innovating with telepsychiatry to improve mental health

December 2, 2020

Innovating with Telepsychiatry to Improve Mental Health Care in Health Centers

@NACHC

America’s Voice for Community Health CareThe National Association of Community Health Centers (NACHC) was founded in 1971 to promote efficient, high quality, comprehensive health care that is accessible, culturally and linguistically competent, community directed, and patient centered for all.

THE NACHCMISSION

@NACHC

John Fortney, PhD

ProfessorDirector, Division of Population HealthDepartment of Psychiatry and Behavioral SciencesUniversity of Washington

[email protected]

©University of Washington

STUDY TO PROMOTE INNOVATION IN RURAL INTEGRATED

TELEPSYCHIATRY

12/2/2020

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SPIRIT Quantitative findings

John Fortney, PhD


Epidemiology of PTSD

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Epidemiology of Bipolar Disorder

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The Problem

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• There are highly effective treatments for PTSD and Bipolar Disorder

• CHC patients do not have access to these treatments• CHC Staffing

• 1 psychiatrist per 49,764 patients • 1 psychologist per 43,505 patients

• A large proportion of patients with PTSD and Bipolar Disorder are:• Unable to engage in specialty mental health treatment• Treated exclusively in primary care• Prescribed medications for depression

• PCPs are increasingly being challenged to care for patients with these complex psychiatric disorders• Obligated, but unprepared and under‐resourced


Potential Solutions: TCC and TER

TCC ‐Telepsychiatry Collaborative Care

TER ‐Telepsychiatry Enhanced Referral Care

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SPIRIT Overview

•Study Period: 2016 – 2020•Patients PHQ‐9≥10 Screened for Bipolar & PTSD

o3,131 screened positive (33% for Bipolar Disorder)o18% already prescribed medications by MH specialist

•1,004 Consented and Randomized to TCC or TER•Survey at baseline, 6‐ and 12‐months

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Characteristics

9/12/2016

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Race/Ethnicity

White Hispanic

African American Other

Insurance

Uninsured Medicaid Medicare

Military Private

Employment

Full Time Part Time

Unemployed Other

Poverty

Poverty Not Poverty


Screening False Positives

9/12/2016

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Screened + for PTSD

Diagnosed Not Diagnosed

Screened + for BD

Diagnosed Not Diagnosed

Comorbid Diagnoses

Depression

Generalized Anxiety

Alcohol UseDisorder

Drug UseDisorder


Engagement

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0

10

20

30

40

50

60

70

80

90

100

TCC Care Manager TCC Telepsychiatry TER Telepsychiatry TER Telepsychology

Proportion With Any Encounters

µ=10.2

µ=1.4 µ=4.3

µ=6.3

Telepsychiatry Collaborative Care Telepsychiatry Enhanced Referral


Telepsychiatrist/Telepsychologist Encounters

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0

1

2

3

4

5

6

7

Telepsychiatry Collaborative Care Telepsychiatry Ehnanced Referral

Specialist Visits Per Patient Per Year

Psychiatrist Psychologist


Mental Health Functioning – Primary Outcome

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‐‐‐‐‐___


PTSD Symptoms (PCL‐5)– Secondary Outcome

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‐‐‐‐‐___


Euthymic Mood (Neither Depression nor Manic)– Secondary Outcome

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‐‐‐‐‐___


Depression– Secondary Outcome

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‐‐‐‐‐___


Generalized Anxiety– Secondary Outcome

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‐‐‐‐‐___


Side Effects– Secondary Outcome

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‐‐‐‐‐___


Conclusions20

•No difference in outcomes between TCC and TER

• Both TCC and TER substantially improved outcomes↑Mental Health Functioning↓PTSD Symptoms↓Bipolar Symptoms↓Depression Symptoms↓Anxiety Symptoms↓Side Effects

•TCC can generate similarly good outcomes with 1/6th

the amount of telepsychiatry/telepsychology time.


Questions

[email protected]


No Show Rates

22

@NACHC

Susan Ward‐Jones, MD

Chief Executive OfficerEast Arkansas Family Health Center, Inc.

