USING TELEMENTAL HEALTH TO EXTEND VA INTEGRATED CARE TO COMMUNITY

SETTINGS: (A WORK IN PROGRESS)

Andrew Pomerantz, MD

Chief, Mental Health and Behavioral Sciences

White River Junction VA Medical Center

White River Junction, Vermont

VA National Office of Primary Care-Mental Health Integration

Eastern Region Rural Health Resource Center

Associate Professor of Psychiatry, Dartmouth Medical School

Some Definitions

• What is Telehealth?

• Varieties in VA:– Home Telehealth

• Health buddies

• IVR

– Store Forward• Retinology, radiology, dermatology

– General Telehealth

The Evidence Base

If you want randomized controlled trials you may have to wait a little longer

VA database

Where are the limits?

PAST AS PROLOGUE

• “WRJ model” of integrated care – APA Gold Achievement Award 2005– VA Advanced Clinical Access National Champion award 2007– Mandated in all VAMCs 2009

• TELEMENTAL HEALTH– Integrated Care to Bennington via Tele implemented 2004– QI study confirms Evidence Based care improved– Berlin, NH Vet Center and second CBOC began 2009

• VT Mental Health VA/National Guard partnership– 2005-present– 2008/9 plans for TMH

INTEGRATION OF WHAT?

• Mental Health/Substance abuse/Primary Care (extending the WRJ model)

• Telemental Health and Primary Care

• VA and rural veterans/families

• VA and Community– Community Mental Health Center– Federally Qualified Health Center

RATIONALE

• Rural Veterans have difficulty accessing MH care, despite its ready access in WRJ VA and 4 CBOCs

• Veterans and NG troops often resist specialized MH care at VA or CMHC

• Evidence suggests that veterans in community treatment may be sicker (more ED visits, higher incarceration rates)

and

• To accomplish several tasks:– Provide integrated care for veterans and

families using other medical homes but in need of “special” understanding (why VA exists)

– Leverage VA funding to catalyze development of integrated care and telehealth as part of the Vermont Healthcare

THUS

• The need to integrate the care, rather than build a stand alone VA system in a foreign land.

• And to take VA employees out of their comfort zone

SITES

CMHCs:Clara Martin Center, Randolph, VT

FQHCs:Richford Health Center (NOTCH), Richford, VT

Little Rivers Health Center, Bradford, VTIndian Stream Health Center, Colebrook, NHCoos Family Services, Berlin, NHMidstate Health Center, Plymouth, NH

FUNDING

• VA Office of Rural Health & Office of Mental Health Services

• VA/National Guard Sharing agreement

Current issues

• Technology– ISDN point to point

• Lowest setup expense

• Highest per-call expense

– T1 line• Higher setup

• Low monthly subscription

• Privacy, security• Waiting for NETC

Implementation Issues

• Cross Sector contract issues

• Credentialling, licensing

• Medical Records

• Fee for service

• Provider motivation and training

• Information sharing

• Infrastructure

• Ethical concerns

Program issues

• Patient Preparation

• Room – lighting, noise, comfort

• What to wear??

• Patient satisfaction

• Choosing patients

• Choosing providers

• Contingency planning

Tasks completed to date

• Engaged with NOTCH 8/08• Mobilizing the internal WRJ facility 10/08• Conference with NOTCH/VA IT 12/08

– Contract prepared 6/09• IT issues addressed• Motivational interviews• Preliminary budget developed• Contracting contracting contracting 11/08-6/09• Planning meetings (X2) with Bradford sites• ORH grant funded (5/09)• Identification of other FQHC sites (ongoing)

Cost per visit?

• So far: About $100,000

• Engineering a prototype costs more than the last product off the assembly line.

WHY DO YOU WANT TO DO TELE?

(or do you?)