matthew e. lambert, ph.d. senior director for rural research f. marie hall institute for rural and...
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BEHAVIORAL TELEHEALTH
Matthew E. Lambert, Ph.D.Senior Director for Rural ResearchF. Marie Hall Institute for Rural and Community HealthTexas Tech University Health Sciences Center
Behavioral Telehealth
Telehealth is the use of electronic information and telecommunications
technologies to support long-distance clinical health care, patient and
professional health-related education, public health and health
administration. (HRSA)
Behavioral Telehealth focuses on using telecommunications
technologies for the provision and support of behavioral healthcare
and education.
The types of technologies used in Behavioral Telehealth include:
telephone audio connections, video teleconferencing, web audio or
video conferencing, web-chatting, e-mail, et cetera.
Benefits of Behavioral Telehealth
Increased access and availability of behavioral health providers and
specialists at reduced cost
Reduced barriers to care from disparities (e.g., geographic,
financial, ethnic/cultural, gender, scheduling)
Improved crisis management and support
Increased opportunities for supervision, training, and consultation
Greater support when using augmented self-help care
Type of Behavioral Telehealth Services
Psychiatry Diagnostic Evaluation
Medication Management
Psychotherapy and Medication Management
Consultation and Supervision
Training
Psychology and Counseling Diagnostic Evaluation
Psychotherapy and Counseling
Cognitive-Behavior Therapy
Group Therapy and
Psychoeducational Groups
Psychological Testing
Biofeedback
Critical Incident Stress
Debriefing/Crisis
Intervention
Consultation and Supervision
Training
Value of Behavioral Telehealth
Demonstrated to be equivalent to face-to-face behavioral healthcare encounters
Can reduce length of hospital stays Can produce better medication adherence Reductions in symptoms Emphasizes “Evidenced-Based” care Can treat special populations (e.g., PTSD, autism, ADHD,
children, geriatrics, those of culture) Reduced costs of care
Issues Impacting Behavioral Telehealth
Regulatory Issues – State by State Psychiatry and the practice of
medicine
Psychology and Counseling board
rules
Interstate commerce - location of
service, liability, licensure
HIPPA compliance
Provider familiarity with telehealth
Reimbursement
Technology requirements
All video conferencing software is
not HIPPA compliant (e.g.. Polydor,
Microsoft Lync, Skype)
Most secure connection is hardware
based with video codex – costly
Cameras have different fidelity
levels
Bandwidth affects fidelity of
interaction (DSL, Cable, Fiber
Optics, Wi-Fi, etc.)
Managing technology glitches and
interruptions
What Is Needed
Revamping of regulatory restrictions on behavioral telehealth
Broader interstate compacts to allow services to cross state
boundaries
Clear delineation of HIPPA rules governing telemedicine in
general and behavioral telehealth specifically
Technology guidelines consistent with HIPPA requirements
Educate health care providers about telehealth as part of their
training
Advocate for telemedicine/behavioral telehealth to be covered
insurance services without conditions
Changes Are Coming Slowly
New Texas Medical Board Telemedicine Rules (on hold) Patients can interact with their physicians via telemedicine beyond the traditional
office visit including receiving appropriate care from their homes, between multiple health care settings, and from other medical sites like a school nurse’s office, a fire station or even an oil rig.
Once a physician has made an initial diagnosis of a patient through a face-to face visit held either in person or via telemedicine, the physician can treat a patient for their preexisting condition, via telemedicine, for up to one year in their home. The presence of another medical provider to assist in communicating the patient’s diagnostic information to the physician is only required for the initial consultation.
A physician can provide mental health services to a patient via telemedicine at the patient’s home, which can include a group or institutional setting where the patient is a resident. No other health care provider is required to be with the patient to present the patient’s symptoms to the physician unless there is a behavioral emergency.
Texas State Board of Examiners of Psychologists The delivery of psychological services by telephone, teleconferencing,
and the Internet is a rapidly evolving area. Board rules do not specifically address telepractice, teletherapy, teleconferencing, or electronically providing services. No rules currently prohibit such services. (Fall 1999)
Telehealth: Chapter 111 of the Occupations Code This statute requires a health care professional obtain informed consent before providing telehealth services (§111.002) and take appropriate steps to ensure confidentiality (§111.003). (Winter 2013)
Internet Activity: Chapter 106 of the Occupations Code Pursuant to §106.001, the fact that an activity occurs through the use of the internet does not affect a licensing authority’s power to regulate the activity or person.
Telemedicine Payments to Expand Under New Breed of ACOs March 15, 2015 waiver of telemedicine restrictions to
only patients in rural areas for Next Generation Accountable Care Organizations
Telemedicine visits will qualify for payment if the patient is at home, not just at a hospital, a physician office, or one of six other "originating sites" specified by Medicare.
