9/26/2013

1

Recording: 9/26/13 VANTS: 1-800-767-1750 Access Code #43515

Adobe Connect (U Pitt Guest invite)

Housekeeping

• Please mute your computer microphone and use the VANTS line for the audio.

• This call will be recorded for future training.

• All documents (handouts) are available to download from the Files ‘pod’

during conference.

• After the conference, the documents may be downloaded from:

a) PM&R SharePoint/TBI Teleconsultation:

http://vaww.infoshare.va.gov/sites/rehab/pmrs/Special%20Projects/For

ms/AllItems.aspx

b) University of Pittsburgh External Site:

http://www.rstce.pitt.edu/VA_TBI/VATBI.html

• Questions:

a) May be typed using the ‘chat’ pod

b) Audio using the VANTS conference call line

Housekeeping

9/26/2013

2

Special Thanks to:

Host for Adobe Connect and Training Modules University of Pittsburgh = “Pitt Crew” Mark R. Schmeler Richard M. Schein Andi Saptono Joseph Ruffing Bambang Parmanto

Faculty and Advisors:

Joel Scholten, MD TBI Specialist and Special Projects Manager Rehabilitation and Prosthetics Services VHCO Washington, DC Ron Riechers, MD Neurologist and TBI Specialist Cleveland VAMC Doug Bidelspach Rehab Planning Specialist and Data Manager Rehabilitation and Prosthetics Service VACO Lebanon VAMC

Telehealth Services

Pat Ryan Associate Chief Consultant VISN 8, Bay Pines, FL John Peters Clinical Video Telehealth Program Manager/Analyst Washington DC Rhonda Johnston Director, Clinical Video Telehealth National Training Center, Denver

9/26/2013

3

Background

Comprehensive TBI Evaluation

via Telehealth Technology

Primary Goals: Comprehensive TBI Evaluation

Teleconsultation Pilot

• Develop a standardized procedure for completing a Comprehensive TBI Evaluation utilizing telehealth technologies

• Improve access to care for Veterans in rural settings

• Increase overall percentage of Comprehensive TBI Evaluation completion

• Increase the number of telehealth visits

This pilot project is possible due to:

- Funding from the Office of Health Care Transformation

- Support by Specialty Care Transformation

- Coordination by Rehabilitation and Prosthetics Services

- Collaboration with Telehealth Service

9/26/2013

4

Advisory Board

Nan Musson, Project Lead

Joel Scholten, MD Lead

Doug Bidelspach, PM&R Office

David Cifu, Director PM&R

Ronald Riechers, Neurologist

Bryan Merritt, Physiatrist

Lisa McPeak, Physiatrist

Belisla Vasquez, Physiatrist

Jack Dryden, PM&R FAB

Patricia Ryan, Telehealth Services

John Peters, CVT Program Manager

Michelle Winslow, CVT Telehealth Lead

Rod Miles, FTC

Bridget Smith, TBI Queri

Robin Hurley, ACOS Research & Ed

Kathy Walker, PNS and Telerehab Lead

Brian Shenal, Neuropsychologist

Betty Dameron, OEF/OIF

In May 2012, the Advisory Board met at the Bay Pines VAMC Hosted by VISN 8 Telehealth staff

Objectives included: Develop a consensus standardized Comprehensive TBI Evaluation to be

delivered via Telehealth (including the TBI Specialist and TCT Roles) Review and Select Telehealth Equipment Recommend Training Modules Identify Outcomes for the Project Develop an Application Process for Potential Pilot Sites

TBI Telehealth Pilot Sites

In FY12, 16 Pilot Sites were selected

9/26/2013

5

TBI Telehealth Pilot Sites

In FY13, 15 additional Pilot Sites were selected and 10 PRC/PNS sites will be joining the project

to expand the network across all VISNs

Education/Training

Knowledge/Skills

Need to Know

Objectives for Today

Introduction and Overview:

• Background

• Business/Administrative Issues

• Telehealth equipment, forms, and supplies

• Documentation

• Outcomes and Reports

• Training

• Communication and Contact Information

9/26/2013

6

It Takes a Team: Telehealth + TBI Facility Leadership

TBI Specialist

“Clinical Champion”

Facility

Telehealth Coordinator

“FTC”

TelePresenter

“TCT”

IT/BioMed

CBOC Managers and Personnel

Decision Support Team

(DSS)

VISN Leadership

Support

Staff

PM&R

Administrative

Sfaff

The FTC to assist with ….

- Identification of Clinic Space and Time for Clinic

- Recommendations for Clinic Profile Titles

- Assist with Equipment Inventory

- All Telehealth Services Documents including:

A Memorandum of Understanding Credentialing and Privileging The Telehealth Service Agreement Telehealth Clinical Protocol Development Tool HT Enrollment Agreement

Preparation

Clinic Profiles Space and Furniture

Telehealth Equipment Office Equipment

Supplies

9/26/2013

7

Clinic Appointments and Profiles

Clinical Video Telehealth Clinics are set-up in pairs.

