Gabriel D. Chavez, Jr. State of New Mexico, Department of Health, Health Systems Bureau, Office of Primary Care and Rural Health

Gabriel D. Chavez, Jr. State of New Mexico, Department of Health, Health Systems Bureau, Office of Primary Care and Rural Health National Organization of State Office of Rural Health Leadership Institute Cap Stone Project October 24, 2013

Table of Content: Page 1. Introduction: 1 2. Background of Rural New Mexico: 3 3. Focal Group of this Project: 4 4. New Mexico s need for Health Care Professionals: 6 5. RPHCA Survey and Findings: 10 6. Example of successful RPHCA Facility using Tele-Health: 25 7. Conclusion/Next Step(s): 26 8. References: 27 9. Attachments: 28

Introduction: 1. Problem Statement: Historically medical, dental and behavioral care has been siloed. This has caused missed opportunities to provide coordinated and efficient health care for patients. The siloing of medical, dental and behavioral care has many reasons. A brief review of articles and interviews with health experts on this subject reveals that the following are key factors to the silo effect of health care. These are a few of the reasons: Payment/coding inconsistence; Inconsistence health care financing; Government and private insurance limits; Patient health records; Communication among health care providers; Limitation of health care services because of geographic location and isolation; Health care policy disparities; Patient eligibility accessing care; Cultural competence in healthcare; Cultural resistance to modern healthcare; Racial and ethnic lack of diversity in the health professional workforce; and, Poverty. 1

2. Cap Stone Project Focus: The focus of this Cap Stone Project will be to gain an understanding of the current use of telehealth in New Mexico Rural Primary Heath Care Act (RPHCA) funded facilities and how they are being used to integrate the various disciplines. At the start of this Cap Stone Project it was hoped that the following question could be answered: Can telehealth provide opportunities to strengthen Medical Health Care, Dental Health Care and Behavioral Health Care integration in RPHCA facilities? The remainder of this paper will be dedicated to answering this question. Also provided in this paper is a brief discussion of rural New Mexico, a description of the focus group of this project (RPHCA facilities), New Mexico s need for Health Care Professionals in rural underserved areas, RPHCA facilities survey and findings of current use of Telehealth, an example of successful RPHCA facility using telehealth, and Conclusion/Next Steps for future exploration of the use of telehealth in RPHCA facilities. 2

Background of Rural New Mexico: The majority of New Mexico geographic area is considered rural or frontier. Out of 33 New Mexico s counties 27 are considered rural or frontier. Only 6 counties are considered Urban (please see map). Even within these urban counties portions are considered rural. New Mexico has a total population of 2,059,179 according to the 2010 US Census Bureau. Rural and frontier counties account for 34% (707,038) of the State of New Mexico s population. The majority of New Mexico s population 66% (1,354,141) is concentrated with the urban counties. 3

Focal Group of this Project: The focus group of this project is the Rural Primary Health Care Act (RPHCA) funded facilities in New Mexico. RPHCA facilities provide basic primary health care services through eligible programs in underserved areas of the State of New Mexico in order to better serve the health needs of the public. RPHCA facilities provide safety net health care services to some of the most underserved communities in rural New Mexico. RPHCA facilities may provide medical, dental and behavioral health care. But not all RPHCA facilities are required to provide all three of these services (see attachment 1). New Mexico currently has 27 non-profit RPHCA facilities at 99 clinic sites throughout New Mexico (please see map). RPHCA funded clinics provided primary care, dental care and behavioral health services to 285,000 New Mexicans in state fiscal year 2013 (7-1-2012 to 6-30-2013). Over 989,000 4

patient visits were report for fiscal year 2013. RPHCA facilities received over $13 million in State of New Mexico funding in fiscal year 2013. Requirements of the RPHCA program are: 1. RPHCA facilities must be located in Health Care Underserved Areas (HCUA s) 2. RPHCA facilities must have a governing board whose membership is representative of the HCUA it serves, including consumers of the primary care services it provides. 3. RPHCA facilities must have policies and procedures to ensure that no person will be denied primary care services because of inability to pay. 4. RPHCA facilities must be a New Mexico nonprofit entity which has obtained and maintains a federal internal revenue service 501c (3) tax exempt status. 5

