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XpioHealth Telehealth Webinar
- 1. Telebehavioral Health: Policy, Technology & Operations Tom Chard, CEO, ABHA Thad Dickson, CEO, Xpio Health Bart Andrews, CCO, Behavioral Health Response Monday, April 6th, 2020
- 2. ABHA Alaskans have access to quality, cost-effective behavioral healthcare. Xpio Health’s mission is to improve the health of organizations, and the people they serve BHR ensures compassionate and immediate barrier free access to healthcare servicesBHR Missions Joining Forces
- 3. AGENDA • Review of federal policy and legislation changes applicable to behavioral health providers • Review of state policy and legislation changes in Alaska • Review of EHR Configuration and Policy (Xpio) • Telehealth Service Provider Option (BHR) • General strategies and best practices for selecting and implementing telehealth quickly
- 4. Policy and Legislative Timeline
- 5. COVID Emergency Response for Behavioral Health Policy & LegislativeTimeline March 13th March 6th March 17th March 18th March 19th April 2nd Coronavirus Preparedness & Response Supplemental Appropriations Act Congress passed this legislation Medicare to pay for telehealth nationally Stafford Act & National Emergencies Act President Trump announced emergency declaration CMS expanded Medicare’s telehealth benefits under 1135 wavier authority Provides regulatory flexibility to ensure behavioral health clients are able to receive services via telehealth CMS Expansion of Telehealth Coverage & HIPAA Penalty Suspension Implementation of 1135 Waiver, enabling clients to receive a wider range of healthcare services via telehealth. Medicare will make payments in any setting OCR and DHHS issued guidance that enforcement of HIPAA penalties around telehealth would be suspended DEA e-prescribing Requirement Change Lifted in-person requirement to allow for easier e- prescribing during pandemic SAMHSA Waiving 42CFR Part 2 Requirements Waiving the patient consent requirement for disclosure of health information during an emergency, with providers being allowed to make their own determination whether a bona fide medical emergency exists for purposes of providing needed treatment to clients. State 1135 Waivers Implementing telehealth for Medicaid patients! 13 States have applied and received a response to 1135 waivers https://www.congress.gov/bil l/116th-congress/house- bill/6074/text https://www.whitehouse.gov/brief ings-statements/letter-president- donald-j-trump-emergency- determination-stafford-act/ https://www.hhs.gov/about/news/20 20/03/17/secretary-azar-announces- historic-expansion-of-telehealth- access-to-combat-covid-19.html https://mhealthintelligence.com /news/dea-okays-telehealth-to- prescribe-opioids-amid-covid-19- emergency https://www.samhsa.gov/sites/defa ult/files/covid-19-42-cfr-part-2- guidance-03192020.pdf
- 6. Telehealth Service Models • Many providers do not have access to HIPAA-approved technology required to conduct a video-enabled virtual session, or video chat platforms. In these situations, telephonic services are able to be delivered in most states. • Providers that have access to HIPAA-approved technology with video options are able to conduct virtual video-enabled session. The only requirement is that it is a non-public facing remote communication product that is available to communicate with members in accordance with OCR’s notice.
- 7. State 1135 Waiver Examples
- 8. • Nebraska • New Hampshire • New Jersey • New Mexico • North Carolina • Virginia • Washington DRAFT PROJECT UNDERSTANDING Medicaid 1135 Waivers • Alabama • Alaska (April 2nd) • Arizona • Arkansas • California • Florida • Illinois • Louisiana Approved Medicaid waivers under Section 1135 of Social Security Act:
- 10. Telehealth Service Models • Many providers do not have access to HIPAA-approved technology required to conduct a video-enabled virtual session, or video chat platforms. In these situations, telephonic services are able to be delivered in most states. • Providers that have access to HIPAA-approved technology with video options are able to conduct virtual video-enabled session. The only requirement is that it is a non-public facing remote communication product that is available to communicate with members in accordance with OCR’s notice.
