Telemedicine Institute of Oklahoma, PLLC

Overview of Telemedicine Needs and Benefits, TIO Staff and Philosophy

Telemedicine Institute of Oklahoma, PLLC• The Telemedicine Institute of Oklahoma, PLLC (TIO)

was established in 2012.• Mission: Provide high quality mental health services

to the rural populations of Oklahoma.• TIO equipment inspected and approved by

ODMHSAS in Oct 2012.• Practice established solely for the purpose of

providing mental health services via video teleconference.

What is Telemedicine?

• The American Telemedicine Association defines telemedicine as: “the use of medical information exchanged from one site to another via electronic communications to improve a patients' health status”

• Allows health care professionals to evaluate, diagnose and treat patients in remote locations using telecommunications technology

• Developed by NASA to monitor and treat astronauts while in space.

Why Telemedicine?

• Barriers exist that may prevent rural Oklahomans from seeking care.

• Problems facing rural health care centers further decrease access to care.

• Telemedicine can provide:– Measurable improvement in patient care in terms of

accessibility and availability.– Documented cost savings to clinics and patients that

participate in telehealth encounters.

Oklahoma’s Mental Health Needs

• Oklahoma in 2008-2009:– 21.6% of Oklahomans experienced a diagnosable mental,

behavioral, or emotional disorder– 7.4% of adults experienced at least one major depressive

episode – 8.09% of youth aged 12-17 experienced at least one major

depressive episode– Data derived from State Estimates of Substance Use and Mental

Disorders from the 2008-2009 National Surveys on Drug Use and Health

• Over 1.27 million of Oklahoma’s population lives in counties defined as rural (less than 50K)

The Problems

• Three factors may prevent rural persons with mental illnesses face from receiving the mental health care they need: accessibility, availability, and acceptability.

• These variables lead rural residents with mental health needs to: – Enter care later in the course of their disease than do their

urban peers; – Enter care with more serious, persistent and disabling

symptoms; and – Require more expensive and intensive treatment response

(Wagenfeld et al., 1994).

Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services

Accessibility

• Three significant components of access to mental health services that put rural residents at a significant disadvantage: knowledge, transportation and financing. – Patients need to know when one needs care and where and

what care options are available to address needs.– The ability to travel to services and to pay for those services if

accessed is a significant barrier to rural persons.– For rural Americans, the cost of health services (only partially

reimbursed by Medicare Part B; or at a discount by Medicaid) may be too expensive—especially prescription drugs.

Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services

Availability

• Lower access to mental health services is directly related to lower availability or supply of mental health providers (Lambert & Agger, 1995).

• The availability of rural mental health services and providers is seriously limited in rural communities. – Over 85 percent of the 1,669 Federally designated mental

health professional shortage areas (MHPSAs) are rural (Bird, Dempsey & Hartley, 2001).

– According to the National Advisory Committee on Rural Health (1993), of the 3,075 rural counties in the United States, 55 percent had no practicing psychologists, psychiatrists, or social workers, and all of these counties identified were rural.

Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services

Acceptability

• Many Americans attach stigma to having or seeking help for mental health or substance abuse problems.

• This is more of an issue in rural communities, as there is less anonymity in seeking help.

• Ethnic minority individuals may be more hesitant to enter treatment based on fear that the provider may not understand their culture and traditions.

Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services

Rural Populations at Risk

• Rural populations often experience stress because of the high poverty rates, high unemployment rates and low educational opportunities.

• Demographics particularly at risk include:– Women– Children– Elderly– Veterans

Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services

These factors result in a loss of health services to rural communities.

Problems Facing Rural Healthcare Centers• Limited availability of mental health providers• Limited availability of outpatient services• Decreased operating budgets• Inadequate access to continuing education and

training

Availability of Providers

• It is estimated that approximately two-thirds of individuals with symptoms of mental illness receive no care at all.

• Of those who do receive treatment in rural areas, approximately 40 percent receive care from a mental health specialist and 45 percent from a general medical practitioner (Regier et al., 1993).

• The availability of mental health services and the number of mental health providers in rural areas is severely inadequate .

• The availability of specialty mental health services (e.g., neuropsychology, geriatric) is even lower than that of general mental health services.

Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services

Availability of Providers (cont.)

• Primary care physicians and other general medical practitioners are often the first-line mental health providers for rural residents.

• Primary care physicians may not be adequately trained to identify and treat mental illness and behavioral disorders (Ivey, Scheffler & Zazzali, 1998; Little et al., 1998; Susman, Crabtree & Essink, 1995).

• Law enforcement is often responsible for responding to mental health emergencies in rural jurisdictions (Larson, Beeson & Mohatt, 1993); they generally do not have the training or experience recognizing mental illness and/or providing triage or stabilization assistance to individuals in immediate crisis.

Derived from “Mental Health and Rural America: 1994-2005”, US Department of Health & Human Services

Decreased Operating Expenses

• Fiscal realities have resulted in declining operating budgets for many rural hospitals, health clinics, and medical practices.

• Priorities for care are focused on acute needs and outpatient services are often eliminated completely or in part.

