Behavioral Health Integration: Treating the Whole Person

Telepsychiatry and Primary Care

Objectives

• Understand urgent need for Telepsychiatry services in North Carolina and across the US in new era of Accountable Care/PCMH

• Review commonly used terminology in the telehealth field

• Explore the benefits of using telemedicine/telepsychiatry

• Explore the ways telepsychiatry can be applied to evidence based models.

What is Telemedicine?

Formally defined, telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. Telemedicine includes a growing variety of applications and services using two-way video, email, smart phones, wireless tools and other forms of telecommunications technology.

Source: http://www.americantelemed.org/about-telemedicine/what-is-telemedicine

Why Telepsychiatry?

• Nearly 30% of the US adult population meets criteria for one or more mental health problems

• 70% of all primary care visits involve behavioral health problems

• 80% of those with mental illnesses will visit primary care at least once in a calendar year

• 2/3 of PCPs have difficulty accessing psychiatric care• Worsening severe shortage of mental health providers• Inadequate insurance coverage (changing rapidly)• Psychiatry practices are full--stable patients are not

being returned to primary care, or are not easily accepted back.Sources: Collins C, Hewson DL, Munger R, Wade T. Evolving Models of Behavioral Health

Integration in Primary Care. Milbank Memorial Fund (2010) Narrow et al., Arch Gen Psychiatry. 1993;50:5-107. Cunningham, Health Affairs. 2009; 3:w490-w501

Why Telepsychiatry? (con’t)

Health Professionals in North Carolina, Physician Specialties, 2011

Type of Physician Specialty

Counties with 0

Counties with 1

Counties with 2 or

more

Total # of Professionals

Statewide

Addiction Psychiatry

95 3 2 9

Addiction/Chemical Dependency

87 9 4 22

Psychiatry 28 18 54 971

Child Psychiatry 70 14 16 146

Geriatric Psychiatry 94 4 2 9Source: Cecil B. Sheps Center for Health Services at UNC—Chapel Hill

Sandhills Telepsychiatry Project

• Increase access to psychiatric care in the Sandhills Region

• Offer real-time Psychiatric Assessments/Consults

• Educate and empower primary care providers to manage patients with behavioral health issues.

• Increase the dialogue/collaboration between primary care and behavioral health providers.

• Build the case for integrated care in the Sandhills region.

• 40 CCS Practices, 3-year–Phased Approach

• Collaborative Project Between:

− Easter Seals− FirstHealth of the Carolinas− Monarch NC− El Futuro, Inc.− Kate B. Reynolds Charitable Trust

What Are the Benefits of Telemedicine?

Improved Access –Telemedicine improve access to patients but it also allows physicians and health facilities to expand their reach, beyond their own offices. Given the provider shortages throughout the world--in both rural and urban areas--telemedicine has a unique capacity to increase service to millions of new patients.

Cost Efficiencies – Reducing or containing the cost of healthcare is one of the most important reasons for funding and adopting telehealth technologies. Telemedicine has been shown to reduce the cost of healthcare and increase efficiency through better management of chronic diseases, shared health professional staffing, reduced travel times, and fewer or shorter hospital stays.

Improved Quality – Studies have consistently shown that the quality of healthcare services delivered via telemedicine are as good those given in traditional in-person consultations. In some specialties, particularly in mental health and ICU care, telemedicine delivers a superior product, with greater outcomes and patient satisfaction.

Patient Demand – Consumers want telemedicine. The greatest impact of telemedicine is on the patient, their family and their community. Using telemedicine technologies reduces travel time and related stresses for the patient. Over the past 15 years study after study has documented patient satisfaction and support for telemedical services. Such services offer patients the access to providers that might not be available otherwise, as well as medical services without the need to travel long distances.

Source: http://www.americantelemed.org/about-telemedicine/what-is-telemedicine

Benefits of Telepsychiatry

• Travel time is reduced or eliminated

• Telehealth equipment costs have plummeted.

