Session #B1a
Friday, October 17, 2014
Telehealth and Primary Care
Lesley Manson, Psy.D.
Robynne M. Lute, Psy.D.
Norman Bell, M.D.
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:
Learning Objective #1
 Identify, define, and discuss multiple forms of telehealth
service provision.
Learning Objective #2
 List at least 3 empirically supported uses of telehealth for
behavioral health care needs.
Learning Objective #3
 Identify at least 3 benefits of using telehealth technology
to assist Triple Aims objectives.
References
1. American Psychological Association (2013). American Psychological Association Joint Task Force on the
Development of Telepsychology Guidelines for Psychologists. Retrieved from
https://www.apapracticecentral.org/ceguidelinestelepsychologyguidelines.pdf
2. American Telemedicine Association State Medicaid Best Practice telemental and
behavioral health (2013). Retrieved from americantelemed.org
3. Anthony, K., Merz Nagel, D., & Goss, S. (Eds). (2010). The use of technology in mental health:
Applications, ethics, and practice. Springfield, IL: Charles C. Thomas Publisher, LTD.
4. Brady, C. (2013). The role of telehealth in an integrated health delivery system: How telehealth can
provide the bridge between patients and health care providers. Managed Care Outlook, 26(15): 1
5. Committee on National Security Systems (2010). National information assurance (IA) glossary. Retrieved
from https://www.cnss.gov/assets/pdf/cnssi_4009.pdf
6. Copeland, J. & Martin, G. (2004). Web-based interventions for substance use
disorders: A qualitative review. Journal of Substance Abuse Treatment, 26(2), 109-116.
7. Dahl, D. (2014). People, technology, and process meet the triple aim. Nursing
Administration Quarterly, 38(1):13.
8. Frueh, B., Henderson, S., & Myri, H. (2005). Telehealth service delivery for persons with alcoholism.
Journal of Telemedicine and Telecare, 11, 372-375.
9. Godleski, L., Darkins, A., & Peters, J. (2012). Outcomes of 98,609 U.S. Department of Veterans
Affairs patients enrolled in telemental health services, 2006–2010. Psychiatric Services, 63(4),
383-385. doi:10.1176/appi.ps.201100206
10. Institute of Medicine (1996). Assessing medical technologies. Washington, D.C: National
Academy Press.
11. LeRouge, C. & Garfield, M. J. (2013). Crossing the telemedicine chasm: Have the US barriers to widespread
barriers to widespread adoption of telemedicine been significantly reduced? International Journal of Environmental
Journal of Environmental Responsibility and Public Health, 10(2): 6472-6484.
12. Maheu, M., Whitten, P., & Allen, A. (2001). E-heath, telehealth, and telemedicine: A guide to startup and
success. San Francisco, CA: Jossey Bass Publishing.
13. Myers, K. & Turvey, C. (2012). Telemental health: Clinical, technical, and administrative foundations of
evidence-based practice. Waltham, MA: Elsevier Inc.
14. Nelson, E., & Bui, T. (2010). Rural telepsychology services for children and adolescents. Journal of Clinical
Journal of Clinical Psychology: In Session. 66(5):490-501.
15. Nelson, E.-L., Davis, K.C., Sharp, S., & Borror, H. (2007). An integrated telehealth intervention for youth
intervention for youth depression. Telemedicine and e-Health, 13(2), 193.
16. Nelson, E.-L., Ellerbeck, K., & Davis, K. C. (2008). Team-based approaches in pediatric telemental health.
Learning Assessment
• A learning assessment is required for CE credit.
• A question and answer period will be conducted at the
end of this presentation.
Telehealth and Primary Care
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What is Telehealth?
Empirical support
Uses within primary care setting
Integrated care and collaboration
– Providers
– Community organizations
– Stakeholders
• Triple Aim objectives
• Case Examples
• Questions and Discussion
Definitions & Terms
• Telemedicine: the use of electronic
information and communications technologies
to provide and support health care when
distance separates the participants. (Institute of
Medicine, 1996)
• Tele-Behavioral Health (TBH): the provision of
psychological and behavioral medicine
services using telecommunication
technologies.
Communications Technologies
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Email
Chat and Instant Messaging (SMS)
Telephone
Cellular phones and Texting
Social Networks
Websites and Blogs
Videoteleconferencing (VTC)
Virtual Reality
Computer-Aided Therapy
Health Information Technology
Why Utilize Telehealth?