- 11. Alaska COVID Emergency Response for Behavioral Health Policy & LegislativeTimeline March 16th March 11th March 20th April 2nd Emergency Declaration & Emergency Response Policy Guidance Telemedicine is temporarily being expanded, during the Covid-19 public health emergency, to include telephone and online digital services. The effective dates of these changes is March 11, 2020 which is the date Governor Dunleavy declared a State of Emergency due to Covid19. Changes to Coverage for Telehealth in Alaska The bill revises AS 21.42.422 to expand telehealth coverage to all covered services of health care insurance plans in the individual and group markets Services must be provided by a health care provider licensed in Alaska. A prior in-person visit must not be required. This requirement is applicable to telehealth. Consumers must be able to access telehealth services from both network and non-network providers. HSS Temporary Expansion of Medicaid Healthcare Services Alaska Medicaid expansion of telehealth coverage Location of member and provider for live interactive, telephone, and online digital modes of delivery are unrestricted Alaska 1135 Waiver Approved Submitted and accepted by CMS https://gov.alaska.gov/newsroom/ 2020/03/11/governor-issues- public-health-disaster-emergency- declaration-for-covid-19/ http://bnaregs.bna.com/?id=AK_- 33355 http://manuals.medicaidalaska.com/docs/ dnld/Update_Temp_Expansion_of_Medic aid_Telemed_Coverage.pdf
- 12. Summary of Alaska Medicaid Telehealth Levels Level of Service Type of Service Description Level 1 In person-individual If individuals are able to attend face-to-face while also adhering to CDC guidelines, they should Level 2 Telehealth - video Providers may utilize any methods of face to face technology; Skype, Facetime, Zoom, Duo Level 3 Telephone Telephonic is an acceptable form of service; however, only utilize level 3 if level 1 or 2 is not an option Level 4 Email Email or exchanges via secure patient portal when available. Level 5 Text Messaging Absolute last resort option, and must have documenting indicating no other options were available. Member and Provider Location: The location of the member or provider for telehealth services including telephone and online digital services is unrestricted to allow for multiple patient and provider settings such as home of facility. Hierarchy of Individual Services
- 13. DRAFT PROJECT UNDERSTANDING Alaska DBH Telehealth Service Codes Telehealth and Quality Assurance: Agencies are encouraged to implement Quality Assurance efforts to insure all services are provided and billed appropriately. Providers may utilize a variety of methods to do so: Having providers submit copies of email or screen shots with progress notes. Utilizing screen shots of text messages will insure that the length of service was adequate for billing and also meets medical necessity. Place of Service is: 02 Telehealth
- 14. DRAFT PROJECT UNDERSTANDINGDBH Telehealth Service Codes for Community Behavioral Health Place of Service is: 02 Telehealth Modifier for codes is: GT via interactive audio and video telecommunications systems
- 15. What Xpio Health Is Doing
- 16. • Providing Complimentary Educational sessions for Regions and Clients as needed • Focusing on Policy and Procedure driven Disaster Response and Protocols • Enhancing Documentation to ensure Emergency Protocols are adapting to the fluid situation. • Updating EHR Systems with new telehealth codes • Documenting / Reporting / Measuring / Metrics related to emergency provisions that have been implemented State / Federally • Advising on technology solutions
- 18. BHR Services Crisis Lines ED/OP Clinic support Phone, Telehealth and Onsite Continuous Placement Services I/P Unit Onsite support for Staff/MDs Care Collaboration/Follow-up
- 20. Transition to Phone/Tele-Barriers Clinicians often a larger barrier to implementation than clients: 1) Identify your early adopters and start with them 2) Let staff ask questions and state concerns 3) Most staff make this transition well 4) Debrief staff after they have implemented 5) Use debrief as lesson learns/process improvements
- 21. Verbal Consent • Verify name and DOB • Request CONSENT for telehealth after explaining • Risks: using a secure platform but still includes risk • Limits of confidentiality (same as usual) • Benefits: response time, same quality of service • Alternatives: telephone • Explain clearly purpose and goal of assessment • Document consent was given