Access to Training

• It is difficult for many rural providers to stay abreast of emerging mental health treatment and medication protocols, especially in those areas served solely by primary care physicians.

A Solution

• Treatment using telemedicine can address gaps in care for rural populations.

• Treatment using telemedicine can provide:– Improvement in Patient Care– Cost Savings– Improved Patient Satsifaction

Improvement in Patient Care

• Telemedicine can provide:– Improved access to care;– Provision of a higher level of care locally or in a more

timely fashion;– Timely medication management;– Improved continuity of care;– Increased family involvement;– Improved treatment compliance; and– Better coordination of care.

Cost Savings

• Cost savings in out-of-pocket expenses for patients have been well documented. – As an example, the 866 mental health encounters

conducted over the Eastern Montana Telemedicine Network from July 2002 – June 2003 represents over $260,000.00 in out of pocket savings for patients. These savings were based on travel cost and lost wages.

Patient Satisfaction

• Studies have consistently shown that the quality of healthcare services delivered via telemedicine are as good those given in traditional in-person consultations.

• In some specialties, particularly in mental health and ICU care, telemedicine delivers a superior product, with greater outcomes and patient satisfaction.

• Patients report high satisfaction with services provided via telemedicine. – On a patient satisfaction scale of 1-8, 1 being not satisfied and 8

being very satisfied patient receiving telemental health service through the Eastern Montana Telemedicine Network reported an average of a 7.0 satisfaction rating for 5 consecutive years.

Key Terms

• Distant Site: Location where the certified medical professional is

• Originating Site: Location where the patient is. • Telemedicine: The use of two-way, real time interactive

audio and video to facilitate the delivery of health care services, including specialist referral, patient consultation, remote patient monitoring, and education/prevention.

• Telehealth presenter: Healthcare provider at the originating site at time of interactive consultation responsible for presenting the patient to the physician or practitioner.

TIO Medical Staff

• Dr. Sarah Land – ABPN Board Certified Psychiatrist

• Dr. Tracy Loper• Dr. Peteryn Miller

TIO Philosophy

A Partnership

OriginatingSite

Provides Emergent Care

Provides Inpatient Care

Provides Laboratory Services

DistantSite (TIO)

Provides Outpatient Specialty Care

Provides Ongoing Med Management

Authorized Originating Sites

• The office of a physician or practitioner • A hospital• A school• An outpatient behavioral health clinic• A critical access hospital• A rural health clinic (RHC)• A federally qualified health center (FQHC)• An Indian/Tribal/Urban Indian (I/T/U) clinic or health

center

Originating Site Requirements

1. Providing a space for the patient during the consultation, including Internet and other necessary telecommunications access.

2. Providing an appropriate certified or licensed health care professional to present the patient to the physician or practitioner at the distant site and remain available as clinically appropriate.

3. Providing client file to the physician or practitioner at the distant site prior to the encounter, to include chief complaint, social-family-medical history, medications, allergies, current diagnoses and treatment plans.

4. Providing, operating, and maintaining all equipment and supplies owned by the originating site to TIO standards.

5. Submitting facility site billing data to state agencies and insurance providers.

TIO Responsibilities:

1. Providing for the scheduling of telemedicine services.

2. Providing intake procedures to include, but not limited to client orientation and consent forms.

3. Distributing prescriptions for Schedule II Controlled Substances to clients as appropriate and with providers signature as required by law.

4. Providing, operating, and maintaining all equipment and supplies owned by TIO.

TIO Responsibilities (cont.):

5. Ensuring that all physicians and providers hold a current medical license and/or certification to provide mental health services, is Medicaid and Medicare registered, possesses a National Provider Identification (NPI) number, and holds and maintains medical malpractice liability insurance for the provision of telemedicine services.

6. Complying with all requirements for provider credentialing and privileging as required by the originating facility and in compliance with CMS and the Joint Commission.

7. Submitting consultation billing data to state agencies and insurance providers.

Partnership Advantages

• Behavioral healthcare that is accessible and affordable to a large number of patients

• Increased scope of services that can be offered to rural populations

• Reduces the number of mental health crisis visits to the ER

• Better discharge options • Routine monitoring and medication checks of at risk

patients

Process

• Signed contract between Rural Healthcare Provider and the Telemedicine Institute of Oklahoma.

• Originating site provides requisite hardware, software and network equipment, as necessary.

• Originating site equipment is inspected and approved by ODMHSAS, as necessary.

• TIO provides a licensed health care professional for patient consultation.

• Rural Healthcenter provides presenter to escort patients, perform initial review of patient status, and conclude patient visit.

• Originating site and distant site submit for costs.

Guidelines

• Requirements derived from Oklahoma Health Care Authority Policies and Rules

• https://www.okhca.org/xPolicy

APA

• The American Psychiatric Association supports the use of telemedicine as an appropriate component of a mental health delivery system to the extent that it is in the best interest of the patient and is in compliance with the APA policies on medical ethics and confidentiality. (American Psychiatric Association, www.psych.org, August 14, 2003)