Telehealth. It s Not about the Technology - It s About Expanding Access and Enhancing Treatment Services. Nancy A. Roget, MS Terra K.

Transcription

1 Telehealth It s Not about the Technology - It s About Expanding Access and Enhancing Treatment Services Nancy A. Roget, MS Terra K. Hamblin, MA University of Nevada, Reno

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4 Over half of country s land mass is designated as frontier or rural (USDA, 2000)

5 Approximately one quarter of U.S. population (62 million) lives in frontier/rural areas with 16-20% of those individuals experiencing substance dependence, mental illness, or co-morbid conditions

6 Individuals residing rural and remote areas have higher mortality rates, suicide rates, and their alcohol/drug problems are more severe

7 Rural communities are thought to offer less privacy than urban areas, and women who misuse alcohol in these locations are more highly stigmatized than men. (Finfgeld, 2002)

8 A 2009 workforce study reported that the lowest concentration of mental health professionals was found in frontier/rural areas (counties with less than 10,000 people)

9 Definitions Telehealth the use of telecommunications and information technologies to provide access to health information and services across a geographical distance Telemedicine use of medical information exchanged from one site to another via electronic communications to improve patient health status (Institute of Medicine, 2012)

10 TELEHEALTH is NOT NEW 1879

11 Telemedicine Annually, 10 million patients receive telemedicine services

12 VA Services 146 hospitals provided 55,000 patients in community-based outpatient clinics with 140,000 telemental health visits Home-based telemental health services were provided to 6,700 patients hospitalization decreased by 25% for those that participated in telemental health services (IOM, 2012)

13 Addiction Treatment Lags Behind

14 Why consider telehealth

15 85% of American adults have cell phones 53% have smart phones (Pew Report,2012)

16 80% send and receive text messages (Pew Report,2012)

17 Over half have gathered health information on their phones Almost 20% have a health app (Pew Report,2012)

18 80% of Americans use the Internet (Pew Report,2012)

19 What do we know about clients? Survey of 8 urban drug treatment clinics in Baltimore (266 patients) Client s access to: Mobile Phone 91% Text Messaging 79% Internet/ /Computer 39-45% (McClure, Acquanta, Harding, & Stitzer, In Press)

21 In 2011, 20.6 million people aged 12 or older met the criteria for substance use disorders Did not feel they needed treatment Felt they needed treatment Did not make an effort 3.3% Felt they needed treatment Did make an effort 19.3 million people needed but did not receive treatment for illicit drug or alcohol use (NSDUH, 2011)

22 Telehealth Technologies Help Address Barriers to Treatment

23 Barriers Include Privacy and Confidentiality (Moyer & Finney, 2004/2005) Travel Costs and Burden (Rheuban, 2012) Time Away From Work (Berwick, 2008) Child Care (Berwick, 2008)

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25 University of Virginia s telehealth program has documented the avoidance of 7.2 million miles of travel

26 Telehealth is not about the technology but serves as a bridge reaching out to clients so services that support behavior change are available. (Shore, 2012)

28 Our Changing Environment Complexity Diversity Uncertainty (Dotlich, Cairo, and Rhinesmith, 2009)

29 Complexity More information More opinions More connectedness More regulation More options

30 Diversity Increasing differences among Markets, i.e., new payors Technologies for business and clinical services Employees Patients/clients/consumers

31 Rapid speed of change Less predictability Workplace and workforce in flux Sometimes scarcity of definitive answers Sometimes requires risk taking Uncertainty

32 Telehealth Challenges & Considerations Money Funding for initial start-up and equipment Reimbursement for services (sustainability) Regulations Provider licensure in the state the patient is located Compliance: HIPPA and 42-CFR and other practice regulations Technology Range of options, complexity, and costs Understanding of equipment and alignment with clinical practices; competency in use of technology Need for new policies, procedures, and new/enhanced service arrays Ease of use by service providers and patients/clients

