC25
EAFHCStaff Providers
• 6 physicians including Pediatrician• 1 Ophthalmologist• 12 NPs including Psych NP• 1 PA• 3 LCSWs• 7 Dentists & 1 Hygienist• 4 Pharmacists• 1 Diabetes Educator
2 Behavioral Health RN/Case Managers 1 Clinical Informatics RN 1 RN Contact Tracer 10 Referral Specialists Care Coordinators – each site 1 Community Health Worker 1 Community Health Navigator Support Staff: 151
ServicesPrimary Care * Dental Care
Behavioral Health * Vision CareChronic Disease Management
Women’s Health Care Pediatric Care
HIV/AIDS Management Nutritional
In–house Lab & X-ray In-house Pharmacy
TransportationPreventive Care
Mobile Medical Clinic
EAFHC26
Establishment of EAFHC’s Behavioral Health Program
NIMH - Depression Outreach Study 2006-2011 Dr. Fortney/UAMS Collaborative Care Model Increased awareness of high prevalence of undetected depression Concern about bipolar disease
NIMH - RISP (Bipolar and Alcohol) 2010-2015 Dr. Fortney/UAMS More aware of undetected bipolar disorder Sustained adoption of bipolar screening Opportunity to publish in the scientific literature
HRSA Mental Health Service Expansion / Behavioral Health Integration Grant 2012 UAMS provided us with data about our patients who had participated in the previous studies and help to demonstrate
the need for integration UAMS helped us to develop an integrative program that was based on evidence‐based treatments.
SPIRIT 2015-2020
EAFHC27
The Team LCSWs Case Managers Psychiatric Nurse Practitioner Telepsychiatry
Challenges Staff engagement (buy-in versus being forced upon them) Providers prescribing psychotropic drugs Workflow changes(care managers were instrumental in reducing workflow
challenges) Patient engagement(apprehension utilizing telehealth) Telepsychiatry Providers (timeliness of entering notes into the EMR) EMR provider license (negotiated a reduced fee for a part-time provider) Malpractice coverage Difficulty with payors particularly Medicaid.
Behavioral Health Program
EAFHC28
Arm Differences - PCP Perspective
EAFHC
TelepsychiatryCollaborative Care (TCC)
TelepsychiatryEnhanced Referral (TER)
Requires greater PCP involvementand management
Requires less PCP oversight; less time intensive; operated like a traditional referral
Direct communication or communication via the Care Manager between PCP and Telepsychiatrist
PCP experienced limited communication with Telepsychiatrist
EAFHC29
EAFHCArm Differences - PCP Perspective
Telepsychiatry Collaborative Care (TCC)
Telepsychiatry Enhanced Referral (TER)
PCPs described increased medication prescribing and management skills
PCPs did not describe increased medication prescribing and management skills
EAFHC30
EAFHCArm Differences - Patient Perspective
Telepsychiatry Collaborative Care (TCC)
Telepsychiatry Enhanced Referral (TER)
Care Manager was critical to mitigating patient barriers and facilitating engagement Care Manager facilitated discharge and transition to usual care Potentially better for patients with difficulty opening up to new care providers
Potentially better for patients who desire or require a higher level of therapy, specifically CBT or CPT
Patients needing an approachable, local contact
Patients amenable to standardized homework
EAFHC31
Quotes Arm Differences - PCP Role
When asked which approach worked better for them:The [TCC arm], in a sense, was more exciting to me because these are my patients. With [TCC], they were seeing me regularly for medication refills, and then we had ready access to psychiatric care through [the care manager], to call down and see how [the psychiatrist] might suggest changing medications and getting an occasional consult. The [TER arm], the patients tended to sort of disappear into a black hole and get their psychiatric care for a year, and I didn't necessarily follow up with them, […] there was more interaction [with TCC]. […] I really appreciate the collaborative care, where I actually have ‒ more input and more feedback from patients.
EAFHC32
Arm Differences - PCP Skill & Capacity
• Bipolar Disorder• I learned how underdiagnosed bipolar disorder is. And I’m starting to now
see that in several more patients where I probably would’ve never even thought to look for it. That’s opened up my eyes a huge amount to treating mental disease and looking for other diagnoses because bipolar is so hidden within depression.
• PTSD• My prescribing practices now mimic [the psychiatric consultant]. […] There
is a level of comfort now where I would be comfortable starting some medications for PTSD while waiting to try to transition and get further help. Even just to simply try to recognize and diagnose is much more comfortable now.
Quotes
EAFHC33
Quotes Arm Differences - Patient Perspective
• I’m very forgetful […] I forget about my appointments all the time. So [the care manager] would call, you know, ask me if I was going to be there and let me know ahead of time so I wouldn’t miss. She was understanding if I missed and everything. So she was great. I can talk to her about anything.
• [Patient] Like I said, I had the [care manager’s] direct phone number. I knew I could call her, message her, whatever; I knew that it was there. So it was really easy to access that.
EAFHC
Quotes Arm Differences - Patient Perspective
• I think the biggest thing that helped me was, [tele-psychologist], she gave me homework to do which made me have to pay attention to what I was doing everyday, and I think that made a big difference.
• I think they did a very good job. They helped me through a lot of things I didn’t realize was going on with me. I would definitely give them an A++.
