rural telecon '07 10 th annual conference of the rural telecommunications congress october 14...
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Rural TeleCon Rural TeleCon ''07071010thth Annual Conference of the Rural Annual Conference of the Rural
Telecommunications CongressTelecommunications CongressOctober 14 – 17, 2007October 14 – 17, 2007
Rural TeleMental HealthRural TeleMental Health
Rural TeleMental HealthRural TeleMental Health
F. Rose Rexroat, R.N.,C., MSN, Manager Community Services, Saint Joseph HealthCare,
Inc. a Market Based Organization of Catholic Health Initiatives
Carol L. Ireson, R.N., PhD, Associate Professor, College of Public Health, University of Kentucky
Rural TeleMental HealthRural TeleMental Health
• Understand how telehealth technology is utilized in a rural primary care setting
• Understand how telehealth technology can support provision of mental health services in rural areas
• Understand achievements, barriers, and future objectives
Why rural telemental health?Why rural telemental health?
Economic ChallengesEconomic Challenges.. • 25% to 39%, in area served, live in poverty
compared to 18.7% in Kentucky and 16.3% nationally
• 80 - 100% of children at the targeted schools are on National Free and Reduced Lunch Program
• 7.8% to 12.6% of residents are unemployed
• 18 - 37% of residents qualified for Medicaid
Gaps in the Health SystemGaps in the Health System
81 of 120 Kentucky Counties are officially designated as a Health Professional Shortage Area (HPSA)
• Wolfe County has 1 PCP per 100,000, • Morgan County has 4.8 PCPs per 100,000 • Lawrence County has 11 PCPs per 100,000
(primarily located in the far eastern border in Louisa.)
Health Care ChallengesHealth Care Challenges
• 37.4% to 42.6% of residents reporting fair or poor health
• Over 6% of the population have diabetes higher than the Kentucky rate of 4.5%
• Obesity and overweight rates are among the highest in the state
• Over 5% of residents suffer from major depression
The BeginningThe Beginning
• Work as chair of the Kentucky Association of Free Health Clinics allowed the opportunity to educate two State Representatives and a Senator about a Mobile Health Service
• This discussion lead to implementation of the Eastern Kentucky Mobile Health Service (EKMHS)
Know your own strengths and Know your own strengths and weaknesses in developing the project!weaknesses in developing the project!
Identified and collaborated with experts…– Clinical experts –always focus on the clinical
needs of patients– Technical experts – always have a technical
consultant that can develop a plan to support your clinical needs
– Research experts – help with assessment, analysis, outcome measurement
CollaboratorsCollaborators
• Saint Joseph HealthCare, Inc.• Catholic Conference of Kentucky • Appalachian Regional HealthCare, Inc.• Saint Claire Regional Medical Center• Cabinet of Health Services, Dept. of Public
Health
Collaborating Agency RolesCollaborating Agency Roles
SJHCHolds a personal service vendor contract with the DPH
for: • provision of services• development and administrative oversight• billing and medical record management
Appalachian Regional HealthCare: • Provides care regardless of ability for payment• Referral for ancillary service
Collaborating Agency RolesCollaborating Agency Roles
St. Claire Regional Medical Center• Second line of referral for care regardless of ability for
payment• Serves as hub manager for the five EKMHS sites and SJH • Annual management fees of approximately $12,000 -15,000
paid by St. Claire for EKMHS / SJH
Cabinet for Health Services / Department of Public Health
• Representatives John Will Stacy and Rocky Adkins, Senator Walter Blevins
• Service provider relationship for continued funding to support operation
Collaborating Agency RolesCollaborating Agency Roles
Catholic Conference of Kentucky
Collaboration in carrying out the mission of the Catholic Church, Catholic Health Care.
