Robert N. Cuyler, Ph.D., Senior Associate, OPEN MINDS

The 2014 OPEN MINDS Planning & Innovation Institute

June 3, 2014 | 11:15am – 12:30pm

I. Overview Of The Current Telehealth Market

II. Telehealth In An Integrated Environment

III. Telehealth Case Studies • Sherrie Williams, LCSW, Executive Director,

Georgia Partnership For Telehealth

• Bob Franko, Vice President, Marketing & National Training Coordinator, Cherokee Health Systems, Inc.

• Jonathan Evans, President & Chief Executive Officer, Safe Harbor Behavioral Health

IV. Questions & Discussion

Overview Of The Current Telehealth Market

Deployment in Major Health Systems

Retail/urgent care

Increased focus on interstate practice (ex. Federation of State Medical Boards)

Employer/payer adoption

Huge increase in mobile solutions

Increase in doctor-patient direct care

Global market for telehealth increase from $11B in 2011 to $27B in 2016

OPEN MINDS © 2013. All rights reserved.

Least complex

technology needs

of any medical

specialty

Just two talking

heads, no need to

‘lay hands’

Robust empirical

base

Readily adopted by

consumers

Practitioners are

clustered in urban

settings

Huge needs in

limited-access

settings

Interstate Practice

limited by

practitioner

license

OPEN MINDS © 2013. All rights reserved.

“The best evidence for telemedicine, especially live interactive

office/hospital-based telemedicine is in the psychiatry and neurology

specialties”

“Verbal interaction is the key assessment component”

ARHQ Research Review - Locatis & Ackerman, NIMH, 2013

• Telemental health services are unquestionably effective in most regards, although more analysis is needed.

• Effective for diagnosis and assessment, across many populations (adult, child, geriatric, and ethnic)

• For disorders in many settings (emergency, home health)

• Are comparable to in-person care, and complement other services in primary care.

Hilty et al 2013 Meta Analysis

• Standards of care defined by states, vary widely

• Restrictions on interstate practice of medicine

• Federation of State Medical Boards attempting to improve portability

• Patchwork reimbursement policies

• Interoperability of Health Records

• Incentives for Providers

• Shift from grant to sustainable and business-viable remains work in progress

• Reimbursement climate improving but fragmented

• Lack of exposure/training in clinical education

• Best fit when provides system leverage

• No business model has emerged as winner yet

Telehealth In An Integrated Environment

• 14% of population receive treatment for BH, but account for 30% of healthcare spending

• Fragmentation of care increases spending and worsens outcomes

• Costs for treating co-morbid conditions two-to-three times higher than ‘uncomplicated’ physical heath problems

• Effective integration could save $26-48 Billion annually ◦ Milliman Report: Economic Impact of Integrated

Medical-Behavioral Healthcare, April, 2014

5. Care coordination through shared consumer data

4. Primary care organization arranges behavioral health services using

specialist web-based and telehealth services

3. Specialist organization merges with primary care organization

2. Specialist organization co-locates services in primary care

organization

1. Specialist organization adds primary care capacity

• Behavioral health services have historically been “siloed”

• Limited models for collaboration

• Problems in maintaining rapid access of behavioral health specialists in physically co-located settings

• Problems in providing access to care in smaller and/or de-centralized primary care settings

• Provider shortage and lack of access outside of urban areas

• Demographics of psychiatrists (aging, limited emergency access, boutique/quality of life choices)

• Telemedicine can be a distribution system for all professionals

• Deliver multi-disciplinary team to all locations

• Can individualize care regardless of location (ex. PTSD, family therapy, eating disorder)

• Can be organized as internal network for larger systems or contracted network for smaller systems

• Dependent on shift away from fee-for-service

• Dependent on risk-based payment systems

• Dependent on system architects to recognize and prioritize innovating behavioral health delivery

• Must be strategically driven by system leadership

• Potential to physically co-locate in central or hub setting and reach other ‘spoke’ sites via telehealth

• Advantage of strong IT resources and integrated system EMR

• System can select, manage, and set priorities of behavioral health providers

• Compensation systems more readily designed for practitioner productivity, quality control, shared savings

• Multi-hospital Health System

• Internal or Contracted Behavioral Heath Network

• Primary Care & Clinic Network

• Single EMR & Integrated Telehealth Network

• May be hub to Rural Hospital ‘Spokes’

• Will open opportunities for inter-organizational work

• RFP to provider groups/networks to provide behavioral health integration

• Fee structure may range from fee-for-service, contracted rates, capitation, or shared savings

• Opportunity for behavioral heath networks to develop solution/services and offer services to multiple ACO organizations

• Technology platform more complicated as ‘between-organization’ system without centrally-controlled IT, purchasing, technical support

• But … allows smaller organizations to participate in behavioral health integration without co-location

• Single or Small System Hospital without Behavioral Health Department

• Reach extends to owned/affiliated Primary Care, FQHC, or Rural Heath Clinic

• Reach may extend to long-term care

• Size & resources will not support internal behavioral health providers

No Risk/Low Risk

No

intervention

necessary

Moderate Risk

(example,

uncomplicated

depression)