[email protected]

Susan Ward-Jones, MD, CEOEast Arkansas Family Health

Center

December 2, 2020

"Innovating with Telepsychiatry to Improve

Mental Health Care in Health Centers"

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EAFHCUsers: 18,590Encounters: 75,252

Service Area: Crittenden, PoinsettMississippi and Phillips County

Sites: 7 Healthcare Delivery Sites 3 SBHCs 1 Admin - HIV/AIDS Case Management Site

Joint Commission Accredited since 1997

NCQA PCMH Level III

HRSA Quality Health Care Leader 2016, 2017, 2018 & 2019

Annual Budget - $20 million

Patient Demographics:

Gender:Female: 62%Male: 38%

Age: 0-17 years: 18%18-64 years: 66%65 and older: 16%

Insurance:Uninsured: 26%Insured: 74%

o Medicaid: 35%o Medicare: 20%o Private Insurance: 19%

Race:Black/AA: 64%White: 33%Other: 3%

EAFHC25

EAFHCStaff Providers

• 6 physicians including Pediatrician• 1 Ophthalmologist• 12 NPs including Psych NP• 1 PA• 3 LCSWs• 7 Dentists & 1 Hygienist• 4 Pharmacists• 1 Diabetes Educator

2 Behavioral Health RN/Case Managers 1 Clinical Informatics RN 1 RN Contact Tracer 10 Referral Specialists Care Coordinators – each site 1 Community Health Worker 1 Community Health Navigator Support Staff: 151

ServicesPrimary Care * Dental Care

Behavioral Health * Vision CareChronic Disease Management

Women’s Health Care Pediatric Care

HIV/AIDS Management Nutritional

In–house Lab & X-ray In-house Pharmacy

TransportationPreventive Care

Mobile Medical Clinic

EAFHC26

Establishment of EAFHC’s Behavioral Health Program

NIMH - Depression Outreach Study 2006-2011 Dr. Fortney/UAMS Collaborative Care Model Increased awareness of high prevalence of undetected depression Concern about bipolar disease

NIMH - RISP (Bipolar and Alcohol) 2010-2015 Dr. Fortney/UAMS More aware of undetected bipolar disorder Sustained adoption of bipolar screening Opportunity to publish in the scientific literature

HRSA Mental Health Service Expansion / Behavioral Health Integration Grant 2012 UAMS provided us with data about our patients who had participated in the previous studies and help to demonstrate

the need for integration UAMS helped us to develop an integrative program that was based on evidence‐based treatments.

SPIRIT 2015-2020

EAFHC27

The Team LCSWs Case Managers Psychiatric Nurse Practitioner Telepsychiatry

Challenges Staff engagement (buy-in versus being forced upon them) Providers prescribing psychotropic drugs Workflow changes(care managers were instrumental in reducing workflow

challenges) Patient engagement(apprehension utilizing telehealth) Telepsychiatry Providers (timeliness of entering notes into the EMR) EMR provider license (negotiated a reduced fee for a part-time provider) Malpractice coverage Difficulty with payors particularly Medicaid.

Behavioral Health Program

EAFHC28

Arm Differences - PCP Perspective

EAFHC

TelepsychiatryCollaborative Care (TCC)

TelepsychiatryEnhanced Referral (TER)

Requires greater PCP involvementand management

Requires less PCP oversight; less time intensive; operated like a traditional referral

Direct communication or communication via the Care Manager between PCP and Telepsychiatrist

PCP experienced limited communication with Telepsychiatrist

EAFHC29

EAFHCArm Differences - PCP Perspective

Telepsychiatry Collaborative Care (TCC)

Telepsychiatry Enhanced Referral (TER)

PCPs described increased medication prescribing and management skills

PCPs did not describe increased medication prescribing and management skills

EAFHC30

EAFHCArm Differences - Patient Perspective

Telepsychiatry Collaborative Care (TCC)

Telepsychiatry Enhanced Referral (TER)

Care Manager was critical to mitigating patient barriers and facilitating engagement Care Manager facilitated discharge and transition to usual care Potentially better for patients with difficulty opening up to new care providers