EAFHC
Successes Enhanced access to meaningful psychiatric care Learned best practices with telepsychiatry Improved “real time” health outcomes Further exemplified the need for health centers to be involved in research
opportunities Improved staff engagement
Sustainability Partnership with the state medical school, UAMS (available workforce and cost
lower than private psychiatrist) Intact team in place with Psychiatric APN, LCSW, and case managers Administrative support and buy-in
EAFHC
EAFHC
Improvement and Remission RatesArkansas Sites
Improvement and Remission RatesAll Sites
Conclusion Was designed with input from Health Center patients and providers
Answers a policy relevant question about whether treatment should be integrated or referred
Met the clinical needs of our patients
Did not overly tax our health center resources
Demonstrates a level of excellence
STEPS 2020-2024Comparative effectiveness PTSD trial of sequenced pharmacotherapy and psychotherapy in primary care
EAFHC
EAFHC
@NACHC
Jackie Chandler, MS
Integrated Health Program ManagerMichigan Primary Care Association
December 2, 2020
Jackie Chandler, MS
Integrated Health Program Manager
Michigan Primary Care Association
The path to sustainability.
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What needs consideration
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Section Title
Time, buy-in, and funds for:• Directly employing or contracting psychiatric providers
• Credentialling and privileging psychiatric providers
• Electronic Health Record (EHR) site licenses for psychiatric providers
• HIPAA-compliant telehealth platform
• Gap insurance to cover health center from malpractice lawsuits when FTCA conditions are not met
Make Treatment Operational
Considerations
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Section Title
• Is the psychiatric provider versed in the CoCM model; comfortable with telemedicine?
• How much FTE can a health center support for a behavioral health care manager?
• Ensure staff assigned meet appropriate professional and State licensing to bill services
• Does the population served, and services offered meet current approved Federal scope of project, or does the health center request a change in scope?
• As an example: psychiatric consultations may be a complementary extension/deemed necessary for the adequate support of primary health care where a substantial number of patients with mental health or substance used disorder diagnoses are served
Additional Considerations
Considerations
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What was uncovered in the process
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• Limitations in CMS Medicare and in Michigan Medicaid originating site and distant site definitions challenged telemedicine claims
• State challenges in how mental health code is interpreted by payers for diagnoses and claims
• Michigan Medicaid did not reimburse for CoCM services during study treatment
• Takeaway: grant funds were required for health centers to remain financially whole to continue providing treatment in the study.
Then: Low or No Reimbursement
Challenges to sustainability
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What progress has been made
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The information presented is as of 12/02/2020. While this information is current, updates to policies and billing may change this information at some point in the future.
Note:
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Section Title
• Virtual Communication Services (VCS) • Available to health centers as of January 01, 2019 for "Virtual Check-ins.” • Expanded under the CARES Act to include Digital Assessment Services.
• Psychiatric Collaborative Care Model (CoCM) • Available to health centers as of January 01, 2017 (HCPCS code: G0512)
• Telehealth Services • FQHCs have been given approval to act as distant site providers under
the CARES Act .• This change is in effect through the COVID-19 Public Health Emergency
(PHE).• Telephone Services
• Temporarily added to the list of telehealth services as of April 30, 2020.
Medicare: Telehealth and CoCM
Medicare
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• General Telemedicine Policy Changes (MSA 20-09)• Released March 12, 2020; Effective March 1, 2020.
• Health centers can perform telehealth services for any code from the Telemedicine Services Database .
• Expanded originating and distant site definitions
• PPS is reimbursed when the service has a qualifying visit count of at least 1 and can be can found on either the Telemedicine Services Database or the COVID-19 Response List
Michigan Medicaid: Telemedicine Services
Medicaid
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Section TitleMDHHS. https://www.michigan.gov/documents/mdhhs/Telemedicine_012020_678209_7.pdf
Michigan Medicaid: Telemedicine Services
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• COVID-19 Response: Telemedicine Policy Expansion (MSA 20-13)• Policy allows services to be furnished by telephone (audio) only.
• Only to be used when using both audio and video are deemed not possible.
• This policy is only in effect from March 1, 2020 and will be in effect until 30 days following the termination of the Governor Declared State of Emergency (or the first of the following month, whichever is later).
• As a response to COVID-19, an additional code list has been added for services that can be performed via telehealth. • These are only in effect until 30 days following the termination of the Governor
Declared State of Emergency (or the first of the following month, whichever is later).
Michigan Medicaid: Telemedicine Services
Medicaid
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• Final Medicaid policy effective August 1, 2020• Coverage of Psychiatric Collaborative Care Model Services
(MSA 20-38)
Michigan Medicaid: CoCM
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What concerns remain to meet needs in community and in
primary care
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• Experiencing pandemic effects and distress (and the aftershocks) will remain with our health centers and communities – a heightened need for services
• Emergency response has relaxed some Medicare/Medicaid rules around telemedicine – what will endure to maintain access and reimbursement?
• Impacts on health center visit volumes, universal usage of telemedicine, staff fatigue and retention, and COVID-19 community outreach (currently in testing, forecasting for vaccine)
What Cannot be Missed: COVID-19
Response
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• Even if a service is eligible for enhanced FQHC Medicaid/Medicare reimbursement, financial impact of adding or increasing a service needs to be assessed to generate adequate revenue to cover all expenses
• Continued need for robust reimbursement rates and responsive policy definitions to meet community need
• Scarce psychiatric services require enhanced collaboration among primary care, community mental health, state medical schools, and payers
• In short: communities get better when they have access to timely, coordinated, and appropriate resources. We need continued monitoring, systems change, and advocacy!
In Summary
Sustainability
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