Med

management

by primary

care

Access to

resources and

consultation

Significant Risk

Crisis

Stabilization &

Emergency

Care

Med

management

by

psychiatrist,

psychotherapy

High Risk /

High Resource

(SPMI, significant

medical co-

morbidity, co-morbid

substance abuse)

Management

by primary,

psychiatrist

and care team

• Opened 120,000 sq. ft. Virtual Care Center

• To support 75 telemedicine offerings

• Range: 24/7 Nurse Call Center

• Home Monitoring

• Tele-ICU

• Projects 3 million visits over 5 years

• System has 300,000 lives in revenue-sharing reimbursement models

• Primary Care locations will offer behavioral health services via co-location & telehealth consultation

• Focus: Team-based management of behavioral health problems in primary care

• Goals: ◦ Improve outcomes for chronic and co-morbid

conditions ◦ Reduce physician burnout via team approach ◦ Lower cost of care by reducing ED visits &

hospitalization

• Massive paradigm shift underway in health care

• Telemedicine has been ‘about to happen’

• Expect tipping point for telemedicine as risk-based payment begins to escalate

• Only practical way to supply right practitioner at right time at right location

• Technology is ready for prime time

• Technology integration not yet ready (interoperability of EMRs is key)

• Lack of exposure and training for practitioners

• Telemedicine training and certification will be essential

• Systems and payers will favor knowledgeable providers and BH systems

Telehealth Case Studies

• Sherrie Williams, LCSW, Executive Director, Georgia Partnership For Telehealth

• Bob Franko, Vice President, Marketing & National Training Coordinator, Cherokee Health Systems, Inc.

• Jonathan Evans, President & Chief Executive Officer, Safe Harbor Behavioral Health

+

TeleMental Health

Lessons Learned From the

Frontline of Care

+ Georgia Partnership For Telehealth

GPT Headquarters is located in Waycross, Ga.

Extended offices in Atlanta and Prattville, AL

Field-Based TM Liaisons

Support for Credentialing and Scheduling

All Specialists & Allied Healthcare Providers are required to complete the modified application that is accepted by The Joint Commission.

Dedicated toll free scheduling line.

+ Facts & Stats

500+ rural and specialty sites within the GPT network.

Over 180 specialists, representing 40 specialties.

8 encounters in January 2006

75,000 + encounters in 2012

140,000 + encounters in 2013

+

“Open Access” Network Model

Creates a web of access points

Any Presentation Site can connect to any other site

Specialty

Center

Specialty

Center

Specialty

Center

Presentation

Site

Presentation

Site

Presentation

Site Presentation

Site

+

+ What We Know

In GA, severe deficit of mental health care providers

376 HPSAs

National mental health HPSA = 3900

Need at least 2600 more psychiatrists to fill gap

Since GPT was developed, Mental Health has ranked as the

top 3 requested services:

C&A Psychiatry

Adult Psychiatry

Geriatric Psychiatry

+ Lessons Learned

Commitment from providers and presentation sites

Providers must understand that telemedicine patients are

treated just like traditional face-to-face patients

Quality of connectivity has to be reliable and crisp

Large screens are better than smaller monitors

Sound has to be good

Contract vs. billing

+ Environments For Care

Corrections

Schools

Community Health Centers

Public Health Departments

SNFs

Hospitals

Private practices

+ PRESENTER

Sherrie Williams, LCSW

Georgia Partnership For Telehealth

Executive Director

Sherrie.williams@gatelehealth.org

Utilization of Telepsychiatry in an Integrated Model of Care

Jonathan Evans

President & CEO

InnovaTel Telepsychiatry. LLC

Telepsychiatry Implementation

• Safe Harbor Behavioral Health pioneered telepsychiatry regionally in 2007, with a SAMSHA Grant.

• 2010 telepsychiatry expansion to a full time employed psychiatrist.

• 2012, providing 20 hours weekly to rural clinic in PA .

• 2013,expansion in multi-state clinics.

Compass Grant

• Compass team consists of nurse care managers,

psychiatrist, PCP and internists. • 2013, Compass Grant with St. Vincent’s Medical Center

to provide telepsych consultation service to 35 physicians in the primary care network.

• Weekly consultation meetings scheduled for case review and consultation.

• Screenings PHQ9 depression rating scales completed on patients during normal outpatient visits.

• A compass nurse care manager calls patients to determine stressors and barriers to care/recovery.

Compass Grant

• The team meets weekly via conference call to review all patients in the program. The telepsychiatrist will make treatment recommendations

• Starting an SSRI, consider switching meds due to blood pressure concerns, recommending therapy.

• Average LOS in the program is 6 months.

Compass Program Results (Unpublished)

• Many patients evaluated by psychiatrist in a timely manner vs. typical months waiting time.

• Multiple issues addressed at once via consultation with nurse care manager linking patient to community resources.

• Consultation model allows many cases for review in an hour.

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