Objectives
 To provide a basic introduction to TMH.
 Provide an overview of the current uses of TMH.
 Educate providers on the clinical considerations before
providing TMH.
 Educate providers on the pertinent risk issues of TMH.
 Provide a list of current TMH resources.
Contributors
Ron Acierno, Ph.D., Anna Hynes Birks, Psy.D., Kathleen Chard, Ph.D.; Lana
Frankenfield, LCSW; Linda Godleski, M.D.; Carolyn Greene, Ph.D.; Leslie
Morland Psy.D.; Peter Shore, Psy.D.; Tracey Smith Ph.D.; Steven Thorp, Ph.D.;
Peter Tuerk Ph.D.; Matthew Yoder, Ph.D.
The goal of the
telehealth provider is
to eliminate disparities
in patient access to
quality, evidencebased, and emerging
health care diagnostics
and treatments.
-American Telemedicine Association, (2009, July).
Evidence-based practice for telemental health
Definitions
•Telemedicine is the use of medical information exchanged
from one site to another via electronic communications to
improve patients' health status.
•"telehealth," which is often used to encompass a broader
definition of remote healthcare that does not always involve
clinical services.
•The term e-health is often used to describe automated
web-based products and services to deliver health-related
education or secondary prevention services.
*Tuerk, Peter Clinical Summit, 2012
What is Telemental Health?
“The term telemental health services typically
refers to behavioral health services that are
provided using communication technology”
National Center for PTSD Fact Sheet “PTSD and Telemental Health”
TMH
Clinical Video Telehealth (CVT)
Typical VA Telemental Health Program
 Majority of Telemental Health Activity is Hub and Spoke
model
 Provides Access to General Mental Health Services and
Medical Center Specialists for Patients in Remote CBOCs
 Ease of Implementation:
 Same Credentialing and Privileging
 Same Medical Record
 Same Workload and Reimbursement Mechanism
 Same Quality Management Oversight
 Same IT Department and IT Infrastructure
Benefits of Telemental Health
 Technology is rapidly increasing system coverage area, thereby
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1
increasing the reach to rural veterans 5
Patient benefits with regard to lost employment time, as well
as transportation costs and time 2-4
Satisfaction with service delivery is high among patients and
providers 6-7
Efficacy data in telemental health: limited but supportive 8
Lower cost without sacrificing quality of care 1
Decreased hospitalization utilization by an average of
approximately 25% (Godleski, 2012)
Morland et al., 2003; 2 Bose et al., 2001 ; 3 Elford et al., 2000 ; 4 Trott & Blignault, 1998;
5 Dunn et al., 2000 ; 6 Frueh et al., 2000; 7 Monnier et al., 2003; 8 Ruskin et al., 2004
Use of Clinical Video Telehealth
 For all diagnoses, with rare exclusions
 For a range of populations
 By all mental health clinicians
 For a range of mental health procedures
 At multiple sites of care
Evidence Base for CVT
American Telemedicine Association (2011):
• Inpatient and outpatient mental health
evaluations
• Diagnostic interviews
• Psychiatry (assessment, treatment and
monitoring)
• Psycho-Education
• Individual and Group Psychotherapy
• Marital and Family Psychotherapy
Evidence Base Cont.
• Psychological Assessment
• Diagnostic instruments and scales
• Personality Assessment
• Neuropsychological Assessment *See Turner et al
(2012); Amarendran et al (2011); Cullum et al (2006);
McEachern et al (2008)
Research Base
 Empirical Studies
 Uncontrolled studies (26)
 Nonrandomized controlled studies (9)
 Randomized controlled studies (12)
Lana Frankenfield
Human Connection & Technology
 “It seems so cold, the human
element is missing from the
encounter”
 “Telehealth doesn’t seem safe”
 “It’s less effective than a ‘real’
encounter”
 “Patients will not like it”
What is a TMH Telepresenter
 Front Line Staff
 LPN
 RN
 Telehealth Clinical Technician
(TCT)
The Role of the TMH Telepresenter
Initial Visit
 Explain Telemental health
 Verbal informed consent
 Outline the experience the patient can expect
 Reassure that the patient will not be "on
television"
 Responsible for any patient education of the
technology
 Address procedures with patient if there
are environmental or technology
emergencies
The Role of the TMH Telepresenter
 Escort patient(s) to room
 Ensure connectivity with provider
 Provider can hear and see patient clearly (patient aligned in
frame)
 Patient can hear and see the provider clearly (provider
aligned in frame)
 Patient is in frame and doesn’t appear to close or too far
away
 Responsible for ensuring manuals and/or patient education
materials are available and distributed
Clinical Considerations
for EBP TMH
Peter Shore
Clinical Considerations
 Patient Considerations
 Treatment Considerations
 Special Considerations
Elderly
Rural
Ethical
Group
 Exclusion Criteria
 Risk management




Special Considerations
 Elderly
 Rural
 Ethical
Veteran Considerations
 Established mental health diagnosis and primary care
assignment.
 Willing to participate in Telemental Health Services via
informed consent.
 Acknowledges and accepts limits of
confidentiality.
Veteran Considerations cont.
