A n d r e w S P o m e r a n tz, M D

T e le h e a lth in V A : B r in g in g h e a lth c a r e to th e u n d e r s e r v e d in c lin ic a n d h o m e A n d r e w S P o m e r a n tz, M D N a tio n a l M e n ta l H e a lth D ir e c to r f o r I n te g r a te d S e r v ic e s V A C e n tra l O f f ic e W a s h in g to n, D.C. ( v ir tu a l f r o m C h e ls e a, V T ) A s s o c ia te P ro f e s s o r o f P s y c h ia tr y, G e is e l S c h o o l o f M e d ic in e a t D a rtm o u th

D is c lo s u r e s I h a v e n o f in a n c ia l r e la tio n s h ip s w ith a c o m m e r c ia l e n tity p r o d u c in g h e a lth - c a r e r e la te d p r o d u c ts a n d /o r s e r v ic e s to th e c o n te n t I a m p r e s e n tin g 2

G o a ls o f th is p r e s e n ta tio n 1. P r o v id e a w o r k in g k n o w le d g e o f th e v a r io u s te le h e a lth c a p a b ilitie s th a t h a v e b e e n p r o v e n e ffe c tiv e in a n a tio n w id e h e a lth c a re s y s te m. 2. U n d e r s ta n d c lin ic ia n r e s is ta n c e a n d o th e r b a r r ir e r s to te le h e a lth a n d h o w to o v e r c o m e it 3. L e a r n w h a t V A h a s d o n e to im p r o v e m e n ta l h e a lth c a r e u s in g in te g r a te d p r im a r y c a r e a n d te le h e a lth. 4. O th e r g o a ls?

VA 101 V A = D e p a r tm e n t o f V e te r a n s A ffa ir s ( s in c e 1 9 8 9 ) T h r e e s u b c o m p o n e n ts : V e te r a n s B e n e f its A d m in is tr a tio n N a tio n a l C e m e te r y A d m in is tr a tio n V e te r a n s H e a lth A d m in is tr a tio n V e t C e n te r s M e d ic a l f a c ilitie s a n d th e ir a s s o c ia te d C o m m u n ity B a s e d O u tp a tie n t C lin ic s (C B O C s ) O r g a n iz e d in to 2 1 r e g io n s c a lle d V e te r a n s I n te g r a te d S e r v ic e N e tw o r k s (V I S N s ) C r u c ia l d is tin c tio n b e tw e e n D e p a r tm e n t o f D e fe n s e C a r e a n d VA c a r e D o D p r o v id e s c a r e to a c tiv e d u ty S e r v ic e m e m b e r s a n d th e ir f a m ilie s, a n d a f te r d is c h a r g e to s o m e w h o h a d a s ig n if ic a n t c a r e e r in th e m ilita r y V A p r o v id e s lif e tim e c a r e to a ll e lig ib le V e te r a n s w h o c h o o s e to s e e k V A h e a lth c a r e 4

T e le h e a lth a n d T e c h n o lo g y in VA C lin ic a l V id e o T e le h e a lth to C lin ic a n d H o m e T e a m b a s e d c a r e ( P C M H - P A C T ) H o m e T e le h e a lth H e a lth b u d d ie s I V R S to r e a n d F o r w a r d R e tin o lo g y, r a d io lo g y, d e r m a to lo g y G e n e r a l T e le h e a lth E - C o n s u lts S C A N /E C H O C o n n e c te d H e a lth S m a r tp h o n e a p p s P a tie n t P o r ta ls w ith s e c u r e m e s s a g in g

T h e E v id e n c e B a s e G r o w in g (e.g. c o m p a r a t iv e e f f e c t iv e n e s s t r ia ls )