New Mexico s need for Health Care Professionals: Most of New Mexico is designated a Health Professional Shortage Areas (HPSA s) for Medical, Dental and Mental Health. New Mexico Medical Primary Care HPSA s: 24 out of 33 NM Counties are completely designated, 8 counties are partially designated and one is not designated (see map). 6

New Mexico Dental HPSA s: 22 out of 33 NM Counties are completely designated, 5 counties are partially designated and 4 are not designated (see map). 7

New Mexico Mental Health HPSA s: 28 out of 33 NM Counties are completely designated, 2 counties are partially designated and 2 are not designated (see map). 8

Also, most of New Mexico is designated an Underserved Areas and Population (MUA/P). 26 out of 33 NM Counties are completely designated, 6 counties are partially designated and 1 is not designated (see map). RPHCA facilities must be located in Health Care Underserved Areas (HCUA). HCUA s are a combination of both the Medical Primary Care Area HPSA and the Medical Underserved Areas and Population designation. Most of rural/frontier New Mexico is currently designated either or both a HPSA or MUA/P. This shows the high need for healthcare professionals in rural New Mexico. 9

RPHCA Survey and Findings: A survey was conducted in August 2013 to gain an understanding of the current use of telehealth in New Mexico RPHCA facilities and how it is being used to achieve integrated health care. All RPHCA facilities were surveyed using Survey Monkey. A total of 12 questions were asked in the survey. Fifteen RPHCA facilities responded to the survey. 1. Results of the survey: Question 1: Does your organization provide integrated medical, dental and behavioral health care services? Answer Options Response Response Percent Count Yes 66.7% 10 No 33.3% 5 answered question 15 skipped question 0 10

Question 2: How does your organization define integrated medical, dental and behavioral health care services? Response Answer Options Count 15 answered question 15 skipped question 0 The following are the responses to the question: Number Response Text Collaborative medical, dental, and behavioral health under one organizational umbrella to 1 ensure seamless flow of healthcare and information 2 not used Services provided in the spectrum of primary care by an integrated team (single medical 3 record, communication between providers etc.) Co-location of services, integrated electronic health records with combined treatment plans, and trans disciplinary mini-treatment team, all staff trainings, cross-training and anti-oppression 4 initiatives such as communications, diversity and trauma-informed care. Our organization employs a dentist and primary care physicians. We work with a local 5 behavior health organization through referrals. Integration of dental and behavioral health care services into primary care is coordination of services for patients that includes continuity of care among providers and their staff by communicating about the patient's care via electronic health record and alerts and providing 6 reciprocal referrals between disciplines. HMS has been actively working on NCQA level 3 recognition, we have multiple facilities that provide 4 core services and work as a team to provide patient care. Medical, Dental, Mental 7 Health and Care Coordinators. We are developing the integrated care model w/ Behavioral Health personnel of LISW and two Comprehensive Support Service (CCSS) who will eventually be housed at each of our 8 sites to work hand in hand with the medical provider who once the medical provider identifies a patients need for BH services will notify the BH staff and remain in communication until the BH 8 barriers to improving the patients health have been solved or diminished. 9 A comprehensive system that addresses the physical, social, emotional and spiritual needs of 11

individuals. Our facility does not offer behavioral health care. Our dental office is not based at the same 10 facility as the medical clinic. services provided within our system and whenever possible in the same location; electronic 11 medical records are used 12 coordination of care plans based upon the patients diagnosis and treatment in those area 13 All services would be provided onsite. 14 Based on a risk acuity screening All our providers use the same EHR and as such each patient only has one chart which includes anything done by medical, dental or behavioral health. So communication between services is seamless and referrals and other communication between providers is all within the 15 EHR. 12

