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The Value of Telepsychiatry Integration in the Medical Home
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The Value of Telepsychiatry Integration in the Medical Home

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The three pillars of healthcare reform are to increase patient safety, improve healthcare quality, ...

The three pillars of healthcare reform are to increase patient safety, improve healthcare quality,
and bend the cost curve. Integration of behavioral health services in the primary care setting can
substantially contribute to all three objectives. Yet despite efforts to recruit behavioral health specialists to rural America the number of mental health profession shortage areas in the U.S. has increased 97% during the past decade. This webinar will provide actionable information that practitioners and Health Center executives can rely on to evaluate and implement telebehavioral health services successfully and thereby realize their substantial value.

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    The Value of Telepsychiatry Integration in the Medical Home The Value of Telepsychiatry Integration in the Medical Home Presentation Transcript

    • Value of telepsychiatry integration in the Medical Home Phil Hirsch PhD – CEO Access Psychiatry Solutions "Efforts to provide everyone a medical home will require inclusion of mental health care if they are to succeed in improving care and reducing costs." 
      • Review key elements of medical home
      • Describe current state of telepsych
      • Integrated telepsych logistics
      • Present rationale – Access & Med Home
      • Review evidence base
      • Discuss demand and sustainability
      • Motivate
    • Telepsychiatry 2011
    • Asynchronous Synchronous
    • Not your father’s telepsychiatry
    • Logistics
    • Integrated 2 telepsychiatry … YOURS
    • Rationale
    • Shortage vs. mal-distribution
    • Safety, Quality, Cost (BH vs. PC) PC PC Druss, BJ Miller, CL Rosenheck, RA Shih, SC Bost, JE (2002) .Mental health care quality under managed care in the United States: A view from the Health Employer Data Set (HEDIS). Am J Psychiat 2002; 159: 860-862. Dolnack DR, Treating patients for comorbid depression, anxiety disorders, and somatic illnesses. J Am Osteopath Assn. 2006 May; 106. Krupnick J, Sotsky S, Simmens S, Moyer J, Elkin I, Watkins J, Pilkonis P (1996). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program.  Journal of Consulting and Clinical Psychology l64(3): 532-539. Pingnone, MP, Gaynes, BN, Ruston, JL, Burchell, CM, Orleans, CT, Mulrow, DC & Lohr, KN (2002). . Screening for Depression in Adults: A Summary of the Evidence for the U.S. Preventive Services Task Force . Anals of Internal Medicine , 36(10), 7650776.
    • Evidence
    • A common first reaction … `
    • Center for IT Leadership – HealthPartners “ … great potential to improve access … adoption in routine health care has been slow … lack of clarity about the value of telehealth … slow adoption. “ The simulation predicted savings of $4.3 billion per year … “ Payers, providers and policy-makers should work together to remove the barriers to the adoption of telehealth in order to make it widely available to all.” SOURCE: The value proposition in the widespread use of telehealth . Cusick CM, et al.Journal of Telemedicine and Telecare . June 2008 vol. 14 no. 4 167-168.
    • E = MC2 Evidence … Systematic review of studies of patient satisfaction with telemedicine . Mair F & Whitten P. BMJ . 2000 June 3; 320(7248): 1517–1520. Sample Kennedy C & Yellowlees P. The effectiveness of telepsychiatry measured using the Health of the Nation Outcome Scale and the Mental Health Inventory. Journal of Telemedicine and Telecare 9:12–16, 2003. Evidence-Based Practice for Telemental Health. American Telemedicine Association: 2009. 2006 – 394 2009 – 146 2011 - 97
    • Yes, but can you do it on TV?
      • 395 markedly depressed patients from seven VA primary care practices
      • Equivalent:
      • Medication adherence – 6 and 12 mo
      • Medication response – 6 and 12 mo
      • Symptom remission – 6 and 12 mo
      • Satisfaction – 6 and 12 mo 1
      South Central Veterans Healthcare System VISN 16
      • 364 markedly depressed patients from five Federally Qualified Health Centers
      • Equivalent:
      • (p) Medication, # meds, dose
      • Medication adherence
      • Treatment response
      • Symptom remission 2