• Patients in distress can be seen more quickly, reducing relapse events.

• Consultations with off-site specialists can be quickly carried out.

• Off-site and part-time behavioral health specialists can be members of the clinic team via telehealth.

• Staff can meet and collaborate more easily, especially when connecting staff located at various sites.

Source: U.S. Department of Health and Human Services, Health Resources and Services Administration, “Increasing Access to Behavioral Health Care Through Technology,” Meeting

Summary, March 30, 2012, Rockville, MD, published February 2013, p. 3.

Practical Applications

• Psychiatric Assessments/Consults (Primary Care, Emergency Department)

• Implementing the IMPACT model in primary care◦ http://impact-uw.org/

• Implementing SBIRT (Screening, Brief Intervention, and Referral to Treatment) in primary care◦ http://www.sbirtnc.org/

• Development of a “virtual” care team

Chronic Pain Initiative - Project Lazarus

Community Education

• Never share meds

• Take medication as prescribed-- If medication is not working, contact your PCP

• Lock up medications

• Property dispose of meds

• Produced a PSA that was shown statewide

Providers and ED Education

• Pain Management

– Test (X-ray, scans, etc.)

– Pain Agreements with Primary Care Physician (PCP’s)

– Referrals for Medicaid Patients

…and by extension, all patients

• Prescribing Policies

– Fortunately our PCP’s and ED’s have prescribing policies. KNOW the POLICY.

– Use of Controlled Substance Reporting System (CSRS).

Concerning prescribing patterns and knowledge deficits around any outpatient treatment or other community resources

• Provider trainings on safe opioid prescribing• Education on behavioral health, substance abuse

and chronic pain resources and how to utilize CCNC/CCPEC case management services

• Promoting and developing controlled substance agreements

• Educating the community on the dangers of the misuse/abuse of prescription drugs

Pain Support

• Plan tailored to patient

• Case Manager work with PCP and Patient on pain management plan

– Pain Clinic

– Exercise

– Diet

– Support Group

– May need Detox /Treatment

The Chronic Pain Initiative (CPI) helps patients in the East by assessing system barriers that our patients face every day and making these barriers our program goals.

Lack of resources for patients in chronic pain• CPI Support Groups• CPI Aquatics Classes• CPI Nurse Case Managers

Keeping prescription opioids off the streets• Selling, stealing meds• Heroin Summit (High

Point)Working with local Law Enforcement• What does an overdose

look like• Medicine Drop Boxes• Naloxone kits• Guilford Co. Sheriff’s

Dept. carry kits.

Diversion Control

Naloxone/Narcan

• Senate Bill 20: Good Samaritan/922/Naloxone

• EMS/EMT already carry it with them

– May record what drug they administer

– May record the incident type

– Train law enforcement on Intranasal Kits.

• Orange County Health Department first to issue standing order

• Project Lazarus (Intranasal Kits)

• N.C. Harm Reduction Coalition (IM Kits)

• Purchased 325 kits for NC Harm Reduction

Supporting our Law Enforcement officers, sharing our expertise and assisting them in program development

• Placed 375 naloxone kits in the patrol cars and Pitt County was the first in the state to have officers standing by to assist on the scene of an overdose because of the Chronic Pain Initiative

• Trained 175 officers• Naloxone kits in all the high schools through the

School Resource Officer• Crisis Intervention Training

Administering Naloxone

Nurse Case Managers as patient advocates• Reviewing the patient’s medical record• “Calling the question”• Making home visits, providing education and setting goals

Nurse Case Managers as process advocates• Attending medical appointments with the patients to help the

physician understand the goals for the visit• Remove a wide variety of process barriers to patient compliance

Nurses Case Managers as system advocates• Promoting an integrated model of care by helping our systems of

care function more effectively for the patients• Helping outpatient treatment providers communicate more effectively with their Primary Care Provider