V H A B lu e p r in t f o r E x c e lle n c e A im in g a t th e u n d e r s e r v e d S tr a te g y 3, P a r t e : E x p a n d V ir tu a l M e d ic a l M o d a litie s to E n h a n c e H ig h - P e r fo r m a n c e, P a tie n t - c e n te r e d C a r e fo r R u r a l, H o m e b o u n d, o r O th e r w is e I s o la te d V e te r a n s E x p a n d in g v ir tu a l m e d ic a l m o d a litie s ( s u c h a s te le h e a lth, e - C o n s u lt, S e c u r e M e s s a g in g, a n d th e M y H e a lth e V e t p a tie n t p o r ta l) o ffe r s V e te r a n s n e w s e r v ic e o p tio n s. D e v e lo p in g a n d la u n c h in g n e w m o b ile a p p lic a tio n s w ill im p r o v e a c c e s s a n d h e lp V e te r a n s ta k e a m o r e a c tiv e r o le in th e m a n a g e m e n t o f th e ir h e a lth a n d w e ll - b e in g. 13

V ir tu a l H e a lth C a r e A c c e s s V ir tu a l a c c e s s is a b o u t e x te n d in g th e r e a c h o f th e h e a lth c a r e s y s te m b e y o n d th e tr a d itio n a l b r ic k s a n d m o r ta r w a lls a n d e m p o w e r in g p a tie n ts to a s s u m e a g r e a te r r o le fo r m a n a g in g th e ir o w n h e a lth 14

V A V ir tu a l A c c e s s I n F Y 2 0 1 4 T r a n s a c tio n s : 1 m illio n + p r e s c r ip tio n s r e f ille d o n lin e p e r m o n th C o m m u n ic a tio n s : 1 m illio n p a tie n ts u s in g S e c u r e M e s s a g in g w ith p r o v id e r s E x te n d in g S p e c ia liz e d C a r e : 1 5 0,0 0 0 p a tie n ts c a s e m a n a g e d b y h o m e te le h e a lth 2 5 0,0 0 0 p a tie n ts u s e d c lin ic a l v id e o a t a V A C B O C 3 8 0,0 0 0 u s e d s to r e a n d f o r w a r d te c h n o lo g y 3 5 0,0 0 0 e C o n s u lts I n fo r m a tio n S h a r in g : 1 m illio n p a tie n ts u s in g B lu e B u tto n to d o w n lo a d E H R d a ta 15

A n o th e r L o o k a t O u r R e s u lts : F Y 1 4 V ir tu a l A c c e s s C o n n e c te d H e a lth T e c h n o lo g ie s Y e a r S ta r te d V e te r a n s S e r v e d in 2 0 1 4 V ir tu a l C a re M o d a lity T o ta ls ( T e le h e a lth, S e c u r e M e s s a g in g, S C A N - E C H O o n ly ) 1,8 3 1,2 2 1 ( 3 2 % V H A p a tie n ts ) V e te ra n P o in t o f S e r v ic e K io s k s 2010 >4M tr a n s a c tio n s M y H e a lth e V e t 2003 ~ 2,9 0 0,0 0 0 B lu e B u tto n 2010 ~ 1,1 0 0,0 0 0 S e c u re M e s s a g in g 2008 1,0 9 3,3 2 7 S to re & F o rw a r d T e le h e a lth 2000 3 7 9,0 1 0 e C o n s u lts 2010 3 5 1,2 3 9 C lin ic a l V id e o T e le h e a lth 2002 2 4 8,7 7 4 H o m e T e le h e a lth 2003 1 5 6,8 2 6 S C A N - E C H O 2 0 1 1 1,4 2 9 V e te ra n M o b ile A p p s 2013 F ie ld te s tin g & In itia l R e le a s e S ta ff M o b ile A p p s 2013 F ie ld te s tin g 16

V A W ill D o M o r e in th e F u tu r e E x p a n d in g T e le h e a lth C a r e R e d e s ig n W e b s ite / F e d e r a te d C r e d e n tia ls V A A p p S to r e L a u n c h / A p p P ilo tin g T e x t M e s s a g in g S y s te m P a tie n t D ir e c t S c h e d u lin g P ilo t N a tio n a l R o llo u t o f 1 5 + M o b ile A p p s V ir tu a l C a r e I n te g r a te d in to e H M P P la tf o r m V id e o V is its P ilo t N a tio n a l D e p lo y m e n t O n- D e m a n d 17

