Session # B1b
Friday, October 17, 2014
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 Conference
October 16-18, 2014
Washington, DC U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
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
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
© 2014 Cherokee Health Systems
All Rights Reserved
Telehealth Services at Cherokee Health Systems
FY 2013-2014
Telehealth
Visits
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
© 2014 Cherokee Health Systems
All Rights Reserved
© 2014 Cherokee Health Systems
All Rights Reserved
© 2014 Cherokee Health Systems
All Rights Reserved
© 2014 Cherokee Health Systems
All Rights Reserved
© 2014 Cherokee Health Systems
All Rights Reserved
© 2014 Cherokee Health Systems
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Implementation
© 2014 Cherokee Health Systems
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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”
© 2014 Cherokee Health Systems
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Implementation: Workflow (Initial Consult)
PCP or nurse notifies
BHC via
phone/telehealth about
new consult
BHC informs nurse/PCP
by phone when ready
and staff member
escorts patient to BHC
telehealth office/patient
exam room
BHC adds patient to
schedule and reviews
Electronic Health Record
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
•
© 2014 Cherokee Health Systems
All Rights Reserved
Implementation: Workflow (Follow-up)
End of Visit: BHC
schedules follow-up (if
any), coordinates with
nurse/point person for
handouts or other
appointments that day
Staff Member informs
BHC that pt has arrived.
When BHC is ready, staff
member escorts patient
to BHC telehealth office
Patient checks-in at front
desk
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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All Rights Reserved
Implementation: Schedule
• Same schedule as Primary
Care
• Mixture of planned followups and availability for “ondemand” 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
© 2014 Cherokee Health Systems
All Rights Reserved
Implementation: Billing & Coding
Behaviorist with
Patient
Primary Focus of
Clinical Attention
Medical
Behavioral
Assessment or Intervention?
Therapeutic or Evaluative?
Initial Assessment
96150
Individual
96152
Re-Assessment
96151
Group (2 or more)
96153
Diagnostic Interview
90791
Family (with patient)
96154
Family (w/o patient)
96155
Individual (16-37 min)
90832
* Can also utilize 99406 (3-10 minutes) or
99407 (>10 minutes) for smoking cessation
NOTE: Primary Diagnosis must match the CPT code selected.
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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
© 2014 Cherokee Health Systems
All Rights Reserved
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
© 2014 Cherokee Health Systems
All Rights Reserved
Implementation: Challenges
Crisis 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
© 2014 Cherokee Health Systems
All Rights Reserved
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
© 2014 Cherokee Health Systems
All Rights Reserved
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
© 2014 Cherokee Health Systems
All Rights Reserved
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)
© 2014 Cherokee Health Systems
All Rights Reserved
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
© 2014 Cherokee Health Systems
All Rights Reserved
Telehealth Guidelines
• American Telehealth Association
• Standards and Guidelines:
http://www.americantelemed.org/resources/standards/ata-standardsguidelines
• American Psychological Association
• Guidelines for the Practice of Telepsychology:
http://www.apapracticecentral.org/ce/guidelines/telepsychologyguidelines.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
© 2014 Cherokee Health Systems
All Rights Reserved
Discussion
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Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!