Potentially better for patients who desire or require a higher level of therapy, specifically CBT or CPT

Patients needing an approachable, local contact

Patients amenable to standardized homework

EAFHC31

Quotes Arm Differences - PCP Role

When asked which approach worked better for them:The [TCC arm], in a sense, was more exciting to me because these are my patients. With [TCC], they were seeing me regularly for medication refills, and then we had ready access to psychiatric care through [the care manager], to call down and see how [the psychiatrist] might suggest changing medications and getting an occasional consult. The [TER arm], the patients tended to sort of disappear into a black hole and get their psychiatric care for a year, and I didn't necessarily follow up with them, […] there was more interaction [with TCC]. […] I really appreciate the collaborative care, where I actually have ‒ more input and more feedback from patients.

EAFHC32

Arm Differences - PCP Skill & Capacity

• Bipolar Disorder• I learned how underdiagnosed bipolar disorder is. And I’m starting to now

see that in several more patients where I probably would’ve never even thought to look for it. That’s opened up my eyes a huge amount to treating mental disease and looking for other diagnoses because bipolar is so hidden within depression.

• PTSD• My prescribing practices now mimic [the psychiatric consultant]. […] There

is a level of comfort now where I would be comfortable starting some medications for PTSD while waiting to try to transition and get further help. Even just to simply try to recognize and diagnose is much more comfortable now.

Quotes

EAFHC33

Quotes Arm Differences - Patient Perspective

• I’m very forgetful […] I forget about my appointments all the time. So [the care manager] would call, you know, ask me if I was going to be there and let me know ahead of time so I wouldn’t miss. She was understanding if I missed and everything. So she was great. I can talk to her about anything.

• [Patient] Like I said, I had the [care manager’s] direct phone number. I knew I could call her, message her, whatever; I knew that it was there. So it was really easy to access that.

EAFHC

Quotes Arm Differences - Patient Perspective

• I think the biggest thing that helped me was, [tele-psychologist], she gave me homework to do which made me have to pay attention to what I was doing everyday, and I think that made a big difference.

• I think they did a very good job. They helped me through a lot of things I didn’t realize was going on with me. I would definitely give them an A++.

EAFHC

Successes Enhanced access to meaningful psychiatric care Learned best practices with telepsychiatry Improved “real time” health outcomes Further exemplified the need for health centers to be involved in research

opportunities Improved staff engagement

Sustainability Partnership with the state medical school, UAMS (available workforce and cost

lower than private psychiatrist) Intact team in place with Psychiatric APN, LCSW, and case managers Administrative support and buy-in

EAFHC

EAFHC

Improvement and Remission RatesArkansas Sites

Improvement and Remission RatesAll Sites

Conclusion Was designed with input from Health Center patients and providers

Answers a policy relevant question about whether treatment should be integrated or referred

Met the clinical needs of our patients

Did not overly tax our health center resources

Demonstrates a level of excellence

STEPS 2020-2024Comparative effectiveness PTSD trial of sequenced pharmacotherapy and psychotherapy in primary care

EAFHC

EAFHC

Susan Ward‐Jones, MD CEO(870) 735‐3842

[email protected]

Questions

@NACHC

Jackie Chandler, MS

Integrated Health Program ManagerMichigan Primary Care Association

[email protected]

December 2, 2020

Jackie Chandler, MS

Integrated Health Program Manager

Michigan Primary Care Association

The path to sustainability.

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What needs consideration

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Section Title

Time, buy-in, and funds for:• Directly employing or contracting psychiatric providers

• Credentialling and privileging psychiatric providers

• Electronic Health Record (EHR) site licenses for psychiatric providers

• HIPAA-compliant telehealth platform

• Gap insurance to cover health center from malpractice lawsuits when FTCA conditions are not met

Make Treatment Operational

Considerations

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Section Title

• Is the psychiatric provider versed in the CoCM model; comfortable with telemedicine?

• How much FTE can a health center support for a behavioral health care manager?