• Lead role with legislative process to assure continued funding for the EKMHS
• Relationship building• Continued presence and communication
with state legislature
SupportSupport
• State Service Provider Contract - $325,000 for annual operations subsidy
• Budget 2007-2008 increase of $34,000 – FTE replacement factor for ARNP
• Bill for Services: Medicare, Medicaid, other third party payers
• SJHC has no expense subsidy for operations
The Goal of the EKMHSThe Goal of the EKMHS
To improve access to primary and specialist care for residents of five extremely rural communities located in Eastern Kentucky and
To build a provider referral network
Role of College of Public HealthRole of College of Public Health
Kentucky Commissioner of Health designated the University of Kentucky, College of Public Health to conduct a community needs assessment to provide baseline data for use in:– Planning focused health promotion – Disease prevention programs– Future evaluations of the impact of the
EKMHS on health status of clients served
Community Health AssessmentCommunity Health Assessment
• 75 item questionnaire assessing disease burden, health risk behavior, access to care
• Administered at the county fair, homemaker groups, senior center
Needs Assessment FindingsNeeds Assessment Findings
• Disease burden– Heart disease, cancer, diabetes, injury,
depression• Health behaviors
– Poor nutrition, lack of exercise• Access to health care
– No insurance, no money, not enough doctors
Service DeliveryService Delivery
• The Eastern Kentucky Mobile Health Service EKMHS) started seeing patients on May 6, 2003.
Communities ServedCommunities Served
• Blaine in Lawrence County
• Hazel Green in Wolfe County
• Ezel, Cannel City, and Crockett in Morgan County
Output: Patient VolumeOutput: Patient Volume
Visits Average/dayFYE 06/2003 73 3FYE 06/2004 970 4FYE 06/2005 2132 9FYE 06/2006 2528 11FYE 06/2007 2360 10
23.3% New patient76.7% Two or more visits
Income By Reimbursement SourceIncome By Reimbursement Source
FYE 06/04 FYE 06/05 FYE 06/06 FYE 06/07
MEDICARE 13.0% 19.0% 20.0% 11%
MEDICAID 5.0% 3.0% 3.0% 5%
SELF PAY 57.0% 55.0% 69.0% 66%
ALL OTHER 25.0% 24.0% 8.0% 18%
self pay includes self pay and other charity (DSH and St. Joseph Charity)
Bill for Services: Medicare, Medicaid, other third party payers
SJHC has no expense subsidy for operations
Patient ProfilePatient Profile
FYE 06/04 FYE 06/05 FYE 6/06 FYE 6/07
Female 64.9% 60.6% 58.2% 58.1%
Male 35.1% 39.4% 41.8% 41.9%
Pediatric 5.9% 2.5% 1.9% 1.3%
Caucasian 99.5% 100% 100% 99.5%
Native Am. 0.5% 0% 0% 0.5%
Disease BurdenDisease Burden
MEDICATION AS AN INDICATOR
HEALTH KY P.A.P.
FYE 06/03 $6,495 $9,078 FYE 06/04 $108,202 $323,898 FYE 06/05 $109,649 $765,242 FYE 06/06 $176,076 $1,174,954
FYE 06/07 $196,461 $1,014,639
H.K.: Health Kentucky, Inc.PAP: Patient Assistance Programs
Disease BurdenDisease Burden
MEDICATION AS AN INDICATOR
TOTAL AMOUNT / VISITFYE June 2003 $15,572 $213FYE June 2004 $432,100 $445FYE June 2005 $874,891 $410FYE June 2006 $1,351,029 $534FYE JUNE 2007 $1,211,101 $513
TOTAL $3,884,693 $423 AVG
The Role of Telemedicine for EKMHSThe Role of Telemedicine for EKMHS
Remote Access:
• To Specialists
• For follow up visits
• Referrals to or from any of the sites in the Kentucky TeleCare Network
Kentucky TeleHealth Network (KTHN) Sites
Telehealth Clinical ConsultationsTelehealth Clinical Consultations
2003 2004 2005 2006
• EKG 3 10 43 67• Internal Medicine 2 2 3
• Pulmonary 1 1 • Conferencing 4• Education Programs 2• Peds Gastroenterology 2• School Nurse access for primary care 3• November 2005 started laying foundation with KRCC for
mental health clinic(s)