33 Telehealth - Challenges & Considerations Evidence Payors and staff need to be convinced that telehealth is a viable alternative and yields equitable results Evidence needs to include cost/benefit data Garnering Support Strong collaboration is needed between payors, developers, researchers, promoters, and users Telehealth requires multilayer teamwork Adoption/Implementation Effective leadership & change management strategies are key Both organizational and technical issues must be addressed, paying attention to agreements, adjustments, assimilation, adaptations, and acceptance Telehealth application has to be anchored in existing structures

34 Telehealth is in the Best Interest of Patients Expanding Access Enhancing Treatment Services

35 Telehealth Technologies

36 The number of publications on telemental health from 2000 to 2008 was more than triple the number of publications from the previous 30 years. (Richardson et al.,2009)

37 Literature Review Addiction Treatment Using Telehealth Technologies Video Computer-based Interventions Web-Screeners Web-based Support Groups Telephone Continuing Care Interactive Voice Response Smart Phones Web-Portals Video Messaging (text and )

38 Video Conferencing

39 Largest provider of telemental health services using video conferencing

40 Training Substance Abuse Clinicians in Motivational Interviewing Using Live Supervision via Teleconferencing Teleconferencing supervision (TCS) was developed to provide remote, live supervision for training MI (Smith, et al., 2012)

41 Computer-Based Interventions Depression Anxiety Poor nutrition Sexual Risk Behaviors

42 Computer-delivered therapy is a computer-based media that provides users with information designed to supply therapeutic treatment

43 Encouraging evidence suggests positive treatment outcomes

44 Advantages to Computer-Based Interventions (Berwick, 2008; Copeland, 2011)

45 Privacy and Anonymity (Berwick, 2008; Finfgeld-Connett & Madsen, 2008)

46 flexible in their ability to provide automated and tailored information (Moyer & Finney, 2004/2005; Fotheringham et al., 2000)

47 Cost-Effective White, 2006; Walters et al., 20

48 Marsch, 2011 Clinician Extenders

49 Examples of Computer-Based Interventions CBT4CBT (Cognitive Behavioral Therapy, Carroll) Outpatient clients (2008) CBT + 6 computer modules on CBT TES (Therapeutic Education System, Marsch & Bickel) Community Reinforcement Approach + Incentives HIV/AIDS Intervention-Opioid treatment clients (2004) Outpatient Opioid Treatment- TAU + TES (2008) Outpatient Treatment-2hrs per week of TES + TAU (2012) Ondersma - found a single-session computer-delivered MI reduced drug use among postpartum women

50 The vital question for this field is not Do computer-assisted therapies work? but..

51 Which specific computer-assisted therapies, delivered under what conditions to which populations, exert effects that approach or exceed those of standard cliniciandelivered therapies. (Kiluk, et al., 2011)

52 Web-based Screeners

53 Web-Based Screeners

54 Web-Based Screeners for College Students

55 Web-Based Support Groups

56 Web-Based Support Groups

57 Podcasts/Radio Shows

58 Telephone

59 Use of Telephone Monitoring and treatment of chronic mental and physical illness Smoking (Stead, et al., 2006) Depression (Simon, et al., 2000) Obsessive Compulsive Disorder (Taylor, et al., 2003) Hypertension (Bosworth, et al,. 2005) Diabetes (Kim & Oh, 2003) Rheumatology problems (Pal, 1998)

60 Telephone Continuing Care

61 Telephone Continuing Care for SUDs Telephone Monitoring and Adaptive Counseling (TMAC) (McKay, 2004) Focused Continuing Care (FFC) (Betty Ford Clinic) Telephone Enhancement of Long Term Engagement (TELE) (Hubbard et al., 2007) Individual Therapeutic Brief Phone Contact (ITBPC) (Kaminer & Napolitano, 2004) ADOLESCENTS Telephone Case Monitoring (TCM) (McKellar et al., 2012) Telephone Continuing Care (TCC) (Godley et al., 2010)