• Provider Distribution
• Capitated Health Care Services/Lower Costs*
• Growing Population Health Concerns
• Patients with Limited Access to Care
• Provider Support Distance/Time/Travel
• Patients and Families
• Outreach Physician
• Isolation of Providers
• Patient Preference
• National/International Travel and Needs
• Cultural Considerations (e.g., use asynchronous communication to overcome
language barriers)
Quick Stats
• 74% of teleconsults led to a change in
diagnosis or treatment
• 60% of telehealth cases solved without a faceto-face visit
• 75% of U.S. Consumers say they would use
telehealth
• 30% of smartphone users are likely to use
wellness apps by 2015
• 500 mobile health projects worldwide
Telehealth Applications
1. Tele Consultation
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Tele Monitoring
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CMEs, CEUs
Tele Mentoring
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Direct and Indirect Monitoring
Tele Education / Learning
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Direct and Indirect Care
Direct Consultation and Professional Development
Tele Conferencing
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Case, Staff, and Professional Conferencing
Our Focus—Patient Care Applications
Photo Credit: Splashmarcomms.com
Tele-behavioral Health (TBH) in
Primary Care
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Mental health, substance abuse, lifestyle and health behaviors, psychosocial
concerns
Research on VTC—mental health including psychiatry
Satisfaction research
– Patients, their families, and clinicians endorse high levels of satisfaction with TMH
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Comparability between TBH and same-room care
– “Studies have demonstrated equivalence between same-room care and TMH care in
psychiatric diagnosis, psychological assessment, treatment plan development, and treatment
outcomes for both psychiatry and psychotherapy” (Turvey & Myers, p. 397)
– Research includes large RCT
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Effectiveness Research
– Supported by large RCTs
– Growing literature supporting asynchronous CBT over the internet
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Future Directions
– “need research into the growing availability of technologic adjuncts to therapy such as webbased programs to support intersession behavioral practice or relaxation”
– Areas for improvement, despite literature supporting clinical and research effectiveness
Empirical Support
• Overwhelmingly positive for TMH
• No contraindications for use of VTC in MH care
• Comparability
– Children
– Adults
– Geriatrics
– Cognitively impaired
Photo Credit: Takomabibelot
Empirical Support
• Mental Health Disorders
– Mood disorders
– Anxiety disorders
– Substance-use disorders
– Psychotic disorders
• Treatment Settings
– Outpatient
– Inpatient
– Institutionalized
– Correctional settings
WHO
and
• Primary Care Providers
• Behavioral Health Providers
• Specialty Medical Care
• Specialty Mental Health Care
• Medical Team Professionals
• School Personnel
• Social Support Network
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WHAT?
Community Support/Services
Individual Direct Service
Medical Care
Behavioral / Lifestyle Medicine
Behavioral Health Services
Specialty Care
Population Health
Self Management
Outcomes / Monitoring
Mentoring
Learning
TRIPLE
AIM
• Improved patient care and satisfaction
• Early identification and intervention w
Specialty
• Holistic approach/collaborative/pt centered
• Improved compliance with medical
treatment
• Improved outreach and communication
• Improved inclusion of support system and
community
• Ease and familiarity with service
• Improvement of population health;
reduced health disparities; consultation;
education; mentoring; increased
compliance
• Improved cost containment; targeted use
of resources; revenue generation; reduced
hospitalizations; reduced non-compliance
leading to additional costs; reduced ED
visits
Telehealth Consultation
Indirect and Direct Care
Photo Credit: averaphoto42012
Photo Credit: ODCHC, 2009
Telehealth
Monitoring
Telehealth Education / Learning
Telehealth Mentoring
Telehealth Conferencing
Core Guidelines
• Competence of Provider
• Standards of Care in Delivery
• Informed Consent
• Confidentiality of Data and Information
• Security and Transmission of Data and
Information
• Disposal of Data and Information and
Technologies
• Testing and Assessment
• Interjurisdictional Practice
A.P.A., 2013
Core Guidelines
• Competence of Provider
• Competence in technology and impact of
technology on pts and other professionals
• Standards of Care in Delivery
• Ensure ethical and professional standards of
care and practice
• Informed Consent
• Obtain informed consent to address
telehealth services and be cognizant of
applicable laws and regulations
• Confidentiality of Data and Information
• Protect and maintain confidentiality of data
and information
A.P.A., 2013
Core Guidelines
• Security and Transmission of Data and Information
• Ensure security measures are in place to protect data/information
from unintended access or disclosure
• Disposal of Data and Information and Technologies
• Dispose of data/information and the technologies used to protect
from unauthorized access and account for safe and appropriate
disposal
• Testing and Assessment
• Consider unique issues that may arise with testing and assessment
approaches designed for in-person implementation
• Interjurisdictional Practice
• Comply with relevant laws and regulations to the practice related
to jurisdictional and international borders.
Legalities: Originating &
Specialty
• Consultation
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Evaluate
Diagnosis
Recommend
Review
• Treatment
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Tests
Confirms
Prescribes
Orders
Follows
• Consents
• Insurances
– Scope
– Additional activities
– Hub and Specialty sites
• Billing
• Location
Boundaries/Rules
• Credentialing
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Hub sites
Spoke sites
Specialists
Consultants
Store and Forward
American Telemedicine Association
Who we are
The mission of the Open Door Community
Health Centers is to provide quality
medical, dental, behavioral health, and
education services to everyone in our
community; regardless of their financial,
geographical, or social barriers.
Open Door Community Health Centers
• Willow Creek Clinic: Primary
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Care, Dental, Teen Clinic (Willow
Creek)
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• Humboldt Open Door: Primary
Care, Teen Clinic, behavioral
health (Arcata)
• North County Clinic: Primary
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Care, Pediatrics, Behavioral health•
(Arcata)
• Mobile Health Services:
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Promotoras, Care Coordination,
Behavioral Health, Pediatrics,
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Telemedicine, Primary Care
(Eureka & Fortuna)
• McKinleyville Community Clinic: •
Primary Care, Teen Clinic
(McKinleyville)
North Country Prenatal Services
(Arcata)
Eureka Community Health and
Wellness: Pediatrics, Primary
Care, Telemedicine, Behavioral
Health (Eureka)
Burre Dental (Eureka)
Ferndale Community Health
(Ferndale)
Fortuna Community Health
(Fortuna)
Del Norte Community Clinic:
Primary Care, Teen Clinic, Dental
(Crescent City)
Telehealth and Visiting Specialist
Center: Telemed, Specialty Care,
HIV (Eureka)
Primary Care Behavioral Health Program
• Open Door Community Health Centers'
Behavioral Health Program partners with
each person to develop an individualized
plan to improve physical and mental
wellbeing leading to a healthier and
happier community and quality of life.
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Federally Qualified Health Center
We Serve 45,506 Community Members per
year
Provide 202,000 Visits
Provide $6,000,000 in Free and Reduced Fee
Services
450 Staff
85 Providers
Budget $40,000,000
Photo Credit: surroundsound5000
ODCHC, 2014
Percentage of Patients with Federal Poverty
Level % Income
60%
50%
40%
Percentage of Patients
with Federal Poverty Level
% Income
30%
20%
10%
0%
Under
101%
101-150% 151-200%
Above
200%
ODCHC, 2014
Percentage of Funding Sources
Medicaid
Medicare
Private Insurance (ACA)
Self-Pay
ODCHC, 2014
Patient Demographics by Age
35000
30000
25000
20000
Patient Demographics by
Age
15000
10000
5000
0
Ages 0-5 yo Under 18 Adults 18- 65 yo and
yo
64 yo
Older
ODCHC, 2014
Patient Demographics by Race, Ethnicity
45000
40000
35000
30000
25000
20000
15000
10000
5000
Patient Demographics by
Race, Ethnicity
0
ODCHC, 2014
Community Health Care Services
Family Practice
Pediatrics
Geriatrics
EMDR & Biofeedback
Population Health
Promotoras
Telemedicine Programs
Family Planning
Urgent Kids Care
Homeless Outreach
Wellness Groups
HIV/AIDS and HCV Care
Nutritional Counseling
Behavioral Medicine
Urgent and Same Day Care
Population
1 in 3 People
Community
Underinsured
Uninsured
Immunizations
Women's Health
Complete Dental Care
Case Management
Complex Case Management
Mobile Health
Health Education
Prenatal & Birth Services
Teen Health
Wellness Outreach
Wellness Community Gardening
Alternative Medicine
STD Testing and Counseling
Mental Health Counseling
Benefits Enrollment Assistants
ODCHC, 2014
Essential to Develop
TeleHealth Partnerships
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Rural Area
Health Center
School Based
Community Based
Public Health
County Mental Health
University Centers
Identified Need
– BH and/or MH
– Pediatrics
– Primary Care
– Specialty Care
Case Example #1
• Male Child in 7th Grade
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Hyperactive
Disruptive behaviors (home, school, social)
Problems with socialization
Familial substance abuse
Lives with mother and stepfather
History of stimulant medication in elementary school
Special education services
Poor judgment
• Consultation with telehealth program for
primary care specialty pediatrics and
behavioral medicine
– Assisted with school based consultation, treatment
considerations, and monitoring
– Obtained formal evaluation
• Identified significant working memory concerns
• Consultation to school re specific considerations for
learning
– Transitioned pharmacotherapy