Role Of Grants / Funding SourcesRole Of Grants / Funding Sources
1. OCTOBER 2002: USDA-RUS GRANT of $90,300.00to add telemedicine technology to the MHS and to SJH
2. JUNE 2004: STEELE-REESE GRANT of $47,880.00to provide cancer and diabetic screening for early detection
3. OCTOBER 2004: USDA-RUS GRANT of $235,636.00 to expand present telemedicine network
Need for Mental Health ServicesNeed for Mental Health Services
• Analysis of diagnoses after one year of EKMHS operation found that number of women diagnosed with mental health disorders exceeded the sum of all other diagnoses
• Residents of the targeted communities do not
use the local mental health service provider because of the stigma of going to a mental health clinic
Rural TeleMental Health ProjectRural TeleMental Health Project
Purpose• To develop a comprehensive network of health
care services by expanding the existing primary care and bringing mental health diagnostic and treatment expertise to residents of local rural communities
Role Of Grants / Funding SourcesRole Of Grants / Funding Sources
2006
Appalachian Regional Commission of $303,882
and
USDA-RUS Grant of $326,893
to expand the Kentucky Telehealth Network
SAINT JOSEPH HEALTHCARESAINT JOSEPH HEALTHCARE SERVICE AREA WITH EKMHS SERVICE SERVICE AREA WITH EKMHS SERVICE
AREA AREA (Morgan, Wolfe and Lawrence (Morgan, Wolfe and Lawrence Counties)Counties)
Primary Service Area
Secondary Service Area
Tertiary Service Area
FloydPike
Living
sto
n Ho
pkins
Ch
ristia
n
Webster
Logan
Simpson
Carlisle
AllenMonroe
Calloway
McCrackenBallard
Trigg
Lyon
Caldwell
Crittenden
FULTON
Hickman
MarshallTodd
Union
HendersonDavies
McLe
an
MuhlenbergButler
Ohio
Warren
Edmonson
Marion
Grayson
Breckinridge
Meade
Hardin
Hart
Barren
Green
LaRue
Metcalfe
TaylorCasey
Adair
Cum
berland
Wayne
Clinton
Russell
McCreary
Pulaski
Lincoln
Boyle
MercerWashington
Nelson
Bullitt
Jefferson
Oldham
Trim
ble Carroll
Boo
ne
Ken
to
n
Cam
p
bell
Gallatin
Henry
Shelby
Spencer
Anderson
Owen
FranklinScott
Grant
Pe
rry
Garrard
Wo
odf
ord
Pendleton
Fayette
Bourbon
Harrison
RobertsonBracken
Nicholas
Clark
Rockcastle
Madison
Jessamine
Knox
Whitley
Laurel
Knott
Leslie
Harlan
Letcher
Bell
Clay
Lee
Jackson Owsley
Wolfe
Breathitt
Johnson
Magoffin
Estill
Morgan
Lawrence
Martin
Menifee
RowanElliott
Powell
BathMontgom
ery
Lewis
Fleming
Mason
BoydCarter
Greenup
GravesHancock
2006 Grant Goals2006 Grant Goals
Appalachian Regional Commission Grant $303,882
• Expand EKMHS telemedicine network adding mental health diagnostic and treatment clinic(s)– 4 school sites served by MHS– 3 Kentucky River Community Care sites of Jackson,
Hazard and Campton– St. Claire Regional Medical Center Mental Health Services– 6 county impact area of Perry, Breathitt, Wolfe, Morgan,
Lawrence and Rowan
Saint Joseph HealthcareSaint Joseph Healthcare Service Area With EKMHS Service Area & ARC Grant Service Area With EKMHS Service Area & ARC Grant
Primary Service Area
Secondary Service Area
Tertiary Service Area
FloydPike
Living
sto
n Ho
pkins
Ch
ristia
n
Webster
Logan
Simpson
Carlisle
AllenMonroe
Calloway
McCrackenBallard
Trigg
Lyon
Caldwell
Crittenden
FULTON
Hickman
MarshallTodd
Union
HendersonDavies
McLe
an
MuhlenbergButler
Ohio
Warren
Edmonson
Marion
Grayson
Breckinridge
Meade
Hardin
Hart
Barren
Green
LaRue
Metcalfe
TaylorCasey
Adair
Cum
berland
Wayne
Clinton
Russell
McCreary
Pulaski
Lincoln
Boyle
MercerWashington
Nelson
Bullitt
Jefferson
Oldham
Trim
ble Carroll
Boo
ne
Ken
to
n
Cam
p
bell
Gallatin
Henry
Shelby
Spencer
Anderson
Owen
FranklinScott
Grant
Pe
rry
Garrard
Wo
odf
ord
Pendleton
Fayette
Bourbon
Harrison
RobertsonBracken
Nicholas
Clark