Building a Behavioral Telehealth Psychotherapy and Counseling Program
Personnel Needed One to three behavioral health providers needed depending on the
number of clinics being served: Recommend at least one Ph.D.
Psychologist while other providers could be a mix of Licensed
Professional Counselors and/or Licensed Clinical Social Workers.
Only Psychologists and Licensed Clinical Social Workers can bill
Medicare. All providers can bill Medicaid.
Originating site communicator: Staff personnel who arranges
appointments, initiates telehealth sessions, insures necessary
forms are completed, and collects co-payments if appropriate.
Telehealth technical support personnel: Manages technical component of telehealth session
Billing and Collection personnel: Complete billing and submit claims for reimbursement
Types of Services Individual psychotherapy and counseling
Evidenced-Based Cognitive Behavioral Therapy
Family Counseling
Marital Counseling
Psychological Testing
Frequency and Duration of Services Initial Diagnostic Interview: First session
Psychotherapy and Counseling Sessions: Total duration of sessions dependent upon presenting problem/diagnosis and evidenced-based treatment guidelines. Typical course of treatment is 12-16 sessions.
Telehealth Codes for Psychotherapy and Counseling
Individual and group health and behavior assessment and intervention
Individual and group health and behavior assessment and interventionCPT codes 96150–96154
Individual psychotherapy Individual psychotherapy CPT codes 90832–90834 and 90836–90838
Telehealth Pharmacologic Management Telehealth Pharmacologic Management HCPCS code G0459
Psychiatric diagnostic interview examination Psychiatric diagnostic interview examination
Neurobehavioral status examination CPT code 96116
Smoking cessation services HCPCS codes G0436 and G0437 and CPT codes 99406 and 99407
Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services
HCPCS codes G0396 and G0397
Annual alcohol misuse screening, 15 minutes HCPCS code G0442
Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
HCPCS code G0443
Annual depression screening, 15 minutes HCPCS code G0444
High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes
HCPCS code G0445
Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes
HCPCS code G0446
Face-to-face behavioral counseling for obesity, 15 minutes
HCPCS code G0447
Psychoanalysis (effective for services furnished on and after January 1, 2015)
CPT codes 90845
Family psychotherapy (without the patient present) (effective for services furnished on and after January 1, 2015)
CPT code 90846
Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI), administered by a computer, with qualified health care professional interpretation and report)
CPT Code 96103
Neuropsychological testing (eg, Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report
CPT Code 96120
Administrative Needs Comprehensive sets of forms: Clinic Information, Consent to Treatment,
Release of Information, Billing Authorizations, Limitations to Treatment, et
cetera
Case Management/Triage of Cases
Emergency Crisis Protocol/After Hours Needs
Electronic Health Record/Practice Management Software
Education for Clinics and Providers
Ongoing Supervision at All Levels
IT Requirements HIPPA Compliant Videoconferencing Software
High Fidelity Video/Audio Equipment
High Speed Internet Bandwidth
Other specific equipment tied to treatment provided
Two Behavioral Telehealth Projects
Telemedicine Wellness Intervention Triage and Referral Project (TWITR)
Vision 21, Building State Technology Capacity Telemedicine Psychiatric Services for Children’s Advocacy Centers of Texas (TPSCAC)
Telemedicine Wellness, Intervention, Triage and Referral Project (TWITR)
The TWITR Project is a demonstration project grant funded by the Office
of the Governor of the State of Texas and is a proposed cooperative effort
between the F. Marie Hall Institute for Rural and Community Health at
TTUHSC and public school entities in Lubbock and surrounding
counties.
The primary purpose of the project is to promote school safety by
providing assessment and referral services to students who may be
struggling due to behavioral and mental health issues.
Telemedicine is leveraged to provide psychiatric services to those
students in schools deemed to have violence risk and suffering
behavioral health problems.
TWITR Results
Over the first two years of the TWITR Project, those students receiving psychiatric services via telemedicine had a 37% reduction in referrals for truancy and discipline problems.
Vision 21, Building State Technology Capacity Telemedicine Psychiatric Services for Children’s Advocacy Centers of Texas (TPSCAC)
To provide support for technology improvements to enhance current systems, build new systems to increase access to technology, increase victims access to resources, and increase the accuracy of administrative reporting.
Builds on the TWITR model to provide psychiatric services via telemedicine to sexually and physically abused children seen at several Children’s Advocacy Centers across Texas without access to psychiatric services.
The project is in its early stages and outcome data are not yet available.
Questions