62 Interactive Voice Response

63 Interactive Voice Response Automated, computer-based interventions have shown promise in treating substance use disorders Fully automated systems offer a number of potential advantages including: low cost consistent delivery greater accessibility and availability of treatment increased flexibility of scheduling and convenience (Cranford, Tennen, & Zucker, 2010; Mundt, et.al., 2006)

64 Interactive Voice Response Alcohol Screenings Alcohol Brief Intervention Adjunct to Substance Abuse Treatment Recovery Line IVR Program developed for patients to use in their own environment obtain immediate assistance, training, and support for improved coping Modules were designed to be brief (<15 minutes) and easy to understand (Moore, In Press)

65 Mobile Apps

66 ACHESS Alcohol-Comprehensive Health Enhancement Support System The ACHESS intervention is explicitly designed to address the three constructs coping competence social support autonomous motivation Primary hypothesis is that ACHESS will reduce risky drinking days

67 ACHESS employs these concepts in the following ways to prevent relapse 1. develop/maintain autonomous motivation to prevent relapse (autonomy supportiveness) 2. offer resources to cope with pressures to relapse, e.g., cravings, withdrawal symptoms, high risk situations (competence) 3. provide access to social support to persevere (relatedness) (Gustafson, et al., 2011)

68 Other Telehealth Technologies

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70 Messaging TEXT & Chat

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72 Privacy, Security, & Confidentiality Issues with Telehealth

73 HIPAA (Health Insurance Privacy & Accountability Act) HITECH (Health Information Technology for Economic & Clinical Health Act) Privacy Rule (Standards for Privacy of Individually Identifiable Health Information) 42 CFR Part II (Substance abuse treatment)

74 Protected Health Information (PHI)

75 The Standards for Privacy of Individually Identifiable Health Information ( Privacy Rule ) establishes a set of national standards for the protection of certain health information. The U.S. Department of Health and Human Services issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of The Privacy Rule standards address the use and disclosure of individuals health information called protected health information by organizations subject to the Privacy Rule.

76 The Federal Confidentiality Rules and Regulations 42 CFR Part II pertain to the confidentiality rights of substance use disorders treatment patients and their records. The general rule of the FCRR states, A program or person may not disclose any information about any patient. Basically, this means that a person s identity as a patient of a Substance Use Disorders treatment program must be protected.

77 De-identified Information

78 When Using Telehealth Technologies to deliver Assessment, Intervention, Treatment, and Recovery Services a provider needs to adhere to: HIPAA Privacy & Security Act and Federal Confidentiality Rules and Regualtions-42CFR Part 2

79 Privacy, Security, & Confidentiality

80 Privacy, Security, & Confidentiality Virtual Storage

81 Final Rule specifically states because "paper-topaper" faxes, person-to-person telephone calls, video teleconferencing, or messages left on voic were not in electronic form before the transmission, those activities are not covered by this rule (p. 8342).

82 The content of a phone call doesn t exist electronically after the phone call ends

83 electronic exchanges

84 However, if the provider records the session and saves a copy. the saved version would be subject to the Security Rule provisions for data at rest. Regardless, the treatment session and all related information and documentation are subject to the Privacy Rule provisions.

85 To ensure the patient s privacy during treatment sessions, clinicians should consider the use of private networks or encrypted videoconferencing software.