Question 3: Does your organization use Telehealth? Answer Options Response Response Percent Count Yes 26.7% 4 No 73.3% 11 answered question 15 skipped question 0 13

Question 4: Does your organization use Telehealth to provide School Based Health Services? Answer Options Response Response Percent Count Yes 0.0% 0 No 100.0% 15 answered question 15 skipped question 0 14

Question 5: Who uses Telehealth at your organization? Answer Options Response Response Percent Count Clinicians 66.7% 4 Administrators 0.0% 0 Aides and Assistants 33.3% 2 Others 16.7% 1 Other (please specify) answered question 6 skipped question 9 15

Question 6: Does your organization use Telehealth to integrate medical, dental and behavioral health care services? Example; Patient Referrals Answer Options Response Response Percent Count Yes 13.3% 2 No 86.7% 13 answered question 15 skipped question 0 16

Question 7: Does your organization believe that Telehealth can be a useful tool to integrated medical, dental and behavioral health care services? Answer Options Response Response Percent Count Yes 61.5% 8 No 38.5% 5 answered question 13 skipped question 2 17

Question 8: Does your organization use Health Information Technologies? Answer Options Response Response Percent Count Electronic Health Record Services 100.0% 13 Electronic Care Coordination 38.5% 5 Distance Learning/Educational Services 46.2% 6 E-Pharmacy 69.2% 9 Others 7.7% 1 Other (please specify) answered question 13 skipped question 2 18

Question 9: How often is Telehealth used at your organization? Answer Options Response Response Percent Count Daily 6.7% 1 2 to 4 Days a week 6.7% 1 Once a week 6.7% 1 A few times a month 26.7% 4 A few times a year 13.3% 2 None 40.0% 6 answered question 15 skipped question 0 19

Question 10: Does your organization participate with the following Telehealth providers? Answer Options Response Response Percent Count UNM Telehealth 14.3% 2 UNM Project Echo 64.3% 9 UNM Pals 7.1% 1 New Mexico Primary Care Association Nurse Advise Line 14.3% 2 Universal Service Administrative Company (USAC) T1 Line 0.0% 0 Other 0.0% 0 None 28.6% 4 Other (please specify) answered question 14 skipped question 1 20

Question 11: What are your organization's barriers to successfully using Telehealth? Answer Options Response Response Percent Count Infrastructure 58.3% 7 Staffing 41.7% 5 Funding 58.3% 7 Training 33.3% 4 Maintenance 33.3% 4 Parts and Equipment (supplies) 58.3% 7 Other 16.7% 2 Other (please specify) answered question 12 skipped question 3 21

Question 12: Is your Telehealth Studio used for other uses (for example: storage, conference room etc)? Answer Options Response Response Percent Count Yes 33.3% 5 No 73.3% 11 answered question 15 skipped question 0 22