Rockcastle
Madison
Jessamine
Knox
Whitley
Laurel
Knott
Leslie
Harlan
Letcher
Bell
Clay
Lee
Jackson Owsley
Wolfe
Breathitt
Johnson
Magoffin
Estill
Morgan
Lawrence
Martin
Menifee
RowanElliott
Powell
BathMontgom
ery
Lewis
Fleming
Mason
BoydCarter
Greenup
GravesHancock
2006 Grant Goals2006 Grant GoalsUSDA-RUS (DLT) Grant $326,893
• Expand Access by expanding the network to:– 4 Health Departments (Menifee, Morgan, Rowan &
Lawrence)– 5 Schools (Owingsville Elementary, Bath County High
School, Morgan County Middle and High School and Menifee Co.Complex K-12)
– 3 SJHC Emergency Departments (SJ Berea, SJH, SJ East)
– First Clinical Application for Sleep Wellness Center in Lexington and Berea
– 8 County impact area (Fayette, Madison, Bath, Menifee, Wolfe, Rowan, Morgan and Lawrence)
Technology Plan for EKMHS for the USDA RUS DLT Grant
SAINT JOSEPH HEALTHCARESAINT JOSEPH HEALTHCARE SERVICE AREA WITH EKMHS SERVICE SERVICE AREA WITH EKMHS SERVICE
AREA & USDA-RUS GRANTAREA & USDA-RUS GRANT
Primary Service Area
Secondary Service Area
Tertiary Service Area
FloydPike
Living
sto
n Ho
pkins
Ch
ristia
n
Webster
Logan
Simpson
Carlisle
AllenMonroe
Calloway
McCrackenBallard
Trigg
Lyon
Caldwell
Crittenden
FULTON
Hickman
MarshallTodd
Union
HendersonDavies
McLe
an
MuhlenbergButler
Ohio
Warren
Edmonson
Marion
Grayson
Breckinridge
Meade
Hardin
Hart
Barren
Green
LaRue
Metcalfe
TaylorCasey
Adair
Cum
berland
Wayne
Clinton
Russell
McCreary
Pulaski
Lincoln
Boyle
MercerWashington
Nelson
Bullitt
Jefferson
Oldham
Trim
ble Carroll
Boo
ne
Ken
to
n
Cam
p
bell
Gallatin
Henry
Shelby
Spencer
Anderson
Owen
FranklinScott
Grant
Pe
rry
Garrard
Wo
odf
ord
Pendleton
Fayette
Bourbon
Harrison
RobertsonBracken
Nicholas
Clark
Rockcastle
Madison
Jessamine
Knox
Whitley
Laurel
Knott
Leslie
Harlan
Letcher
Bell
Clay
Lee
Jackson Owsley
Wolfe
Breathitt
Johnson
Magoffin
Estill
Morgan
Lawrence
Martin
Menifee
RowanElliott
Powell
Bath
Montgom
ery
Lewis
Fleming
Mason
BoydCarter
Greenup
GravesHancock
SAINT JOSEPH HEALTHCARESAINT JOSEPH HEALTHCARE SERVICE AREA WITH EKMHS SERVICE SERVICE AREA WITH EKMHS SERVICE
AREA & USDA-RUS AND ARC GRANTAREA & USDA-RUS AND ARC GRANT
Primary Service Area
Secondary Service Area
Tertiary Service Area
FloydPike
Living
sto
n Ho
pkins
Ch
ristia
n
Webster
Logan
Simpson
Carlisle
AllenMonroe
Calloway
McCrackenBallard
Trigg
Lyon
Caldwell
Crittenden
FULTON
Hickman
MarshallTodd
Union
HendersonDavies
McLe
an
MuhlenbergButler
Ohio
Warren
Edmonson
Marion
Grayson
Breckinridge
Meade
Hardin
Hart
Barren
Green
LaRue
Metcalfe
TaylorCasey
Adair
Cum
berland
Wayne
Clinton
Russell
McCreary
Pulaski
Lincoln
Boyle
MercerWashington
Nelson
Bullitt
Jefferson
Oldham
Trim
ble Carroll
Boo
ne
Ken
to
n
Cam
p
bell
Gallatin
Henry
Shelby
Spencer
Anderson
Owen
FranklinScott
Grant
Pe
rry
Garrard
Wo
odf
ord
Pendleton
Fayette
Bourbon
Harrison
RobertsonBracken
Nicholas
Clark
Rockcastle
Madison
Jessamine
Knox
Whitley
Laurel
Knott
Leslie
Harlan
Letcher
Bell
Clay
Lee
Jackson Owsley
Wolfe
Breathitt
Johnson
Magoffin
Estill
Morgan
Lawrence
Martin
Menifee
RowanElliott
Powell
Bath
Montgom
ery
Lewis
Fleming
Mason
BoydCarter
Greenup
GravesHancock
How telemental health services will be How telemental health services will be delivereddelivered
• Patients needing mental health services will be referred by the EKMHS Primary Care ARNP to a psychiatric nurse practitioner and psychiatrists located at St. Claire Regional Medical Center or Kentucky River Community Care
• Students with behavior or mental health problems will be referred by school nurses employed by the Gateway Regional Health Department to the Mental Health Nurse Practitioner or Psychiatrists specializing in child and adolescent psychiatry via the Kentucky Telehealth Network