V ir tu a l m o n ito r in g h e lp s

I m p le m e n ta tio n I s s u e s a r e n o t to o d if f e r e n t C r o s s S e c to r c o n tr a c t is s u e s C r e d e n tia llin g, lic e n s in g M e d ic a l R e c o r d s F e e fo r s e r v ic e P r o v id e r m o tiv a tio n a n d tr a in in g I n fo r m a tio n s h a r in g I n fra s tr u c tu r e E th ic a l c o n c e r n s

C lin ic a l V id e o is s u e s P a tie n t P r e p a r a tio n R o o m lig h tin g, n o is e, c o m f o r t W h a t to w e a r?? P a tie n t s a tis f a c tio n C h o o s in g p a tie n ts C h o o s in g p r o v id e r s C o n tin g e n c y p la n n in g

M e n ta l H e a lth a s E x a m p le M o s t in d iv id u a ls w ith m e n ta l illn e s s a r e e ith e r n o t id e n tif ie d, n o t tr e a te d, o r in a d e q u a te ly tr e a te d P o o r a c c e s s to tim e ly c a r e is c o m m o n - a n d it w o r s e in r u r a l a n d o th e r u n d e r s e r v e d p o p u la tio n s M o s t o th e r h e a lth c o n d itio n s a r e e x a c e r b a te d b y m e n ta l illn e s s O R b y h e a lth r e la te d b e h a v io r s

R A T I O N A L E R u r a l V e te r a n s h a v e d if f ic u lty a c c e s s in g M H c a r e, d e s p ite its r e a d y a c c e s s in W R J V A a n d 4 C B O C s V e te r a n s a n d N G tr o o p s o f te n r e s is t s p e c ia liz e d M H c a r e a t V A o r C M H C E v id e n c e s u g g e s ts th a t v e te r a n s in c o m m u n ity tr e a tm e n t m a y b e s ic k e r ( m o r e E D v is its, h ig h e r in c a r c e r a tio n r a te s )

PCPs, specialists, etc. PC-MHI, HBC, SW, pharmacy, etc. I n c lu d e s s ig n if ic a n t o th e r s a n d c a r e g iv e r s Community Non-VA providers Specialty Care Team Members Discipline-specific Team Members Core Primary Care Team Members Patient/family Public health agencies, non-profit agencies, etc. Cardiology, podiatry, etc. P C P, R N C M, c lin ic a l a s s o c., a d m in. a s s o c. The Patient Aligned Care Team (PACT)

S P E C IA L T Y M H S e c o n d a r y a n d T e r tia r y C a r e : O u tp a tie n t C a re fo r tre a tm e n t re s is ta n t, s e v e re o r c o m p le x illn e s s e s P T S D s p e c ia lty tre a tm e n t; S u b s ta n c e d e p e n d e n c e tre a tm e n t T re a tm e n t o f s e rio u s m e n ta l illn e s s (in c lu d in g M H IC M ) F u ll s p e c tru m o f p s y c h o s o c ia l re h a b ilita tio n a n d re c o v e r y s e rv ic e s In p a tie n t p s y c h ia tric c a re R e s id e n tia l tre a tm e n t S u p p o rte d a n d th e ra p e u tic e m p lo y m e n t H o m e le s s p ro g ra m s PC- M H I I n te g r a te d C a r e f o r p h y s ic a l a n d m e n ta l h e a lth in o n e s e ttin g E v a lu a tio n a n d tre a tm e n t fo r m ild to m o d e ra te m e n ta l h e a lth c o n d itio n s (d e p re s s io n, s u b s ta n c e m is u s e, a n x ie ty, P T S D ) F o llo w -u p e v a lu a tio n fo r p o s itiv e M H s c re e n s B e h a v io ra l h e a lth in te rv e n tio n s fo r c h ro n ic d is e a s e C a r e m a n a g e m e n t R e f e r r a l m a n a g e m e n t P R IM A R Y C A R E S c re e n in g fo r m e n ta l h e a lth c o n d itio n s In itia tio n o f p h a rm a c o lo g ic a l tre a tm e n t fo r m ild to m o d e ra te m o o d s y m p to m s Co-m a n a g e m e n t o f V e te ra n c a re w ith PC- M H I a n d s p e c ia lty M H p ro v id e rs H e a lth B e h a v io r 24