2. Findings of Survey: The overall response to this survey indicates the integration of Medical Health Care, Dental Health Care and Behavioral Health Care is a moderate part of the RPHCA facilities that responded to this survey. Two thirds (67%) of the respondents indicate that integration is a part of their current Medical Health Care, Dental Health Care and Behavioral Health Care services. Key word phrases that came up with the question concerning the definition of the integration of Medical Health Care, Dental Health Care and Behavioral Health Care services are Patients, Providers, and Primary Care. This may indicates that any integration of Medical Health Care, Dental Health Care and Behavioral Health Care must have a relationship with primary care providers and patients. Electronic health and plan treatments were also mentioned in the definition of integration of Medical Health Care, Dental Health Care and Behavioral Health Care services. Surprisingly, almost 73%, 11 out of 15 survey respondents indicated that telehealth was not used at their organization; and no school based health services used telehealth. Clinicians (66%) were identified as being the likely users of telehealth, however, only 6 out of 15 responded to this question. Also surprisingly, 87% of the RPHCA facilities surveyed indicated that they did not use telehealth to integrate Health Care, Dental Health Care and Behavioral Health Care services. Only 8 out of 13 (61%) respondents believed that telehealth would be a useful tool to integrate Health Care, Dental Health Care and Behavioral Health Care services. In comparison, the RPHCA facilities indicated that Health Information Technologies (Electronic Health Record Services, Electronic Care Coordination, Distance Learning/Educational Services, E-Pharmacy and others) were being used. 100% (13) of the RPHCA facilities indicated that they use Electronic Health Record Services, 69% use E-Pharmacy, 46% use Distance Learning/Educational Services and 39% use Electronic Care Coordination. This seems to indicate that Health Information Technologies is not defined by the RPHCA facilities as telehealth. The survey seems to indicate that telehealth is not often used by RPHCA facilities. The highest response showed that 40% (None) do not use telehealth, with (A few times a month) 27% 4 of 15, being the second highest. 23

The RPHCA facilities indicated that Telehealth providers (UNM Telehealth, UNM Project Echo, UNM Pals, New Mexico Primary Care Association Nurse Advise Line, Universal Service Administrative Company (USAC) T1 Line and others) participation was moderate. UNM Project Echo was the highest with 64%, UNM Telehealth and New Mexico Primary Care Association Nurse Advise Line receiving 14% each. 29% indicated (None) to this question. A question was asked what are the barriers to successfully using telehealth at RPHCA facilities, these included, Infrastructure, Staffing, Funding, Training, Maintenance, Parts and Equipment (supplies) and other. Infrastructure, Funding and Parts & Equipment (supplies) were indicated as being the highest barriers with 58% each. Staffing received 42%, Training and Maintenance each received 33%. The finally question asked if the RPHCA facilities telehealth studios were being used for other uses (storage, conference room etc). 73% indicated No to this question. 3. Conclusion of Survey The definition of telehealth seems to be an issue with the RPHCA facilities that responded to survey. As was shown with the finding telehealth was not being used by a majority of the RPHCA facilities surveyed. However, Health Information Technologies (Electronic Health Record Services, Electronic Care Coordination, Distance Learning/Educational Services, E- Pharmacy and others) were shown to being used by the RPHCA facilities. Also, the moderate use of telehealth providers (UNM Telehealth, UNM Project Echo, UNM Pals, New Mexico Primary Care Association Nurse Advise Line, Universal Service Administrative Company (USAC) T1 Line and others) indicate that telehealth is being use at the RPHCA facilities surveyed. For the purpose of this paper Health Information Technologies are included with telehealth. This indicates that more education and awareness of the different types of telehealth is needed. The use of telehealth by primary care clinicians and their patients seems to be another area of potential growth for the integration of Health Care, Dental Health Care and Behavioral Health Care services. However, barriers that deal with Infrastructure, Funding, Parts & Equipment (supplies), Staffing, Training and Maintenance need to be addressed to better implement telehealth in RPHCA facilities. 24

Example of successful RPHCA Facility using Telehealth: Hidalgo Medical Services (HMS) is located in the southwest region of New Mexico along the Arizona border. HMS has locations in 6 rural communities in Grant County and Hidalgo County and provides serves in 7 facilities. HMS provides Medical, Dental, and Behavioral Health Care services to 14,577 persons for fiscal year 2013. 51,246 patient visits were recorded for fiscal year 2013. According to Charlie Alfero, Director, HMS Center for Health Innovations; HMS has a long history of the use of telehealth in their efforts to integrate Medical, Dental and Behavioral Health Care services. The following are his observations and recommendation to better use telehealth for the integration services. Observation of successful use of telehealth at HMS facilities: Improved patient care through direct consultation with providers; Improved quality of care through subspecialty consultations with providers. (Project Echo); Improved comprehensive services through subspecialty training. Certifications of subspecialty for primary care providers. (i.e. Pain management); Improved training of graduate students and residency through communication with their sponsoring institutions; Reduce travel for partnering and collaboration. Lowing cost, increase connectivity and reduces isolation; and Improved communications for complex diagnostics Recommendations to improve use of telehealth: Being proactive in developing professional relationships with telehealth providers. (UNM); Identify priority services for your facility; and Identify health services needs of patients (i.e. asthma, hepatitis c, child psychiatry) 25