2 Clinic Profiles/Appointments

1) Patient site (20 – 30 min. early to complete screening forms)

2) Provider site (actual appointment time)

Example:

• Tallahassee CVT TBI Consultation - 8:30 a.m. (Patient site/90 min.)

• Gainesville CVT TBI Consultation - 9:00 a.m. (Provider Site/60 min.)

Stop Codes and 4CHAR Codes

Primary Stop Code/Polytrauma: 197

Secondary Stop Code/Telehealth: 690 or 692/693

4CHAR Code: PLVT

Example:

Patient Site: 197690 PLVT

Provider site: 197692 PLVT

Emergency Procedures:

- Provider telephone numbers

- Telepresenter telephone numbers

- OPC/CBOC telephone numbers

- Medical Emergency procedures

- Crisis procedures

- Patient/Family contact information

9/26/2013

8

Recommended Equipment

Provider - Desk Top EX90 - Document Reader - VA Desktop Computer - CPRS

- My Healthe Vet - PM&R SharePoint

- Telephone or Cell Phone

Telepresenter - Education or Global Med Cart - Document Reader or Fax - VA Desktop Computer - CPRS

- My Healthe Vet - PM&R SharePoint

- Telephone or Cell Phone - Chair (no rolling chairs) - Table or Desk space

Provider: Space and Telehealth Equipment

Telepresenter (patient site): Room, Telehealth Equipment, Table/Chair

9/26/2013

9

Peripheral Telehealth Equipment

Document Reader

Equipment Contract

Eric Silvernail, Iron Bow

Deliveries and Tracking Numbers

Supplies to support Teleconsultation (Telepresenter Side)

*plus safety pin!

9/26/2013

10

Supplies for the Telepresenter

1) Screening Forms (PDF, clip board, pen) – Neurobehavioral Symptom Inventory (NSI) – Post-Traumatic Stress Disorder Checklist-Military (PCL-M) – Patient Health Questionnaire (PHQ)

2) Montreal Cognitive Screening (MoCA) 3) *Brief Identification Smell Test - A and #2 pencil 4) *Reflex Hammer and sharp/pin 5) Education Handouts (link, PDF or SharePoint) 6) Telehealth Patient Satisfaction * Sent by snail mail to the TBI Specialist

Comprehensive TBI Evaluation Standardized Teleconsultation

Provider and Telepresenter Responsibilities: - Before the Teleconsultation - During the Teleconsultation - After the Teleconsultation

Prior to this October 3, 2013 The following training Modules were recommended:

• PITT RSTCE TBI Modules (http://www.rstce.pitt.edu/VA_TBI/VATBI.html )

– Overview of TBI Diagnosis and Co-Morbidities (Ron)

– Demonstration of MoCA Administration (Ron)

– Demonstration of Brief Smell Test A

– Demonstration of Pain Module

9/26/2013

11

Before the Teleconsultation

Telepresenter • Provide the patient with Screening Tools to be completed in the waiting

area (clip board and pen): – Neurobehavioral Symptom Inventory (NSI) – Post-Traumatic Stress Disorder Checklist-Military (PCL-M) – Patient Health Questionnaire (PHQ)

• Prep room if necessary (set-up of telehealth equipment and peripherals) • Verbal consent for telehealth visit • Obtain Pt.’s main complaint • Vitals (i.e. height, weight, pain level) TBI Specialist • Review history in CPRS • Ensure that Veteran had + TBI screen if using Comprehensive TBI

Evaluation (CTBIE) template • Check telehealth equipment and peripherals

Screening Tools (PDF)

PTSD CHECKLIST – MILITARY VERSION (PCL-M)

Administration and Scoring

9/26/2013

12

PCL-M Case Example

NEUROBEHAVIORAL SYMPTOM INVENTORY (NSI)

Administration and Scoring

9/26/2013

13

NSI Case Example

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

TBI Tele-training - Administration and Scoring

9/26/2013

14

PHQ-9 Case Example

DURING TELECONSULTATION

9/26/2013

15

During the Teleconsultation Telepresenter Assistance • Review of Screening Results and Vitals with the provider • Olfactory Testing • Montreal Cognitive Assessment (MoCA) • Pain/Musculoskeletal Module (if needed at the end of the evaluation) • Tandem Romberg • Assists with the handouts and brochures (as needed at the end of the session)

TBI Specialist

• Review of telehealth ‘consent’ • Complete Interview and record responses in CTBIE template • Complete Telehealth Examination

– General Appearance and Observation (speech, distractibility/attention, thought process) – Cranial Nerves (EOM, grimace, tongue protrusion, hearing intact to conversational volume) – Motor and Coordination (finger to nose, Luria motor sequencing, Rapid Alternating

movements, seated heel to shin, pronator drift) – Gait AND completes Pain /Musculoskeletal module if warranted

• Determine treatment plan and discuss recommendations with Veteran • Provide Education on symptom management and prognosis

MONTREAL COGNITIVE ASSESSMENT (MOCA)

TBI Tele-training - Administration and Scoring

9/26/2013

16

BRIEF IDENTIFICATION SMELL TEST – VERSION A

Author: Richard L. Doty, Ph.D.