- 22. Beta testing/Work Arounds • Identify tech savvy champions to beta • Create workflow as you test • Identify areas you can’t replicate remotely • Work around it (or not) • Mitigate security concerns and document • Use office as backstop
- 23. Phone Work •Yes, it is harder •Set expectations •Who is there/with you? •Need to attend to something, let me know •Normalize what’s different so you can focus on what is the same •They can’t see you, so you must be overt with “listening” sounds/vocalizations
- 24. Easy Steps: RECEIVE Respond warmly/positively Explore need/explain process Check in and get permission Expect to go off protocol Include customer in your actions Validate emotional content Evaluate and adjust as needed 25
- 25. Irvin Yalom - 2017 • Authentic Healing Relationship is key • We cannot anticipate what will or will not be key • DX may impair or distort understanding • Existential crisis MORE common and important • Don’t lose sight of whole person • PROCESS CHECKS • What is state of our encounter in the moment • Do you have questions for me? • Comment on relationship • Honest and transparent with focus on BOND between • The goal is helping on how to have a meaningful life 26
- 26. Discussion Points •When is face-to-face is preferable? •Client concerns about privacy? •Mitigate tech issues •Documentation tips •Documenting clinician's work/quality outcomes •Recording – DON’T*
- 27. Rapidly Implementing Telehealth with Best Practices
- 28. • Bullet Points • Potential risks and limits to confidentiality and encryption methods to secure communication • Process for documentation and storage of information including how electronic information is stored, accessed and disposed of • Possibility of interruption caused by technology failure • Methods of alternative communication if technology fails • Methods, expectations and frequency of contact and protocol for contact between sessions • Emergency Contact information and Plan • Involvement of third parties and procedures for coordination of care with other professionals TECHNOLOGY & PRIVACY RISKS
- 29. AMA’s Quick Guide to Adopting Telehealth • Set up a team that will help facilitate the expedited implementation of telemedicine services and be able to make decisions quickly to ensure launch as soon as possible. • Check with your malpractice insurance carrier to ensure your policy covers providing care via telemedicine. • Familiarize yourself with payment and policy guidelines specific to various telemedicine services. Ensure that you are providing services in accordance with your state laws and regulations. • Licensure • If you are licensed in the state where the patient is located, there are no additional requirements • https://www.ama-assn.org/practice-management/digital/ama- quick-guide-telemedicine-practice
- 30. Vendor Evaluation, Selection & Contracting • Check with your existing EHR vendor to see if there is telehealth functionality that can be turned on. • Reach out to your state association/society for guidance on vendor evaluation, selection and contracting. • Introducing new technology into practice quickly can be challenging, but a few things to keep in mind as you navigate a speedy implementation: • Ensure HIPAA-Compliance/BAA in place • Make sure you understand who has access to and owns any data generated during a patient visit •
- 31. Workflow & Patient Care • Determine when telehealth visits will be available on the schedule • Set up space in your practice to accommodate telehealth visits. This can be an exam room or other quiet office space to have clear communication with patients. • Ensure you are still properly documenting these visits – preferably in your existing EHR as you normally would with an in-person visit. or telehealth visits. • Ensure you receive advanced consent from patients for telemedicine interactions. This should be documented in the patient’s record. Check to see if your technology vendor can support this electronically. • Let your patients know the practice is now offering telehealth services when they call the office. Have your office staff help support pro-active patient outreach. Additionally, post announcements on your website, patient portals and other patient- facing communications. • Have a plan for supporting patients on how to access telehealth visits based on your practice’s technology and workflow to keep the clinic flow moving and avoid disruptions to care.
- 33. PROJECT OPPORTUNITIESABOUT US “Our mission is to improve the health of organizations and the people they serve.”