Conclusion/Next Step(s): At the beginning of this Cap Stone Project I proposed a question that I want to answer. This question was: Can telehealth provide opportunities to strengthen Medical Health Care, Dental Health Care and Behavioral Health Care integration in RPHCA facilities? As I come to the end of this Cap Stone Project I have concluded that yes telehealth can strengthen Medical Health Care, Dental Health Care and Behavioral Health Care integration in RPHCA facilities. This has come apparent that telehealth is being used at New Mexico RPHCA facilities even though many RPHCA facilities may not realize that they are using it. However, telehealth seems to be under used based on the findings of the survey. Also, there seems to be barriers that are currently preventing RPHCA facilities from using telehealth to integrate Medical Health Care, Dental Health Care and Behavioral Health Care. As was mentioned in this paper, Hidalgo Medical Services in southwestern New Mexico is an example of a RPHCA facility that has successfully implemented telehealth in the integration of Medical Health Care, Dental Health Care and Behavioral Health Care services. HMS should be a example to all RPHCA facilities that telehealth can be an excellent tool to help integrate of Medical Health Care, Dental Health Care and Behavioral Health Care services. The following are recommendation for future focus to help RPHCA facilities better implement telehealth for the integration of Medical Health Care, Dental Health Care and Behavioral Health Care services. Develop a definition of telehealth applicable to RPHCA facilities-. Telehealth use at RPHCA facilities should be Primary Care Clinician based to integrate Medical Health Care, Dental Health Care and Behavioral Health Care services. Reduce barriers for : o Infrastructure o Funding o Parts & Equipment (supplies) o Staffing o Training o Maintenance 26

References: 1. Jerry Harrison, PhD., interview, at New Mexico Health Resources, Inc., Albuquerque, New Mexico, October, 2013 2. Kevin McMullan, Health Professional Recruiter, New Mexico Health Resources, Inc, interview, at New Mexico Health Resources, Inc., Albuquerque, New Mexico, October, 2013 3. Ken Reid, New Mexico Department of Health, interview, at New Mexico Department of Health, Albuquerque, New Mexico, October, 2013 4. LeeAnn Roberts, New Mexico Department of Health, interview, at New Mexico Department of Health, Albuquerque, New Mexico, October, 2013 5. Julie Molina, New Mexico Department of Health, interview, at New Mexico Department of Health, Albuquerque, New Mexico, October, 2013 6. Charlie Alfero, Hidalgo Medical Services, Center for Health Innovations, Interview by phone. Silver City, New Mexico, October, 2013. 7. A State Rural Health Plan 2012 2015, New Mexico: Strategic Opportunities For Rural Health Care Systems Improvement 8. Oliver, Wayne, Executive Director, Patients for Fair Compensation, Breaking Down Healthcare Silos: The Need of Healthcare Integration, December 5, 2012. 9. DeMuro, Paul, The Lund Report, Breaking Down Healthcare s Silos, March 16, 2013 10. Rodak, Sabrina, Becker s Hospital Review, Breaking Down Silos to Improve Patients Flow, Hospital Efficiency, March 12, 2012 11. Deveau, Denise, Financial Post, Breaking Silos Best Medicine for Inefficient Healthcare System, September 17, 2013 12. Chase, Dave, Techcrunch.com, Federal Government Makes Silo-Busting, Startup Unleashing Healthcare Move, February 26, 2013. 27

ATTACHMENTS 28

Attachment 1. 29