      Arkansas’ Mississippi Delta and Ozark Highlands 1 Fortney, J et al. A Randomized Trial of Telemedicine-based Collaborative Care for Depression. J Gen Intern Med. 2007 August; 22(8): 1086–1093. 2 Fortney J et al. A Pragmatic Randomized Comparative Effectiveness Trial of Practice Based Versus Telemedicine Based Collaborative Care for Depression in Rural Federally Qualified Health Centers. Submitted for publication. National Institute of Mental Health, (R01 MH076908, MH076908-04S1)
    • Demand and Sustainability
        • Demand and sustainability
    • Medicare Medicare will pay for [telehealth for] a limited number of Part B services.
      • Located in a rural Health Professional Shortage Area
      • County outside of a Metropolitan Statistical Area.
      The originating sites authorized by law
      • The office of a physician or practitioner;
      • Hospitals;
      • Critical Access Hospitals (CAH);
      • Rural Health Clinics (RHC);
      • Federally Qualified Health Centers (FQHC);
      • Hospital-based or CAH-based Renal Dialysis Centers (including satellites);
      • Skilled Nursing Facilities (SNF); and
      • Community Mental Health Centers (CMHC).
    • Medicaid
      • Medical Advisory Committee TELEMEDICINE February 17, 2010
      • 2006, Florida Medicaid began to cover for Children Medical Service-enrolled in select rural counties
      • Physician office visits (evaluation and management services) and consultation services.
      • Florida Center and the Big Bend Regional Healthcare Information Organization, 1 Gbps fiber optic network, nine hospitals
      • In year two of this project, a broadband wireless network community for health centers and not-for profit clinics in each county.
      • In addition, the Mental Health Program Office at DCF recently received a grant that allows them to look at the elimination of disparities in mental health care .
      • DCF chose to examine the rural environment, with a specific focus on telemental health .
      • Many behavioral health providers, Medicaid managed care plans, lobbying groups, and advocacy centers have requested that Medicaid start covering telemedicine.
    • Medicaid SECTION 20 – TELEMEDICINE Use of an electronic media to link beneficiaries with health professionals Via a real-time Consultation; Office visits; Individual psychotherapy; Pharmacological management Face to face not required for TBH Prior auth. F4F vs County Health Plans (CHPs) and Medicaid Health Plans (MHPs) ORIGINATING SITES: 􀂃 County mental health clinic or publicly funded mental health facility 􀂃 Federally Qualified Health Center (FQHC) 􀂃 Hospital (inpatient, outpatient, or critical access hospital) 􀂃 Office of a physician or other practitioner (including medical clinics) 􀂃 Renal dialysis facility 􀂃 Rural health clinic 􀂃 Skilled nursing facility 􀂃 Tribal Health Center (THC) AUTHORIZED PRACTITIONERS The following health professionals may provide telemedicine services: 􀂃 Physician (MD, DO, DPM) 􀂃 Nurse Practitioner 􀂃 Nurse Midwife 􀂃 Physician’s Assistant (billed under the supervising physician) 􀂃 Psychologist∗ 􀂃 Social Worker∗ In-state providers are to be used whenever possible for distant site services.
    • Commercial health plans
    • Cost offset and value
    • ROI vs Value: Cost offset
      • 20% reduction in overall h/c expenditures 1
      • 4.5% increase in expenditures for new BH costs 2
      • $128 PPPM less for overall health cost among patients with diabetes and depression (UC vs IC) 3
      • $457 to > $775 PPPM higher cost for chronic illnesses + depression than for chronic illnesses alone (< 6% for BH) 4
      1 Chiles JA, Lambert MJ, Hatch AL.. The Impact of Psychological Interventions on Medical Cost Offset: A Meta-analytic Review. Clinical Psychology: Science and Practice Volume 6 ,  Issue 2 ,  pages 204–220 ,  June 1999 2 Bachman RE. An actuarial analysis of comprehensive mental health and substance abuse benefits in the state of New York. PriceWaterhouseCoopers, May 2002. 3 Bogner, H. et al. Diabetes, Depression, and Death A randomized controlled trial of a depression treatment program for older adults based in primary care (PROSPECT). Diabetes Care  December 2007 vol. 30 no. 12  3005-3010 4 Melek, R. & Norris D. Milliman Chronic conditions and comorbid disorders. Milliman. July 2008.
    • Value
      • Improved detection and case finding
      • Improved treatment adherence
      • Better response monitoring and outcomes
      • Better chronic illness management with less cost (P4P)
      • Redeployment of PCP time
      • Morale
      • (Positive immediate net revenue)
      • Positive overall net revenue
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    •  
    • Phil Hirsch, PhD Access Psychiatry Solutions 206.365.3096 [email_address]