 Has adequate sensory abilities to participate.
 No active suicidal or homicidal ideation with or without
high lethality.
 No active psychosis or uncontrolled substance use disorder.
 Established primary care provider and/or mental health
point of contact at local CBOC.
EXCLUSION CRITERIA
 Reject telehealth
 Requiring involuntary commitment
 With immediate need for hospitalization.
 Acutely violent or unstable patients with poor impulse
control
 Active suicidal or homicidal ideation
 Severely decompensated
EXCLUSION CRITERIA
 Psychotic disorders that may be exacerbated
by telemental health (e.g. ideas of reference
regarding television)
 Untreated Substance abuse/dependence
(current and/or extensive history with
elongated sobriety and relapse)
 Significant sensory deficits
Ron Acierno & Peter Shore
Pre-Session
 Direct phone numbers
 Safety plans
 Walk through the back-up plan: Patient and Patient
Site
 Emergency Contact
Contingency Plans
 Same-day communication plan
 Technology back-up plan
 Responding to emergencies
 Emergency plans:
 Medical Emergencies
 Voluntary and involuntary psychiatric hospitalization
 Transportation
 Other emergencies?
Imminent risk
#1: Ensure safety of patient, means and
likelihood of self harm/others, level of
urgency necessary to prompt immediate transport.
 Do not leave the patient alone.
 If Patient becomes unconscious and disappears from site
of the provider:
 Provider to contact PSA or Patient Support Person to provide
visual assistance and evaluation of circumstances. “Veteran is
on the ground, they are unconscious, Veteran is having a
seizure.”
 Provider instructs PSA to Contact Onsite MD and PSP to
contact 9-1-1 from their home phone. (Active suicide intent
and/or medical emergency when PSA or PSP is unavailable).
Leslie Morland; Peter Tuerk; Ron Acierno
Evidence Based Therapy
for PTSD in the VA
• Dissemination Efforts for Prolonged Exposure (PE) and
Cognitive Processing Therapy (CPT) in the VA11
– Nationwide dissemination initiatives
– Multi-year rollouts
– Multi-day workshops, ongoing consultation and
supervision
– As of Feb 2012, the VA has provided training in CPT
and/or PE to about 4,000 staff
11
Karlin, Ruzek, Chard, Eftekhari, et al., (2010)
Evidence-Based Therapy for PTSD in the VA
 There have been several studies with VA samples
that have demonstrated that CPT and PE is an
effective treatment for PTSD
 There have been a few studies with Veterans that
suggest that CPT and PE delivered via VTC is as
effective as when it is delivered in traditional face-
to-face sessions.
 These treatments should be made available to
Veterans in need regardless of their geographical
location
PE studies
Active treatment (N)
 Rauch, Defever, Favorite et al., 2009
(10)
 Tuerk, Yoder, Ruggiero, Gros & Acierno, 2010
(34)
 Rauch, et al., 2011
(51)
 Gross, Yoder, Tuerk, Lozano, Acierno, 2011
(62)
 Tuerk, Yoder, Grubaugh, Myrick, Acierno, 2010
(65)
 Yoder, Tuerk, Price, Myrick, Acierno, 2012
(65)
 Schnurr, Friedman, Engel, Foa, et al., 2007
(141)
CPT studies
Group CPT studies
 Morland, Hynes, Mackintosh, et al. (2011) (13) Group
 Owens, Chard, & Cox (2008)
(99) Group
 Alvarez, McLean, Harris, et al. (2011)
(104) Group
 Gilman, Schumm, & Chard (2011)
(164) Group +
Ind.
Individual CPT studies
 Monson, Schnurr, Resick, et al. (2006) (30) Ind.
 Chard et al (2010)
(101) Ind.
Lana Frankenfield, LCSW
Resources
 VHA Office of Telehealth Service Website
http://vaww.telehealth.va.gov
 VHA Office of Telehealth Service SharePoint
http://vaww.infoshare.va.gov/sites/telehealth/def
ault.aspx
OTS Website: Telemental Health Resources
OTS Home Page http://vaww.telehealth.va.gov
 Telemental Health Resources
 Ops manual
 Credentialing and Privileging
 Informed Consent
 Coding
 Clinic Setup Guide
 SharePoint Portals
 VISN Contacts
 Training
 Publication Archives
 TMH Journal Club
TMH Training Program
OTS Home Page http://vaww.telehealth.va.gov
 Training Tab
 Click on RMTTC
 Training Programs
 TMH Training Program
TMH Training Program
•Telemental Health Toolkit: Video Conferencing
•Telemental Health Suicide Prevention and
Emergency Care
•Telemental Health Skills Assessment
What is a TMH Skills Assessment?
 Controlling What You See
 Controlling What You Hear
 Setting Up Your
Environment
 Privacy and Confidentiality
 Making and Receiving Calls
 Emergency Procedures
Recommended Readings
 Backhaus et. Al (2012). Videoconferencing Psychotherapy: A
Systematic Review. Psychological Services, Vol 9, No 2, 111-131.
 American Telemedicine Association, Telemental Health Standards and
Guidelines Working Group (2011)
 Available on the ATA Website