P r im a r y C a r e -M e n ta l H e a lth I n te g r a tio n I n V A T w o P C - M H I C o m p o n e n ts : Co- lo c a te d C o lla b o r a tiv e C a r e C a r e M a n a g e m e n t B le n d e d p r o g r a m s h a v e b o th o f th e s e c o m p le m e n ta r y c o m p o n e n ts F o c u s p r im a r ily o n c o m m o n m e n ta l c o n d itio n s : D e p r e s s iv e a n d A n x ie ty D is o r d e r s A lc o h o l M is u s e a n d A b u s e P T S D S c r e e n in g /A s s e s s m e n t H e a lth B e h a v io r C o o r d in a to r s im p le m e n t h e a lth p s y c h o lo g y p r o g r a m s a lo n g w ith H e a lth P r o m o tio n /D is e a s e P r e v e n tio n P r o g r a m M a n a g e r s 25

CO- L O C A T E D C O L L A B O R A T I V E C A R E M e n ta l h e a lth p r o v id e r (s ) e m b e d d e d in p r im a r y c a r e c lin ic w ith s h a r e d r e s p o n s ib ility f o r e v a lu a tio n, tr e a tm e n t p la n n in g a n d m o n ito r in g o u tc o m e s C o n s u lta tio n a n d e d u c a tio n to th e P A C T O p e n o r a d v a n c e d ( s a m e d a y ) a c c e s s A s s e s s m e n t a n d B r ie f tr e a tm e n t w ith in P A C T

B o tto m lin e S e r v ic e s a v a ila b le in p r im a r y c a r e S a m e d a y m e n ta l h e a lth c a r e

M a jo r ity o f V A u s e r s a r e in c o m m u n ity b a s e d c lin ic s F e w e r r e s o u r c e s a n d s p e c ia lty a c c e s s M a n y v e r y r u r a l a n d w ith o u t tr a n s p o r ta tio n S o m e a r e h o m e b o n d H ig h b u r d e n o f illn e s s V A m ir r o r s g e n e r a l p o p u la tio n : a c c e s s ( p e r c e iv e d a n d a c tu a l) is v a r ia b le a t b e s t.

T e le h e a lth u s e in m e n ta l h e a lth c a r e : s o m e e x a m p le s T e le p h o n e c a r e m a n a g e m e n t ( e x te n s iv e R C T e v id e n c e ) s o m e c e n tr a liz e d h u b s C lin ic a l V id e o to c lin ic V id e o to h o m e : p a in, P T S D B e h a v io r a l a p p r o a c h e s b y g r o u p v id e o : M O V E f o r w e ig h t c o n tr o l H o m e b a s e d p r im a r y c a r e te a m s

A d d in g c o n n e c te d h e a lth S e c u r e m e s s a g in g S m a r tp h o n e a p p s : P T S D c o a c h P r o b le m s o lv in g tr a in in g C h r o n ic p a in I n s o m n ia c o a c h H e a lth r is k a s s e s s m e n ts On- d e m a n d v id e o v is its m a y b e n e x t

T h e f u tu r e is a ll a b o u t b r in g in g h e a lth c a r e ( a n d s e lf m a n a g e m e n t) to th e p o p u la tio n D r u g s to r e s a n d o th e r c h a in s L o c a l c o m m u n ity h e a lth p r o g r a m s D o c in a b o x D o c o n a s c r e e n H o m e la b w o r k w ith a s in g le d r o p o f b lo o d

W h e r e a r e th e lim its?

C o n ta c t in f o r m a tio n A n d r e w.p o m e r a n tz @ v a.g o v A n d r e w.p o m e r a n tz @ d a rtm o u th.e d u 802-6 2 5-2 0 4 0 h ttp s ://m o b ile.v a.g o v /a p p s to re