86 SKYPE

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88 Counselors Use of Technology

89 Do you or your staff or TEXT clients?

90 SO WHAT S THE

91 Text Message Transmission Process

92 Traditional Short Message Service (SMS) text messaging is non-secure and noncompliant with safety and privacy regulations under the HIPAA. Messages containing ephi can be read by anyone, forwarded to anyone, remain unencrypted on telecommunication providers servers, and stay forever on sender s and receiver s phones. (American Academy of Orthopaedic Surgeons, August 2012)

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94 No it is not acceptable for physicians or licensed independent practitioners to text orders for patients to the hospital or other healthcare setting. This method provides no ability to verify the identity of the person sending the text and there is no way to keep the original message as validation of what is entered into the medical record. The Joint Commission November 10, StandardsFaqId=401&ProgramId=1

95 Safe Practices

96 maintain physical control of your mobile device/computer (

97 unsecured networks

98 unintentional disclosure

99 password protect EVERYTHING

100 check out what is downloaded on your mobile device/computer and keep the security software updated (

101 activate wiping and/or remote disabling

102 use a secure portal to send or receive PHI over public Wi-Fi networks?

103 Implement policies & procedures to restrict access to, protect the integrity of, & guard against unauthorized access to electronic PHI (e-phi) (HHS Office for Civil Rights)

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105 Ethical Codes Ethics is about how one should or should not act and is based on values. Most professions establish ethical codes in order to set standards about how professionals should behave.

106 A profession is defined as a collective of expert service providers who have jointly and publicly committed to always give priority to the existential needs and interests of the public they serve above their own and who in turn are trusted by the public to do so. (Welie, 2004)

107 A solid code of ethics professionalizes an occupation by creating a social contract with the public that balances professional privilege and responsibility with a commitment to the welfare of clients. (Koocher & Keith-Spiegel, 1998)

108 Use of technology Ethics by counselors continues to evolve. Related technology continues to advance and be used more by increasing numbers of professional counselors. Use of technology presents unique ethical dilemmas to professional counselors. (NBCC Policy, 2012)

109 Ethical Codes Related to the use of Technology in Counseling/Therapy/Treatment NAADAC (Association for Addiction Professional)s National Board of Certified Counselors (NBCC) American Counseling Association (ACA) American Mental Health Counselor Association (AMHCA) American Association of Marriage and Family Therapy (AAMFT) National Association of Social Workers (NASW)

110 Ethics Need to be re-written to address technology (Telemental Health Institute)

111 Ethical Codes American Psychological Association (APA) Currently, telehealth technologies are not included in the APA Code of Ethics. The APA recognizes the need for development of guidelines and in 2011 approved a joint task force to develop telehealth guidelines for psychologists.

112 Ethical Codes IC&RC The IC&RC organization does not create or maintain a Code of Ethics. It is a matter dealt with by IC&RC member boards individually. IC&RC recommends contacting member boards directly. The link below provides contact information for all member boards.

113 Can a meaningful clinical relationship be developed if a client and counselor do not share the same physical space? (Chester & Glass, 2006)

114 Ethical Codes related to 3 areas of telehealth technology Informed Consent Confidentiality/Privileged Communication & Privacy Records & Data (NAADAC Code of Ethics, Rev. March 28, 2011)

115 Ethical Considerations in Designing Telehealth Technologies How provider- or patient-centric is the technology? Does the shift to remote services promote the values traditionally at the heart of caregiving? To what extent should technology usage involve attempts to manipulate users into different behaviors? (Kaplan & Litewka, 2008)

116 Ethical Considerations in Designing Telehealth Technologies How might the replacement of human contact by new technologies be improved? To what extent is the use of technology aimed toward creating market needs over the improvement of health or well-being? (Kaplan & Litewka, 2008)

117 Counselor or Client Convenience?

118 Ethics E-health is not only a technological improvement, but a re-engineering of healthcare processes requiring consideration of sociotechnical aspects of their design and development. It is meant to broaden the scope of healthcare delivery, place citizens at the center of services, and provide them increased interaction with health professionals who look after their health needs. (Nykanen 2006, in Kaplan & Litewka, 2008)

119 License Portability

120 Nurse Licensure Compact (NLC) (

121 Conducting Therapy Across State Lines What each state licensing board allows/requires? Which state governs? (American Psychologist,2009)

