Telehealth Behavioral Health Consultation Services: Implementation Strategies and Challenges

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

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

© 2014 Cherokee Health SystemsAll Rights Reserved

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


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


Implementation


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”


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


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


Implementation: Schedule

• Same schedule as Primary Care

• Mixture of planned follow-ups and availability for “on-demand” consults

• Coordinated visits


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


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


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


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


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


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



• 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



• 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)


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


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


Discussion

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!

Telehealth Behavioral Health Consultation Services: Implementation Strategies and Challenges

Documents

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