Vendor: Sensonics, Inc

Brief Smell Identification Test - A

9/26/2013

17

PAIN MODULE

After the Teleconsultation

Telepresenter • Patient Satisfaction (national form) • Progress Note (templates are available if requested): Veteran consents to participate in a Telehealth Visit Vitals and other observations • Completes the Encounter TBI Specialist: • Complete CTBIE template (include NSI, PCL-M, PHQ) • Complete the Encounter • TBI (Community Reintegration) Care Plan • Enter appropriate orders/consults

9/26/2013

18

Fill out VISN

Fill Out Facility

Fill Out Date

Inform the Veteran to fill in bubbles. Tell them that checkmarks, x’s, circling the answer, etc. are not acceptable.

Inform the Veteran to only write in comments inside of the box. Any answers outside do not scan!

Specialty Clinic: TeleRehabilitation

How to Properly Fill Out ‘Telehealth Satisfaction’ Form

9/26/2013

19

Example: Diagnostic and Procedure Codes Don’t Forget - Encounters need to be completed for both appointments.

Helpful Hint: Attach the note to the correct appointment.

Provider example:

Diagnostic Code:

854.01

Procedure Code:

99204

Telepresenter example:

Diagnostic Code:

854.01

Procedure Code:

Q3014

INTERDISCIPLINARY REHABILITATION AND COMMUNITY REINTEGRATION (IRCR) CARE PLAN

9/26/2013

20

Rehabilitation/Reintegration Care Plan The Individualized Rehabilitation and Community Reintegration (IRCR) Care Plan should

be completed for EVERY individual who is being discharged from inpatient rehabilitation or receives outpatient rehabilitation services and meets the all of the following criteria:

Is diagnosed with TBI/Polytrauma;

Referred to the TBI/Polytrauma team for assessment and treatment;

Required and received interdisciplinary rehabilitation assessment including medical, case management PLUS at least one of the following; PT, OT, SLP, Psych, RT, KT, Voc, Blind Rehab;

Determined to benefit from rehabilitation treatments for functional disabilities related to TBI/polytrauma;

Rehabilitation treatments require intervention by interdisciplinary specialists including medical, case management PLUS at least one of the following: PT, OT, SLP, Psych, RT, KT, Voc, Blind Rehab.

Rehabilitation/Reintegration Care Plan

Revised Care Plan – Additional point/click

selections and specific free text areas

9/26/2013

21

Revised Care Plan – When all fields are completed, either ‘Save Draft’ or ‘Save and

Prepare Note’ to send to CPRS

PATIENT EDUCATION MATERIALS HTTP://WWW.MIRECC.VA.GOV/VISN16/PROVIDERS/TUFF.ASP

MIRECC, HOUSTON VAMC

Pilot Project Outcomes Data (Spread Sheet)

• Provider Location (Text) • Provider Zip Code (5 digit number) • TCT Location (Text) • TCT Zip Code (5 digit number) • Positive TBI Screen (MM/DD/YYYY) • TBI Teleconsultation (MM/DD/YYYY) • Did the TBI Specialist recommend a face-to-face visit to complete the

exam (Yes/No) • Referrals after the TBI evaluation: • OT (Yes/No) • PT (Yes/No) • Speech Pathology (Yes/No) • Neuropsychology (Yes/No) • Interdisciplinary Care Plan initiated (Yes/No) • Comment (open text)

63

9/26/2013

22

During monthly calls (4th Tues of the month at 3:00 p.m. EST)

In FY14, each site will be asked to provide two updates: • Slide #1 TBI Specialist, Facility Telehealth Coordinator, Telehealth Clinical

Technician • Slide #2 Start Date, Clinic Name and Stop Codes, Number of TBI

Teleconsultations completed • Slide #3 Lessons Learned, Suggestions, Challenges, Additional Comments

Research Project: “Examining Telehealth Applications for Evaluation of

Mild Traumatic Brain Injury”

Bridget Smith, Primary Investigator

• Aim 1: Characterize approaches to using telehealth to provide CTBIEs.

• Aim 2: Examine the association between patient characteristics and use of telehealth to perform the CTBIE and outcomes associated with telehealth.

• Aim 3: Convene an expert panel and develop recommendations to facilitate the implementation of telehealth strategies to provide comprehensive TBI evaluations.

• Aim 4: Conduct a preliminary cost analysis.

Comprehensive TBI Evaluation Teleconsultation Project Contact information…

• Nan Musson

e-mail: nan.musson2@va.gov

telephone: 352-376-1611 x5607

• Joel Scholten at joel.scholten@va.gov

9/26/2013

23

Telehealth Services Links

VHA Telehealth Services Intranet - http://vaww.telehealth.va.gov/

VHA Telehealth Services Share Point - http://vaww.infoshare.va.gov/sites/telehealth/default.aspx

Traumatic Brain Injury Training

Please download the list of training available.

Concluding Remarks

Questions and Answers:

Adobe Connect ‘Chat’ Box or

VANTS line 1-800-767-1750 Access Code 43515#

9/26/2013

24