122 Reimbursement for Telehealth Addiction Treatment Services

123 General Reimbursement Requirements Benefits/Covered Services Practitioner/Provider Requirements Eligibility, Enrollment or Patient/Beneficiary Participation Allowable Codes

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125 Service Center for Medicare and Medicaid Services (CMS) does not mandate reimbursement for Medicaid, states have the option to reimburse for the service

126 States Define Medicaid Eligible services Populations to receive services Qualified practitioners Location the service can be provided Define the services delivered in managed care vs. fee for service arrangements

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129 Benefits Improvement and Protection Act of 2000 (BIPA)

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131 CCHP Report Highlights 44 states have a form of TH reimbursement Live video most prominent reimbursed 7 states provide Medicaid reimbursement remote patient monitoring 10 stated require informed consent 9 medical boards issue special licenses/certificates for TH 13 states have pending legislation on TH

132 No two states are alike in how telehealth is defined and regulated. (

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135 Serve as the national subject area expert and key resource to PROMOTE the awareness and implementation of telehealth technologies

136 Create addiction treatment telehealth competencies and develop policy recommendations for national license portability to encourage the addiction treatment and recovery workforce to ADOPT the use of telehealth services

137 Use state-of-the-art culturally-relevant training and technical assistance activities to help the frontier/rural addiction treatment and recovery workforce IMPLEMENT telehealth services

138 PREPARE pre-service addiction treatment and allied health students on using telehealth technologies by DEVELOPING and DISSEMINATING academic curricula for infusion into existing courses

139 Advisory Board Work Group Members NASADAD- Executive Director SAAS- Executive Director NAADAC- Executive Director IC&RC-Executive Director HRSA s Telehealth Resource Centers ATTCs Telehealth Experts Frontier/Rural Addiction Treatment Providers Researchers National Focus Area ATTC

140 Year 1 Key Events Build compendium through Literature Searches Develop Graphics/Marketing Themes Conduct Telehealth Needs Assessments Develop Curricula Present at National Conferences Present at Regional Summer Institutes Sponsor two TOTs Conduct State Presentations - 2 x each ATTC Region Sponsor Early Adopters Summit

141 TARGET POPULATION Addiction Treatment Providers & Counselors

142 Upcoming Trainings Brief Introductory Training - Counselors Administrators Training

143 Curricula Brief Introductory Workshop for Counselors Types of telehealth used and treatment outcomes Ethics Scope of Practice Issues Competency Privacy/Security and Confidentiality Issues Administrators Workshop Types of telehealth used and treatment outcomes Reimbursement and Billing Issues Telehealth Policies Privacy/Security and Confidentiality Issues Decision Matrix

144 Where in the World is NFAR?

145 Years 2-5 Film and Disseminate Two Telehealth Workshops Develop Clinical Supervisor Curriculum Annotate Bibliographies Create Marketing Videos Host Webinars of Curricula Build Addiction Educators Curriculum and Sponsor Training Sponsor Telehealth Competencies Workgroup and Develop a Product Create and Implement Peer Recovery Curriculum Develop Addiction Treatment Curricula

146 Terra Hamblin Annie Vicente Nancy Roget Joyce Hartje Wendy Woods Trisha Dudkowski Michelle Padden

147 John Dell Mike Wilhelm

148 Whether its Group Counseling or Like This Like This

149 or Client Homework Like This Or Like This

150 Telehealth is in the Best Interest of the Clients Expanding Access Enhancing Treatment Services

151 Thank you

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154 Refrain from becoming a patient's "friend" on Facebook; Avoid posting personal information or pictures to public forums; Use "extreme caution" and obtain consent when texting with patients; Ensure that patients understand the privacy risks of (USA Today, 4/11); Use secure systems; Establish rules for responding to s or other communications from non-patients, such as patients' family members or friends; Conduct regular "self-auditing" of physician rating websites and other forums; Consider writing their own online profiles for such sites (Conaboy, "White Coat Notes," Boston Globe, 4/11). Read More: