Telepsychiatry's Role in
Improving Access to Mental
Health Care
Presented to FADAA/FCCMH 2011 Annual Conference
By J. David Moore,M.D., DLFAPA
ValueOptions Vice President and Medical Director
August 24th 2011
1
Florida Needs and Issues
• Limited access to Psychiatrists
• Significant transportation problems for consumers
especially in more rural counties
• Loss of revenue when Psychiatrists have to travel
• Significantly High “No Show” rates causing even
more limited access to Psychiatrists
• Difficulty in getting timely initial assessments done
for both urgent and routine cases
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Support from CMS
• Reimbursement for Medicaid covered services, including those
with telemedicine applications, must satisfy federal requirements
of efficiency, economy and quality of care. With this in mind,
States are encouraged to use the flexibility inherent in federal
law to create innovative payment methodologies for services
that incorporate telemedicine technology. For example, States
may reimburse the physician or other licensed practitioner at the
distant site and reimburse a facility fee to the originating site.
States can also reimburse any additional costs such as technical
support, transmission charges, and equipment. These add-on
costs can be incorporated into the fee-for-service rates or
separately reimbursed as an administrative cost by the state.
3
Support from CMS
• Telemedicine
• For purposes of Medicaid, telemedicine is the use of medical
information exchanged from one site to another via electronic
communications to improve a patient's health. Electronic
communication means the use of interactive telecommunications
equipment that includes, at a minimum, audio and video
equipment permitting two-way, real time interactive
communication between the patient, and the physician or
practitioner at the distant site. Telemedicine is viewed as a costeffective alternative to the more traditional face-to-face way of
providing medical care (e.g., face-to-face consultations or
examinations between provider and patient) that states may
choose to cover. This definition is modeled on Medicare's
definition of telehealth services located at 42 CFR 410.78.
4
AHCA Support for the Technology
• AHCA released the draft language for use in the upcoming
Community Mental Health Handbook in July, 2010
• The Draft language has continued to be modified up until the
release of the handbook.
• AHCA gave the go-ahead with our Pilot and informed us of the
codes to use prior to the publication of the Handbook
• AHCA representatives received a live demonstration of our
system and were convinced that we more than met any of
their concerns about clarity, lack of delays, and sufficient
audio and video to provide the services through this
technology
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AHCA Guidelines
• Telepsychiatry may be done by a psychiatrist enrolled in
Medicaid and contracted or employed by a CMH Provider
• Telepsychiatry may be used for all but initial psychiatric
evaluations, assessments, or examinations
• A current psychiatric evaluation needs to be documented in
the clinical record before doing telepsychiatry
• The psychiatrist must be at a CMH Provider location (not at their
home)
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AHCA Guidelines (cont.)
• Telepsychiatry providers must have technical written policies
and procedures that comply with HIPAA privacy regulations
and address the safeguards required by CFR Title 45, Part
164.312
• Asynchronous transmissions not accepted (live interactions
only)
• The clinical record must include a brief explanation of why
services were not “face-to-face”
• Documentation of the assessment including findings and plan
must be documented in the record.
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Pilot Development
•
July 09, 2010 – ValueOptions®, the nation’s largest independent
behavioral health care company, leverages Verizon Telehealth
Collaboration Services to securely offer cost‐effective telepsychiatry
to residents of Immokalee, Fla., a remote community in the
headwaters of the Everglades.
• Immokalee, is a rural agricultural community 30 miles east of Naples.
Nearly half the residents of this largely migrant population live below
the poverty line and struggle accessing healthcare due to language
barriers, transportation issues and childcare. Providing the same timely
access to psychiatric services as the individuals living in the more
urban Naples area has been a challenge.
• ValueOptions chose David Lawrence Center, with offices in Naples
and Immokalee, to provide real‐time consultations between clinical
specialists and those in need of services. The remote consultations
were enabled by high‐definition video conferencing units.
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Concerns for the Pilot to Address
• Will this technology be accepted by the consumers and the
physicians/therapists?
• Will this technology help with the transportation issues?
• Will this approach reduce no show rates for medication Management
appointments
• Will consumers see this as an effort by the provider to help them with
their problems accessing Psychiatrists in rural/remote areas?
• Will the provider be able to address getting the prescriptions to the
consumer or pharmacy?
• Will the technology effectively address the safety and privacy of the
consumer
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Do the Homework
• ValueOptions partnered with Verizon to develop the clearest and
safest software and hardware possible for its pilot in Florida
• The Tampa ValueOptions Medical Director developed the different
care scenarios that we wished to use in the pilot
• ValueOptions tested and re-tested the equipment prior to its
deployment at the CMHC
• ValueOptions staff met with the CMHC clinical, administrative and IT
teams to make sure all questions were answered
• When it became clear that a home to office scenario was not going to
meet our criteria of clarity and consistent signal strength,
ValueOptions determined that only the office to office scenario would
be piloted
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Improved Access?
July 2010-June, 2011
• David Lawrence Center Reports:
– 65% Increase in Total Number of Services Provided
in Immokalee
– 79% Increase in the Total Number of Medication
Management Services
– 229% Increase in Targeted Case Management in
Immokalee
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“No Show” Changes
• From 7/1/10-4/21/11, there were 333 FHP members seen using
the Telepsychiatry technology.
• There were 43 who called to reschedule instead of not showing
up for their appointment ( A rate of 15%)
• There were 7 no shows ( A rate of 2%)
• It appears that the use of the technology gave the consumers
the feeling that since the provider was making an effort to help
them access services, then they wanted to not just not show for
the appointment and even wanted to reschedule.
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Consumer Acceptance Rates
I saw the doctor/therapist
using tele-behavioral / telepsychiatry equipment.
159
Yes159
No0
100%
I felt safe and comfortable
using the tele-behavioral /
tele-psychiatry health
equipment.
158
Yes157
No1
99%
Using tele-behavioral health
helped me with transportation
problems.
157
Yes155
No2
99%
I would be willing to use telebehavioral / tele-psychiatry
for future visits with the
doctor / therapist.
159
Yes159
No0
99%
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Provider Acceptance Rates
I saw the patient
using telebehavioral /
telepsychiatry
equipment.
I felt comfortable
using the telebehavioral / telepsychiatry health
equipment to conduct
the patient visit.
The tele-behavioral
equipment made it
easier to see the
patient.
I would be willing to
use tele-behavioral /
tele-psychiatry for
future visits with the
patient.
14
9
8
1
89%
8
8
0
100%
8
8
0
100%
8
8
0
100%
Current Billable Uses of
TelePsychiatry for Medicaid
• Medication Management
• Assessments
• Individual Therapy
15
Florida Telepsychiatry Expansion
– Developed first State-approved telepsychiatry pilot
for Medicaid behavioral health
– Developed care scenarios to improve access to
care in rural market
– Expanded telemedicine presence with additional FL
providers.
– Presented to AHCA with goal of expanding codes
to include CM, initial assessments, practitioner
consults, etc.
– Deployment of 30 new connection points via new
purchases and 1-3 year contracts.
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Future Uses of Telepsychiatry
• Consultations with Emergency Department Physicians
regarding Baker Acts and treatment recommendations
• Psychiatric Assessments in the Emergency Departments
• Consultations with FQHCs regarding mental health issues
• Having Virtual Team of Psychiatrists available for Psychiatric
Assessments and Medication Management for other agencies
• Expansion of Assessments and Medication Management in the
members home
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This is Only the Beginning
Questions?
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