Benefits for the PatientBenefits for the Patient• Linked to physicians in a regional medical center
and a metropolitan hospital(s) via a telemedicine connection – real time audio and video consultation
• Connected to any agency / organization on the KTHN
• Patients will not have to travel long distances to be seen
• Eliminates the stigma of “going to the psychiatrist office”
Benefits for the CommunityBenefits for the Community• Will impact the economic development of the region
by reducing the absenteeism and decreased productivity of workers suffering from mental health problems
• Early intervention for mental health problems will enhance their successful growth and development and prevent these problems from following them into adulthood
• Through access to obtain mental health services for the EKyMHS, the end sites obtained access to primary care and other services
Evaluation PlanEvaluation Plan
• Number of adults and children receiving mental health services in their local communities
• Distance and costs required to travel to receive mental health services vs. using technology
• Satisfaction of patients with the telemedicine mental health services
• Satisfaction of health care providers with the telemedicine technology for providing mental health service
Cost effectivenessCost effectiveness
• We believe the program will be the most cost effective way to address the mental health needs of the rural population served– Reduces travel for the patient– Reduces travel for practitioners– Brings services to rural communities that can
not support a FT or PT health care provider or specialist
SustainabilitySustainabilityLooked at how we could develop
partnerships with our collaborators to build a network that can support the program– All end sites are responsible for T1 installation
and ongoing costs– All end sites are responsible for all equipment
repair / replacement after the first year warranty period
– Education of end sites users on value of new delivery model to their clinical practice
Future GoalsFuture Goals
Expansion of the TeleMental Health Network through an Appalachian Regional Commission Grant
• To connect 3 rural CHI hospitals to the Network• To expand mental health services by adding 5
more KRCC clinics to the Network• To provide primary care services to the 5 new
KRCC clinics• 8 county impact area
Lessons learned Lessons learned • Working with two federal granting agencies
requires a lot of communication• Important to identify champions in each agency
who can help with interagency communication, interpretation of regulations and correct processes
• Pay very close attention to the guidelines for definitions of in-kind and matching funds of each agency
• Patience and persistence are needed
Recommendations for joint federal Recommendations for joint federal grantsgrants
• Written guidelines • Clear identifiers on application for joint grant with
another federal agency• Don’t try to maintain integrity of parts of one or
both grants (scope of work) and then try to consolidate other parts (budget)
• When one grantee allows for funding to be used as match, all agents reviewing the grants need to know that provision
Recommendations for joint federal Recommendations for joint federal grants (continued)grants (continued)
• Point of contact for each organization for questions
• Joint federal grants should require different documents than those for a traditional grant
• Clarify reporting requirements and report cycle
• Clarify process for fiscal allocations and management
QuestionsQuestions
Discussion