Telehealth Behavioral Health Consultation Services: Implementation Strategies and Challenges
Jean Cobb, Ph.D.
Behavioral Health Consultant, Cherokee Health Systems
J. David Bull, Psy.D.
Behavioral Health Consultant, Cherokee Health Systems
Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.
Session # B1bFriday, October 17, 2014
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Gain an increased awareness of how telehealth behavioral health consultation services can achieve the Triple Aim by helping to reduce costs, improve patient experience and population health, and reduce barriers to access care
• Gain understanding of an effective clinical model that implements telehealth behavioral health consultation services in integrated primary care settings
• Discuss challenges and recommendations for successful implementation of telehealth behavioral health consultation services
• Describe equipment and technology capabilities necessary for successful implementation of telehealth behavioral health consultation services
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Overview• Increased workforce demand for behavioral
health clinicians to practice in primary care• Patient access to behavioral health services
• Rural clinics• Advances in technology
Achieving the Triple Aim: Reducing costs, improving patient experience and population health, and reducing barriers to access to care
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Telehealth Services at Cherokee Health SystemsFY 2013-2014
TelehealthVisits
Telehealth Patients
Providers Delivering Telehealth Services
Locations with Telehealth
Services
18,270(5.7% of
total visits )
6,469(10.6% of
total patients)
43 20
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Implementation: Staffing Needs
• IT Support• Behavioral Health Consultant • Primary Care Provider(s)• Nursing & Front Office Staff – one on-site staff
person specifically designated as BHC’s “point person”
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Implementation: Workflow (Initial Consult)PCP or nurse notifies
BHC via phone/telehealth about
new consult
BHC adds patient to schedule and reviews
Electronic Health Record
BHC informs nurse/PCP by phone when ready
and staff member escorts patient to BHC
telehealth office/patient exam room
•
End of Visit: BHC schedules follow-up (if any), coordinates with
staff member for handouts or other
appointments that day
BHC provides feedback to PCP via telehealth,
phone, or EHR. Patient escorted to check-out area or clinical area as
appropriate
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Implementation: Workflow (Follow-up)
Patient checks-in at front desk
Staff Member informs BHC that pt has arrived. When BHC is ready, staff member escorts patient to BHC telehealth office
End of Visit: BHC schedules follow-up (if any), coordinates with nurse/point person for
handouts or other appointments that day
•
BHC may provide feedback to PCP via
phone or EHR as appropriate
Patient escorted to check-out area or clinical
area as appropriate
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Implementation: Schedule
• Same schedule as Primary Care
• Mixture of planned follow-ups and availability for “on-demand” consults
• Coordinated visits
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Implementation: Clinical Model
• CHS current model• BHC is covering two clinics simultaneously for
warm hand-offs• Scheduled follow-ups limited to one clinic on
specific days of the week • BHC physically on-site at least monthly – critical
for good working relationships and some strategic face-to-face encounters with patients
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Behaviorist with Patient
Implementation: Billing & Coding
Primary Focus of Clinical Attention
Medical Behavioral
Initial Assessment96150
Re-Assessment96151
Individual96152
Group (2 or more)96153
Family (with patient)96154
Assessment or Intervention?
Family (w/o patient)96155
Therapeutic or Evaluative?
Diagnostic Interview90791
Individual (16-37 min)90832
NOTE: Primary Diagnosis must match the CPT code selected.
* Can also utilize 99406 (3-10 minutes) or 99407 (>10 minutes) for smoking cessation
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Implementation: Billing & Coding• Add modifier GT “via interactive audio and video
telecommunications systems”• Originating Site = location of patient• Distant Site = practitioner who furnishes and receives
payment for covered telehealth services • Per Centers for Medicare & Medicaid Services - can
include MD, NP, PA, Nurse Midwife, Clinical Nurse Specialists, Clinical Psychologist, Clinical Social Worker, Registered Dietitian or Nutrition Professional
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Implementation: Challenges• Introduction & explanation of telehealth encounter
• Managing patient resistance• Maintaining integrity of communication and care
coordination• Work flow
• Patient handouts• When “point person” is busy• Coordinating multiple follow-up appointments
• Provider/ staff awareness of BHC schedule• Technology problems
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Implementation: ChallengesCrisis Situations
• Must have strong & efficient communication between BHC and on-site staff
• Important to train staff in advance and have plan in place (guided by on-site and community resources)
• May need staff to assist by:• Informing other patients that BHC is running late• Changing patient rooms if needed• Help patient access telephone and other crisis resources as needed• Monitor patient for physical safety during crisis assessment &
intervention
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Implementation: Lessons Learned
• The right team members• BHC with strong communication skills with
provider(s) and support staff is essential• Anticipate the need for increased support staff
resources• Importance of initial training with providers &
support staff (when & how to refer, services you can offer, etc.)
• Invite ongoing feedback from patients and team members
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Implementation: Lessons Learned
• Importance of training staff to let you know a patient has arrived or needs to be seen (allowing time for chart review, etc)
• Staff person should teach patient how to adjust equipment volume and give patient access to volume control
• Consider sound control measures (i.e. white noise machine) to protect confidentiality
• Consider staying connected in between patient visits, so that providers and staff can “drop by your office” as needed
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Implementation: Lessons Learned
• It helps to have remote access to an on-site printer, but if not available have commonly used handouts on-site (or alternative plan to send by fax or email)
• Recommend scheduled BHC follow-up appointments be limited to one “originating site” on a given day
• Use clinical judgment for patients who are more appropriate for face-to-face encounters, strategically schedule them on days you are physically present
• Coach support staff on how to appropriately introduce telehealth (don’t “make a fuss” over it)
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Implementation: Recommended Technology Components
• Polycom high definition video codec* • High Definition LED/LCD TV - 720p or higher, using HDMI or Component
connections• Bandwidth capable of supporting 615kb** of video/audio traffic per telehealth
session• End to End Quality of Service (QoS) across the LAN/WAN*** to prioritize audio
and video traffic* Cisco and LifeSize also make video codecs, but require more bandwidth to initiate a "high definition" call**This is what is recommended for a high definition connection using Polycom video codec***The Wide Area Network Provider (such as AT&T, Windstream, Verizon) should also create QoS policies within the WAN
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Telehealth Guidelines• American Telehealth Association
• Standards and Guidelines: http://www.americantelemed.org/resources/standards/ata-standards-guidelines
• American Psychological Association• Guidelines for the Practice of Telepsychology:
http://www.apapracticecentral.org/ce/guidelines/telepsychology-guidelines.pdf
• 8 key issues: Competence, Standards of Care, Informed Consent, Confidentiality, Security and Transmission of Data, Disposal of Data and Information and Technologies, Testing and Assessment, Interjurisdictional Practice
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