• Significant transitions over 4 years treatment
• Headaches, anorexia, syncopal attack, sleepiness
• Utilized monitoring, assessments
– Improvements / Progress
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Making friends
Sports
Academics “Presidential Achievement Award”
Graduated CA Exit Exam
A in math
Considering college
Self managing and monitoring
Satisfaction others are listening, supporting, and
helping
• Improved communication with caregivers/parents,
school, medical professionals
• Motivated to get a job
• Improved patient and family care and
satisfaction
• Early identification and intervention w
Specialty
• Holistic approach/collaborative/pt centered
• Improved compliance with medical treatment
• Improved outreach and communication
• Improved inclusion of support system and
community
• Ease and familiarity with service
Triple Aim
• Improved health; reduced health disparities;
consultation; provider and community
education; provider mentoring; increased
friendships, social support, self-mgmt
• Improved cost containment; targeted use of
resources; revenue generation minimal; pt
motivated toward college/employment
Case 1
Case Example #2
• 12 yo male
– Poor school performance
– Concerns of Autism Spectrum
– Trouble socializing
– Unusual hobbies
– Difficulty completing homework
– Disruptive behaviors at school and home
• Consultation with telehealth program for
primary care specialty pediatrics and
behavioral medicine/behavioral health
services
- Assisted with school based consultation,
treatment considerations, and monitoring
- Assisted with family and community
support
- No medication assistance needed
- Obtained formal evaluation
- Identified significant dysgraphia
concerns
- Consultation to school re specific
considerations for learning
– Improvements / Progress
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Making friends
Considering Sports
Academic progress
Likes school
Reduced homework time
No fighting behaviors
Photo Credit: Eva Blue
Using voice recognition programs
Increased support from school
Motivation toward college
Self managing and monitoring
Satisfaction others are listening, supporting, and helping
Improved communication with caregivers/parents,
school, medical professionals
• Improved patient and family care and
satisfaction
• Early identification and intervention w
Specialty
• Holistic approach/collaborative/pt centered
• Improved compliance with medical treatment
• Improved outreach and communication
• Improved inclusion of support system and
community
• Ease and familiarity with service
Triple Aim
• Consultation; provider and community
education; provider mentoring; increased
friendships, social support, self-mgmt
• Improved cost containment; targeted use of
resources; revenue generation; decreased
other specialty visits, pt motivated toward
college
Case 2
USC Tele Behavioral Health
• Reserved for USC’s TeleBH Slides
Benefits of Telehealth
Photo Credit: U.S. Department of Agriculture
Helpful Resources
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Journal of Medical Internet Research
HHS Offices with Telehealth Projects
HRSA Office of Special Health Affairs
HRSA and Behavioral Health
HRSA Office for the Advancement of
Telehealth
SAMHSA Center for Substance Abuse
Treatment Technology Assisted Care
Grants
Telemental Health Guide
Telehealth Operations Module
Telehealth Technology Assessment
Center
American Telemedicine Association
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Association of Telemedicine Service
Providers
Telemedicine Information Exchange
Federation of State Medical Boards:
Model Act for Licensing of Telehealth
HRSA Health Center Telehealth Policies:
Liability coverage of telehealth under
the Federal Tort Claims Act
CMS, Medicare Learning Network
Center for telehealth and e-Health Law
on reimbursement
Interim Billing and Financial
Worksheets, By State: SAMHSA HRSA
Center for Integrated Health Solutions
Helpful Resources
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HRSA’s Office for the Advancement of
Telehealth
Centers for Medicaid and Medicare
Services (CMS) Telemedicine
CA Healthcare foundation
UC Davis Center for health and
technology
Teleconnect funds
Universal Services administrative
company
Telehealth optimization initiative
QUESTIONS
Lesley Manson, Psy.D.
Doctor of Behavioral Health Program
Arizona State University
Email: lesley.manson@asu.edu
Phone: (602) 496-6790
Robynne M. Lute, Psy.D.
The School of Professional Psychology
at Forest Institute
Email: rlute@forest.edu
Phone: (417) 893-7979
Norman Bell, M.D., Pediatrician
Open Door Community Health Centers
Email: nbell@opendoorhealth.com
Phone: (707) 496-3984
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!