Editor's Notes
- After several weeks, our world community is still in the wake of the coronavirus pandemic. Behavioral health providers are quickly acting and ramping up to be able to provide remote care – so clients are still able to receive mental health and addiction services – while also ensuring social distancing practices are in place to limit exposure to the virus. This is a time where panic and uncertainty can cause mental illness to worsen, and clients to become more symptomatic, so ensuring access to care via telehealth has never been more critical. Clients struggling with mental health or substance use disorders are depending on agencies to understand policy and legislative changes in order to leverage technology to ensure that they receive continuity of care; providing medically necessary behavioral health supports that could prevent relapse or decompensation. Tom would like us to mention this: The Alaska Department of Behavioral Health provided a webinar last Friday 3/27 focusing on SUD treatment providers and telehealth. They provided a clinical checklist, reviewed legal, ethical, and patient safety concerns, as well as privacy/HIPAA concerns. Providers are quickly searching for virtual technology solutions – if they don’t already have them in place. They are looking to augment care delivery models or completely change them temporarily in some states. Technology will enable you connect with and serve your clients in their homes, but finding the right technology platform and implementation plan is important. In this webinar, we will cover the following: Review of federal policy and legislation changes applicable to behavioral health providers Review of state policy and legislation changes in Alaska Telehealth service provider option General strategies and best practices for selecting and implementing telehealth quickly
- On March 6th, Congress passed the Coronavirus Preparedness and Response Supplemental Appropriations Act. This legislation allowed for CMS announced that Medicare will temporarily pay clinical professionals to provide telehealth services to beneficiaries across the entire country. On March 13th, president Trump announced an emergency declaration under the Stafford Act and the National Emergencies Act. In conjunction with the president’s declaration, CMS expanded Medicare’s telehealth benefits under 1135 wavier authority and the Coronavirus Preparedness and Response Supplemental Appropriations Act. This provides regulatory flexibility to ensure that our most vulnerable populations – those struggling with mental illness and addiction – are still able to receive the services that they may need even more with the fear associated with a pandemic. On March 17th, CMS announced expansion of the Medicare telehealth coverage that will enable clients to receive a wider range of health care services via telehealth remote services. The Office for Civil Rights (OCR) and the Department of Health and Human Services issued guidance that the enforcement of HIPAA penalties around telehealth, patient communication, and remote communication technologies will be suspended during the COVID19 emergency. On March 18th, the DEA temporarily lifted that in-person requirement to allow for easier e-prescribing during the COVID-19 emergency. CMS being a part of the Department of Health and Human Services that administers the Medicare program, works in partnership with state governments to administer Medicaid and other health insurance programs. State governments are working with CMS towards 1135 waivers to ensure all Medicaid beneficiaries are able to receive remote services from healthcare facilities with reduced barriers. March 19th, Substances Abuse and Mental Health Services Administration has also issued guidance around 42 CRF Part 2, and waiving the patient consent requirement for disclosure of health information during an emergency, with providers being allowed to make their own determination whether a bona fide medical emergency exists for purposes of providing needed treatment to clients. Due to aforementioned legislation, a wide range of health care professionals are now able to provide telehealth services to beneficiaries for a wide range of behavioral health and addiction services.
- Tele-health was once thought of to be a fad that would not be useful in mainstream healthcare, with the exception of care delivery in rural settings. That said, we are now at the precipice of a change in paradigm due to a pandemic – coupled with a generation of technology enabled digital natives – that will demand services being delivered remotely in the future. Innovation, technology, and human compassion are paramount in reducing the cost of care, improving population outcomes, and improving upon continuity of care and overall client satisfaction. Healthcare leaders are very concerned about the long-term impact on service lines and overall revenue, and are quickly looking into virtual care options for now and that impact their long-term strategies moving forward. The two primary methods being used are telephonic and virtual video-enabled sessions.
- Tele-health was once thought of to be a fad that would not be useful in mainstream healthcare, with the exception of care delivery in rural settings. That said, we are now at the precipice of a change in paradigm due to a pandemic – coupled with a generation of technology enabled digital natives – that will demand services being delivered remotely in the future. Innovation, technology, and human compassion are paramount in reducing the cost of care, improving population outcomes, and improving upon continuity of care and overall client satisfaction. Healthcare leaders are very concerned about the long-term impact on service lines and overall revenue, and are quickly looking into virtual care options for now and that impact their long-term strategies moving forward. The two primary methods being used are telephonic and virtual video-enabled sessions.
- This is an example of the most common service to be provided in client’s homes, and the services level hierarchy that has been established.
- Regional and national approach to provide 24/7 services Next Day Urgent Appointments – made by our Mobile Outreach Team, there are certain number of slots available. No appointments for the weekend St. Louis and St. Charles County for Texting and Chat