• Ensure staff assigned meet appropriate professional and State licensing to bill services

• Does the population served, and services offered meet current approved Federal scope of project, or does the health center request a change in scope?

• As an example: psychiatric consultations may be a complementary extension/deemed necessary for the adequate support of primary health care where a substantial number of patients with mental health or substance used disorder diagnoses are served

Additional Considerations

Considerations

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What was uncovered in the process

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• Limitations in CMS Medicare and in Michigan Medicaid originating site and distant site definitions challenged telemedicine claims

• State challenges in how mental health code is interpreted by payers for diagnoses and claims

• Michigan Medicaid did not reimburse for CoCM services during study treatment

• Takeaway: grant funds were required for health centers to remain financially whole to continue providing treatment in the study.

Then: Low or No Reimbursement

Challenges to sustainability

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What progress has been made

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The information presented is as of 12/02/2020. While this information is current, updates to policies and billing may change this information at some point in the future.

Note:

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Section Title

• Virtual Communication Services (VCS) • Available to health centers as of January 01, 2019 for "Virtual Check-ins.” • Expanded under the CARES Act to include Digital Assessment Services.

• Psychiatric Collaborative Care Model (CoCM) • Available to health centers as of January 01, 2017 (HCPCS code: G0512)

• Telehealth Services • FQHCs have been given approval to act as distant site providers under

the CARES Act .• This change is in effect through the COVID-19 Public Health Emergency

(PHE).• Telephone Services

• Temporarily added to the list of telehealth services as of April 30, 2020.

Medicare: Telehealth and CoCM

Medicare

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• General Telemedicine Policy Changes (MSA 20-09)• Released March 12, 2020; Effective March 1, 2020.

• Health centers can perform telehealth services for any code from the Telemedicine Services Database .

• Expanded originating and distant site definitions

• PPS is reimbursed when the service has a qualifying visit count of at least 1 and can be can found on either the Telemedicine Services Database or the COVID-19 Response List

Michigan Medicaid: Telemedicine Services

Medicaid

46

Section TitleMDHHS. https://www.michigan.gov/documents/mdhhs/Telemedicine_012020_678209_7.pdf


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• COVID-19 Response: Telemedicine Policy Expansion (MSA 20-13)• Policy allows services to be furnished by telephone (audio) only.

• Only to be used when using both audio and video are deemed not possible.

• This policy is only in effect from March 1, 2020 and will be in effect until 30 days following the termination of the Governor Declared State of Emergency (or the first of the following month, whichever is later).

• As a response to COVID-19, an additional code list has been added for services that can be performed via telehealth. • These are only in effect until 30 days following the termination of the Governor

Declared State of Emergency (or the first of the following month, whichever is later).


Medicaid

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• Final Medicaid policy effective August 1, 2020• Coverage of Psychiatric Collaborative Care Model Services

(MSA 20-38)

Michigan Medicaid: CoCM

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What concerns remain to meet needs in community and in

primary care

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• Experiencing pandemic effects and distress (and the aftershocks) will remain with our health centers and communities – a heightened need for services

• Emergency response has relaxed some Medicare/Medicaid rules around telemedicine – what will endure to maintain access and reimbursement?

• Impacts on health center visit volumes, universal usage of telemedicine, staff fatigue and retention, and COVID-19 community outreach (currently in testing, forecasting for vaccine)

What Cannot be Missed: COVID-19

Response

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• Even if a service is eligible for enhanced FQHC Medicaid/Medicare reimbursement, financial impact of adding or increasing a service needs to be assessed to generate adequate revenue to cover all expenses

• Continued need for robust reimbursement rates and responsive policy definitions to meet community need

• Scarce psychiatric services require enhanced collaboration among primary care, community mental health, state medical schools, and payers

• In short: communities get better when they have access to timely, coordinated, and appropriate resources. We need continued monitoring, systems change, and advocacy!

In Summary

Sustainability

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@NACHCwww.nachc.org | 58

Questions?

@NACHC

ARE YOU LOOKING FOR RESOURCES?Please visit our website www.healthcenterinfo.org

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innovating with telepsychiatry to improve mental health

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